THE ENCYCLOPEDIA OF Second Edition

THE ENCYCLOPEDIA OF SUICIDE Second Edition

Glen Evans Norman L. Farberow, Ph.D. Kennedy Associates

Foreword by Alan L. Berman, Ph.D. Executive Director, American Association of The Encyclopedia of Suicide, Second Edition

Copyright © 2003 by Margaret M. Evans

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Library of Congress Cataloging-in-Publication Data

Evans, Glen The encyclopedia of suicide / Glen Evans, Norman L. Farberow.—2nd ed. p. cm. Includes bibliographical references and index. ISBN 0-8160-4525-9 1. Suicide—Dictionaries. 2. Suicide——Dictionaries. 3. Suicide—United States—Statistics. 4. Suicide victims—Services for—United States—Directories. 5. Suicide victims—Services for— Canada—Directories. I. Farberow, Norman L. II. Title. III. Series. HV6545 .E87 2003 362.28'03—dc21 2002027166

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This book is printed on acid-free paper. The man who kills a man kills a man. The man who kills himself kills all men. As far as he is concerned, he wipes out the world. —G. K. Chesterton h

The great tragedy of life is not , but what dies inside of us while we live. —Norman Cousins h

That life is worth living is the most necessary of assumptions, and were it not assumed, the most impossible of conclusions. —George Santayana

CONTENTS

Foreword ix Preface xi Acknowledgments xiii Introduction: The xv Entries A–Z 1 Appendixes 251 Bibliography 303 Index 307

FOREWORD hy an encyclopedia of suicide? What is it tially productive lives and cost this country an Wthat the average teenager or young or estimated $11 billion annually. repre- older needs to know about suicide? The sent our collective failure to observe and help answers to these questions are both simple and our fellow human in distress. . Suicide, although ultimately a very private In the decade 1990–99, more than 300,000 act, is a serious problem. It is signif- people in the United States took their own life. icant enough for our nation’s chief physician— In the same decade, an estimated 8 million the U.S. Surgeon General—to have issued a worldwide died by their own hand. National Strategy for in 2001. It is Each and every year, suicide accounts for far significant enough for the Institute of Medicine more than both and AIDS and to have issued in 2002 a report entitled Reducing HIV-related diseases in the United States and far Suicide: A National Imperative. Note the word more than are caused by wars around the world. imperative. In China, the most populous country in the These reports remind us that we know world, suicide is the leading . enough to approach suicide as a preventable Each year in the United States, almost 20 per- problem. With information such as the reader cent of high school students consider suicide— will find in this volume, and the willingness to and almost half that number report that they partner with those who have the tools to help, made an actual . Across all ages, suicide prevention is everyone’s business. more than 650,000 people in the United States Suicide is a complicated subject; as the French receive emergency medical care each year after novelist and playwright (1913–60) trying to take their own life. wrote, it is “the only truly serious philosophical Suicide and suicidal behaviors know no problem.” It is the province of public health and boundaries. They are tragic outcomes to prob- , of biology and , of psy- lems affecting the young and the old, the rich chology and religion. We have no single unifying and the poor, males and females, whites and theory of why a person takes his or her own life, blacks and Native Americans. They are tragedies and yet we have a treasure trove of empirical that, for the most part, need not happen. studies to help us reasonably understand the Suicides leave family members and friends, many answers to that question. classmates and teachers, coworkers and neigh- There is no one type of suicidal person, yet bors emotionally wounded—some for many, across cultures and personality types we know many years. Suicides rob our society of poten- much to describe risk for and protection from

ix x The Encyclopedia of Suicide the urge to self-harm. This volume is a starting mote an investment of energy to make the dif- point for the reader to explore the complexity of ference in the life of a potential suicide. suicide and better understand what is known. In —Alan Berman, Ph.D. turn, we trust that this understanding will pro- Executive Director, American Association of Suicidology PREFACE

uicide is a tragic and potentially preventable state and international statistics on suicide have Spublic health problem that is currently the been completely updated. eighth leading cause of death in the United In addition, the book discusses the latest States. About 11 of every 100,000 Americans research into the alleged link between certain commit suicide each year, and about half a mil- drugs and suicidal behavior, such as Prozac and lion others are treated in hospital emergency Accutane. Most of the biographies of famous rooms as a result of attempted suicide. individuals throughout history who committed Many Americans believe that urban violence suicide have been expanded and enlarged, and and are the country’s most pressing recent suicides by well-known individuals (such problems, but what most people do not realize is as Kurt Cobain and Vince Foster) have been that while it may seem that the pages of news- added. Other all-new topics include papers are filled with murder stories, in fact there are 50 percent more deaths by suicide than • gender differences in suicide by homicide. The very old and the very young • suicide bombers are most at risk. • ethnicity and suicide In May 2002, Surgeon General David Satcher • launched a national campaign to combat this • different types of suicide (such as gestured sui- problem, seeking to create suicide-prevention cide, love pact suicide, penacide, agenerative programs in schools, on the job, in prisons, old- suicide, , and so on) age facilities, and community service groups. • This book has been designed as a guide and • specific jobs and suicide reference to a wide range of terms related to sui- • murder-suicide cide and to additional information and addresses • new organizations of organizations that deal with this topic. It is not • psychological tests, such as a substitute for prompt assessment and treatment by Questionnaire experts trained in crisis management, depression, and • school violence and suicide the diagnosis of suicidal thoughts or behavior. In this new, revised edition, we have tried to In addition to the all-new entries, almost present the latest information in the field, based every entry has been revised and extensively on the newest research and statistics. Readers updated to include the newest information on will learn the latest developments in a range of statistics, publications, and events in the field topics, including suicide and the law, physician- of suicidology. Likewise, appendixes have been , and the . All state-by- completely updated, including all addresses and

xi xii The Encyclopedia of Suicide phone numbers for organizations, together with not true that suicidal thoughts are simply threats new Internet websites. or cries for attention. A suicidal threat is a med- Information in this book comes from the most ical emergency and should be promptly referred up-to-date sources available and includes the to mental health professionals, crisis hotlines, or most recent research in the field of suicidology. crisis counselors. A bibliography has been provided for readers —Carol Turkington who seek additional sources of information. All Kennedy Associates entries are cross-referenced, and appendices Cumru, Pennsylvania provide additional information. Incidences of suspected or threatened suicidal attempts should never be ignored, because it is ACKNOWLEDGMENTS

o book is written or revised in a vacuum, tion, the Association for and Nand there are many groups and individuals Counseling, the Center for Suicide Research and to thank who provided invaluable help during Prevention, the Center for Re- the revision of this book. search and Education, Compassionate Friends, Thanks to the staffs of the American Associa- CONTACT USA, Dying with Dignity, Lifekeepers tion of Suicidology, the American Psychological Foundation, the National Alliance for the Men- Association, the American Psychiatric Associa- tally Ill, San Francisco Suicide Prevention Cen- tion, Profnet, the , the National ter, SA/VE, and SOLO. Institutes of Health, the Centers for Disease Con- Thanks also to Lanny Berman; my agents, trol and Prevention, the National Library of Bert Holtje and Gene Brissie; my editor, James Medicine, the American Foundation for Suicide Chambers, for patient editing; and Sarah Fogarty, Prevention, the American Sociological Associa- for handling details so well.

xiii

INTRODUCTION: THE HISTORY OF SUICIDE

uicide has been a part of human history since At one time, it was thought that suicide was a Srecorded time. It is not universal, for there by-product of civilization and therefore are some places throughout the world where unknown in primitive societies. To some extent suicide does not occur, but such places are quite this belief was influenced by the notion of the rare. “happy savage” advanced by philosopher Jean- The word suicide is of relatively recent origin. Jacques Rousseau (1712–78). Reliable evidence, It does not appear in the Old Testament, nor in however, indicates that suicide has existed in early Christian writings, nor even in the text of numerous primitive tribes around the globe. In John Donne’s Biathanatos (1644), one of the ear- 1894, suicide was reported among the North and liest English-language works defending suicide. South American Indians, Bedouins, people of Although the word seems to come from the the Caucasus, Indians, Melanesians, Microne- Latin, there was no original single Latin word for sians, Polynesians, and Indonesians. For exam- the act; the Romans always used phrases to ple, there were two ways the Trobriand Islanders express the thought. The expressions used most killed themselves: by jumping from the top of a often were sibi mortem consciscere (“to procure his palm tree and by taking fatal poison from the own death”), vim sibi inferre (“to cause violence gallbladder of a globe fish. Others reported a rel- to himself”), or sua manu cadere (“to fall by his atively high suicide rate in Tikopia, a Polynesian own hand”). community in the western Pacific; in the Maria The word suicide first appeared in 1662, when and other aboriginal tribes of central ; the Edward Philips, in his New World of Words, called American Indians; the Netsilik Eskimos of suicide “a barbarous word, more appropriately ; and different rates of suicide among derived from sus, a sow, than from the pronoun the Africans. sui, as if it were a swinish part for a man to kill On the other hand, researchers have found himself.” The Oxford English Dictionary, however, that suicide was unknown among the Yahgans states that suicide was first used in English in of Tierra del Fuego, the Andaman Islanders, and 1651, derived from the modern Latin word sui- various Australian aborigine tribes. cidium, which in turn had been produced by Attitudes toward suicide have varied a great combining the Latin pronoun for “self” and the deal, usually reflecting the psychocultural his- verb “to kill.” Almost a hundred years later, in tory of the society in which suicide has occurred. 1752, the word appeared in , in the Dictio- Those societies that strongly condemned suicide nnaire de Trevoux. most often associated the act with superstition

xv xvi The Encyclopedia of Suicide and magic and reacted to it with horror and which the man, tired of life, tries to convince his antagonism. Taboos on suicide were developed soul to accompany him into death. Many of the in order to ward off the evils that were thought arguments address the question of whether a to accompany self-inflicted death or to keep the person has a right to take his or her life under spirit of the person who committed suicide in any circumstance, reflecting the conflict be- prison so that it could not return to haunt the tween individual freedom and social responsibil- living. ity. The soul hesitates, afraid the man will be Suicide usually took two forms: social or indi- deprived of a proper if he commits sui- vidual. Social suicide was generally the self- cide, destroying the soul’s chances for a blissful destruction of an individual demanded by a . The soul argues that death is accompa- society as a price for being a member of that soci- nied by separation and , but the suicidal ety. For example, sacrificing one’s life for man contends that death for him would be a another is a practice found in some Eskimo cure and a vacation. tribes in which the old and sick were expected to Ambivalence toward the choice between life sacrifice themselves to help ensure the survival and death is the central theme of this discourse. of their group. In some primitive cultures, sui- The soul argues that death is no respecter of cide was also a way of expressing anger and social position, but the suicidal self is motivated revenge in a rigidly prescribed way; for example, by other forces: the dishonor of his name, the when a Trobriander was accused of violating a loss of personal worth, the injustice and deprav- tribal taboo he could climb to the top of a palm ity of society, the reversal of value and honor, tree, name his accuser, and then jump head first the absence of the good, the severance of friend- from the tree. Individual suicide, on the other ship, a general mistrust of the world, and a fan- hand, usually occurred as a way of preserving tasy with death. In death he expects to achieve honor, expiation of cowardice, termination of the triumph of and to be a god who pain, preservation of chastity, escaping from per- will punish the unjust. The soul’s advice, how- sonal disgrace by falling into the hands of an ever, is to cling to life, to assume religious enemy, or intense despair from separation or loss responsibilities and to approach death gradually of loved ones. in old age. The Egyptians allowed a person condemned Suicide in Ancient Times to death to take his own life (execution by sui- cide). Later, the Romans also followed this prac- In ancient Egypt the attitude toward suicide was tice. Further evidence of the acceptance and neutral, inasmuch as death was seen as merely a tolerance of suicide by the Egyptians is reported passage from one form of existence to another by L. D. Hankoff, who points out that among the and suicide as a humane method of escaping 42 questions concerning sinful acts ritualistically from intolerable hardship and injustice. The asked of a dead person as a Negative Confession dead were considered abstract coequals with the or a Declaration of Innocence, there was no living and with the gods and thus had the same question indicating a prohibition against suicide, physical and emotional needs. even though there were questions about vio- The first known writing about suicide was lence, bloodshed, and vicious or cruel acts. found in an Egyptian papyrus entitled A Dispute Among the ancient Hebrews suicide was over Suicide (also known as The Dialogue of a Mis- infrequent, apparently for several reasons. The anthrope with His Own Soul), written by an Hebrews maintained a strong attachment to life unidentified writer during Egypt’s First Interme- and a positive attitude toward the world, which, diate Period (2280–2000 B.C.). In one papyrus, a according to their teachings, God had made good dialogue occurs between the soul and the self in especially for them, His chosen people. There- Introduction xvii fore humans should not find fault with God’s him. Saul took his own life so as not to fall into work; those who did commit suicide were usu- the hands of his enemies, who would have tor- ally considered insane or temporarily deranged. tured him and desecrated God (I Samuel 31:4; II As a result, sanctions were not usually imposed Samuel 1:6; I Chronicles 10:4). Zimri killed him- against suicide; the bodies of suicide victims self by burning the king’s house over him when were not desecrated and they were not refused the city of Tirzah in which he was besieged was major funeral rights. captured and he became aware of the hopeless- Nevertheless, suicide was clearly prohibited ness of the situation (I Kings 16:18). Razis, a by Judaism, which underscored the sacredness patriotic elder of Jerusalem, also chose to com- of life as well as the dignity of humans and the mit suicide rather than be slain by his enemies value of the individual. It was considered an (II Maccabees 14:46). affront to God to end one’s life. Life was to be The New Testament also neither specifically preserved, except when a person was guilty of prohibits suicide nor condemns suicidal behav- murder, sexual immorality, or idolatry. To com- ior. The suicides of Judas Iscariot (Matthew mit suicide even under the most trying circum- 17:5), who hangs himself after betraying , stances was to give up hope in God. The value of and the suicide attempt of Paul’s jailer (Acts life, however, was not absolute; life could be sac- 16:27) are reported factually and briefly. rificed for the sake of goodness, morality, and The deaths of Saul and his armor bearer was God. Exceptions to the prohibition of suicide related to one of the most important Hebrew were made specifically for extreme conditions, taboos of that era—a strong prohibition against such as when a Jew was forced to betray his human bloodshed. Suicide was abhorrent to the faith, when he had committed a grave sin, or ancient Hebrews because it exposed the commu- when he faced capture and disgrace in war. nity to the possibilities of uncontrolled blood- The Old Testament and related books neither shed and an unattended corpse. Saul’s suicide condemn nor condone suicide. The Old Testa- was a breach of the suicide prohibition and ment matter-of-factly relates seven instances of therefore required much justification, such as self-destructive behavior: Abimelech’s skull was the inevitability of his death and the degradation crushed by a stone thrown from a tower, report- that would have followed had he lived as a cap- edly by a woman, and he had one of his soldiers tive of the Philistines. The Old Testament states kill him with his sword so that it could not be that he was beheaded by the Philistines and his said he had been slain by a woman (Judges body hung on the wall of the city. The of a 9:54). When Samson’s hair grew long again, and nearby town are reported to have courageously his strength returned, he pulled down the pillars taken the body down in the middle of the night of a Philistine temple, crushing to death himself and carried it back to their town for a dignified as well as the multitude gathered there to mock under a sacred tree. Before the burial they and taunt him (Judges 16:28–31). Ahitophel, burned the body as an act of reverence and as a foreseeing military defeat with his coconspirator way of undoing the illegal spilling of Saul’s Absalom in the revolt against King David, blood. hanged himself (II Samuel 17:23). Saul, the first The Torah does not explicitly forbid suicide. It king of Israel, led his army in a battle against the is only in the accumulated body of rabbinical lit- Philistines on Mount Gilboa. Against over- erature that prohibitions against suicides and the whelming odds Saul fought as long as he could exceptions to them are provided. The example of and then killed himself only after three of his Saul is explained as a taking of one’s own life in sons had been killed and he had been severely order to avoid the greater sin of profaning God’s wounded. Seeing his sovereign dead, Saul’s name. Suicides were permissible if committed to armor bearer also fell on his sword and died with prevent dishonor to God’s name. xviii The Encyclopedia of Suicide

There was some question concerning burial providence of God” he and one soldier remained rituals for ancient Jews who committed suicide. as the last survivors, and Josephus was able to Burial was generally accompanied by an ela- persuade the soldier to surrender with him to borate set of ritual acts. The specific rule was the Romans. that there would be no rending of clothes and The most spectacular mass suicide occurred in no eulogizing in the case of a suicide. However, A.D. 74 and was reported by Josephus. Pursued the general rule was that the public should by the Romans, a group of Zealots and their fam- participate in funeral rites out of respect for ilies led by Eleazar Ben Jair took refuge on a the living rather than for the dead and should high plateau at . By this time, the Second say the mourner’s blessing. For all practical Temple had been destroyed by the Romans, and purposes, suicides have been treated as individ- belief in the hereafter among the Jews had uals who destroyed themselves unwillfully, so become widespread. After three years of siege the honors and rights have usually been Ben Jair realized their stores were low and that granted. they could not hold out much longer. Eleazar However, suicide during war was acceptable called his troops and the people together, for ancient Jews. For example, Josephus, born reminded his troops of their promise never to Joseph Ben Matthias, was originally a priest and become slaves of the Romans, and persuaded a general in the army of the Jews. He was cap- them to die by their own hand. He argued that tured by the Romans and lived the rest of his life “death affords our souls their liberty and sends as a Roman citizen in a time when great change them to their own place of purity where they are was taking place in the lives of the Jewish peo- to be insensible to all sorts of miseries.” The sol- ple. He wrote the history of the time in four diers then killed their wives and children and books, The Jewish War, Antiquities of the Jews, His followed this by killing each other—a total of Life and Against Apion. 960 people. Even the battle-hardened Roman Josephus was involved in a mass suicide were reported to have been awed by when he commanded a detachment of Jewish the discipline, pride, and contempt for life troops at Jotopata in A.D. 68. Surrounded by the shown by the people. The only survivors were Roman army led by Vespasian, his soldiers two women and five children who had hidden wanted to kill themselves to avoid surrender. in a cave. Josephus argued against it, insisting that “for In his books Josephus lists a number of those who have laid mad hands upon them- individual suicides, some of them concerned selves, the darker regions of the netherworld with Herod and members of his family. For receives their souls, and God, their father, visits example, he reports the suicide of Herod’s upon their posterity the outrageous acts of the younger brother, Phasael, who had been cap- parents. That is why this crime, so hateful to tured by King Antigones. Phasael, thinking God, is punished also by the sagest of legislators. Herod to be dead, had killed himself by hitting With us it is ordained that the body of a suicide his head against a large rock while he was in should be exposed, unburied until sunset. . . .” chains awaiting execution. A year later, Herod He was, however, accused of cowardice and conquered Antigones and executed him in threatened with death. Josephus finally agreed revenge for Phasael’s death. The suicides that this was a situation in which they were described by Josephus ranged all the way from defending the Torah and sanctifying the holy Abimelech, in 1200 B.C., through the mass sui- name, and therefore even suicide was justified. cide by the Jews at Masada in A.D. 74. He also He proposed the usual solution in such circum- described two suicide attempts by Herod, one in stances—“that they commit mutual slaughter by 41 B.C. by sword and the second in 4 B.C.by lot”—and they agreed. “By chance or by the knife. Introduction xix

The Greeks and Romans Many suicides during the Roman Republic were of the heroic type. Among the more The attitude toward suicide among the Greeks famous are those of P. Decius Mus, 337 B.C., who and the Romans varied widely over time. raced ahead of his troops to certain death in a condemned suicide in general, although he out- battle near Vesuvius; Decius the Younger, son of lined a few exceptions, but Aristotle condemned Mus, who also invited his death in 295 B.C., in a suicide as an act of cowardice and an offense fight against the ; and Cato the Younger of against the state. The Epicureans and Stoics con- Utica, who killed himself in Africa when his sidered it a reasonable expression of human troops were defeated by Caesar. Another heroic freedom, but their beliefs remained unusual suicide was that of Regulus, the consul who was throughout that period. captured by the Carthaginians and sent back to Honor and its various aspects were important Rome to propose peace. He gave his pledge to concerns among the Greeks and Romans. Suicide return no matter what happened. When in was considered an appropriate solution to dis- Rome, however, he argued strongly against honor during the period of Homer. One of the peace and then returned to Carthage knowing first examples is of Jocasta, the mother of Oedi- that he would be killed. pus, who was unaware that he was her son, and Unrequited love and the death of a loved one married him after he had unknowingly killed his were also considered reasonable cause for sui- own father. Another example is that of Ajax, the cide. Dido was queen of Carthage when Aeneas Greater, who was able to retrieve the body of landed there on his flight from Troy. Dido fell in Achilles after the latter had been killed by Paris, love with him and killed herself when he con- the Trojan, with an arrow to his only vulnerable tinued on his journey. The Aegean Sea is named spot, his heel. However, the armor of Achilles was after the father of Theseus who forgot to raise given to Odysseus rather than to Ajax, who felt so the white sail that indicated victory as he dishonored as a result that he killed himself. returned from his voyage to slay the Minotaur in Suicide to maintain one’s honor was highly Crete. When Aegeus saw the black sail he approved. One example is that of Charondas, a assumed his son was dead and drowned himself prominent citizen who helped write the laws in in the sea, which from then on bore his name. Catania, a Greek colony in Sicily. One of the Another story involving loss of love is that of the laws he formulated was that no man who was suicide of Hero, whose lover, Leander, used to armed was to enter the town assembly, on pain swim the Dardanelles nightly from Abydos to of death. When he inadvertently entered with- the Hellespont, where she lived. One night, out removing his dagger and realized what he however, the wind blew out the light that Hero had done, he drew it and used it to kill himself. set out to guide Leander and he drowned. When Suicides of honor, to avoid capture and Leander’s body washed ashore the next morn- humiliation, were common in the wars among ing, Hero was beside herself with grief—and the Greeks and Romans. For example, Demos- drowned herself as well. thenes, who took poison when he was about to Greek history also relates heroic mass suicides be captured by the leader of the Macedonians; of some Greek soldiers after they were captured. Vulteius and all his troops killed themselves Thucydides recounts two incidents, both taking when they were surrounded by soldiers of Pom- place at Corcyra two years apart, in 427 B.C. and pey and escape was impossible; and many of 425 B.C. The first involved 50 men, who, taken Otho’s soldiers killed themselves when they prisoner and condemned to death, escaped exe- learned that their emperor had killed himself cution by killing one another or them- rather than continue further slaughter of his selves. Two years later, when another group was men in his war against Vitellius. again taken prisoner in large numbers, the pris- xx The Encyclopedia of Suicide oners realized their fellow men were being taken Epictetus, a noted Greek Stoic philosopher, out and executed, so they killed themselves by stated “live as long as it is agreeable; if the game thrusting arrows into their throats or by hanging does not please you, go; if you stay, do not com- themselves. plain.” However, he urged restraint and felt a According to historians, the period between person should have good reason before commit- the seventh and fourth centuries B.C. was filled ting suicide. with pessimism and disenchantment with life; a In general, the Romans did not encourage number of philosophers, such as Theognis of suicide, and the government officially opposed Megara, Sophocles, Euripides, Herodotus, and it. Nevertheless, there was a permissive attitude Democritus, advocated suicide, stating that it toward it, and in some of the municipal senates, was “best to leave this world as quickly as possi- free poison containing hemlock was supplied to ble.” It was at this time, in 403 B.C., that hem- anyone who could give valid reasons for want- lock was introduced. Although not readily ing to commit suicide. Suicide was frequent available, it was given to as a special under the first Roman emperors, with whole favor. The possibility of a quick and painless families sometimes committing suicide in public. death may have been a major reason that the Most often these were families under threat of 70-year-old Socrates made the decision to end prosecution for treason. By committing suicide, his own life. Later, when the Greek senate was a condemned person avoided forfeiture of prop- convinced that any committed crime deserved erty. Also, the suicide victim was permitted cus- death, the individual who wished to commit sui- tomary burial, which would have been cide was allowed to do so by choosing to drink otherwise denied for those who were executed hemlock. for a crime. It was not until later that Roman law Despite his choice of suicide, Socrates is known was changed to forbid suicide committed in to have disapproved of ending one’s life before order to avoid forfeiture of property. It was still God had decided it was time to die. “Man is sit- possible, however, for the heirs to bring to trial uated in this life as if he were on a post or sta- the question of the of the deceased. If inno- tion which he must not quit without leave; cence was proved, the heirs were then entitled because the gods exert a providential care over to the deceased’s effects. us on which account we are a part (as it were) of Suicide in Rome was also punished primarily their property and possessions; and because we when the interests of the state were involved, as should think it unjust and punishable (if it were when soldiers or slaves killed themselves. If the in our power to punish) for any slave of our own soldier who committed suicide did so for no ade- to kill himself without our permission.” quate reason (sickness or disease would suffice) Seneca, in Epistles and De Ira, defended suicide or to avoid military duty, he was considered as a last buffer against intolerable suffering. “The guilty of desertion. If the attempt was unsuc- eternal law has done nothing better than this, cessful he was then punished with death. If his that it has given us only one entrance into act was because of depression, sorrow, or mad- life, but a thousand ways of escape out of it,” ness, however, his punishment was less severe. he wrote. “Does life please you? Live on. Does it Under Roman law those whose crimes mer- not? Go from whence you came.” Also, “Wher- ited execution would have their property offi- ever you look there is the end of evils. You see cially confiscated and would also be deprived of that yawning precipice—there you may descend proper burial. Therefore, when Nero ordered the to liberty. You see that sea, that river, that well statesman, dramatist, and philosopher Seneca to —liberty sits at the bottom. . . . Do you seek commit suicide because he suspected his former the way to freedom? You may find it in every teacher of having plotted against him, the order vein of your body.” was viewed as a kindness. Nero also caused the Introduction xxi death of Seneca’s nephew, the poet Lucan, and and, according to their beliefs, the opportunity of Petronius, considered the most witty, elegant, to enter heaven. In addition, the church under- and sophisticated Roman of his time. The fear of took care of the surviving family, thus relieving dishonor brought on the suicide of Cassius, who the suicide victim of any guilt or about ordered his slave to stab him. abandoning them. This attitude persisted well One of the more striking suicides was that of into the fourth century. Arria, the wife of Caecina Paetus, a senator who The early Christians were morbidly obsessed was involved in plotting against Emperor with death. For them, life on earth was impor- Claudius. She is reported to have plunged a tant only in preparation for the hereafter, so that sword in her breast to show her husband how men studied how to die rather than how to live. and then handed the sword to him, assuring him The primary objective became the avoidance of that it did not hurt. sin, because to engage in sin would result in per- Lucrece committed suicide after being raped petual punishment. Suicide was committed out by Sextus Tarquinius, a Roman general who of fear of falling before temptation, at times indi- threatened to kill her unless she yielded to him, rectly by provoking nonbelievers to kill them, at saying that he would tell everyone he had killed other times directly, as by jumping off cliffs in her because he had found her with a slave who large numbers. According to St. Augustine, the was her lover. The next morning Lucrece sum- heretical Donatists and Circumcelliones in North moned her family and her husband, told them Africa killed themselves in vast numbers by leap- what had happened, and then killed herself. This ing from cliffs with “paroxysms of frantic joy . . . story has been immortalized in one of Shake- till the rocks below were reddened with their speare’s poems. blood.” Stoicism accepted and, under certain condi- Finally, St. Augustine, in the City of God, vig- tions, even recommended suicide. Zeno, the orously condemned suicide, stating that no pri- founder of Stoicism, wrote that a wise man vate person could take upon himself the right to could accept suicide if it provided escape from kill a guilty person—this right rested with the intolerable pain, mutilation, or incurable dis- church and state; that suicide precluded the pos- ease, or if it was for his country’s safety or the sibility of repentance, and that it violated the sake of his friends. Zeno is reported to have Sixth Commandment (“Thou shalt not kill”). It taken his own life because, feeling advanced in was, therefore, a greater sin than the sin one age, he did not wish to endure the discomfort of might wish to avoid by killing oneself. St. a broken toe. Cleanthes, Zeno’s successor, is Augustine had to account for accepted suicides reported to have fasted because of a boil on his and sacrifices in the Old Testament, such as that gum. When the boil disappeared, Cleanthes by Samson and Abraham’s willingness to sacri- decided he had gone so far toward death he fice his son, Isaac. His answer was that in such might as well go the rest of the way, and he instances divine authority had been granted for killed himself. the death. St. Augustine’s stand against suicide was probably a necessary corollary of the The Middle Ages church’s teaching about the importance of the hereafter. If a human’s life on earth was merely Suicide in general was tolerated and even a period of waiting for divine glory, the true approved in the Roman Empire until Christian believer was naturally tempted to hasten the views began to influence social and legal atti- time when he or she would enter eternal bliss. tudes. At the very beginning of the Christian era, In addition to St. Augustine, other early however, suicide was highly attractive to many fathers of the church who contributed to the Christians because it offered them martyrdom development of the church’s attitude toward xxii The Encyclopedia of Suicide suicide were St. Cyprian, St. Ambrose, St. Ire- for the insane who committed suicide. In addi- naeus, and St. Athanasius. tion, the Council of Troyes (878) modified the The first Christian prohibition of suicide is strictness of previous legislation and allowed cer- sometimes attributed to the Council of Arles in tain rituals for suicidal deaths. In 855, however, 452. However, this measure was directed only the Third Council of Valence denied Christian against the suicide of servants, and it described burial to those who died in tournaments, jousts, the suicidal person as being possessed by the and other forbidden contests considered similar devil. The second Council of Orleans, in 533, to suicidal deaths. indirectly expressed disapproval of suicide by Finally, after King Edgar’s canon in 967 allowing the church to receive offerings from accepted the ecclesiastical dictum denying burial those killed in the commission of a crime pro- rights to suicide victims, the Synod of Nîmes in vided that they had not laid violent hands on 1204 reaffirmed all the previous council decisions themselves. In other words, suicide was re- against suicide and then extended their judg- garded as worse than any other crime. ments by refusing people who committed suicide The 15th canon of the Council of Braga in 563 even the right of burial in holy ground. While it took the decisive step of imposing penalties on did not go so far as to demand punishment for the all suicide victims and their families by denying dead, the severe penalty of depriving burial rights them the usual funeral rights with the eucharist suggested a reemergence of some of the earlier and the singing of psalms. The Council of Aux- pagan horror against such deaths and the practice erre in 578 decreed that no oblation would be of dishonoring the corpses. Bodies were buried at received from any person who had killed him- crossroads with a stake through their heart to self, and it also reaffirmed the penalties and the prevent the soul from wandering. This practice principle of indiscriminate condemnation for continued as late as 1811 and did not actually suicide. The Antisidor Council in 590 invalidated stop until 1823, when a suicide victim named the offerings of a suicide victim as a means of Griffith was buried at the crossroads formed by expiation for sin. The canon of the Council of Eaton Street, Grosvenor Place, and King’s Road. Braga that denied suicide victims the usual The following month a statute was passed to funeral rights was adopted in England by the abolish the practice. Council of Hereford in 673, bringing England In France the body of a suicide victim was into line with the practices on the Continent. dragged through the streets head downward and The Capitula of Theodore, archbishop of Canter- then hanged on a gallows. In England the prop- bury, decreed that neither mass nor Christian erties of suicide victims were confiscated until burial was to be performed for suicide victims 1870, and, as late as 1882, by law the person had unless they had been insane, but that prayers to be buried at night. The service of the Church and psalms could be offered. of England still cannot be used for a suicide vic- In the seventh century, there were reportedly tim. However, other Protestant denominations a number of cases of persons condemned to do provide for a service. In Danzig, now a part of church penance who could not face the severi- Poland (Gdansk),´ the body of a suicide victim ties involved and attempted to kill themselves in was not permitted to be taken out through the desperation. The 16th Council of Toledo, in 693, door but had to be passed through a window, punished a person who attempted suicide with even if a hole had to be knocked in the wall exclusion from the fellowship of the church for when there was no window. two months. However, heretics and Jews continued to The church relaxed its attitude toward suicide commit suicide frequently during the Middle briefly and provided in the texts of the Peniten- Ages. Pogroms were conducted against Jews in tials in 829 that masses and prayers could be said England, especially in the early years of Richard Introduction xxiii the Lionhearted, which triggered a number of destruction. In his Divine Comedy, Dante instances of mass suicides. At York in 1190, 600 described the souls of suicides as being encased Jews killed themselves to escape oppression. in thorny, withered trees on which Harpies fed Another group of suicide was the Albi- and inflicted severe wounds, drawing hideous genses in southern France, 5,000 of whom cries of lamentation and pain from the trees. reportedly were put to death as heretics in 1218. The Augustinian-Thomistic view regarding The Albigenses believed in the Catharic heresy suicide still remains essentially the position of that substituted belief in a dualism—God versus the Roman Catholic Church, although today the Satan—for the belief in the Christian idea of a church acknowledges two kinds of suicide: the unitary God. The main tenets of their doctrine illicit act of taking one’s life and the licit sacrifice favored suicide because they included detach- of one’s life. In the former, an individual may ment from worldly concerns, rejection of private cause his or her own death by doing something property, and abolition of marriage, inasmuch as that is self-destructive or by refusing to do some- it led to the perpetuation of the human species. thing that is necessary for survival; either is an Their favorite methods of suicide were by fire, by act of self-destruction. In general, Catholic the- jumping, and by the endura, a voluntary fast. ologians agree that direct suicide is intrinsically Another group in which large numbers of sui- evil. It is permissible, however, if it is committed cides commonly occurred was the Russian in response to an inspiration from God, an ex- Raskolniki, who, early in the 17th century, clung planation used to justify the deaths of martyrs to the old faith in the form of the Russian Or- who have sacrificed their lives in defense of their thodox Church. A number of incidents of mass virtue or their faith. However, current thinking suicide by immolation are reported to have oc- among Catholic theologians is that an individ- curred in crowded churches and remote monas- ual’s faith can be defended by means other than teries. Suicide in great numbers was also direct self-murder. reported to have occurred among wives of Sacrifice is deemed licit when the person does priests after celibacy for the priesthood was not desire death, or when death is not the spe- decreed in the 11th century. There were also cific aim but rather a consequence of an other- reports of numerous suicides occurring during wise legitimate action that is performed. The epidemics, particularly when the Black Plague important criterion used in judging the act is that swept Europe in the 14th century. the greater the risk to one’s life the greater must In the 13th century, St. for- be the compensating good to be obtained. For- mulated an authoritative church position on sui- merly the church denied ecclesiastical burial to a cide in his Summa Theologica. He set forth three suicide victim unless signs of repentance had arguments against suicide: self-destruction is been shown before death. However, for many contrary to man’s natural inclinations; man has years the church has not applied this rule and no right to deprive society of his presence and generally grants the benefit of the doubt to the activity; and man is God’s property and it is up to victim. It is now assumed that a physical or emo- God, not man, to decide on our life and death. tional misfortune has caused a psychic distur- The years between St. Augustine and St. bance severe enough to make the person not Thomas Aquinas were filled with continual responsible for the act and therefore incapable expressions of rejection of and resistance to sui- of sin. cide, with increasingly harsh edicts both against the corpse of the suicide victim and his surviving Eastern Attitudes family. Dante’s Inferno appeared early in the 14th century and illustrated the strong element of Among Asian sacred writings, suicide was viewed fear in human’s reaction to deliberate self- with many contradictions, with encouragement xxiv The Encyclopedia of Suicide in some and vigorous condemnation in others. In toward an awareness of the world and its beauty Japan, suicide was a way in which warriors could and a euphoric feeling that life was wonderful. expiate their crimes, apologize for error, escape This attitude lasted throughout much of the 14th from disgrace, redeem their friends, or prove their and 15th centuries. The individual became sincerity. In China, suicide was so commonplace important as humans became aware that they that it was accepted as a normal feature of every- were the master of their own destiny. Values and day life. The wretchedness of people’s lives in the religion began to change. Luther became the Far East made suicide seem logical, and it was representative of orthodox Protestantism, with a accepted without condemnation. shift in principles from absolutism and obedi- The Hindu attitude is ambiguous, condemning ence to personal inquiry and personal responsi- suicide in most instances but approving it in spe- bility. Inevitably, as questions and challenges cial cases. Suicide is considered justified when the arose and the Industrial Revolution caused person has lived a full life or has acquired a high sweeping social and economic disruption, there measure of ascetic power. Hinduism institutional- came a sense of self-consciousness and isolation. ized and sanctioned suttee, a ceremonial sacrifice A marked increase in melancholy appeared of widows, which persisted in India for more than along with recognition of life’s transience. Death 2,000 years. This suicide by self-immolation was became an escape from the disappointments demanded of the widow after the death of her of life, and suicide began to appear much more husband, and she was highly praised when the often. tradition was followed and severely condemned Calvinism appeared in the middle of the 16th when there was a failure to carry it out. Pregnant century, starting first in Switzerland and sweep- women and mothers of minors were excused ing across France (with the Huguenots) to reach from the traditional requirement. Today suttee is England, while Lutheranism became firmly forbidden but may still be practiced in some of the entrenched in Scandinavia. The exaltation of rural provinces of India. God in John Calvin’s theology tended to mini- The Brahman doctrine was sympathetic to mize humans and make them feel even more suicide in that it incorporated denial of the flesh, humble, raising indirectly the question of the which the philosophies of the Orient constantly value of the individual human. Italy saw a sought to attain. One goal of Asian mysticism revival of learning and a of ideas was to divorce the body from the soul, extin- that began to diminish the strong feeling of sui- guishing craving and passion and allowing life’s cide-horror. Erasmus in his Praise of Folly (1509), chief purpose to prevail, the acquisition of Sir Thomas More in Utopia (1516), and Michel knowledge. Both Brahmanism and Buddhism de Montaigne in his Essais (1580–88) show the are considered religions of resignation and absolute condemnation of suicide disappearing, despair. with suicide justified, albeit under still strictly has condemned suicide with the utmost defined circumstances. Erasmus took the posi- severity, following the cardinal teaching of tion that God meant death to be an agony in Muhammad that the divine will was expressed order to keep men from committing suicide. in different ways and that man must submit Nevertheless, in one of his books he commends himself to it at all times. those who voluntarily kill themselves in order to leave a miserable and troublesome world, The Renaissance and considering them wiser than those who are the Reformation unwilling to die and who insist on living longer. Montaigne extolled voluntary death but later The Renaissance saw the emergence of a radical came to a more moderate practical position, change in attitudes toward suicide, with a shift concluding only that unsupportable pain, or a Introduction xxv worse form of dying, were acceptable justifica- necessary duties of a man’s calling, change in tions for suicide. manifest behavior, a distracted countenance in With the spreading of the Renaissance the courage, speaking and talking to and with them- economic conditions became more and more selves in solitary places and dumps, reasoning oppressive as one realized his or her poverty and and resolving with themselves about that fact lack of a future. The Anatomy of Melancholy by and their motives to it in a perplexed, disturbed Robert Burton (1621) condemned suicide but manner.” also pleaded for a charitable attitude towards it, Johannes Neser (1613) wrote that those who asserting that it was up to God to judge. John committed suicide when sane and with premed- Donne wrote Biathanatos in 1608, the first itation were damned, while those who killed defense of suicide in English up to that point, but themselves in a state of madness were not it was not published until 1644, after Donne’s damned because they were mentally deranged death. Donne, like Burton, felt that the power and were not responsible. Like Burton, he felt and the mercy of God were great enough that that God could decide whether salvation was the sin of suicide could be forgiven. In his words appropriate in those cases where the circum- it was “not so naturally a sin that it could never stances were unclear. be otherwise and suicide was not incompatible with the laws of God, reason and nature.” Bur- The Industrial World ton felt that eternal damnation was not neces- sarily the punishment for every suicide because Throughout the Renaissance and post-Renaissance of the possible presence of mitigating circum- periods, suicide had become more and more tol- stances, such as madness. erated by the educated people both on the Con- The preoccupation with death that character- tinent and in England, but the church still ized this era resulted in many new editions of remained powerful in its condemnation of sui- the “Danse Macabre” which were illustrated by cide, which it now branded not merely as mur- the presence of a skeleton. Rowlandson, a der but also as high treason and heresy. An prominent graphic artist of that time, drew a important, additional cultural element was number of the scenes. In “The Gamester’s Exit,” added in this era—the stigma of poverty. Up to for example, a man is shown shooting himself in this time, being poor had not been associated the head while holding a wine glass aloft in his with any moral position. With the rise of com- other hand. In the doorway stands a woman mercialism, the development of the Industrial vainly attempting to stop him while on the other Revolution, and the appearance of Protestant- side of the table a skeleton watches grimly. ism, a drastic change in the attitude of society Shakespeare also produced psychological studies toward the poor appeared. Social relationships in depth, with suicide appearing no less than 14 began to be evaluated from purely economic times in his eight tragedies. standards. Good was now rewarded by prosper- John Sym, an English clergyman of this ity and evil by poverty; economic failure was an period, identified suicide victims as those who indication of sinfulness. Most of the condemna- were sick in mind. His textbook (1637) was the tion was directed toward those persons who suf- first to show a concern for understanding and fered a decline in their fortune, from prosperity prevention, listing premonitory signs and giving to poverty, and it was this change rather than suggestions on how to protect the suicide victim. the fact of poverty itself which accounted for Sym divides suicides into direct and indirect, many suicides at that time. The impact of condemning especially the indirect type. Among poverty was illustrated in 1732 when Richard the premonitory and diagnostic signs of suicide Smith and his wife killed their infant daughter, he lists “unusual solitariness, neglect of the hanged themselves, and left a long letter xxvi The Encyclopedia of Suicide addressed to the public describing the hopeless- George Cheyne associated suicide in England ness of poverty and complaining that life was with inclement weather, rich heavy food, not worth living. and wealthy and sedentary living in large urban The 18th century saw many additional centers. changes in the attitudes toward suicide, such as At about this time (1763), Merian offered one opposition against the penalties imposed on sui- of the important new arguments by separating cide. During this period of Enlightenment, suicide from morality and approaching it from a prominent French literary giants such as medical point of view. He suggested that suicide Voltaire, Paul-Henri d’Holbach, Jean-Jacques was not a crime but an emotional illness. The Rousseau, and Cesare Beccaria condemned the natural extension of this argument was that all conventional harsh treatment of suicides and suicide victims were mentally ill in some degree encouraged the exercise of empirical observation and so could not run counter to the law of and critical reason. Voltaire (1766) brought a nature. This rationalization eventually paved the reasonable approach toward suicide, Rousseau way to the church’s verdict of “suicide while of (1761) suggested a romanticized approach, and unsound mind,” allowing the church to skirt its Charles-Louis de Montesquieu (1721) brought own laws against suicide. for the first time a criticism of suicide from the Bishop Charles Moore continued to be critical point of view of the survivors. He urged a view of suicide but was not so dogmatic as other less prejudiced against suicide in his Persian Let- ecclesiastical writers, stating that each case of ters and opposed the traditional Christian atti- suicide had to be judged on its own merits. In his tude toward suicide as sinful. book A Full Inquiry into the Subject of Suicide One of the most significant publications in (1790), he argued that humans did not know this period was written by David Hume, a Scot- the importance of their own lives even if they tish philosopher, entitled “Essay on Suicide” appeared to be useless and that suicide might be (1783). Hume argued that if suicide were to be an interference with the design that God has abhorred it had first to be proven a crime against fashioned for each person. God, neighbor, or self. He argued that suicide In Germany, Immanuel Kant (1797) argued was not a crime against God because He gave that human life was sacred and had to be pre- humans the power to act; therefore, death at served at all costs. He also stated that each indi- one’s own hand was as much under His control vidual had a definite place in the great universe as if it had proceeded from any other source. according to the laws of nature and that man’s Second, suicide was not a breach against neigh- ability to reason made suicide inconsistent with bor and society, “for a man who retires from life the sacredness of human life. does no harm to society, he only ceases to do good and which, if it is an injury, is of the lower The Romantics kind.” Third, Hume stated that suicide cannot be a crime against self because he believed that no During the last half of the 18th century and the man ever threw away a life while it was still early part of the 19th century, the romantic poets worth keeping. had a great impact on the concept of death. It was The discussion on suicide in this era saw some in 1770 that Thomas Chatterton at the age of 17 writers attempting to relate it to national charac- committed suicide by poison, which the ro- ter. Suicide was associated particularly with the mantics took as a vivid example of death by English, for example, and became known as an alienation—premature death in a blazing genius. English symptom because England’s inhabitants Youth and poetry and death became synony- showed a characteristic gloominess of tempe- mous, with each glorified in the writings of rament. In his book The English Malady (1733), Novalis and Jean Paul in Germany, René de Introduction xxvii

Chateaubriand and Alphonse de Lamartine in and personal gain, making people more interde- France, and John Keats and Percy Bysshe Shelley pendent economically but isolating them socially. in England. Keats died in 1821 at the age of 25, Material values supplanted religious and social Shelley the next year at 29, and Lord Byron, two values. Suicide began to be considered a disgrace, years later, at age 36. Johann Wolfgang von supplementing the attitudes of the preceding cen- Goethe’s Sorrows of Werther (1774) was inspired tury, when it had been associated with sin and by the suicide of a young diplomat, and set a crime. A strong middle class was growing, consis- Europe-wide pattern for the romantic style of tent with the development of increasingly larger suffering. The romantics thought of death and urban centers where industry and business could suicide as a supreme dramatic gesture of con- interact. Along with this new middle class came tempt toward a dull world. Suicide was fashion- the need for the family to maintain social status able and was practiced almost as an elegant sport. within the community, making suicide something Writings nevertheless continued to appear in to be hidden and denied. This was especially true the early 1800s against suicide. In France, one of for the upper class, as suicide became more fre- the most prominent efforts was that of Madame quently associated with insanity. de Staël (1814), who wrote that living through An increasing number of scientists investi- pain and crisis made a person better, and thus it gated suicide from medical and sociological was unnecessary to commit suicide. She argued points of view. One of the earliest works was by that God never deserted man and that the indi- Osiander (1813) who attributed suicide to men- vidual need never feel that he or she was com- tal illness, blaming such things as diseases in the pletely alone. Her strongest argument was that head, congestion of blood in the brain, weaken- suicide was against the moral dignity of humans, ing of the brain by repeated intoxication, epilep- an argument directly opposed to that of the Sto- tic attacks, progressive inflammation in the small ics and the Epicureans, who felt that suicide intestine, cardiac aneurysm, swelling of the helped preserve dignity and self-concept. abdominal glands, persistent constipation, and Léon Meynard (1954), a 20th-century French defects in the sexual organs. Osiander’s study of philosopher, reasoned that suicide was caused melancholic persons led him to conclude they basically by suffering and was essentially a hanged themselves to avoid the sensation of refusal to submit to it. In order not to kill one- blood sinking from the brain on account of sus- self, one must know how to suffer. Suffering, pended aerial electricity. however, could be understood only in the reli- Jean-Pierre Falret’s (1822) contribution was gious perspective. Meynard felt that the exis- significant in that he was one of the first to use tence of God was the supreme argument against statistical data on suicide, albeit not very exten- the legitimacy of suicide, and that the purpose of sively and with very few conclusions. Falret life was not to find happiness but to seek purifi- attributed suicide to four major causes: (1) pre- cation through suffering. Suffering needed nei- disposing, such as heredity, temperament, cli- ther to be accepted nor resigned to, but rather to mate; (2) accidental direct, such as passions and be used as a means of salvation. worries at home; (3) accidental indirect, such as bodily pain, disease, and state of health; and (4) The 1800s civilization and religious fanaticism. He equated suicide and insanity, considering the former to During the 1800s a number of significant changes be a special form of insanity. appeared in society. The old religious and social A number of investigators of this period groupings that had offered the strongest resis- searched for suicide’s relationship to psychosis tance to suicide began to lose their effectiveness. and pathoanatomical signs. Did suicide automat- Capitalism introduced incentives for individual ically mean the subject was insane? Were there xxviii The Encyclopedia of Suicide neurological lesions or anatomical defects that gations seeking to pinpoint this relationship fol- “explained” suicide? The consideration of sui- lowed. Social disorganization and alienation also cide as a special form of insanity served as a were identified as strong contributors to suicide. for all kinds of medical observations Lisle (Du suicide, 1856) also used statistics in into the connection between a suicide’s behavior dividing the causes into two major groups, pre- and anatomical lesions found in . Clinical disposing and immediate. Like Brierre de Bois- pathologists in France pursued this course mont he opposed characterizing suicide as a earnestly in the first half of the 19th century. mental disease, although suicide was often due Jean-Étienne-Dominique Esquirol, in his to mental illness. He found insanity, monoma- chapter on suicide in his book Mental Illness nia, and brain fever in only about one out of (1838), refused to accept the doctrine that sui- every four cases of suicide. cide was a mental disease in itself, but insisted, Adolph Wagner (1864), using suicide statis- rather, that it was a consequence of other ill- tics, agreed that insanity could not be equated nesses and only a symptom of insanity. He pro- with suicide, but he did conclude that it was by posed that suicide might depend on hereditary far the most common cause for suicide, occur- factors. While he urged that the individual dis- ring in about one-third of all the cases. He also position be observed very closely, he did offer concluded that suicide was 100 times more com- some general observations: Men committed sui- mon in mentally ill individuals than in mentally cide more often than women, and the number of healthy persons. suicides was greatest in the spring. However, he Siljestrom (1875) studied the increase in sui- did not believe in the influence of climate. cides from 1730 to 1870 in Sweden and con- Alexandre-Jacques-François Brierre de Bois- cluded the increase was due to the political, mont studied 4,500 suicides in the Seine Depart- social, and industrial states of transition through ment over a period of 10 years and also reported which society had passed during that time. data gathered from 265 persons who either During this period the German philosopher made a suicide attempt or planned one. For de Arthur Schopenhauer expressed the pessimism Boismont, suicide causes fell into two types, pre- of the era in his writing (“Parerga and Par- disposing and determinant. In the former could alipomena,” 1851). While often considered an be found demographic variables, such as civil advocate of suicide he actually was strongly status, age, sex, religion, marital status, and oth- against it. He felt that moral freedom, the high- ers. Thus, he confirmed that older people com- est ethical ideal, could be obtained only by deny- mitted suicide more often than younger people ing the . Suicide, however, was not and that men killed themselves in a ratio of such a denial. For Schopenhauer the denial lay three to one over women. He denied strongly in shunning the joys, not the sorrows of life. He that all suicides were insane but did indicate that felt the suicidal person had the will to live but an attempt at suicide was often the first indica- was dissatisfied with the conditions under which tion of insanity, even where mental illness had he was forced to live. not been suspected before. Among the behav- Another important work of this period is that ioral and social causes, he identified such items of Enrico (Henry) Morselli (1881). Analyzing as trouble at home and with the family, intense data from Italy, he concluded that suicide was worry, poverty and misery, and inebriation. primarily a result of the struggle for life and Among somatic diseases he found pulmonary nature’s evolutionary process, by which weak- conditions were most frequent, followed by brained individuals were sorted out by insanity blindness and then cancer. He was one of the and voluntary death. Other unhappy results in- first to mention pellagra as a disease that often cluded misery, disease, prostitution, and insan- seemed to lead to suicide. A number of investi- ity. That men committed suicide more often Introduction xxix than women and more often than chil- based his work on an extensive evaluation of dren merely illustrated the struggle of life that suicide statistics in France. He concluded that led to suicide. To reduce suicide one needed to suicide was a collective phenomenon that was reduce the number of people, which could be specifically influenced by factors characterizing accomplished only by birth control. In Morselli’s the society in which it appeared. The basic fac- opinion the progress of civilization and Protes- tors were regulation and integration, with vary- tantism, which refused all external worship in ing degrees of each of these factors, and their favor of free discussion and individual thought, interaction, producing characteristic forms of were the most powerful factors in increasing the suicide. Durkheim’s basic concepts are illustrated number of suicides. by examples of societies that fell at the opposite Thomas G. Masaryk, in Suicide and the extremes of each concept. Thus, at one extreme of Civilization (1881), also stressed the difficulty in of regulation a society characterized by chaos, determining the boundary between normal and confusion, and loss of traditional values and abnormal mental life. He felt that civilization and mores would produce “anomic” suicides. At the the state of semi-culture were responsible for the other extreme of regulation would be found increasing suicide frequency in almost every “fatalistic” suicides, where expressive and re- country. The causes of suicide lay in both the bio- pressive constraints would produce an extreme logical and social constitution of humans. Suicide feeling of lack of freedom and choice. At one could not be explained only in terms of mental extreme of the integration concept would be illness but must be looked for in the moral disor- found “egoistic” suicides where the person felt der of modern societies. Since religion was the alienated and separated from the institutions source of morality, the increasing secularization and traditions that were significant in the soci- that characterized contemporary societies meant ety. At the other extreme of integration would a loss of faith. Like Morselli, Masaryk felt that be “altruistic” suicide, in which an overidentifi- Protestantism stimulated the development of free cation with the values or the causes of a society inquiry, which in turn fostered a much higher might produce a too-ready willingness to sacri- degree of individualism than the Catholic fice one’s life in a burst of patriotism or - Church. The Protestant was more easily left open dom. Durkheim’s writings have stimulated a to doubt and to despair, which essentially was a host of sociological-statistical investigations up consequence of a decline in religious belief rather through the present time. than the result of Protestant theology. Masaryk The second most important event in 1897 urged that what was needed was to revive the was the publication of the essay “Is Life Worth moral meaning that came from belief in a supe- Living?” by . James concluded rior being. Thus, the moral crisis of modern civi- that humans did not commit suicide because of lization could only be resolved through a religious faith, but rather because faith itself religious revival, not a reversion to the repressive was lacking. It was faith that helped humans to control that the church had exerted in previous believe, even in deep depression, that life ages. Eugen Rehfisch (1893) also saw suicide as was still worth living. Faith leads to religion, the final link in a chain of pathological states, which essentially postulates the existence of with civilization the underlying cause for “men- an unseen order in a universe beyond our tal degeneration.” Alcoholism was also important comprehension. in suicide, he felt. Two of the most important events in the his- Early 20th Century tory of suicide studies occurred near the end of the 19th century. The first was the publication of The interest in medical investigations in sui- Emile Durkheim’s Le Suicide in 1897. Durkheim cide that had begun in the last half of the 19th xxx The Encyclopedia of Suicide century continued strongly into the 20th. Au- suicide dynamics was the growth of the psycho- topsies were used as a primary source of data analysis movement in under the lead- as investigators looked for relationships be- ership of its founder, . Freud’s tween suicide and physiological or neurological approach was a radically new conceptualization conditions. of the workings of the mind, with the concept of Researchers in the early 20th century found levels of functioning ranging from conscious essentially organic changes in three-fourths of through unconscious (id, ego, and superego), the suicides on which were conducted; and with remarkable insights into the variety of others concluded that an anatomically visible defenses and coping mechanisms, the failures of cause was related to such motives as alcoholism, which may lead to severe neurosis and psy- financial distress, somatic disease, morality, or chosis. Freud approached suicide first from his conflict with society. On the other hand, some studies of melancholia and depression, and his researchers did not see anything related to men- first theory of suicide was developed from the tal status in one study of 923 suicides; changes in dynamics that characterized the two states. He the central nervous system were present in only used his earlier theoretical concept of introjec- 13 percent. tion, in which any person in an intimate rela- A number of other investigators in the early tionship with another incorporates parts of that 1900s explored suicide from the socio-statistical person into his own personality, with that per- point of view. One of the most prominent was son becoming a “part of the self.” Inevitably, all Maurice Halbwachs (1930), who collected sta- intimate relationships also develop ambivalent tistics in France on both attempted suicide and or contradictory feelings toward the person, evi- committed suicide and found the ratio to be 164 denced by fluctuating feelings of like and dislike, to 100, respectively. This is in marked contrast love and hate. Freud thought that suicide to the more recent studies in the United States, occurred with the loss of the love object or with which found a ratio of 8 to 1 for the total popu- the experience of extreme frustration from the lation (Shneidman and Farberow, 1957) and as loved one. The rage against that introjected but high as 50 to 1 and 100 to 1 in adolescents and lost or frustrating person is retroflexed against youth. Halbwachs felt that every person is anx- the self and the acting out of that rage may result ious at the time that he commits suicide and in death or serious injury. may actually be in a state caused by anxiety or Freud was not completely satisfied with his be so emotionally distressed that his state looks theory, because there were many suicides to psychopathological. Every suicide is thus the whom this formulation did not seem to apply. In result of both organic and social factors. 1922, in Beyond the Pleasure Principle, Freud Ruth Cavan (Suicide, 1928; reprint 1965) and developed his more complicated theory in which Louis Israel Dublin and Bessie Bunzel (To Be or suicide became an expression of the death Not to Be, 1933) conducted extensive sociological instinct. Freud postulated two basic instincts in analysis of data on suicide, affirming that the man, the life instinct (Eros) and the death elderly, on the basis of rate, showed the greatest instinct (Thanatos) and saw these in continuous tendency to suicide in comparison to any of the conflict with each other throughout any per- other groups. Dublin and Bunzel also were able son’s life. Under conditions of extreme stress to point out that nationalities in the United and/or emotional distress, regression occurred States frequently showed the same rates as the within the individual, more primitive ego states populations in their respective homelands. emerged, and the potential for self-destructive The most significant development in the early behavior was markedly increased. part of the 20th century in terms of exploring Karl Menninger (1938) extended Freud’s con- and stimulating investigations of cept of the death instinct even further, hypothe- Introduction xxxi sizing three elements that could be found in all that made living impossible—while maintain- self-destructive behavior: (1) the wish to kill, ing the ego, rather than destroying it, by mak- emerging from primary aggressiveness; (2) the ing and carrying out one’s own decision to kill wish to be killed, modified from primary aggres- oneself. sive impulses; and (3) the wish to die, derived Hans W. Gruhle (1940) attributed about 15 to from primary aggressiveness and other sophisti- 20 percent of the suicides to psychosis and felt cated motives. Menninger was the first to cate- that the role of alcoholism was overestimated. gorize and relate to suicide the more indirect Among the factors he listed as most closely forms of self-destruction that did not end in linked to suicide were social factors, such as immediate death but came out in life-threaten- financial distress, increasing population density, ing, life-injurious activities. Some he called job and home, aging, marital status, or childless- “chronic suicide,” such as addictive behavior and ness, and psychiatric factors, such as alcoholism asceticism; some were “focal suicides,” in which or mental illness. Factors that helped prevent the focus is on a part, organ, or system of the suicide included decreasing density of the popu- body, such as in polysurgery or purposive acci- lation, a rural occupation, youth, marriage, chil- dents; and some were “organic suicides,” in dren, and general circumstances in which which parts of the body are used in illnesses emotional stimulation was experienced. against the health and well-being of the person. Serin (1926) initiated a procedure that was Other psychoanalytic formulations appeared the forerunner of the psychological autopsy as some of Freud’s disciples and colleagues broke method, later developed by Theodore Curphey, away and developed their own theories. Alfred , Edwin S. Shneidman, and Adler (1937) related the pathology derived from Robert Litman (1961). Serin sent specially a person’s striving to overcome his innate inferi- trained assistants to obtain information from rel- ority, coming to a loss of self-esteem and then atives, neighbors, and others, to inquire about attempting to hurt others by hurting himself. the lifestyle and attitudes of the suicide in the considered the self-destructive act to days preceding his death. be an effort at rebirth and a way of escaping While the above investigators were evaluating intolerable conditions of the present (Klopfer, deaths by suicide a number of studies were also 1961). focusing on attempted suicides. Among these Henry Stack Sullivan (Green, 1961) postu- Gaupt (1910) analyzed all the cases of attempted lated that the subject evaluates himself in terms suicide brought to a psychiatric clinic in Munich of the reactions of significant others toward during the period of his study and found that one- him. The early integration of hostile appraisals third were “insane,” about one-fourth were of significant others leads to an incorporated drunk, and one-fourth were psychopaths. Stelz- concept of negative self frequently expressed in ner (1906) studied women treated at a psychiatric hostile attitudes toward others. When his situ- clinic in Berlin and found psychiatric symptoms in ation becomes unbearable the individual trans- 84 percent of the cases. East (1913), in the first fers the “bad me” into a “not me” and redirects English study on attempted suicide, found alco- his hostile attitude, which has been toward holism more prevalent and more of a factor in other people, against the self. Karen Horney attempted suicide. He felt this contrasted with (De Rosis, 1961) considered suicide to be a completed suicide where mental illness was more “performance failure” arising from the individ- prevalent. Wassermeyer (1913) found a high ual’s inability to meet the standards expected occurrence of alcoholism in attempted suicides. by society. Gregory Zilboorg (1936) felt that He anticipated Erwin Stengel (1971) in his cau- suicide was a way of paradoxically “living by tions that suicide and attempted suicide could not killing oneself,” of thwarting outside forces be directly compared to each other because of the xxxii The Encyclopedia of Suicide differences in the populations. Schneider (1933 and in 1551, under Spain’s Charles I, the Holy and 1934) found only 12 percent of his attempted Roman emperor Charles V, a law was passed that suicides could be called mentally ill and that sui- confiscated the property, both goods and land, of cide was more likely to be a primitive reaction, an anyone who committed suicide while under a escape, or nonlethal communication. charge of felony. Attempted suicide was identified as a crime Suicide and Civil Law and written into the statutes of English law in 1854. It continued as such until 1961, when the In early history civil and religious law were so law was repealed. Before 1916, imprisonment intertwined that it was practically impossible was the normal punishment for attempted sui- to differentiate between them. This was espe- cide; in 1916, attempted suicides were no longer cially true in , which was the source punished but instead were placed in the charge of increasingly severe attitudes of condemnation of relatives and friends. However, criminal statis- that governed the civil attitudes and were incor- tics show that although the policy of both police porated into civil regulations toward suicides. and courts was lenient, a considerable number Preceding Christianity, in Athenian and Greek of persons were sent to prison for attempted sui- law the body was denied burial rights and the cide. From 1946 to 1955, 5,794 attempted sui- hand of the suicide was chopped off and buried cide cases were tried by the courts and 5,447 separately. Theban law also deprived the suicide were found guilty. Of these, 308 were sentenced of funeral rights. Roman law, on the other hand, to imprisonment without the option of a fine. contained no penalties against suicide and no The practice of forfeiture of the goods of a sui- prohibitions relating to burial and funeral rights. cide to his lord was already known to Danes Roman law, with its practical and economic before they came to England. The fact of suicide approach, condemned suicide especially when was considered equivalent to a confession of guilt committed by criminals, soldiers, and slaves. The for the crime of which he had been accused. In soldier was condemned because it was consid- England, the goods went to the Crown instead of ered desertion, and if he was unsuccessful in his to the local lord. During the 18th century the attempt he was killed afterward. The slave was Crown limited forfeiture of goods, in cases where condemned because he was depriving his master suicide was committed, to conviction of a felony. of his services. Later, even that was waived when the forfeiture In English law the ecclesiastical denial of bur- act was abolished in 1870, giving legal effect to ial rights became a civil punishment when it was an already established practice. adopted by King Edgar in A.D. 967. Along with British jurist William Blackstone (1723–80) this the custom of dishonoring and degrading declared the suicide to be guilty of a double the corpse became incorporated as part of the offense—the first was spiritual in evading the law and the suicide’s goods were forfeited to his prerogative of the Almighty and rushing into his lord unless it was the result of an act of madness presence before called for, and the second was or illness. temporal and against the king who had an inter- Suicide in the middle of the 13th century was est in the preservation of all of his subjects. punished by forfeiture of goods and land unless, In France, the corpse of the suicide victim was as stated by English juridical writer Henry de subjected to the same kind of degradation as in Bracton (Samuel E. Thorne, 1968), the suicide England. The French criminal ordinance of resulted from “weariness of life or impatience of August 1670 required the body of a suicide to be pain,” which then limited the loss to goods only. dragged through the streets and then thrown In the 14th century it was declared that the into a sewer or onto the town dump. In the early intentional taking of one’s own life was a felony, 18th century the law required that the body of a Introduction xxxiii person who committed suicide be buried under However, this usually results only in registration the gallows. The attitude toward suicide fluctu- of suicide attempts. Registration of attempted ated along with French politics. Suicides and the suicide has been abolished in other European survivors of successful suicides were punished countries such as Germany, Italy, Switzerland, when the liberal legislation of the Napoleonic and the Scandinavian countries. code was overthrown. When liberty and democ- In the United States, following English law, ratic government reappeared the rights of the Massachusetts passed a status in 1660 that the suicide also reappeared and were respected. body of a suicide was to be buried at the cross- In many countries, the imposition of penalties roads of a highway. Again following English law, varied according to the social rank of the suicide this was repealed in 1823. The view that suicide victim and his family, as well as the circum- was a felony was also incorporated into the laws stances of the suicidal act. Physical illness and of the individual states. As recently as 1969, mental and emotional disease were not pun- seven U.S. states still had suicide as a crime on ished in Prussia while poverty, dishonor, despair, their books, but currently there is no state that and debt were. considers suicide or suicide attempts a crime. In many middle European countries, secular Physician-assisted suicide is legal in only one law continues to hold attempted suicide a crime. state ().

ENTRIES A–Z

A

abuse, alcohol See ABUSE, SUBSTANCE. Only 1.1 percent of adults who reported no negative childhood experiences attempted sui- cide, whereas 35 percent of adults who reported abuse, child Adults who suffered abuse dur- seven or more negative childhood experiences ing their childhood are more likely than their had tried to kill themselves. peers to attempt suicide decades later, according Experts believe that early exposure to child to federal health officials. Researchers found that abuse may disrupt the proper development of individuals with at least one type of harmful communication pathways within the brain, childhood experience were two to five times affecting subsequent mental health. Children of more likely to attempt suicide. abusive parents generally do not completely For example, those who reported being emo- understand the problems that cause such con- tionally abused as a child were five times more duct, and are confused about their responsibility likely to report a suicide attempt. People who for their parents’ behavior. As a result, children experience several traumatic events may be 30 subjected to mental, emotional, or physical to 50 times as likely to attempt suicide at some abuse run a high risk of developing a variety of point in their life (either in childhood or adult- problems later in life. hood) as those with a more carefree past. Indeed, researchers discovered that adverse childhood experiences have serious long-term abuse, drug See DRUG ABUSE. consequences, such as suicide attempts. In one recent study, researchers evaluated abuse, substance Substance abuse is fre- more than 17,000 healthy adults who visited a quently associated with suicide, and anyone primary care clinic in between 1995 who abuses drugs or alcohol could be at risk. For and 1997. The adults were asked to report instance, high school students who view them- whether they had experienced eight various selves negatively, who are depressed, or who harmful experiences as a child, including sexual, find little meaning in their lives are more likely emotional, or physical abuse, parental separa- to consider suicide and to abuse drugs. Almost tion or divorce, witnessing domestic violence, half of the teenagers who complete suicide are and living with family members who were sub- under the influence of drugs or alcohol shortly stance abusers, mentally ill, or criminals. before their death; that figure soars to 75 percent The investigators found that 3.8 percent of of those teens who attempt suicide unsuccess- the adults reported they had attempted suicide fully. at some point in their lives, with women three While no cause-and-effect relationship times more likely than men to attempt suicide. between the use of alcohol or other substances Two-thirds of the adults who had attempted sui- has been established in research to date, the use cide had experienced at least one of the negative of such substances often is a contributing factor, experiences during childhood. and the research does indicate several possible

1 2 Academy of Certified Social Workers explanations. First, substance abuse may lessen accredited by the Council on Educa- inhibitions and impair the judgment of someone tion, and have accumulated at least two full- contemplating suicide, making the act of suicide time years (or 3,000 hours) of postgraduate more likely. Second, the use of substances by social work experience. An exam is also given to family members or the individual may aggravate determine certification. other risk factors for suicide, such as depression For address, see Appendix I. or other mental illnesses. Indeed, those who abuse drugs or alcohol often do so as a result of accident prone Authorities speculate that underlying feelings of hopelessness, anxiety, or many “accident-prone” individuals are actually depression. If substance abuse fails to relieve the suicide attempters. For example, fatal auto acci- negative , the abuser may turn to sui- dents account for about 37 percent of all deaths cide as a way to “fix” the problem. in the 15- to 24-year-old group. Some of these Among the , sub- crashes may be suicides listed as accidents, espe- stance abuse is second only to depression as a cially single-passenger, single-car accidents. distress signal. Forensic experts speculate that an estimated 25 Experts note that even if suicidal thoughts percent of these “accidents” are deliberate. In never occur to the substance abuser, that person addition, “accidental” poisonings are sometimes is committing suicide just as surely as the indi- suicide attempts in reality. However, the concept vidual who puts a gun to his head. “Chronic suicides” are those people who say of death is known to be very different for the they do not want to kill themselves, but because five-year-old and the 14-year-old. of crippling feelings of dejection and worthless- See also AUTOCIDE. ness, they opt to kill themselves indirectly and slowly. Accutane and suicide The acne medication Between 31 percent and 75 percent of heavy isotretinoin (Accutane) has been linked to a pos- substance abusers have had suicidal thoughts, sible increased risk of suicide in a few patients and are four times more likely to complete sui- taking the drug. Some reports noted the appear- cide. Among all those who complete suicide, 70 ance of depression following Accutane use, percent have used drugs frequently, 50 percent including some cases in which symptoms had alcohol in their blood, and 75 percent fit the resolved and then re-emerged when the medica- criteria for drug or alcohol use disorder. tion was stopped and restarted. See also DRUG ABUSE. However, neither the government nor the manufacturer has found proof of a solid link Academy of Certified Social Workers A between the drug and suicide or depression. In professional association of health care workers response to fears about a possible relationship who hold a minimum of a baccalaureate degree between Accutane and suicide, researchers in in social work. The ACSW was established in Great Britain and Canada studied the drug’s risk 1960 by the National Association of Social Work- of suicide in comparison with antibiotics. In the ers to provide certification of competence by study, 7,195 patients taking Accutane were com- social workers. A social worker applies for mem- pared to a control group of 13,700 acne patients bership in ACSW to support high standards of who were treated with antibiotics. All were fol- social work and to demonstrate commitment to lowed for at least 12 months after stopping their ethical and competent practice. Potential mem- medication. Neither the British nor Canadian bers must also belong to the National Associa- groups found any differences between subjects tion of Social Workers; must have a master’s treated with Accutane or antibiotics, and there degree from a graduate school of social work were no differences between either groups in adoption 3 terms of suicide. A separate study actually found seems to happen—if not today, then some other a reduction in anxiety and depression in patients day. with severe acne who had used Accutane. See also CHRONIC SUICIDES. Despite the fact that thousands of patients take Accutane without experiencing depression adolescent suicide See TEENAGE SUICIDE. or suicide, the U.S. Food and Drug Administra- tion (FDA) required a new warning label about suicide, depression, and psychosis, after accumu- adoption Although most adopted teenagers lating more than a dozen reports linking recur- do not try to kill themselves, studies do suggest rence of psychiatric symptoms with restarting of that adopted teenagers are at higher risk for medication. This was in addition to 12 reports attempted suicide than their peers who live with since 1989 of patients on the medication who their biological parents. completed suicide. In one Ohio study, almost 8 percent of the Many suicide experts believe that any link adopted teens reported suicide attempts within between Accutane and suicide is related to the the previous year compared with only 3 percent fact that teens, the largest age group using the of nonadopted teens. Researchers from the Uni- drug, have a higher incidence of depression than versity of Cincinnati Medical Center in Cincin- most—especially those teens with severe, recal- nati, Ohio, used data from a national survey of citrant acne for which Accutane is indicated. In adolescent health to identify 214 adopted and this case, experts say, the suicides were probably 6,363 nonadopted teens. The teens completed caused by reaction to the underlying skin disease questionnaires and interviews at home and in for which the drug is taken—not by the drug school, and the parents of the teens were asked itself. to complete separate questionnaires. Teens were The revised FDA label warns of the serious- asked questions about their general and emo- ness and persistence of depression and of the tional health, including questions about self- possible occurrence of suicide. It warns that dis- image, depressive symptoms, and whether they continuing Accutane might not be enough to had attempted suicide during the past year. stop the symptoms and that further evaluation Teens also revealed whether they smoked, drank and treatment may be necessary. alcohol, used drugs, or had sex. The survey also asked teens to answer questions about their school performance, and both teens and parents acting out Term used by professionals to were asked to respond to questions about family describe the use of behavior instead of words to relationships. express emotional conflicts. Attempters may “act In the Ohio study, teens who attempted sui- out” and show aggressive, hostile, defiant behav- cide were more likely to be girls, and were more ior. Others exhibit passive patterns that include than four times as likely as teens who didn’t withdrawal, melancholy, and uncommunicative attempt suicide to have received mental health behavior. Sometimes attempters will switch counseling in the past year. In addition, teens from wild, impulsive, loud behavior to quiet, who attempted suicide were more likely to gloomy, uncommunicative demeanor. Some sui- report risky behaviors, including using ciga- cidal people are hyperactive, while others seem rettes, alcohol, and marijuana, to have had sex, depressed. and to be aggressive and impulsive. See also DISTRESS SIGNALS. In addition to adoption, depression, recent mental health counseling, female gender, ciga- acute suicides Suicidal cases with a triggering rette use, delinquency, low self-image, and ag- factor as opposed to those where suicide just gression were all factors that increased a teen’s 4 adults and suicide likelihood of attempting suicide. Teens who per- Africa It is very difficult to generate an overall ceived themselves as highly connected to their suicide rate for the entire continent of Africa. families were less likely to have attempted sui- With so many different nations representing cide regardless of whether they were adopted or such varied cultures and subcultures, compara- not. bility of even regional suicide rates in Africa are questionable. An overview of suicide, however, makes it clear that the rate of suicide is in direct adults and suicide Risk factors for suicide rise relationship with changes in social controls and as adults age from 30 to 65, although the biggest different emphasis on the value of the individual spike is among elderly adults over age 65. In in comparison with the state. Where control is men between ages 25 and 64, 23.6 per 100,000 greatest, the suicide rate is lower; where individ- complete suicide, whereas women do so at a rate uals are more free, the rate is higher. of 6.0 per 100,000. Anthropological studies among African tribes Many adults cannot negotiate the adjust- reveal that the frequency of suicide was compa- ments necessary in midlife, such as dealing with rable with that of European countries having unfulfilled dreams and plans from youth, coping moderate to low suicide rates, and that suicide with the aging process, reaching a job plateau, among them was considered evil. In certain facing divorce, or experiencing unresolved deve- tribes, physical contact with the body of a per- lopmental issues. Suicides by women are highest son who has committed suicide is thought to in this age group, partially due to mothering and trigger illness or suicide among relatives. The nurturing disconnections, such as children leav- tree on which a person hanged himself is ing home and menopause. quickly felled or burned; ancestors are placated Male executives and midlife males in crisis or by sacrifices; and the spot where the suicide burnout are also more likely to commit suicide, took place is believed to be haunted by evil spir- as well as middle-aged alcoholics or drug its. In some regions, suicide is a source of dread abusers, and those who may be acutely de- in the community. pressed or mentally ill. Often the warning signs In one primitive tribe described by BRONISLAW for these adults are not noticeable, since they are MALINOWSKI in “Suicide: A Chapter in Compara- not in institutions or schools where they would tive Ethics,” an individual accused of a trans- be easily observed. gression of a tribal taboo would climb to the top of a palm tree, declare his hurt at the charge, Treatment name his accuser, and then plunge head first to Interventions for midlife adults primarily focus his death. on treatment for specific disorders (especially Without doubt, attitudes toward suicide in depression). A combination of antidepressants Africa, as elsewhere in the world, differ among and supportive can often lessen various tribal societies and countries, and were the suicide risk for these adults. Substance abuse irrevocably tied to ideologies concerning death treatment is also a very important component of and afterlife, as well as the values and/or rules of treatment. In addition, adults must receive sup- the different social structures. port in negotiating life stages, and clear up any developmental issues that may block progress. Resolving financial and job worries and marital African Americans and suicide Historically, difficulties through counseling can also help pre- African Americans have had much lower rates of vent adult suicides. suicides compared to white Americans. How- See also CHILDREN AND SUICIDE; ELDER SUICIDE; ever, beginning in the 1980s, the suicide rate for TEENAGE SUICIDE. African-American boys began to rise at a much aggression 5 faster rate than their white contemporaries. nancy are higher. In addition, the exposure of From 1980 to 1995, suicidal behavior among black youths to poverty, poor educational oppor- both black and white boys increased dramati- tunities, and discrimination may have negatively cally—but especially among blacks, as the gap influenced their expectations about the future between rates for black and white boys nar- and, consequently, enhanced their tendency to rowed. consider suicide. Scientists from the Centers for Disease Con- Scientists predicted as long ago as the 1930s trol and Prevention in Atlanta say that from that the rate of suicide among African Ameri- 1980 to 1995, the suicide rate for blacks between cans was going to rise as they moved into the 10 and 19 jumped 114 percent, from 2.1 to 4.5 white American culture. Children of upwardly per 100,000 people. The scientists say a total of mobile black families may feel as if they are 3,030 black youths killed themselves in that trapped between the poor black community and period. The rates of suicide among black chil- the middle class, and that they are not accepted dren, between the ages of 10 and 14, skyrock- by either. This type of social limbo, experts sus- eted by 233 percent, compared to whites of the pect, may be in part a cause of the rising suicide same age group, whose rate of suicide increased rate. about 126 percent. The biggest jump was among young black men living in the South. age-adjusted suicide rates The practice of However, suicide rates for both black and weighting suicide rates by a population standard white girls are much lower and have decreased to allow for comparisons across time and among or remained the same over the period. risk groups. The U.S. 1999 mortality data is cal- While in 1980 the suicide rate among white culated using figures from the 2000 census, youths was 157 percent higher than the rate whereas previous years have been calculated among black youths, by 1995 the suicide rate using 1940 census data. For this reason, compar- among white youths was only 42 percent higher isons between 1999 and earlier U.S. mortality than the rate among black youths. data should be made carefully. Moreover, the peak age for suicide in African- American men continues to be in the 20s, while age and suicide While there is a common for white men the risk of suicide rises each that suicide rates are highest among year beyond the 20s. Firearm-related suicides the young, in fact it is the elderly (particularly accounted for 96 percent of the increase in the older white men) who have the highest suicide suicide rate among black children and teens, rate. Among white men 65 and older, risk goes with the largest percentage increase in the sui- up with age; white men 85 and older have a sui- cide rate among black teens recorded in the cide rate that is six times that of the overall South, followed by the Midwest. national rate. Experts believe the increasing suicide rate See also CHILDREN AND SUICIDE; ELDER SUICIDE; among all youths include the breakdown of the TEENAGE SUICIDE. family, easier access to alcohol and illicit drugs, and easier access to lethal . Experts believe that loss of a loved one and agenerative suicide Suicide triggered by per- weakening family and community ties are con- sonal alienation. tributing factors in black suicide. The situations for black youth continues to aggression Aggressive behavior toward others grow worse judged by factors correlated with is often evident in suicidal behavior, especially in suicide rates. Thus, rates of unemployment, a homicide followed by suicide, and in the sig- delinquency, substance abuse, and teenage preg- nificant incidence of suicide among prisoners 6 aggressive behavior who committed violent crimes. In these cases, represents a suicide rate among male Albanians the suicide appears to be directed at other, sig- of 6.3 per 100,000, and a rate among Albanian nificant persons the victim has known. women of 3.6. aggressive behavior Forceful physical, ver- alcoholism and suicide Although many cases bal, or symbolic behavior is recognized as a gen- of suicide occur as a result of alcoholism, the vast eral distress signal that, along with other cues, majority of alcoholics do not take their own may predict suicidal behavior. In some cases, sui- lives. Alcoholism is a factor in about 30 percent cidal adolescents show wildly hostile behavior, of all completed suicides, and approximately 7 such as threatening a teacher with a knife, ter- percent of those with alcohol dependence will rorizing brothers or sisters, stealing a neighbor’s die by suicide. About half of all people who kill car and narrowly missing smaller children at themselves were intoxicated at the time. play, running away from home, and even dis- Alcoholics kill themselves in reaction to playing serious violence against parents. events in their environment: Of the alcoholics Teenagers who fit the aggressive pattern often who complete suicide, one-third experience the abuse alcohol and drugs. Psychiatrists believe loss of a close relationship within the prior six wild behavior is sometimes a coverup to mask weeks, and one-third expect to sustain an the suicidal person’s painful, depressive feelings. equally severe interpersonal loss. Seven risk factors commonly predict suicide agitation Extreme restlessness common in among alcoholics: individuals during a suicidal crisis. See also AKATHISIA. • continued substance abuse right up to the end of their lives Ahitophel The Old Testament counselor to • communicating suicidal thoughts to others, King David, who supported Absalom in his often over a long period of time revolt against the king. When Ahitophel realized • major depression that Absalom would be defeated, “he saddled his • no spouse, family, or friends offering social ass, and went off home to his own city. And he support set his house in order and hanged himself.” • unemployment This ALTRUISTIC SUICIDE is an example of sui- cide as a means of escaping political or military • serious medical problems defeat, a common occurrence within select soci- • living alone. eties and at certain periods of history. See also MASADA. While each of these seven risk factors is impor- tant, they are also cumulative; that is, the more factors an alcoholic has, the greater the suicide Extreme restlessness and agitation akathisia risk. An alcoholic with at least three risk factors that occurs as an adverse effect of some psy- is considered to be highly at risk for suicide. Of chotropic medications. Akathisia has been impli- all seven risk factors, continued drinking (found cated in suicidal thoughts and behavior of some in 95 percent of alcoholic suicides) is the most patients taking these medications. important risk factor, driving all the others. While alcohol reduces tension and anxiety, it Albania According to statistics from the World also dulls the senses, reduces inhibitions, and Health Organization, the suicide rate of Albania clouds judgment. As the alcoholic drinks more, in 1998 was a fairly low 4.95 per 100,000. This the person’s physiological problems worsen. alcoholism and suicide 7

Appetite and energy levels decline; sleep often Serotonin and Suicide becomes restless and troubled. Insomnia follows. Scientists studying suicide have also discovered a Then irritability and depression increase, height- link between alcoholics and low levels of a brain ening the desire to drink more. Consciously or chemical called serotonin. Serotonin is a neuro- unconsciously, the alcohol abuser seeks relief transmitter important in the experience of emo- from depression and irritability through alcohol. tion; in low levels, it has been linked to Indeed, the urge to drink is so strong that 96 per- depression. Recent studies also reveal that al- cent of alcoholics who commit suicide continue coholics also have a lower number of serotonin their substance abuse up to the end of their lives. receptors in the brain. Experts aren’t sure Because alcoholism often causes deep feelings of whether the shortage is genetic or developmen- remorse during dry periods, alcoholics are sui- tal and so help predispose someone to alco- cide-prone even when sober. holism—or it may just be another of alcohol’s A number of recent national surveys have many toxic effects. Whatever the cause, it seems helped shed light on the relationship between that alcoholics lack the ability to compensate for alcohol and other drug use and suicidal behavior. weak serotonin signals, which could help ex- A review of minimum-age drinking laws and sui- plain why suicide rates in this group are aston- cides among youths age 18 to 20 found that lower ishingly high. minimum-age drinking laws were associated with higher rates. In a large study fol- Alcoholics at Risk lowing adults who drink alcohol, suicide thoughts Federal studies of alcoholics who attempt sui- were reported among persons with depression. In cide have found that attempters have more another survey, persons who reported that they mental health problems than alcoholics who do had made a suicide attempt during their lifetime not try to commit suicide. There were signifi- were more likely to have had a depressive disor- cantly higher rates of psychiatric disorders der, and many also had an alcohol and/or sub- among alcoholic suicide attempters as com- stance abuse disorder. In a study of all nontraffic pared to non-attempters. Major depression, injury deaths associated with alcohol intoxication, drug abuse, antisocial personality, panic disor- more than 20 percent were suicides. der, generalized anxiety disorder, and phobias In studies that examine risk factors among were about twice as likely to be found among people who have completed suicide, substance alcoholic attempters. In addition, alcoholic use and abuse occurs more frequently among attempters were more likely to have multiple youth and adults, compared to older persons. psychiatric disorders; 66 percent of attempters For particular groups at risk, such as American had two or more of these diagnoses, as com- Indians and Alaskan Natives, depression and pared to 29 percent of alcoholics who did not alcohol use and abuse are the most common risk attempt suicide. factors for completed suicide. Alcoholic suicide attempters also tend to be Alcohol and substance abuse problems con- more hostile, more fearful, more impulsive, tribute to suicidal behavior in several ways. Per- and deviant. These findings suggest that alco- sons who are dependent on substances often holic suicide attempters experience a combina- have a number of other risk factors for suicide. tion of mental problems and a lack of restraint In addition to being depressed, they are also over their behavior that may lead to destructive likely to have social and financial problems. Sub- behavior toward themselves and others. stance use and abuse can be common among It did not appear that a family history of alco- persons prone to be impulsive, and among per- holism had much effect on whether or not an sons who engage in many types of high-risk alcoholic tried to commit suicide, but suicide behaviors that result in self-harm. attempters did report more episodes of drunken- 8 alcohol myopia ness before age 15. Attempters also reported a alcohol myopia A theory in which many of significantly higher rate of receiving counseling alcohol’s social and stress-reducing effects are for alcoholism. explained as a consequence of alcohol’s nar- Alcoholic suicide attempters were more likely rowing of perceptual and thought functions. to be divorced, separated, or widowed, and less This effect on a person’s thought processes likely to be married; they also were more likely may be associated with a propensity to com- to be unemployed and have lower levels of plete suicide. income. Basically, alcohol myopia occurs when people There were no differences between the two are intoxicated and cannot absorb as much groups with regard to racial or ethnic status, information from the social context as they can age, the level of education, or intellectual when sober. The information they use to guide performance. their responses is increasingly limited in propor- A combination of violence and depression is tion to the amount of alcohol consumed. a warning sign of potential suicide among As inebriation increases, they begin to focus alcoholics. Furthermore, a person who has on small parts of the situation, one at a time, attempted suicide in the past is more likely to try because the ability to perceive the situation as a again. whole is impaired. This results in unstable, fluc- tuating and reactions, depending on Treatment which narrow aspect of the surroundings they Fortunately, there are a number of effective pre- are paying attention to. This is why there is an vention efforts that reduce risk for substance increased risk of misunderstandings and misin- abuse in youth, and there are effective treat- terpretations when someone is drunk, which ments for alcohol and substance use problems. can in some contexts lead to aggressive Researchers are currently testing treatments responses or suicide attempts. specifically for persons with substance abuse problems who are also suicidal, or who have alliance for safety A joint plan between clin- attempted suicide in the past. Treatment pro- ician and client with the shared goal of prevent- grams for alcoholics that include measures ing a suicide. aimed at preventing suicides would probably reduce the suicide rate. altruistic suicide Suicide as self-sacrifice, as a Depression, found in nearly three-quarters result of social bonds that are too strong or of alcoholics who commit suicide, is highly smothering. Altruistic suicide can also be consid- treatable with antidepressants and cognitive be- ered as an act of duty when individuals feel they havioral therapy. Sobriety, social support, med- are a burden on society at large or when they ication, and psychotherapy can reduce suicides cannot cope with the demands of a society. Self- among alcoholics. sacrifice is the defining trait, where individuals Alcoholic clients who shows signs of suicidal are so integrated into social groups that they lose tendencies benefit from extra time and care dur- sight of their individuality and become willing to ing sessions, and longer follow-up care or sacrifice themselves to the group’s interests, booster sessions to help decrease the risk of sui- even if that sacrifice is their own life. The most cide or suicide attempts. Counseling sessions common cases of altruistic suicide occur among should be doubled or tripled for those clients at members of the military. high risk for suicide to enable clients to work on “Altruistic suicide” was the idea of sociologist self-control strategies and more constructive ÉMILE DURKHEIM, who wrote in Le Suicide that coping strategies. suicide was more understandable when consid- American Association of Suicidology 9 ered as a reaction to society. He believed that American Association of Suicidology (AAS) self-destruction could be traced to the social con- A nonprofit organization whose goal is to under- ditions of the suicide attempter. stand and prevent suicide. Founded in 1968 by Durkheim, whose work is still widely quoted Edwin S. Shneidman, PhD, AAS promotes as a landmark of sociological research in suicide, research, and offers public awareness programs, believed there were four types of suicide: egois- and training for professionals and volunteers. In tic, anomic, altruistic, and fatalistic. addition, the association serves as a national See also ANOMIC SUICIDE; EGOISTIC SUICIDE. clearinghouse for information on suicide. Members include mental health professionals, Alvarez, Alfred (1929– ) English writer researchers, suicide prevention and crisis inter- and critic who wrote THE SAVAGE GOD: A STUDY OF vention centers, school districts, crisis center vol- SUICIDE, in which Alvarez dispels the notion held unteers, survivors of suicide, and others who by many people that suicide is either a terrifying have an interest in suicide prevention. aberration or something to be ignored alto- A primary objective of AAS is to help suicide gether. He documents and explores man’s and crisis intervention centers throughout the changing attitudes toward suicide, from primi- United States and Canada provide quality ser- tive societies through the Greek and Roman cul- vices. The AAS has developed standards for cer- tures and the suicidal martyrdom of the early tification of these centers that are described in Christian church, to the attitude of the late 19th the AAS Certification Standards Manual for Cri- century and the gradual shift in the responsibil- sis Intervention Programs. ity of suicide from the individual society. The AAS, publishes quarterly a journal, Sui- In his book, Alvarez discusses various theories cide and Life-Threatening Behavior, and Newslink, a of suicide, and explores the minds and emo- quarterly newsletter. In addition, AAS produces tional states of Dante, Cowper, Donne, and oth- a number of suicide prevention pamphlets for ers. The author includes a personal memoir of the public as well as a Directory of Suicide Preven- the young American poet SYLVIA PLATH and dis- tion and Crisis Intervention Agencies in the U.S. cusses why she, and so many artists in the 20th The AAS holds an annual conference every century, chose to commit suicide. From there, spring; state and regional groups affiliated with the author enters into the closed world of the the AAS conduct periodic meetings and work- suicidal person, providing readers with his own shops. personal view of suicide, and chronicles with AAS also produced public service announce- startling candor his attempt on his own life. ments and releases on suicide prevention. Involvement in suicide prevention legislative ambivalence The coexistence of opposing efforts also is a priority of AAS. Members often feelings such as love and hate, respect and con- consult on potential or pending legislation at tempt, or sadness and joy, toward the same per- both the federal and state levels; many have pro- son or thing. It is perhaps the single most vided expert testimony for congressional com- important psychological concept in the under- mittees and subcommittees. standing of suicide. Ambivalence can be seen in The AAS presents yearly awards to outstand- the person who wants to commit suicide but ing contributors in the field of suicidology. The doesn’t want to, who simultaneously wishes to group assists and encourages survivor activities die even while fantasizing rescue. The ambiva- by maintaining information on survivor groups lence is so strong that often suicide victims and lists of books, films, newsletters, and pam- have been found dead, the telephone clutched in phlets that focus on survivor concerns. their hand. For contact information, see Appendix I. 10 American Foundation for Suicide Prevention, The

American Foundation for Suicide Prevention, sors a special committee to study suicide. The The A nonprofit group dedicated to advancing AMA also provides advisory, interpretative, and the understanding of suicide and how to prevent referral information on medicine, health care, it. The foundation’s activities include research and science. Statistics, clipping services, bro- support, providing information about depression chures/pamphlets, library searches, placement and suicide, educating professionals about sui- on mailing lists, and a newsletter are available cide, and publicizing the magnitude of the prob- through the AMA, and they also will supply a lems of depression and suicide and the need for publications list. AMA publishes the prestigious research, prevention, and treatment. The group Journal of the American Medical Association also supports programs for treat- (JAMA). ment, research, and education, and maintains For contact information, see Appendix I. local chapters throughout the world. The foundation was begun in 1987 by a group American Psychiatric Association The pro- of suicide experts together with business and fessional medical society that represents U.S. community leaders and survivors of suicide. The and Canadian psychiatrists. The association’s early members believed only a combined effort goals are to improve treatment, rehabilitation, would make it possible to fund the research nec- and care of the mentally ill, to promote essary for progress in the prevention of suicide. research, to advance standards of all psychiatric Since then, the foundation’s institutional grants services and facilities, and to educate other helped begin important centers for suicide medical professionals and scientists as well as research at major medical centers throughout the general public. The association provides the country, such as Columbia, Einstein, Har- advisory, analytical, bibliographical, historical, vard, Western Psychiatric in Pittsburgh, the Uni- how-to, interpretative, referral, and technical versity of Texas Medical Branch at Galveston, information on psychiatric care, psychiatric and Emory University. insurance, and mental illness. Publications The group also holds educational conferences include advance and post-convention articles and offers postdoctoral fellowships and young and news releases each May concerning annual investigator awards for young scientists inter- meetings and scientific proceedings; more than ested in suicide research. The foundation also 400 individual papers on a wide range of topics, supports workshops for survivor group leaders, including suicide, are available each year. Also, conferences on survivor problems, regional sur- periodic news releases are furnished throughout vivor group directories, and maintains a special the year concerning new studies published in 800 number for referrals to these groups. The the APA journals. group also maintains a relationship with more For contact information, see Appendix I. than 300 “survivors of suicide” groups around the country. American Psychological Association (APA) In addition, AFSP’s National Suicide Data Bank Based in Washington, D.C., the APA is a scien- is accumulating information about completed sui- tific and professional organization that repre- cide that has been heretofore unavailable. sents psychology in the United States. With For contact information, see Appendix I. more than 155,000 members, the APA is the largest association of worldwide. American Indians See NATIVE AMERICANS. Psychology is the study of the mind and behavior. The discipline embraces all aspects of American Medical Association (AMA) This the human experience, from the functions of the organization of physicians and surgeons spon- brain to the actions of nations, from child devel- anomic suicide 11 opment to care for the aged. In every conceiv- anniversary trigger The idea that people tend able setting from scientific research centers to to die (or commit suicide) near key dates in their mental health care services, the understanding lives. of behavior is the enterprise of psychologists. For contact information, see Appendix I. anomic suicide Suicide triggered by a dis- rupted relationship or insufficient regulation in amputation metaphor An analogy in loss society (anomie means “lawlessness”). The term commonly used by grieving parents who describes one of the four types of suicide as out- describe the loss of a child in ways similar to loss lined by sociologist ÉMILE DURKHEIM. (The others of a limb. are egoistic, altruistic, and fatalistic suicides.) A society is regulated to the extent that it con- Anatomy of Melancholy, The The first major trols the motivations of its members. When a text in the history of Western cognitive science society undergoes rapid changes and regulations written by ROBERT BURTON (1577–1640), pro- are in a state of flux, an individual may be vides the first modern interpretation of suicide. unable to adjust to the lack of definitive rules or At the time Burton was writing, early 17th-cen- customs. Psychologically, the individual may no tury physicians were relying on the authority of longer be able to adjust, or to feel that he or she the great Greek and Arabian physicians such as belongs to a group. An example of such a situa- Galen and Hippocrates. Because there was no tion might be a long-term employee who sud- new scientific knowledge on which to generalize denly loses a job, or a man whose wife dies after about suicide and psychology, Burton focused on 45 years of marriage. all previous thinkers about cognition. Burton Anomic suicide was of particular interest to assimilated these previous thinkers to produce a Durkheim, and he divided it further into four model of human consciousness brought together categories: acute and chronic economic anomie, by a set of conceptual divisions of the human and acute and chronic domestic anomie. Each psyche and body. involved an imbalance of means and needs, in One of the major documents of modern Euro- which a person’s means were unable to fulfill pean civilization, Burton’s astounding com- needs. pendium surveys melancholy in all its forms. In suicide due to acute economic anomie, Lewellyn Powys called it “the greatest work of there are sporadic decreases in the ability of tra- prose of the greatest period of English prose- ditional institutions such as religion or social sys- writing,” while celebrated surgeon William Osler tems to regulate and fulfill social needs. believed it was the greatest of medical treatises. Suicide linked to chronic economic anomie involves a long-term relaxation of social regula- anniversaries Survivors of suicide often find tion. Durkheim identified this type of suicide that each year, on the anniversary of the suicide, with the ongoing industrial revolution, which they experience renewed grief, anger, anxiety, eroded traditional social regulators and often loneliness, and depression. As with a loss by failed to replace them. Industrial goals of “natural” death, a process is started within the wealth and property were not enough to pro- survivor’s psyche that psychiatrists call the “an- vide happiness, as was demonstrated by higher niversary reaction.” Psychiatrists and other coun- suicide rates among the wealthy than among selors suggest these emotions be discussed by the poor. survivors with qualified clinicians who can assist Suicide caused by acute domestic anomie them in working through their traumatic loss. involves sudden changes in interpersonal rela- Otherwise, the pain can be needlessly prolonged. tionships, leading to an inability to adapt—and 12 anorexia nervosa therefore higher suicide rates. Widowhood is a clear cause-and-effect evidence to support this. prime example of this type of anomie. While the data are preliminary, scientists Suicide due to chronic domestic anomie refers believe the link could be real, since depression or to the way marriage as an institution regulated related illness is often seen in people who com- the sexual and behavioral means-needs balance mit suicide. Changes in unemployment did not among men and women. Bachelors tended to appear to explain the altered suicide rates. Sui- commit suicide at higher rates than married men cide took 30,575 American lives in 1998, for an because of a lack of regulation and established age-adjusted rate of 10.43 per 100,000 popula- goals and expectations. On the other hand, mar- tion, down from 11.11 in 1995, according to fed- riage has traditionally served to constrict the eral data. lives of women by further limiting their already See also PROZAC AND SUICIDE. diminished opportunities and goals. Unmarried women, therefore, do not experience chronic Antisthenes (440–ca. 360 B.C.) Greek phi- domestic anomie nearly as often as do unmar- losopher who founded the Cynic School of ried men. Philosophers at ; he advocated a simple, See also ALTRUISTIC SUICIDE; EGOISTIC SUICIDE. austere life. After the death of his beloved teacher, SOCRATES, in 339 B.C., Antisthenes anorexia nervosa A disorder characterized by established a school called Cynosarges—hence severe and prolonged refusal to eat, resulting in his followers bore the name “Cynics”—although major weight loss and physical debilitation. It is others argue that his followers were called Cyn- usually associated with an intense fear of ics because of the gloomy habits of the school. becoming obese and is most frequently found in Indeed, the older Antisthenes got, the gloomier girls and young women. Bulimia is often associ- he became, until he was a worry to his friends ated with this condition. Experts believe most and the object of ridicule to his enemies. He individuals with anorexia nervosa are poten- taught that pleasure and desire were evil, and so tially suicidal. In essence, they are literally starv- he wore only a coarse cloak, did not cut his ing themselves to the point of self-destruction. beard, and carried a sack and staff like a wan- People with anorexia tend to suffer with a pro- dering beggar. This was meant to express his found sense of inadequacy, low self-esteem, and opposition to the increasing luxury of the age in self-hatred. This malady affects teenage females favor of simplicity in life and manners. Indeed, for the most part (an estimated one-half million Antisthenes appears to have been carried to in the United States alone); 15 percent of those excess in his virtuous zeal against luxury. with severe cases of anorexia nervosa die. In one story, perhaps tired of his continual gloom, his friend DIOGENES offered Antisthenes a antidepressants A major classification of dagger, saying: “Perhaps you have need of this, drugs developed to improve mood medically in friend?” Antisthenes replied, “I thank you, but severely depressed patients. unfortunately, the will to live is part of the world’s evil, as it is part of our nature.” antidepressants and suicide Increased use of antidepressants are linked to a decreasing U.S. Antisuicide Bureau The first crisis center suicide rate, according to at least one study. established by the SALVATION ARMY in 1906. From 1995 to 1998, prescriptions for newer anti- depressants such as Prozac rose 41 percent, Antony, Mark (Marcus Antonius) (ca. 83 while the age-adjusted national suicide rate B.C.–30 B.C.) Roman statesman and soldier dipped about 6 percent. However, there is no who served under Julius Caesar in . After Aristotle 13

Caesar’s assassination in 44 B.C., Antony met In Summa theologica, St. Thomas formulated and fell in love with CLEOPATRA. Ignoring his sec- the authoritative church position on suicide, ond wife, Octavia, he settled in Alexandria and writing that suicide was absolutely wrong and ruled from there in a luxurious court until Octa- unnatural. He believed that every man was a vian, his wife’s brother, deprived him of power. member of some community, and suicide was In the ensuing civil war, Octavian’s forces tri- therefore antisocial. Since life was a gift of God, umphed at Actium in 31 B.C., and Antony fled to he reasoned, it was not up to man to throw that Alexandria, where he and Cleopatra committed gift away. For St. Thomas, all life was merely suicide upon his brother-in-law’s approach. preparation for the eternal. He stressed the See also ALTRUISTIC SUICIDE. sacredness of human life and absolute submis- sion to God. St. Thomas was one of the greatest anxious suicidality The combination of suici- and most influential theologians of all time. dal thoughts and severe anxiety in children. He was canonized in 1323 and declared Doc- tor of the Church by Pope Pius V.

Apaches, White Mountain Suicide and Argentina Suicide in Argentina has slowly de- homicide among the White Mountain Apaches creased from a 1960s rate of 10 per 100,000 to (who live on a reservation in the central moun- 6.4 per 100,000 in 1996. As in most countries of tain region of Arizona) are closely related. In the world, men commit suicide at a far higher certain situations, the Apaches appear to believe rate than do women; 9.9 per 100,000 compared the only options open to an individual are self- to 3.0 for women. destruction or murder. The rise in female sui- The age group most at risk for suicide in cides among the Apaches is part of this Argentina, as in many other countries, is the suicide-homicide system. elderly—specifically, men over 75 have an The Apache suicide rate is between 50 and extremely high rate of 42.4 deaths per 100,000, 133 per 100,000. During the 1930s, the male to soaring far beyond the rate for women of the female rate of suicide was four to one, but by the same age: just 7.7 per 100,000. This continues a 1960s, it had developed to six male suicides to trend begun during the 1960s of suicide occur- every female suicide. ring predominantly among older Argentinians. According to police files, apparent reasons for April suicides The spring months of March, suicide among Argentinians include weariness of April, and May have consistently shown the life, physical suffering, mental alienation, family highest suicide rate, 4 percent to 6 percent disgust, lack of resources, and love contradic- higher than the average for the rest of the year. tions. Contrary to popular myths, the suicide rate dur- ing the Christmas season is below average. Aristotle (384–322 B.C.) Greek philosopher See also HOLIDAYS AND SUICIDE. who described suicide as a failure in courage. “To run away from trouble is a form of cowardice,” Aquinas, Saint Thomas (1225–1274) Bril- he wrote in Ethics, “and, while it is true that the liant Dominican priest and philosopher of the suicide braves death, he does it not for some 13th century who was one of the greatest Chris- noble object, but to escape ill.” Aristotle believed tian philosophers to ever live. Called the Doctor the attainment of the human form to be of great Angelicus (the Angelic Doctor), he is best known moral significance; therefore, destroying human for writing the Summa theologica and the Summa life at any stage was morally offensive. In com- contra Gentiles. mitting suicide, Aristotle believed a person was 14 Armenia also committing an offense by robbing the state ognized his thesis as a “misinterpretable” subject, of civic and economic contributions. and asked the person to whom he had entrusted the original manuscript to “publish it not, yet Armenia One of the lowest suicide rates in burn it not; and between those, do what you will Europe is found in Armenia, which listed a rate with it.” of just 1.8 suicides per 100,000 people in 1999. DAVID HUME’s essay, “ON SUICIDE,” was also This breaks down to 2.7 per 100,000 among published posthumously in 1777, a year after his Armenian men, and 0.9 for women. death. The essay, immediately suppressed, is today considered a convincing argument against the moral prejudice that many still hold against Arria (d. A.D. 42) The wife of Roman senator suicide. Hume’s view was that at the worst, one Cecina Paetus, who was accused of being does not harm society by suicide, but merely involved in a plot against the emperor and ceases to do good. He also believes, that one who ordered to commit suicide. When Paetus hesi- is tired of life often is a burden on society—and tated, Arria snatched the dagger from her hus- hinders the work of others. band, stabbed herself, then handed the weapon Perhaps ALBERT CAMUS summed up neatly the back with the words, “Paete, non dolet” (Paetus, ambivalence and division among artists and it does not hurt). writers over the years with regard to suicide: See also COMPULSORY SUICIDE. “What is called a reason for living is also an excellent reason for dying.” art, literature, and suicide In art and litera- ture, attitudes toward suicide remain as ambiva- assisted suicide The completion of suicide by lent and divided today as they were in ancient a terminally ill or suffering person with the help Greece and Rome. There have been apologists of a doctor or other clinician, but in such a way for suicide in both cultural fields. Eminent artists that the person technically dies by his own hand. and writers have over the years proclaimed For example, a person who dies by swallowing man’s right to self-destruction, whereas many pills supplied by a doctor for the purpose of caus- others have condemned suicide with equal con- ing death would be considered an assisted sui- viction. cide. Oregon, Belgium, and the Netherlands are JOHN DONNE’s BIATHANATOS (subtitled “A Decla- the three jurisdictions in the world where laws ration of that Paradoxe, or Thesis, that Self- specifically permit assisted suicide. Homicide is Not So Naturally Sinne, that It May There is a difference between assisted suicide Never Be Otherwise”) was a classic example of and . If another person performs the what was then a new look at an old practice. last act that intentionally causes a patient’s Through the years, many other writers—both death, euthanasia has occurred. Giving a patient inside and outside the Church—explored the a lethal injection or putting a plastic bag over a endless possibilities of the topic. MONTAIGNE,in person’s head would be considered euthanasia. his famous ESSAIS, calls death “a very secure Assisted suicide indicates that the person who haven, never to be feared and often to be dies actually performs the last act, and only gets sought.” Romantic suicide has long been used by “assistance” from a second person. Therefore, a playwrights and poets; Shakespeare’s ROMEO AND patient who pushes a switch to trigger a fatal JULIET is a popular example. injection after the doctor has inserted an intra- Interestingly, Donne’s thesis, written early in venous needle into the patient’s vein would be the 17th century, was not published until 1646, committing an assisted suicide. 15 years after the poet-chaplain’s death. Born a Assisted suicide remains extremely controver- Catholic, Donne later took Anglican orders, rec- sial in the United States and in many countries assisted suicide 15 around the world because it reverses the physi- helping someone else commit suicide is a crime cian’s usual approach to patients. Some patients punishable by up to 14 years in prison. A seven- desire an assisted suicide if they believe adequate judge panel of the European Court of Human relief is not possible. Others may request earlier Rights in Strasbourg, France, sided unanimously death to exercise autonomy and to end their with British authorities. lives on their own terms. Proponents argue that In their ruling, the judges rejected her terminally ill patients should have the right to lawyers’ claims that British laws infringed on end their suffering, and that involving another portions of the European Convention on Human person (such as a doctor) makes the suicide eas- Rights guaranteeing the , prohibiting ier and less risky. Critics worry that assisted sui- inhuman or degrading treatment and protecting cide might lead to abuse, exploitation, and respect for private life. The court said any change erosion of care for vulnerable people. to the law would seriously undermine the pro- Numerous attempts by other states to pass tection of life which Britain’s Suicide Act was laws legalizing assisted suicide have failed. In intended to safeguard. November 1998, voters defeated an The court’s judgment was considered a test initiative that would have legalized assisted sui- case for Europe, where the Netherlands became cide by a vote of 71 percent. In January 2000, the first country to fully legalize euthanasia an attempt to legalize assisted suicide in the on April 1, 2002. Belgium approved a similar California Assembly (AB 1592) failed, and on law a month later. Legislation is expected to be November 7, 2000, voters in Maine also enacted soon in Switzerland, France, Germany, rejected the proposed “Maine Death with Dig- and Sweden. nity Act.” This law was virtually identical to the This has not always been the case. In English assisted suicide law that passed in Oregon in common law—the system of legal tradition 1994. inherited by the United States from Britain—sui- The frequency of physician-assisted suicide cide was at one time a felony. It was called Felo for the terminally ill is unknown, but, based on de se—the felony of self-murder. Under the law, anecdotal evidence, is probably both substantial property of a person who committed suicide was and increasing. forfeited and burial was “ignominious.” While it is against the law in all states except Moreover, anyone who assisted a suicide and Oregon to assist another person to commit sui- was present when the suicidal act was initiated cide, it is not against the law to give general was considered to be guilty of murder. If the per- information to people on ways to kill them- son assisting was not present, he or she was still selves. considered an “accessory before the fact” and In April 2002, Europe’s leading human rights was considered guilty of murder or manslaugh- court rejected an appeal by a terminally ill and ter. In certain jurisdictions, however, the one paralyzed British woman who wanted her hus- assisting sometimes escaped punishment be- band to help end her life. She died a month cause the person who committed suicide, being later. deceased, could not be convicted and thus, the Diane Pretty, 43, suffered from a motor neu- accessory could not be tried. ron disease that left her paralyzed and confined In the past 100 years, most common law pro- to a wheelchair. She brought her case to the visions have been abolished in the United States. European court after Britain’s highest appeals The English Suicide Act of 1961 legalized suicide court ruled in November 2001 that her husband in that country but still made aiding and abetting could not be guaranteed immunity from prose- suicide a criminal offense. cution if he helped her die. Suicide is legal in If suicide is no longer a crime in the United Britain as it is in the United States, but in Britain States, aiding a suicide remains a potentially 16 assisted suicide serious offense. In a 1920 case in Michigan, Peo- defense. The risks for aiding and abetting in the ple v. Roberts, a husband who had prepared a poi- suicidal act are both real and serious. Still, there son and placed it within his wife’s reach was is considerable room for argument under certain convicted of first degree murder and given a life circumstances (such as providing information sentence. The man had done as his wife only to a terminally ill patient about the deadli- requested (she suffered from an incurable and ness of various drugs). Then the focus in a crim- physically incapacitating affliction). The decision inal case usually becomes one of intent of the was upheld in appellate court. person to cause—or assist in—the death. In Today, there remains real risk of criminal today’s society, information about drugs is fairly prosecution for anyone who assists a suicide, common knowledge. Thus, the closer the person even for humanitarian and compassionate rea- who assists is to a terminally ill person (and the sons—and even at the victim’s request. How- more specific the response to a request for help ever, prosecution under criminal law does not in the suicide act), the more likely the chance of begin until police or other law enforcement offi- criminal prosecution. cials believe that a crime has been committed In addition, the laws of conspiracy (an agree- and they can identify those responsible. If no ment among two or more people to commit a one knows a crime has occurred, no charges are criminal act and some action by at least one of filed. If, for instance, a terminally ill person’s them toward further preparation) form a sepa- death is declared “natural” by the attending rate basis for prosecution. physician because no one knew another person Therefore, even for advocates of euthanasia helped in the suicidal act, then no charges would who support the option of active voluntary “self- be filed and no prosecution would begin. This deliverance” for the terminally ill, the risk of undoubtedly happens more than the public gen- criminal charges is real and serious for those erally realizes. who would help someone commit suicide. Should there be some question or suspicion as All this concerns only criminal law. Of con- to final cause of death, authorities may order an cern to professionals such as physicians, psy- autopsy. A family can usually refuse to give per- chologists, psychiatrists, nurses, social workers, mission for the autopsy, if they do not, in their and attorneys is the potential jeopardy to their refusal, arouse suspicion of “foul play.” Should license should their participation in assisting that happen, officials will probably order that another’s self-destruction become known. The the autopsy be performed. revocation or suspension of professional licenses Whether or not criminal proceedings are comes under administrative law, which is com- started is within the discretion and judgment of plicated and involves a formal administrative the prosecutor, usually the district attorney. A proceeding, the accused professional’s proce- number of factors affect the prosecutor’s deci- dural rights of due process, a list of charges, and sion, such as: if a death causes considerable pub- the right to an impartial hearing on the charges, lic attention; if public attention is generated by a with opportunity to cross-examine adverse wit- particularly vocal group opposed to the act of nesses and produce evidence refuting the suicide; if there appears to be a likelihood of sig- charges. Clearly, this involved process is but one nificant financial gain or other selfish motive on important reason why professional people are the part of the person assisting the suicide; or, if generally very reluctant to offer or provide the person helping happens to be a total stranger active assistance even to tragic victims of painful to the suicide victim. terminal illnesses. Once it has been determined to prosecute, a Finally, in contrast to criminal law, there is request by the victim for help in the suicide is civil law which involves one citizen or more almost certain not to be considered a valid legal bringing a lawsuit against another, alleging Association for Death Education and Counseling 17 injuries to themselves or one of their recognized muted to life imprisonment. In the United “interests.” A typical case in civil law might be States, in the past 10 years, there have been sev- one concerning alleged direct bodily injury to eral cases where juries refused to indict or con- the plaintiff (the one bringing a lawsuit) as a vict “mercy killers,” though all evidence result of medical malpractice (against the defen- weighed against such a decision. dant physician). In March 1986, the American Medical Associ- The required elements for having grounds to ation decided that it would be ethical for their file a civil suit include: liability, damages, and members to withhold “all means of life-prolong- causation. In the context of those who have cho- ing medical treatment,” including food and sen to assist a suicide, there are at least three water, from patients who are in irreversible potential areas of “exposure” to civil litigation: comas. The AMA’s judicial council, meeting in (1) dissent by survivors (some family member New Orleans, decided unanimously that with- learns of the helper’s role and actively disagrees holding treatment in such cases, even when with actions taken); (2) unsuccessful attempt death is not imminent, would be ethically appro- (perhaps brought about by the potential suicide priate. The council made clear its decision does himself against the helper who either withdrew not oblige any physician to stop therapy, and or who inadvertently botched the suicide that each case should be decided individually. attempt); (3) wrong person dies (when someone At present, there are an estimated 10,000 other than the suicide, perhaps a child, comes people who are in irreversible comas in institu- into possession of the drug(s), ingests them, and tions in the United States, according to The New fatal results are misdirected). York Times. In such cases, doctors in the past have It is clear there are legal risks for anyone who often refused to withhold or withdraw treat- might agree to assist someone in suicide. That is ments (such as respirators or artificial feeding), why the groups (BRITISH citing ethical standards and fear of criminal pros- VOLUNTARY EUTHANASIA SOCIETY, THE HEMLOCK ecution or malpractice suits—despite the SOCIETY, and CONCERNS FOR DYING) advise follow- requests of family members and the previously ers always to proceed with great care and cau- expressed wishes of the patients to have such tion when considering help to a terminally ill treatments withdrawn. patient in “self-deliverance.” The opinion of AMA’s judicial council has no Assisting a person whose personal choice is legal standing, although it is an indication of a suicide is not to be confused with “mercy killing.” shift of social opinion. Today, an estimated 80 Whereas voluntary self-destruction involves per- percent of the 5,500 Americans who die each sonal decision and self-control, mercy killing is day are wired and incubated and in institutions. the unrequested taking of another’s life in order to The crux of AMA’s policy lies in the stipula- save that person further suffering. Mercy killing tion that the patient need not be terminally ill is usually an act of desperation and despair, and for halting treatment to be acceptable. Such often the life-taker is near emotional collapse decisions to remove life-support systems will caused by the stress that comes from caring for probably be difficult for many doctors. The and watching someone terminally ill. Pushed to recent AMA decision is but one more cautious such limits, the life-taker at some point feels step in the evolution of a social policy in the compelled to hasten death—by whatever complex, delicate and shadowy area of dying means—because no one else will. and death. Mercy killers are usually confronted with the criminal charge of murder or manslaughter. Up Association for Death Education and Coun- until the 1960s, “mercy killers” in Western soci- seling The oldest interdisciplinary organiza- ety often were sentenced to death, later com- tion in the field of dying, DEATH EDUCATION, and 18 attempted suicide bereavement. Members of this nonprofit organi- alcohol or other drug use disorder, physical or zation include educators, counselors, nurses, sexual abuse, and aggressive or disruptive physicians, hospital and hospice personnel, behaviors. Most suicide attempts are expressions mental health professionals, clergy, funeral of extreme distress, and are not just harmless directors, social workers, philosophers, psychol- bids for attention. For this reason, a suicidal per- ogists, sociologists, physical and recreational son should never be left alone and needs imme- therapists, and volunteers. ADEC works to pro- diate mental health treatment. mote and share research, theories, and practice in dying, death, and bereavement. Treatment The group was formed in 1976, when a group Many people who attempt suicide are admitted of interested educators and clinicians organized to a hospital emergency department in a coma. the Forum for Death Education and Counseling, After an overdose of a potentially lethal drug has eventually changing the name to the Associa- been confirmed, the drug should be removed tion for Death Education and Counseling from the patient, so as to prevent absorption and (ADEC). expedite excretion. Treatment of symptoms to For contact information, see Appendix I. keep the patient alive should be started; and any known antidote should be given if the specific attempted suicide A suicidal act that is not drug can be identified. fatal, possibly because the self-destructive inten- Every person with a life-threatening self- tion was slight, vague, or ambiguous. Most peo- injury should be hospitalized to treat the phy- ple who try to kill themselves are ambivalent sical injury and also to get a psychiatric about their wish to die, and the attempt may be assessment. Although most patients are well a plea for help that fails because of a stronger enough to be discharged as soon as the physical wish to live. There may be as many as 20 at- injury is treated, they should always be given tempted suicides to every one that is completed; follow-up care. Psychiatric assessment should be the ratio is higher in women and youth, and performed as soon as possible for all patients lower in men and the elderly. who attempt suicide. Each year, at least 300,000 Americans survive After the attempt, the patient may deny any a suicide attempt. Most have injuries minor problems, because the severe depression that led enough to need no more than emergency room to the suicidal act may be followed by a short- treatment, but about 116,000 people are hospi- lived mood elevation. Nevertheless, the risk of talized; of these, most are eventually discharged another suicide at a later date is high unless the alive. The average hospital stay is 10 days. patient’s problems are resolved. Without knowledge of proper dosages and The patient needs a secure, strong source of methods, suicide attempts may be bungled, leav- help, which begins when the physician provides ing the victim worse off than before. For exam- sympathetic attention and expresses concern, ple, some suicide attempts by gunshot leave the commitment, and understanding of the patient’s person alive but brain-damaged; drug overdoses troubled feelings. Although only 10 percent to that are not fatal may have the same effect. 15 percent of attempters go on to kill them- About 17 percent of attempted suicides (about selves, it is estimated that between 30 percent 19,000 Americans) are permanently disabled or and 40 percent of suicides make at least one unable to work. nonfatal attempt. Risk factors for attempted suicide in adults It is believed that most suicide attempts, for include depression, alcohol abuse, cocaine use, whatever reasons, are essentially a cry for help. and separation or divorce. Risk factors for However, it is sometimes hard to tell whether an attempted suicide in youth include depression, attempt is genuine or a dramatic gesture toward attitudes 19 self-destruction. For instance, there are reported suicide, together with Virgil, Cicero, and Ovid. cases where the person took a small number of IMMANUEL KANT called suicide “an insult to sleeping pills and called a physician. On the humanity.” The Roman Stoics accepted the other hand, a suicide attempt that turns deadly option of suicide, as did the EPICUREANS,who is the last in a long series of cries for help. Yet considered that one’s destiny was a matter of another myth that persists today, despite statis- individual choice. Cato, Pliny, and Seneca all tics to the contrary, is that once a person tries to considered suicide to be acceptable. kill himself and fails, the pain and will On the whole, however, society began to take prevent a second attempt. a hostile attitude toward self-destruction or In the United States, the ratio of suicide is unnatural deaths. about three men to one woman, although Suicide became taboo as superstitions and women usually make two-thirds of the unsuc- myths were created to discuss the act. The law cessful attempts at suicide. In most countries, began to deal with suicide in punishing terms, attempted suicide is no longer a punishable even going so far as to enact statutes against the offense, though it is still frowned upon by many suicide’s survivors, and as a deterrent for future segments of society and causes guilt feelings to offenders. In ENGLAND, suicide attempters were those closely involved. imprisoned until 1916; then, instead of prison, The peak age for suicides lies between 55 and the suicidal person was placed in custody of rel- 64; for attempted suicides, between 24 and 44. atives or friends. In fact, not until 1961 did the Nine out of 10 teenage suicide attempts take British Parliament abolish the criminality of sui- place in the home, between the hours of 3 P.M. cide and declare that the act of self-destruction and midnight, when parents are home. was not “a species of felony.” The more lethal and violent methods (guns, Today legal restrictions have been abolished explosives, hanging) are used less often in the in most countries. As research in mental health nonfatal attempts than in the successful sui- increased and improved, legislation changed (if cidal acts. only gradually). In India, attempted suicide is still an indictable offense. For many years, nine attitudes Suicide and suicidal behavior have states in the United States still considered been a part of human culture since ancient man attempted suicide a misdemeanor or felony. But first realized he could kill himself. Still, the act of even in those states (Alabama, Kentucky, New self-destruction is often considered taboo, an act Jersey, South Carolina, North Carolina, North that stigmatizes not only the victims but the sur- Dakota, Oklahoma, South Dakota, and Washing- vivors as well. The word suicide, however, is a ton) such laws were seldom enforced. relatively recent term, first used in 1651 and The world’s various religions have profoundly taken from the Latin sui, “of oneself,” and cide, “a influenced the American legal position on sui- killing”—literally, to kill oneself. cide, because laws in America are based on En- Attitudes concerning suicide and those who glish common law, which in turn was impacted try it have varied widely in societies and the by religion. groups within those societies over the centuries. The three denominations of modern Judaism These attitudes run the spectrum of feelings and consider the act of suicide a crime against God, emotions from revulsion, condemnation and but an act that can sometimes be explained, total disapproval, to pity, benign acceptance, and understood, and forgiven. But in Judaism, as in reluctant recognition of the right to die volun- other religions, there has never been universal tarily under certain circumstances. agreement. Through the years, philosophers have pon- After the birth of Christ, suicide was com- dered the problem: PLATO strongly condemned monplace in Greece and Rome. Early Christians 20 Augustine of Hippo, Saint seemed to accept the attitudes prevailing at the In modern times, Dietrich Bonhoeffer con- time. The Apostles did not denounce suicide, sidered suicide a sin because it represented a and the New Testament mentioned the matter denial of God. Yet he suspended that judgment only indirectly, in the report of Judas’s suicide. for prisoners of war, for the obvious reasons. For centuries, church leaders did not condemn Perhaps Bishop John Robinson best sums it suicide. up: “Truth finds expression in different ages. Then Augustine denounced suicide as a sin Times change and even Christians change with that precluded the possibility of repentance, call- them.” Overall, it appears that society’s attitude ing the act “a form of homicide, and thus a viola- toward suicidal behavior is less moralistic and tion of the DECALOGUE ARTICLE, ‘Thou shalt not punitive than it was a generation ago. Increas- kill.’” The earliest institutional disapproval didn’t ingly, suicide is recognized not only as a philo- come until 533, however, with the Second Coun- sophical, religious, legal, and cultural question, cil of Orleans. Suicide, it was determined, became but also as a psychosociobiological problem. the most serious and heinous of transgressions. This may be another reason why there is a In 563, the Fifteenth Canon of the Council of greater readiness today to understand rather Braga denied funeral rites of the Eucharist and than condemn. the singing of psalms to anyone who committed suicide. The Council of Hereford of 673 withheld burial rites to those who died of self-destruction. Augustine of Hippo, Saint (354–430) North In 1284, the Synod of Nimes refused self-mur- African theologian and one of the outstanding derers even the quiet interment in holy ground. theologians of the Catholic Church. Son of Saint SAINT THOMAS AQUINAS refined and elaborated Monica, a Christian, Augustine had been influ- on Augustine’s concept, opposing suicide on the enced by the pagan philosophers until his con- basis of three postulates. His opposition was version. After a dissolute youth, he returned to predicated on the sacredness of human life and his native town following his baptism at age 32 absolute submission to God. on Easter Sunday, 387. He was ordained in 391, The philosophical and religious stances have and then was consecrated a bishop of Hippo in changed over time and brought new attitudes 396. His City of God and Confessions are among the regarding suicide. JOHN DONNE, dean of St. greatest Christian documents. In Confessions, Paul’s Cathedral, London, reacted against the Augustine recounts how even his youthful Church’s view of suicide. He admitted it was insincerity was reflected in prayers for repen- contrary to the law of self-preservation, but saw tance: “Da mihi castitateur et continentiam, sed it as neither a violation of the law nor against noli modo” (Give me chastity and continence, reason. His position was supported in time by but not yet.) secular writers and philosophers, including Augustine’s denouncement of suicide as a sin DAVID HUME, Montesquieu, Voltaire, and JEAN- greatly influenced thinking at the time. He JACQUES ROUSSEAU. espoused four arguments to justify the Church’s Among other religions, Brahmanism tolerates antisuicide position: (1) no private individual suicide, whereas the attitude of Buddhism is may assume the right to kill a guilty person; (2) ambiguous, although it encourages suicide in the suicide who takes his own life has killed a the service of religion and country. Hindus con- man; (3) the truly noble soul will bear all suffer- sider suicide an ultimate death, thus leading to ing from which the effort to escape is an admis- an earthbound, ghostly existence. In Japan, sion of weakness; and, (4) the suicide dies the compulsory hara-kiri was declared illegal in worst of sinners because he is not only running 1868, though voluntary hara-kiri occurs occa- away from the fear of temptation, but also any sionally even today. possibilities of absolution. autoerotic asphyxiation 21

Australia The suicide rate in has who fails in performing to role expectations is risen from a low of 12.7 per 100,000 in the often morally condemned. 1960s to a high in 1977 of 14.3 per 100,000. Within the Australian island continent, suicide autocide Suicides disguised as automobile rates have varied, and will probably continue to accidents. Forensic experts and highway trans- vary, among the five continental states (Queens- portation safety officials say that auto fatali- land, New South Wales, Victoria, South Aus- ties (which, in any given year, account for about tralia, and West Australia). 37 percent of deaths in the 15- to 24-year- Unlike many other industrialized countries in old group) are accidents that are probably delib- which the age group with the highest suicide erate in roughly one-fourth of reported cases. rate tends to be older citizens, in Australia men Although some reports indicate emotional stress age 25 to 31 have the highest rate (31 per may be present, the conditions of the road, traf- 100,000). Australian women age 45 to 54 have fic flow, weather, and status of the car are the highest suicide rate—7.7 per 100,000, still pointed out most of the time as the cause in auto far below the men’s rate. accidents. These fatalities probably represent the biggest block of suicides disguised as acci- Austria This country has a relatively high inci- dents. If these “autocides” are added to known dence of suicide, unlike other such predomi- suicides, argue authorities, they would make nantly Catholic countries as Ireland, Italy, and suicide the number one killer in the 15-to-24 Spain. The suicide rate, which peaked in the age group. 1930s and then dropped, rose and then dropped again, from 22.8 per 100,000 in 1965 to 24.8 in autoerotic asphyxiation Also known as sex- 1978, then back down to 19.5 in 1998. ual hanging, this is a type of abnormal sexual Suicide among Austrian men has been rising behavior in which a person tries to restrict the from 14.9 per 100,000 in 1965 to 17.2 in 1978 to supply of oxygen to the brain (usually with a 28.7 in 1999. Although the suicide rate for Aus- rope around the neck) while masturbating to trian women is much lower than for men, it has orgasm. The most common practitioners are risen from 7.8 in 1965 to 10.3 in 1999. teenage boys. In one study, researchers concluded that the People who engage in this practice do not Viennese seemed socially alienated and isolated, intend to kill themselves; instead, they are sim- and in poor communication with spouses, rela- ply seeking sexual gratification by blocking the tives, and close friends. Alcohol was a serious flow of oxygen to the brain. Experts estimate problem for about one-third of the suicides in that between 500 to 1,000 deaths a year are the the study. result of autoerotic asphyxiation. However, the actual incidence is likely underreported. Teenage authoritarianism Favoring blind submission victims are most often found by parents or other to authority. Historically, authoritarian cultures relatives who, because of the graphic, highly have produced a very high suicide rate. Some emotional, and often shocking circumstances experts believe that this type of culture affects a under which the victims are found, may clean person’s self-concept. For example, in the past, up or change the death scene. In addition, emer- the highly authoritarian Japanese culture pro- gency personnel and police investigators often duced a very high suicide rate in that country, don’t understand the signs of this behavior, so according to sociologists Mamoru Iga and Kichi- autoerotic asphyxiation cases are often officially nosuke Tatai. When an authoritarian society reported as an intentional teen suicide. It may produces intense desires for success, the person often be easier for relatives to handle teen sui- 22 auto-euthanasia cide resulting from depression or drug abuse A person who practices AEA is not necessarily than from this form of sexual behavior. Denial disturbed or perverted. Typically, these are not and repression on behalf of parents and relatives adolescents who have problems in school, give likely contribute to the underreporting of AEA their parents trouble, or don’t have friends. cases. Instead, they are usually normal, well-adjusted Conservative estimates suggest AEA may teenagers who tend to come from a middle-class make up as many as 6.5 percent of adolescent background, appear happy, and are generally suicides and at least 31 percent of all adolescent very intelligent, are popular, and have a good . Therefore, up to 4,379 teens and relationship with parents. The FBI estimates that young adults may have taken their lives in the 500 to 1,000 deaths of this nature occur every past decade through the practice of autoerotic year in the United States. asphyxia. Warning Signs auto-euthanasia Euphemism for suicide The most obvious warning sign is any type of involving a suffering person. trauma to the neck area, such as abrasions or rope burns, any sign of black and blue marks, autopsy, psychological See PSYCHOLOGICAL blood clots, or pressure marks. In addition, any AUTOPSY. kind of padded ropes, belts, knotted sheets, pil- lows, towels, or underclothes that are hidden in a special place may be another warning sign. Azerbaijan Although most of the countries of Possible personality traits include: eastern Europe show alarmingly high suicide rates, the rate for Azerbaijan is extraordinarily • risk-taking behavior low—a mere .65 per 100,000. Such an abnor- mally low rate may indicate irregularities in • experimental behavior reporting of statistics, experts suggest. In 1999, • impulsive behavior Azerbaijan reported 1.1 suicides per 100,000 • thrill seeking men, and 0.2 for women. B

Baechler, Jean (1937– ) French moral Balzac, Honoré de (1799–1850) French philosopher and author of Suicides, who novelist who agreed with the Romantic dogma described the suicidal motive of transfigura- that the intense, true life of feeling does not—in tion. As an example, Baechler describes a fact, cannot—survive into middle age. Balzac pair of young people who drove off the cliffs in wrote in La Peau de Chagrin: “To kill the emotions a car. The couple left a letter in which they and so live on to old age, or to accept the martyr- explained that they killed themselves ‘to dom of our passions and die young, is our fate.” preserve their love.’” This report was evidently sufficient for Jean Baechler to classify the case Barbados Islands typically reveal very low as a suicide of “transfiguration,” which he de- suicide rates, and Barbados in 1995 reported a fined as one undertaken by the suicide vic- rate of 6.65 per 100,000 citizens—9.6 per tim(s) to achieve a state infinitely more 100,000 for men, and 3.7 for women. desirable. Most suicidologists are skeptical of young couple SUICIDE PACTS as transfiguration, because barbiturates Any one of a class of drugs that motives often involve anger, coercion, and act as central nervous system depressants, induc- revenge. In cases like this, as in most others, sui- ing drowsiness and muscular relaxation. They cide notes are designed to conceal—not reveal— can make an already depressed person even . more depressed. The drugs slow a person’s movements, thoughts, feelings, and recollec- tions. By interfering with chemical messengers Bahamas Life in the idyllic islands appears to in the brain, the drugs also slow the activity of be linked to a low suicide rate, because the over- nerves that control breathing and heart action, all rate of suicide per 100,000 in 1995 was just creating effects ranging from relaxation to coma 1.1. This is broken down into 1.1 suicides per and death. 100,000 among Bahaman men, with no Barbiturates mixed with alcohol claimed the reported suicides at all for women. lives of rock star Jimi Hendrix, actress Marilyn Monroe, radical guru Abbie Hoffman, American Baldwin, James (1924–1987) American Conservatory Theater founder William Ball, and author who explored the racial significance Jeanine Deckers, the “Singing Nun,” who killed of suicide in his novel Another Country. For herself with 150 pills and a shot of cognac. homosexual African Americans who are also Each year more than 15,000 deaths caused by suicidal, the rage and bitterness caused by barbiturate poisoning, often combined with rejection may either be expressed in their alcohol, are reported in the United States. homosexual relationships or by depression and Almost certainly a high percentage are suicides, suicide, according to Baldwin. but exact figures are impossible to obtain.

23 24 Barnard, Christiaan

When they were created in the late 1800s to giant Enron, the biggest corporate failure in U.S. cure insomnia, barbiturates were heralded as history, who committed suicide by firing a gun “continuous sleep therapy” and welcomed as an to the head. His body and a were improvement over traditional substances such as found in his car in his hometown of Sugar Land, alcohol and opiates. Since then, several thou- Texas, a suburb of Houston. sand kinds of barbiturates have been synthe- Sources suggest that he could not stand the sized. There are several different categories, pain of the Enron scandal, and was depressed based on how quickly they are broken down that he might have to testify about the role his chemically in the liver and eliminated: ultra- colleagues had played in the collapse of the fast, short-acting, and long-acting. It is the short- giant corporation. He is said to have questioned acting barbiturates that are the choice for most the company’s accounting practices before his suicides. resignation as the firm’s vice chairman and These drugs—pentobarbital (Nembutal), chief strategy officer in May 2001. Two days amobarbital (Amytal), secobarbital (Seconal), before he died, he broke down in tears as and a secobarbital-amobarbital mixture known he discussed the firm’s collapse with a business as Tuinal—are the type commonly known as colleague. “sleeping pills,” taking 20 to 45 minutes to work. The intoxicating effect lasts four to five hours. Befrienders International Nonprofit volun- Suicidologists believe most and/or teer organization that works for suicide preven- medical examiners in other countries, and in tion in 41 countries. Befrienders International some areas of the United States, appear to be develops volunteers to try to prevent some of more inclined to give an accident verdict or de- the 1 million suicides around the world, and clare the cause of death “undetermined” in cases provides information about suicide, including of narcotic poisoning than in other cases of self- the world’s most comprehensive online direc- inflicted death. tory of emotional first aid helplines. Suicidal individuals are considerably more Befrienders International involves a network prone to be violent or substance abusers. People of 357 “befriending centers” around the world do kill themselves by a simple overdose of barbi- run by trained volunteers offering a service that turates; mixing them with alcohol (the organ is free, nonjudgmental, and completely confi- most immediately affected by alcohol is the dential. People are befriended by telephone, in brain) produces a synergistic effect that only face-to-face meetings, by letter, and by email. enhances the possibility of lethality. Founded in 1974, Befrienders International See also ABUSE, SUBSTANCE; ALCOHOLISM AND coordinates and develops the work of its mem- SUICIDE. ber centers around the world, advises new cen- ters and is involved in new approaches toward Barnard, Christiaan (1923–2001) Interna- suicide prevention. The most exciting of these is tionally acclaimed physician recognized for his Reaching Young Europe, a program that teaches pioneering work in heart transplant surgery. coping skills to six-year-olds. U.S. centers are Barnard was a strong advocate of euthanasia and known as the . candidly supported a doctor’s right to participate For contact information, see Appendix I. in euthanasia as a humane and compassionate end to human suffering. Belarus Suicide rates have risen in Belarus since 1990, and suicide rates are higher in rural Baxter, John Clifford (1958–2002) A for- than in urban areas. The regional distribution of mer senior executive of the bankrupt energy suicide rates suggests a north-south variation Berryman, John 25 that may be a result of ethnic and cultural dif- subsequent treatment at McLean Hospital in ferences between the regions. As of 1999, the Belmont, Massachusetts. It represents a culmi- suicide rate nationwide was 35.5 per 100,000; nation of Plath’s attempts to describe her experi- this breaks down to an astounding 61.1 per ence of mental illness and treatment and is 100,000 for men and 10 per 100,000 for women. considered to be one of the best-told tales of a woman’s descent into insanity. Belgium The third country to approve physi- cian-assisted suicide for terminally ill adults who bereavement groups There are a number of are suffering unbearable pain. The new law, self-help organizations for families and friends passed on May 17, 2002, sets out strict safe- struggling to come to terms with the loss of guards to protect the vulnerable, after research loved ones due to suicide. Such groups try to showed assisted dying was going on anyway in help families, friends, and close associates of the an unregulated way. The law has overwhelming victim deal with the death. public and parliamentary support. More than 72 Surviving loved ones of suicide are too often percent of Belgians support the new law. forced to carry the stigma for years, if not for The law stipulates that prospective patients life. All too often, suicide of a family member must be over age 18, suffering from an incurable or close friend is never completely forgotten and illness, and have made repeated requests for forgiven. help to die. They must be of sound mind and in constant suffering, and at least one month must Berryman, John (1914–1972) American elapse after a patient has made a written request poet who was born John Smith in McAlester, for help to die before medical assistance is given. Oklahoma, whose major theme was . All assisted deaths must be reported to a national He wrote of poetic mourning for the suicide of committee. his father, the premature deaths of friends, and The Belgian law was passed in response to his own prevalent suicidal despair. research showing that vulnerable people were Berryman received an undergraduate degree not protected by the law. Nonvoluntary from Columbia College in 1936 and attended euthanasia (when a doctor deliberately hastens Cambridge University on a fellowship. He went the death of an incompetent patient) was shown on to teach at Harvard and Princeton, and from to be five times as common in Belgium as it is in 1955 until his death he was a professor at the countries that regulate physician-assisted sui- . cide. Belgian rates of nonvoluntary euthanasia His early work was published in Five Young (3.2 percent) dwarfed the incidence of nonvol- American Poets in 1940. Poems (1942) and The Dis- untary euthanasia in the Netherlands, where possessed (1948) reveal great technical control. assisted dying is regulated (0.7 percent). However, it was not until he published Homage to Mistress Bradstreet in 1956 that he won wide- Bell Jar, The A brilliant novel about a gifted spread recognition as a boldly original poet. This young woman’s mental breakdown beginning was followed by 77 Dream Songs, which was pub- during a summer internship as a junior editor lished in 1964 and awarded a Pulitzer Prize. In at a magazine in New York City in the early succeeding years Berryman added to the se- 1950s. quence, until there were nearly 400 collected as Written by poet SYLVIA PLATH, the book was The Dream Songs. published in 1963 only weeks before Plath killed Unfortunately, however, Berryman never herself. The book is based largely on Plath’s own recovered from the childhood shock of his suicide attempt in the summer of 1953, and her father’s suicide. Prone to emotional instability 26 Bettelheim, Bruno and alcoholism throughout his life, he died by was originally circulated in manuscript form and throwing himself off a bridge in Minneapolis. only published posthumously, in 1644. In his work, Donne proposed to demonstrate that sui- cide is not incompatible with the laws of God, Bettelheim, Bruno (1903–1990) American reason and nature. Moreover, inherent in the developmental who was born in condition and dignity of being a man is the right Austria and received his doctoral degree in 1938 to end one’s life. As Donne expressed it, from the University of Vienna. Dr. Bettelheim “methinks I have the keys of my prison in mine was imprisoned in the concentration camps at own hand, and no remedy presents itself so Dachau and Buchenwald during the Nazi occu- soone to my heart, as mine own sword.” pation of Austria. After immigrating to the Biathanatos was the model of thought on the United States in 1939, he published an influen- subject of suicide for almost a century and a tial essay on the psychology of concentration half. During that period, Rationalists such as camp prisoners. A professor of psychology at the Voltaire and Hume openly and persistently University of Chicago from 1944 to 1973, he attacked suicide taboos and superstitions and directed a Chicago school for children with emo- the primitive punishments for suicide. This led tional problems. to legal changes in the prosecution of suicide In his book The Uses of Enchantment: The Mean- attempters. ing and Importance of Fairy Tales, Bettelheim dis- cusses the power that fairy tales and myths have over children, contending that children love biblical suicides There are a number of sui- these stories because they embody their strong- cides reported in the Old Testament of the Bible, est hopes and fears. and they are presented either neutrally or as One prevalent fear that is virtually universal appropriate, under the circumstances. Neither in fairy tales is fear of being separated from par- the Old or the New Testaments of the Bible pro- ents. Many suicidologists believe that the “typi- hibit suicide. cal” suicidal adolescent is likely to be a teenager Examples include: who early in life was literally separated from vital relationships or who never truly experi- • Abimelech (Judges 9:54), dying of a skull frac- enced a trusting family relationship. ture during a siege, ordered his armor-bearer The young person who hasn’t had sufficient to kill him to avoid the embarrassment of hav- nurturing to develop a sense of self has nothing ing been killed by a woman (she threw a mill- when he separates from his parents. Of course, stone at him). not every person separated early in life from his • Samson (Judges 16:26–31) killed himself to parents becomes suicidal. Other vital relation- avoid being “made sport of” by the Philistines, ships may occur that help blunt the impact of after his capture and haircut, taking his tor- such separation. mentors with him. As an adult, Bettelheim was plagued by fits of • Saul (1 Samuel 31:3–6), wounded and de- depression and haunted by the memory that his feated in battle with the Philistines, asked his father had died of syphilis. In 1990 he commit- armor-bearer to kill him. When the aide hesi- ted suicide at the age of 86, an act that surprised tated, Saul fell on his own sword. The armor- many, given the optimistic tone of many of his bearer then did likewise. books. • AHITOPHEL (2 Samuel 17:1, 23), plotted to overthrow King David. When the plan failed, Biathanatos The first defense of suicide writ- he hanged himself and was buried in his ten in English by poet JOHN DONNE in 1608. It father’s sepulchre, in contrast to the Christian birthdays and suicide 27

Church’s long history of refusing burial in hal- brief episodes of depressions. Still others have a lowed ground to suicides. “physical” depression or physical pain, with no • ZIMRI (1 Kings 16:18) usurped the throne of obvious emotions at all. Occasionally, a person Israel; when he failed, he burned down the with bipolar disorder may have accompany- palace around himself. ing psychotic problems such as delusions or hal- lucinations. When mania and depression occur at the See NEUROBIOL- biological aspects of suicide same time, doctors refer to this condition as a OGY OF SUICIDE. “mixed state.” bipolar disorder The medical term for manic Treatment depression. Bipolar disorder is a neurobiologi- Treatment with effective medications and regu- cal brain disorder involving extremes in mood, lar counseling discussions about coping with the one of the three major mood disorders. (The illness reduces the risk of suicide. While there is other two are depression and schizoaffective no cure for bipolar disorder, it may be managed disorder.) with medication (usually lithium and Depakote) If untreated, the rate of suicide and associated and psychotherapy. Supportive is accidental injury among bipolar patients is at also often recommended. However, finding the least five to 30 times higher than that of the gen- right medication is not always easy; what works eral population. About 1 percent of the world’s for one person may not work for another. Some- population is thought to have some form of times a combination of medications is required, bipolar disorder, from mild to severe, and including a mixture of antipsychotics, benzodi- approximately one in five people with bipolar azepines, antidepressants, thyroid supplements, disorder eventually complete suicide. More- and sleeping aids. over, between 20 percent and 50 percent of people with bipolar disorder attempt suicide at birthdays and suicide While there are some least once. instances of suicides on a person’s birthday, the Patients with bipolar disorder are far more incidence of self-destruction does not necessarily likely to complete suicide than individuals in any correlate with the birthdate. Although a poten- other psychiatric or health risk group, yet this tially suicidal person may suffer symptoms of risk is often underemphasized. For a person with loneliness, despair, and loss of self-esteem on bipolar disorder, suicidal thoughts and plans may such an occasion, suicide rates are instead linked occur during depression or mania. to other factors, such as gender, increasing age, widowhood, single and/or divorced states, child- Symptoms lessness, residence in urban centers, high stan- Most people with bipolar disorder have extreme dard of living, economic crisis, drug and alcohol cycles of depression and mania only once every consumption, history of a broken home in child- few years. Rapid cyclers go through four or more hood, mental disorder, and physical illness. episodes of mania and depression per year. As for month of birth and suicide, more sui- Ultra-rapid cyclers have episodes shorter than a cides take place in the spring than in the winter, week. Ultradian cyclers have distinct and dra- with March, April, and May the most common matic moods shifts within a 24-hour period. months. Some people have mild symptoms of mania Sometimes suicidal people do attach particu- (hypomanias), while others have wild manias. lar significance to birthdays; for example, if a Some people have depressions that are deep parent committed suicide on the 40th birthday, and long-lasting, while others experience only the child might feel destined to die before or on 28 black Americans that day. If the potential suicide arbitrarily sets suddenly of a stroke when Charles was only 10 the next birthday as the very last day to remain years old. His mother sold the family business and alive, suicide will be attempted either before or concentrated on raising her son. A year later, on that day. Charles discovered the cinema and professional theater. Mme. Boyer tried to pretend that her black Americans See AFRICAN AMERICANS AND son’s infatuation with dramatics was only a SUICIDE. phase, since she hoped he would eventually become a doctor or a lawyer. However, all he bonding The strong attachment of mother to wanted was to act. Eventually, Charles left Figeac infant and infant to mother that develops shortly in 1918 to enroll at the Sorbonne and pursue an after birth. Many authorities in the suicidology acting career in Paris. Soon he was one of the field see a direct correlation between lack of busiest actors in the city, and eventually moved bonding and the development of suicidal ten- on to success in Hollywood. dencies. The infant whose physical and psycho- During one of his stays in Hollywood, he met logical needs are satisfied develops a sense of a young Fox starlet, Pat Paterson, and three well-being. Proponents of this theory maintain weeks later they married. The marriage would that the suicidal can therefore be in- last 44 years, until Pat’s death in 1978. During grained within the first months of life. For these the filming of Gaslight (1944), Charles became a people, any problem in the child’s life may pre- father for the first and only time when Pat Boyer cipitate a suicide try, but the underlying cause gave birth to their son, Michael. frequently can be traced to emotional scars Sadly, tragedy struck in Boyer’s later years. His inflicted during infancy. son, Michael, committed suicide at age 21, PLATO believed that the first step is always reportedly over a broken relationship with a what matters most, particularly when dealing young woman he wanted to marry. Then, in with children. “That is the time when they are 1977, Pat Boyer was diagnosed with cancer and taking shape,” he wrote, “and when any impres- Charles devoted himself to her care. She died on sion we choose to make leaves a permanent August 23, 1978, and after her funeral, Charles mark.” quietly put his affairs in order. On August 25, Freud, writing some 2,000 years later, made two days before his 79th birthday, he took a fatal the same point: “The very impressions we have overdose of barbiturates. He was buried alongside forgotten have nevertheless left the deepest his wife in Holy Cross in . traces in our psychic life, and acted as determi- nants for our whole future development.” Brahmanism and suicide Among the earliest of the great cultures, Oriental sacred writings Boyer, Charles (1897–1978) French singer contained many contradictions about suicide. and actor who completed suicide just two days Although it was encouraged in some parts, it after his beloved wife died. Unlike so many of was vigorously condemned in others. Brahman- his Hollywood contemporaries, Charles Boyer ism institutionalized and sanctioned suttee, a married once and only once. ceremonial sacrifice of widows that was as com- Boyer was born in the country town of Figeac mon in China as in India. The Brahman doctrine in southwestern France. Charles was an only was sympathetic to suicide, for it was consonant child, the son of a self-educated merchant who with the denial of the flesh, a common objective dealt in farming implements and coal; his mother, in philosophies of the Orient. Louise, was an amateur musician. Charles was a Brahmanism is the religious and social system precocious, introverted child, whose father died of orthodox Hindus, interpreted and enforced by Buddhism 29 the Brahmans (the highest or priestly caste). acute morphine poisoning in Hollywood. His Their system of doctrine and religious obser- lifelong involvement with drugs and his lifestyle vances was codified c. 550 B.C., but has long in general prompted many authorities to classify since been simplified or modified in both theol- his behavior as that of a CHRONIC SUICIDE. ogy and ritual. It borrowed freely from newer Born Leonard Alfred Schneider, Lenny Bruce sects of the Vedic religions such as Buddhism was a brilliant satirist who created controversy and Jainism, to create the philosophical basis for because of his use of “dirty words” in his night- modern Hinduism in the Bhagavad-Gita and club comedy act. The satire and black humor of commentaries on the Upanishads. Bruce’s largely improvised shows often over- stepped the bounds of what was considered As is typical of many countries in South respectable in the 1950s and 1960s. Bruce was America, Brazil has a fairly low suicide rate, per- one of the first performers to usher in a new, haps related to the strength of the Catholic reli- more honest, more permissive, and more indul- gion on the continent. As of 1995, the national gent brand of American humor. rate of suicide was 4.2 per 100,000. This breaks down to a rate of 6.6 per 100,000 for men and bloodless means Methods of suicide that do 1.8 for women. However, indications are that not involve drawing of blood, such as toxic sub- the suicide rate varies widely from different parts stances, drowning, hanging, suffocation. of the country, and the reporting rates do not include all parts of the country uniformly. Buddhism The religious, monastic system, founded c. 500 B.C. by Buddha, the son of a British Voluntary Euthanasia Society See petty raja who ruled over a small community on EXIT. the southern border of the district now known as Nepal. Buddha’s family name was Gotama (in Sanskrit, Gautama), and it was probably by this Children who are broken homes and suicide name that he was known in life; it was only after victims of broken homes through either divorce his death that his disciples gave him the name or death may frequently begin to see themselves Buddha (“the enlightened one”). as either guilty or unloved, and sometimes both. One goal in Oriental mysticism is to divorce They can become increasingly despairing, angry, the body from the soul so that the soul might anxious, and depressed. The irony is that the occupy itself only with supersensual realities. more confused, the more depressed they be- Buddhism emphasizes that through of come, the more need they have for the parent or craving or passion, life’s chief purpose of acqui- parents who may no longer be there. They grow sition of knowledge could be achieved. into adolescence at one and the same time furi- Buddhists believe that suicide occurs because ous with their predicament but feeling guilty. of one’s lack of tolerance or patience toward Such children are often are potential suicides. stress. Although there is some sanction against Many experts in the field of suicidology see suicidal behavior in Buddhist concepts, it is nev- broken homes, latchkey children, and the shift- ertheless accompanied with sympathy, regret, ing state of the American family as among the and a feeling of mercy. Buddhists believe human several major reasons for the rising suicide rate life is stressful and that the individual who kills among children. himself is destined to remain in a hundred-year- hell and cannot expect in any form. Bruce, Lenny (1925–1966) Noted comedian Buddhism is based essentially on the doc- who died on August 3, 1966, at the age of 41 of trines that life is intrinsically full of suffering and 30 bulimia stresses self-denial and ascetic disciplines. There Experts believe that there is a relationship are a number of alternative forms of Buddhism, between bulimia and depression. One survey on collectively known as Mahayana, that have eating disorders showed 60 percent of the developed outside of India, generally marked by women studied in the project reported feeling proliferation of local deities (buddhas, bod- depressed most of the time; 20 percent had tried hisattvas), and religious observances drawn from suicide at least once. Bulimics also may experi- local . In its various forms, Mahayana now ence other serious side effects that range from claims almost half a billion adherents, especially ulcers to hernias, dehydration, stomach rupture, in China, Tibet, Korea, Japan, and Mongolia. and disturbance of the blood’s chemical balance that could cause heart attacks. The obsession bulimia A serious, potentially life-threatening with food is similar to an addiction to alcohol eating disorder characterized by a secretive cycle and generally ends in dominating the young of bingeing and purging. Bulimia is a distress sig- person’s life. nal that may be one of many signs of trouble in Treatment suicidal teenagers. Often called the “binge-purge syndrome,” bulimia is thought to be a disorder Bulimia is best treated when diagnosed early. with emotional and physical roots. Although not Unfortunately, even when family members con- clearly established, persons with eating disorders front the ill person, or physicians make a diagno- have been identified to be at significant in- sis, individuals with eating disorders may deny creased risk for completed suicide. that there is a problem. Treatment is vital, and Bulimia patients are 95 percent to 98 percent the sooner, the better, because the longer abnor- young girls, who are also usually white, single, mal eating behaviors persist, the harder it is to ambitious, educated, and mid-to-upper class. overcome the disorder and its effects on the body. Girls gorge and then purge in secret, in behavior In some cases, long-term treatment may be that some experts believe is potentially suicidal. required. Families and friends can play an impor- Bulimia affects between 1 and 3 percent of tant role in the success of the treatment program. middle school and high school girls, and 1 to 4 The complex interaction of emotional and percent of college-age women. People struggling physiological problems in eating disorders calls with bulimia, who often appear to be of average for a comprehensive treatment plan, involving a body weight, develop complex schedules or variety of experts and approaches. Ideally, the rituals to provide opportunities for binge-and- treatment team includes an internist, a nutri- purge sessions. Many people struggling with bu- tionist, a therapist, and someone who under- limia recognize that their behaviors are unusual stands medications useful in treating these and perhaps dangerous to their health, but can- disorders. The combined use of cognitive-behav- not stop. ioral therapy and antidepressant medications such as desipramine, imipramine, and fluoxetine Warning Signs was most helpful. The combination treatment is Warning signs include: particularly effective in preventing relapse once medications were discontinued. • self-induced vomiting • using laxatives to prevent weight gain bullycide Suicide in children that is triggered • an obsession with gaining weight by . The term was coined by writers Neil Marr and Tim Field in their book, Bullycide: Death • a fascination with food at Playtime. Victims of bullying have increasingly • rapid consumption of large amounts of food been identified as being at increased risk for • extreme guilt over food eaten. depression and suicidal behavior. burial 31 burial (for suicides) Since ancient times, 18th-century law required that a victim of sui- almost all cultures prohibited normal burial for cide be buried under the gallows. people who committed suicide, although the The degree to which such burial restrictions precise restrictions varied according to time and or penalties were applied varied from time to place. At the Council of Braga in 563, the time and place to place. In general the penalties Catholic Church condemned suicide—a position against the body of a suicide tended to lessen by that was subsequently confirmed by the councils the latter part of the 17th century, and even the of Auxerre (578) and Antisidor (590) and sanction of confiscation was handled more remained as canon law in 1284, when the Synod leniently. Important factors in such cases were of Nimes refused burial in consecrated ground to the social rank of the suicide and the family, as suicides. The one exception was for the insane. well as the circumstances of the suicidal act. The Carolina, the Criminal Constitution of Between 200 and 500 A.D., an increasing Charles V of Spain, in 1551 confiscated all prop- number of suicides was recorded among the erty of suicides who took their lives while under Jewish population, partly due to spiritual and accusation of a felony. More severe was the pun- social crises, and partly to a growing Roman ishment given to a corpse after the suicide. A influence. Now that suicide had become more common practice in England was to bury the frequent, it became less accepted. A person who suicidal person at a crossroad by night with a committed suicide forfeited his share of the stake driven through the heart. The practice was world to come and was denied burial honors. not discontinued until 1823. The Talmud decreed that suicides could not TACITUS, the Roman historian and distin- receive a eulogy or public mourning. They were guished lawyer, reports on “bog ,” the buried apart, in community . practice of pinning down the body with a stake. There was never universal agreement, how- This practice, confirmed by numerous authori- ever. Various scholars and legal authorities dis- ties, seems to antedate Christianity among the agreed on the matter, pointing out that Germanic peoples of Europe. The purpose was to extenuating circumstances generally accompa- ensure that the spirit of the dead person would nied any suicide. The big question was how to be not return to haunt or harm the living. certain that a death was truly a suicide. Attitudes toward the act of suicide remained If the act was prompted by madness, some conservative well into the 18th century. In fact, Jewish scholars believed the suicide should at that time suicide was equated with murder in be treated as an ordinary deceased person. Some many parts of Europe, and the corpse was legal experts of the time believed that while sui- treated accordingly. For example, in France cide was considered a crime against God, it could and England, the suicide’s body was dragged be explained rationally, understood, and for- through the streets, head downward on a sledge, given. This enlightened view has been in- on which criminals were dragged to their place corporated into the approach of the three of execution, and then strung up to hang denominations of modern Judaism. The gener- from public gallows. The French Criminal Ordi- ally accepted custom is to give burial and nance of August 1670 still decreed that the sui- last rites in a manner similar to any other de- cide’s body be dragged through the streets, and ceased person. then thrown into a sewer or onto the town In most Christian groups today, suicide is rec- dump. Because of spectator reaction against the ognized not only as an ethical-religious-social practice of dragging the corpse, the penalty sciences question, but also as a major medical was not carried out after 1768. Still, burial in problem. Many, if not most groups have revised consecrated ground was frequently denied to the harsh religious laws governing suicides. For people who committed suicide; in Prussia, early example, the Anglican Church and the Lutheran 32 Burnett v People

Church do not deny the victim of suicide a Burton, Robert (1577–1640) Oxford-edu- Christian burial. cated author of THE ANATOMY OF MELANCHOLY, first In the Catholic Church, the Code of Canon Law, published in 1621. The book is a curious com- Canon 1240, forbids Christian burial to “persons pendium of esoteric knowledge with reference guilty of deliberate suicide.” The late Richard to melancholy: its definition and causes; its var- Cardinal Cushing of Boston’s archdiocese inter- ious types; the life of man and the institutions of preted this to mean that the element of notori- society, all written in a style characterized by ety must be present in a suicide for the penalty high fancy, extravagance, outlandish imagina- to be incurred. “Hence, no matter how culpable tion, whimsy and affectation, and far-fetched it may have been, if it is not publicly known that figures of speech. the act was fully deliberate, burial is not to be Burton was sympathetic to the idea of suicide. denied,” he said. “Ordinarily, there is not too “These unhappy men are born to misery, past all great a difficulty in granting Christian burial to a hope of recovery, incurably sick; the longer they suicide, since most people these days consider live, the worse they are; and death alone must the fact of suicide to be a sign of at least tempo- ease them,” he wrote. His views were considered rary insanity.” courageous for the times. In general, Catholic funeral rites for a suicide Robert Burton is said to have hanged himself differ only in a relatively few instances from the to fulfill his own astrological prophecies about rites accorded those who have died a natural the date of his death. death. Exemption from sanctions on the grounds of mental disturbance or “temporary business cycle Some experts believe that sui- insanity” is more frequently granted than in the cide rates can be related to economic cycles. In past. this theory, suicidal behavior is determined by See also BURNETT V PEOPLE. both external and internal forces operating together. Burnett v People Leading U.S. case regarding People in high-status categories may experi- suicide. The 1903 case of Burnett v People states: ence greater frustration during downswings in “We have never seen fit to define what charac- business and less frustration during upswings in ter of burial our citizens shall enjoy; we have business than do those in “low-status” cate- never regarded the English law as to suicide as gories, according to this theory. applicable to the spirit of our institutions” (Bur- When the stock market crash occurred on nett v People, 68 N.E. 505 [Sup. Ct. IL, 1905]). The October 29, 1929, and stock prices plummeted, United States never adopted the English common a number of businessmen committed suicide as a law method dealing with suicide or suicide vic- consequence of their financial losses. These sui- tims, in which suicide was a felony and cides would appear to support the concept of attempted suicide a misdemeanor. In 1961, both “hope” as the basis of suicide theory. According British laws were abolished. to this theory, suicide occurs when the individu- In another famous American case, the 1908 als’s life outlook (for whatever reason or rea- Texas case of Sanders v State, it was declared: sons) is one of despairing hopelessness. Whether “Whatever may have been the law in En- or not one completes suicide in such a situation gland . . . so far as our law is concerned, the sui- depends upon a personality factor experts call cide is innocent of criminality” (Sanders v State, “the sense of competence,” which is related 112 S.W. 68 [Ct. Crimm App. TX, 1908]). inversely to the potential for suicide. C calcium channel blockers Drugs to treat zem (diltiazem), Procardia and Adalat (nifedip- high blood pressure that should be considered as ine), Calan and Isoptin (verapamil), Plendil a possible cause of depression and suicide. One (felodipine), Dynacirc (isradipine), and Nimotop study of 3,397 outpatients in 152 Swedish (nimodipine). municipalities revealed a five-fold greater inci- dence of suicide among those using calcium Camus, Albert (1913–1960) French philo- channel blockers than among patients using sopher and one of the most important authors of other antihypertensive drugs. No other cardio- the 20th century, who wrote of poverty, existen- vascular drugs studied were linked with suicide tialism, and the horror of human mortality. risk once the research team adjusted the data to Although born in extreme poverty, Camus account for varying rates of use. For this reason, attended the lycée and university in Algiers, the researchers conclude that the increased sui- where he developed an abiding interest in sports cide risk was unrelated to cardiovascular disease and the theater. His university career was cut itself. short by a severe attack of tuberculosis, an illness Previous research has suggested that the use from which he suffered periodically throughout of calcium channel blockers increases the risk of his life. After winning a degree in philosophy, he depression. This effect may constitute a link with worked at a variety of jobs, including journal- risk of suicide. ism. In the 1930s, he ran a theatrical company, Researchers suggest that the drugs may trig- and during World War II was active in the ger depression and suicide because they easily French Resistance. penetrate the blood-brain barrier, where they Author of such well-known works as The Fall, may be able to interfere with neurons and recep- The Stranger, and The Plague, he addressed the tors involved in the regulation of mood. issue of suicide in The Myth of Sisyphus and Other Although calcium channel blockers were Essays. In this work, he stated, “There is but one introduced within the past decade and are truly serious philosophical problem, and that is longer-lasting than other blood pressure medica- suicide. Judging whether life is or is not worth tions, they are also significantly more expensive, living amounts to answering the fundamental costing up to 15 times more than some diuretics. question of philosophy.” The shorter-acting versions have been shown to Camus ultimately affirmed the value of life, be dangerous. Now the longer-acting versions although he also wrote that “if one denies that are being shown to be ineffective and possibly there are grounds for suicide, one cannot claim dangerous as well, so some doctors believe the them for murder. One cannot be a part-time future does not look very promising for these nihilist.” In his Notebooks, Camus determined drugs. that “there is only one liberty, to come to Calcium channel blockers include Norvasc terms with death. After which, everything is (amlodipine besylate), Vascor (bepridil), Cardi- possible.”

33 34 Canada

Albert Camus won the Nobel Prize in litera- where there is increased availability of familiar- ture in 1957 for his “important literary produc- ity with guns. The most common nonfatal sui- tion, which with clear-sighted earnestness cide attempts in both sexes are drug overdoses illuminates the problems of the human con- and poisonings. science in our times.” He died in a car crash near The SUICIDE INFORMATION AND EDUCATION CEN- Sens at the age of 47 on January 4, 1960, as he TRE (SIEC), one of the world’s most extensive was returning to Paris from the southern part of resource libraries on all aspects of suicidal France. behaviors, is located in Canada. SIEC has devel- oped it own bibliographic database and provides literature searches, online access, and document Canada One in seven Canadians has seriously delivery. Publications include monthly newspa- considered suicide, and more than 3,500 Cana- per clipping services, a quarterly Current Aware- dians kill themselves each year. Canada’s suicide ness Bulletin, selected reading lists, and rate of 12.3 is consistently higher than the information kits on selected topics. United States’s rate of 11.2 per 100,000. Be- For contact information, see Appendix I. tween 1980 and 1986, Canada’s suicide rate ranked 22nd of 62 countries reporting statistics to the World Health Organization. Canadian Association for Suicide Prevention In 1997, Canadian men committed suicide at (CASP) A nonprofit Canadian organization a rate of 19.6 per 100,000, compared to the that was incorporated in 1985 by a group of pro- female rate of 5.1. Unlike other countries with a fessionals interested in reducing the suicide rate very high suicide rate among elderly citizens, in and minimizing the harmful consequences of Canada the group at highest risk for committing suicidal behavior. The group supports research, suicide was men age 45 to 64 (25.5 per holds conferences, and advocates for policy 100,000). Suicide rate among Canadian teens development. age 15 to 19 was 12.9; the rate for children age For contact information, see Appendix I. 14 and under was 0.9. Suicide is not illegal in Canada, but attempted Canadian Mental Health Association suicide was not removed from the country’s (CMHA) A professional group that provides a Criminal Code until 1972. However, counseling wide range of suicide prevention data and ser- suicide (sometimes referred to as “aiding and vices. The association has branches throughout abetting” suicide) remains a criminal act. the country, including the remote Northwest Mental disorders are a factor in more than Territories and the Yukon Territory. Though half of the suicides in Canada. These people typ- Canada does not have a nationwide system of ically suffer from an identifiable condition, most county mental health clinics as does the United often depression or alcohol/drug abuse. Native States, it does provide universal health insurance Canadians and in particular, young Native men, that includes treatment of both physical and are especially at risk. However, not all native mental illness. The CMHA has been instrumen- groups have high rates of suicide, and many tal in working closely with groups operating a native communities have suicide rates equal to vast nationwide network of suicide hotlines and or lower than the general population. distress centers. In Canada, the Salvation Army There are important differences between the also operates several suicide prevention agen- methods chosen by men and women. Regional cies. The country has branches of the SAMARI- differences in Canada depend in part on the TANS and CONTACT USA (in Canada called availability of the method. For example, death Tele-Care). by firearms is more common in rural areas, See also Appendix II. cancer and suicide 35 cancer and suicide Studies indicate that the There are also risk factors that are specific to can- incidence of suicide in cancer patients can cer patients. These include: be up to 10 times as common as suicide in the general public. While some studies suggest • having oral, pharyngeal, or lung cancers relatively few cancer patients complete suicide, (often associated with heavy alcohol and they are at increased risk for suicide. Men tobacco use) with cancer in particular are clearly at an in- • advanced stage of disease and poor prognosis creased risk of suicide compared to the general • confusion/delirium population. • inadequately controlled pain Indeed, experts have found that passive sui- cidal thoughts are relatively common among • problems such as loss of mobility, loss of bowel cancer patients, yet the relationships between and bladder control, amputation, sensory loss, suicidal tendency and the desire for a hastened paraplegia, inability to eat and to swallow, death, requests for PHYSICIAN-ASSISTED SUICIDE, exhaustion, fatigue. and EUTHANASIA are complex and poorly under- Treatment stood. A therapist should carefully assess suicidal can- Overdosing with analgesics and sedatives is cer patients to determine whether the underly- the most common method of suicide in the can- ing cause of the suicidal thoughts are due to a cer patient, with most cancer suicides occurring depressive illness or an expression of the desire at home. Reports identify a higher incidence of to have ultimate control over intolerable symp- suicide in patients with oral, pharyngeal, and toms. Prompt identification and treatment of lung cancers, and in HIV-positive patients with major depression is essential in lowering the risk Kaposi’s sarcoma. for suicide in cancer patients. A 1995 study of Experts suspect that the actual incidence of advanced cancer patients who expressed a con- suicide in cancer patients is probably underesti- sistent and strong desire for suicide suggested mated, perhaps because there may be a reluc- that this wish is, in fact, related to depression. tance to report death by suicide in these Patients with the desire to die should be care- circumstances. fully assessed and provided with help in treating General Risk Factors depression. Whether this desire to die would persist or decrease with improvement in mood There are a number of risk factors for suicide in disorder has not yet been studied. the general cancer patient. These include: The assessment of hopelessness is not • a history of psychiatric disorders, especially straightforward in the patient with advanced those associated with impulsive behavior disease with no hope of cure, but it is important (such as borderline personality disorders) to understand the underlying reasons for feel- ings of hopelessness, which may be related to • a family history of suicide poor symptom management, fears of painful • a history of suicide attempts death, or feelings of abandonment. • depression Treatment with therapy and antidepress- • hopelessness (an even stronger risk factor ants may be helpful in easing a cancer patient’s than depression) suicidal thoughts. On the other hand, the principle of respecting patient autonomy has • substance abuse been one of the driving forces behind the hos- • recent death of a friend or spouse pice movement and right-to-die issues that • lack of social support range from honoring living wills to promoting 36 carbon monoxide poisoning euthanasia. These issues can create a conflict Cardano, Girolamo (1501–1576) An Italian between patient autonomy and the doctor’s mathematician, physician, and astrologer well obligation to keep patient alive. known throughout Europe for his medical A 1994 survey suggests that hospice physi- prowess. cians favor vigorous pain control and strongly His unhappy childhood began after he was approve of the right of patients to refuse life born despite attempts to induce an . The support even if life is thereby shortened by this illegitimate son of the jurist Fazio Cardano and choice. However, these physicians strongly Chiara Micheri, his early years were marked by oppose euthanasia or ASSISTED SUICIDE, clearly frequent illness and unkind treatment by his making a sharp distinction between these two parents. In 1520, he escaped his family situation interventions. by enrolling at the University of Pavia, eventu- ally earning a medical degree from the Univer- carbon monoxide poisoning Carbon mo- sity of Padua. He set up a medical practice near noxide is a colorless, odorless gas that is used by Padua and married a local woman, Lucia Ban- more than 2,000 Americans each year to commit darini, with whom he had two sons and a suicide by intentionally poisoning themselves. daughter. Considered to be a “silent killer,” carbon monox- Reflecting on this time in his life in his auto- ide can cause sudden illness and death. biography, Cardano observed that “enterprises I It is found in combustion fumes, such as those have undertaken before the full moon have produced by cars, small gas-powered engines, turned out successfully.” It is clear that at least stoves, lanterns, burning charcoal and wood, this early part of his adult life was happy. and poorly functioning gas ranges or heating In 1534, Cardano and his family moved to systems. Carbon monoxide from these sources Milan, where he began teaching Greek, astron- can build up in enclosed or semi-enclosed omy, dialectics, and mathematics, marking the spaces; people and animals in these areas can be beginning of his active interest in mathematics. poisoned by breathing it. In 1539, he began writing mathematical trea- tises, while maintaining a growing medical prac- Symptoms tice. In 1543, he accepted the chair of medicine The most common symptoms of carbon monox- at the University of Pavia, and by 1552 he was ide poisoning are headache, dizziness, weakness, traveling as far away as Scotland to treat the nausea, vomiting, chest pain, and confusion. archbishop of Edinburgh. High levels of carbon monoxide can cause loss of Sadly, by the mid-1500s, his life began to consciousness and death. unravel. In 1560, his eldest son was accused of In addition to the effects already mentioned, trying to poison his wife while she was re- carbon monoxide exposure can cause long-term covering from childbirth, and eventually he psychiatric problems (more likely to occur in was beheaded. Calling his son’s problems “my older individuals) such as personality changes, supreme, my crowning misfortune,” Cardano dementia, and psychosis. was forced in disgrace from Milan, ending up as a medical professor at the University of Diagnosis Bologna. Unless suspected, carbon monoxide poisoning But Cardano’s troubles began to multiply. can be difficult to diagnose because the symp- Like many during the Renaissance, Cardano was toms mimic other illnesses. People who are always a firm believer in astrology, even travel- sleeping or intoxicated may die of carbon ing to England to cast the horoscope of the monoxide poisoning before ever experiencing young King Edward VI. In 1570, he was impris- symptoms. oned by the Inquisition for the heresy of casting Cato the Younger 37 the horoscope of Jesus Christ. An arch-believer placed the garland over Cassius and took his in the accuracy of his own craft of astrology, he own life. cast his horoscope and predicted the hour of his Mark Antony later committed suicide himself death. When the day dawned and found him in in Alexandria in 30 B.C. excellent health and safe from any harm, Car- dano committed suicide that day rather than Cato the Younger (95–46 B.C.) Born Marcus face the humiliation of having his own horo- Porcius Cato Uticensis, Cato the Younger was a scope publicly found to be in error. great-grandson of Cato the Elder, and was raised by his uncle Marcus Livius Drusus. Cato showed Cassius Longinus, Gaius (?–42 B.C.) A an intense devotion to the principles of the early Roman general and statesman who, with Mar- republic, and was considered the most honest cus Junius Brutus, led the conspiracy against and incorruptible man of ancient times. Called Julius Caesar. An honorable soldier with an “the conscience of Rome,” his Stoicism put him admirable amount of capability and power, Cas- above the graft and bribery typical of the times, sius was a man ruled by his own ambition and but his extreme conservatism and refusal to vanity, with an uncontrollable temper and a compromise made him unpopular with some of sharp tongue. his colleagues. During the civil war between Caesar and As a violent opponent of Julius Caesar, he was Pompey, Cassius commanded a fleet for Pompey. eventually exiled to Cyprus, and he and his Caesar won the war, but pardoned Cassius and party supported Pompey after the break with made him praetor (administrator of the courts) Caesar. He fought on the Pompeian side in the in 44 B.C., and promised him a governorship of civil war of 49 and governed Utica with great Syria. honor. However, Cassius helped murder Caesar later After Pompey’s forces in Africa had been that year, ostensibly to revive the republic. His defeated during the civil war by Julius Caesar, conspiracy, involving some 60 to 80 prominent Cato fell on his sword in Utica during an men, culminated in Caesar’s assassination in the unwatched moment, claiming that at last he was Senate on March 15, 44 B.C. Cassius and his free and bidding his people make their peace brother-in-law Brutus fled east and raised a large with Caesar. However, he was discovered by army, but Mark Antony aroused the populace those watching him and a doctor was called to against Caesar’s murderers; together with Octa- bandage him tightly. Knowing that Caesar’s vian, MARK ANTONY defeated Cassius and Brutus arrival in the city was imminent, Cato ripped at Philippi. through his bandaged abdomen and bled to While at Philippi, Cassius saw a troop of sol- death, literally taking his life with his own hands diers approaching and sent his best friend, rather than surviving to be pardoned by the man Titinius, to see if the troop was friend or foe. Due he believed would destroy the republic. to his nearsightedness, he asked his servant, Pin- He may have killed himself in part to spare darus, to stand on a nearby hill and make sure the city from attack by Caesar, but his undying Titinius was safe. When the friendly troop sur- hatred of Caesar was probably the main reason rounded Titinius to give him a garland to prove behind his particularly violent suicide. It was they were friends, Pindarus misunderstood and said he would rather die than give Caesar the thought they were attacking. When he reported pleasure of pardoning him in defeat. this to Cassius, the great statesman became dis- Cato is said to have read PLATO’s twice traught and asked Pindarus to hold his sword on the night before he killed himself. The Greek while Cassius ran it into himself. When Titinius philosopher CLEOMBROTUS is said to have been returned to camp and found Cassius dead, he inspired by the same book to drown himself. 38 celebrity suicides

In death, Cato’s stubborn determination was paint poisoning, urban rat control, and health praised as the highest example of Roman patrio- education. The Centers deal with programs that tism, but Caesar appears to have disliked Cato as include tracking, combating and publicizing epi- he disliked few men. When told of Cato’s sui- demic and disease outbreaks, foreign travel cide, Caesar is said to have spoken, as if to the (making health recommendations and setting living man: “I envy you this death, for you forth requirements), surveillance of interna- [denied] me the chance to save you.” tional health activities, training of foreign health Austere, humorless, puritanical, and unable workers, etc. The CDC will provide references, to compromise, Cato was a fanatic in defense of background materials, and photographs on liberty and the republic. For his steadfast hon- communicable diseases and other subjects, such esty and courage, he was deeply admired by as suicide. Americans in the Revolutionary period. Publications include The Morbidity and Mortal- ity Weekly Report and Surveillance Reports. celebrity suicides Studies done in the past have shown that suicide rates rise after the sui- Charondas Lawgiver of Catana, a Greek cide of a prominent person or celebrity has been colony in Sicily, committed suicide after discov- heavily publicized. For example, the youth sui- ering that he had broken one of his own laws. cide rate went up briefly after 23-year-old actor- The particular law forbade citizens to carry comedian FREDDIE PRINZE shot himself to death. weapons into the public assembly. Charondas Prinze, who skyrocketed to fame as costar of the momentarily forgot this, wore his sword into television series Chico and the Man, died in a Los the public meeting one day, and was re- Angeles hospital on January 29, 1977, 36 hours proached by a fellow citizen for violating one of after shooting himself in the head with a his own laws. “By Zeus,” said Charondas, “I will revolver. Prinze left a note in his apartment that confirm it.” He then drew his sword and killed read: “I cannot go on any longer.” himself. Another and more celebrated case in point is that of actress MARILYN MONROE. In the calendar Chatterton, Thomas (1752–1770) British month after she overdosed on sleeping pills, the writer and forger who committed suicide at the suicide rate in the United States rose by 12 per- age of 17, and who was subsequently trans- cent. Several of the suicides left behind notes formed by romantic poets of his age into the that linked their lethal acts to the movie star’s symbol of the doomed poet. presumed suicide. The son of a poor Bristol schoolmaster, Chat- And although Beatle John Lennon was a terton was a voracious reader and developed an murder victim, not a suicide, the youth suicide early interest in antiquities. Chatterton’s access rate increased noticeably after his death on De- to a chest in his uncle’s parish church, which cember 8, 1980. contained historical documents, enabled him to Studies suggest that sensational media cover- obtain scraps of ancient parchment. It was on age of suicide and other tragic deaths results in these scraps that at the age of 12 he began pro- an increase in suicide immediately afterward. ducing manuscript poems that he claimed were the work of a 15th-century Bristol monk and Centers for Disease Control and Prevention poet, Thomas Rowley. These were hailed as a One of six agencies of the U.S. Public Health Ser- magnificent find and many antiquaries were vice responsible for surveillance and control of taken in. communicable diseases, occupational safety and Initially, Chatterton’s audience was limited to health, family planning, birth defects, lead-based local antiquaries who were thrilled to learn of children and suicide 39 the existence of this early Bristol poet. But soon ture. While there were many critics, others be- Chatterton became more ambitious and began to lieved in the authenticity of the poems, and it send samples of his work, including some of the was not until the end of the 19th century that Rowley poems, to Town and Country magazine. experts finally began to accept that Chatterton Next, in an effort to impress Horace Walpole, was undoubtedly the true author of the Row- whose gothic novel, The Castle of Otranto, the ley poems. An original genius as well as a author had claimed to be a translation of a lost gifted imitator, Chatterton used 15th-century manuscript, Chatterton sent Walpole samples of vocabulary, but his rhythms and his approach his Rowley poems. to poetry were quite modern. As a result, After initially encouraging the young pro- the Rowley poems were eventually recognized digy, when Walpole was advised that the poems as modern adaptations written in a 15th- were not genuine, he returned them and ended century style. the correspondence, denouncing Chatterton Throughout the controversy, however, even in the process. After this crushing defeat, Chat- Chatterton’s harshest critics nearly all agreed terton went to London in 1770 to sell his that while he might have been a forger, he was poems to various magazines, but only one of also a genuine poet of enormous talent. The the Rowley poems was ever published during medieval beauty of poems like “Mynstrelles his lifetime (in Town and Country magazine in Songe” and “Bristowe Tragedie” revealed Chat- May 1769). terton’s poetic genius. After his rebuke by Walpole, Chatterton This gifted, rebellious youth later became an turned aside from poetry and began writing icon to the romantic and Pre-Raphaelite poets. political satire and magazine articles, usually Keats dedicated “Endymion” to Chatterton’s writing under pseudonyms. He was moderately memory, while Wordsworth dubbed him “the successful as a writer, and developed a reputa- marvelous boy.” To Shelley he was one of the tion of some note in literary circles. Despite his “inheritors of unfulfilled renown,” and remains achievements, he led the life of a pauper and today a symbol of the misunderstood poet. became severely depressed, dogged by health and financial problems. On the point of starva- See ABUSE, CHILD. tion, he was too proud to borrow or beg. child abuse Neighbors at Chatterton’s lodging house found his body lying on his bed on the afternoon children and suicide While most people rec- of August 25, 1770. According to a local sur- ognize the high incidence of suicide among geon, he was “a horrible spectacle, with features teenagers, many do not realize that children distorted, as if from convulsions.” He had swal- under age 12 are also capable of killing them- lowed arsenic three months before his 18th selves. Over the last several decades, the suicide birthday. rate among young children has increased dra- The first published collection of the Rowley matically. In fact, between 1980 and 1996, the poems appeared in 1777, seven years after Chat- suicide rate among children age 10 to 14 terton’s death, and was greeted with both enthu- increased by 100 percent. In 2002, suicide was siasm and skepticism. The poet Thomas Warton, the sixth leading cause of death for five- to 14- in particular, questioned the authenticity of the year-olds, and the third leading cause of death in Rowley poems and pronounced them forgeries preteens (10-to 14-year-olds). in his History of English Poetry. Most suicides in the five-to-14 age group are And so the great debate over Chatterton’s among those children age 12 to 14; it is fairly work began, eventually becoming a pivotal rare—but not impossible—for children under episode in the history of 18th-century litera- the age of 10 to take their own lives. Although 40 children and suicide official suicide rates are much lower for children Children are more likely to attempt suicide under 15, suicidal behavior has been reported shortly after a stressful event, such as a discipli- even in very young children. The reason why nary crisis, a recent disappointment or rejection suicide is so rare before puberty is not known, (such as a dispute with a girlfriend, bad grade, or but it is a universal phenomenon found in all failure to get a job). In addition, studies show countries. A likely explanation is that critical risk that children exposed to violence, life-threaten- factors such as DEPRESSION or exposure to drugs ing events, or traumatic losses are at greater risk and alcohol are rare in very young children. It is for depression and suicide. generally accepted that many suicides are unre- Youngsters who complete suicide are some- ported or misreported as accidents or death due what more likely to come from a broken home to undetermined causes (particularly for young than are other youngsters of the same ethnic children), and that the actual number of suicides group, although about 50 percent of children may be two to three times greater than official who kill themselves live with both biological statistics indicate. parents at the time of the death. Many children In the United States, youth suicide rates who complete suicide have had significant com- (uncorrected for ethnicity) are highest among munication problems with their parents. Chil- the western states and Alaska, and lowest in dren also may suffer from the effects of social the southern, north-central and northeastern problems such as divorce, poverty, negative peer states. Overall, the U.S. suicide rate of children pressure, drug abuse, and violence. under age 15 is twice the rate for all other Depression is also a significant risk for suicide countries combined. For suicides involving in children. About 5 percent of children in the firearms, the suicide rate in the United States is general population suffer from depression; chil- almost 11 times the rate for all other countries dren under stress, who experience a loss, or who combined. have learning, conduct, or anxiety disorders are Methods also at a higher risk for depression. Despite some similarities, childhood depression differs in Hanging is more common in early adolescence important ways from adult depression. Psychotic than in later years in all locations. The other most frequent methods by location include features do not occur as often in depressed chil- firearms (rural), asphyxiation (suburban), and dren, and when they occur, auditory hallucina- jumping (urban). tions are more common than delusions. Anxiety symptoms such as fear of separation or reluc- Risks tance to meet people, and general aches and Every child’s personality, biological makeup, and pains, stomachaches, and headaches, are more environment are unique, and both depression common in depressed children than in adults and suicidal thoughts in children are complex with depression. issues that involve a myriad of factors. A high proportion of children who attempt Some research suggests that there are two suicide had a close family member (sibling, par- general types of suicidal youth. The first group is ent, aunt, uncle, or grandparent) or friend who chronically or severely depressed; their suicidal attempted or completed suicide. Familial suicide behavior is often planned. The second type is the could be a function of imitation or genetics; if child who shows impulsive suicidal behavior genetic, it is not clear whether the inherited risk consistent with a conduct disorder, and who is related to underlying personality or predispo- may or may not be severely depressed. This sec- sition to mental illness. ond type of child often also engages in impulsive There is good evidence that more than 90 per- aggression directed toward others. cent of children who complete suicide have a children and suicide 41 mental disorder. The most common disorders problems, with increased irritability and aggres- that predispose to suicide are some form of sion and suicidal threats. Parents often say that mood disorder and certain forms of anxiety dis- nothing pleases these children, that they hate order. Although the rate of suicide is much themselves and everything around them. higher among children with , Parents should be aware of the following signs because of its rarity it accounts for very few sui- of children who may try to kill themselves: cides in this age group. Gender Differences • change in eating and sleeping habits Among children age 10 to 14, girls and boys • withdrawal from friends, family, and regular commit suicide in about the same numbers; this activities changes as they get older; once they reach • violent actions, rebellious behavior, or run- puberty, teenage boys are far more likely to com- ning away plete suicide than teenage girls. Controlled stud- • drug and alcohol use ies of completed suicide suggest similar risk • unusual neglect of personal appearance factors for both boys and girls, but with marked differences in their relative importance. • marked personality change Among girls, the most significant risk factor • persistent boredom, difficulty concentrating, for suicide is being depressed, which in some or a decline in the quality of schoolwork studies increases the risk of suicide 12-fold. The • frequent complaints about physical symp- next most important risk factor is a previous sui- toms, often related to emotions, such as stom- cide attempt, which increases the risk about achaches, headaches, fatigue threefold. Among boys, a previous suicide attempt is the most potent predictor, increasing • loss of interest in favorite activities the rate more than 30-fold. This is followed by • intolerance of praise or rewards depression (increasing the rate by about 12- • previous suicide attempts fold), disruptive behavior (increasing the rate by • depression (helplessness/hopelessness) twofold), and substance abuse (increasing the rate by just under twofold). • risk-taking behavior (acts of aggression, gun- play, and alcohol/substance abuse) Warning Signs • self-destructive behavior can occur among There are a number of warning signs among children as young as elementary school age, children under age 14 that they may be thinking and includes running into traffic, jumping about suicide. While young children may not be from heights, and scratching, cutting, or able to express their feelings in words, they may marking the body provide indirect clues in the form of acting-out or violent behavior, often accompanied by suici- • changes in physical habits and appearance dal threats. Among preschool children, those at • death and suicidal themes in classroom draw- risk for suicide may have a somber appearance, ings, work samples, journals, or homework lacking the bounce of their nondepressed peers. They may be tearful or spontaneously irritable A child who is planning to complete suicide may (not just upset) when they do not get their way. also complain of being a bad person or give They make frequent negative self-statements verbal hints such as: “I won’t be a problem for and are often self-destructive. In elementary you much longer,” “Nothing matters,” “It’s no school, children at risk may experience disrup- use,” or “I won’t see you again.” The child may tive behavior, problems in school, and peer give away favorite possessions or throw away 42 Chin, Larry Wu Tai important belongings, become suddenly cheerful All available evidence indicates that talking to after a period of depression, or experience hallu- a suicidal child lowers the risk of suicide. The cinations or bizarre thoughts. message should be: “Suicide is not an option. Help is available.” Parents of a suicidal child Treatment should suicide-proof the home, making sure all Any child who threatens suicide should always knives, pills, and guns are inaccessible. Any child be taken seriously. When a child says, “I want to who mentions suicide should receive immediate kill myself,” or “I’m going to commit suicide,” help, and should not be left alone, even if the parents and teachers should always take the child denies “meaning it.” If necessary, the par- statement seriously and seek help from a child ents should drive the child to a hospital emer- psychiatrist, child psychologist, family doctor, or gency room to ensure a safe environment until a other mental health care worker. Asking chil- psychiatric evaluation can be completed. dren whether they are depressed or thinking Teachers should know the school’s responsi- about suicide can be helpful, and will not “put bilities. Schools have been held liable in the thoughts in a child’s head.” Such a question courts for not warning parents quickly, or for not will provide assurance that someone cares and adequately supervising a suicidal student. Stu- will give a young child the chance to talk about dents should be encouraged to confide in teach- problems. ers and to let them know if they or someone Parents or teachers who notice any of the they know is considering suicide. A suicidal child warning signs above should talk to the child should not be “sent” to the school psychologist about their concerns and seek professional help or counselor, but should be escorted by a teacher if the worries persist. With support from family to a member of the school’s crisis team. If a team and professional treatment, children who are has not been identified, the teacher should suicidal can heal. notify the principal, psychologist, counselor, nurse, or social worker. Prevention Talking about suicide, depression, and mental Chin, Larry Wu Tai (1928–1986) Retired health issues is the best way to prevent suicide CIA analyst convicted of spying against the among children. This may be done in a health United States for the People’s Republic of China class, by the school nurse, school psychologist, for 33 years. He was found dead in his jail cell, guidance counselor, or outside speakers. Educa- apparently a suicide. tion should address the factors that make a per- Chin appeared to have suffocated himself son more vulnerable to suicidal thoughts, such with a plastic trash bag at the Prince William- as depression, family stress, loss, and drug abuse. Manassas Regional Adult Detention Center in “Turn off the TV Week” campaigns can increase suburban Virginia. A convicted spy, Chin was 63 family communication, especially if the family years old and faced two life terms in prison and continues with the reduced TV viewing. Parents fines totaling $3.3 million at his sentencing, should understand the risk of unsecured scheduled less than a month from the day he firearms in the home. killed himself. Peer mediation and peer counseling programs can make help more accessible, although it is critical that a child seek help from an adult if China China has the world’s largest number serious behavior or suicidal issues emerge. Many of suicides (more than 300,000 each year) not schools have a written protocol for dealing with just because of its large population. China also a student who shows signs of suicidal or other has a very high suicide rate per 100,000 popula- dangerous behavior, as well. tion—two to three times higher than that of the China 43

United States. China’s suicide rate, which corre- The Chinese government itself addressed the sponds to about 22 people out of every 100,000, problem of suicide among rural women by sug- is higher than in affluent Western nations such gesting that the country could cut its suicide rate as the United States, Canada, and Britain, but in half by keeping pesticides out of the reach of fewer than in places such as Hungary and desperate women in the countryside, according Lithuania, where the ratio is between 40 and 50 to the official Xinhua news agency. per 100,000. Oddly enough, both women and men over While it’s clear that suicide is a big problem in age 55 are also at increasing risk for suicide, China, it is also clear that the Chinese kill them- even though Chinese society has always selves for different reasons than do people in the revered the elderly. This may be in part because West. While 40 percent of all suicides in the the elderly Chinese commit suicide rather than world occur in China, depression there is three become a burden on limited resources for their to five times less common than in the West, and families. substance abuse, often viewed as another cause According to ELISABETH KÜBLER-ROSS,in of suicide, is much less common in China than in Death: The Final Stage of Growth, the Chinese the West. The Chinese also have emphasized the are not only a practical people, but also fatalis- social dimensions of suicide and have shown tic. She explains, “They believe that death is that it correlates with social problems. one of the true certainties in life, that when And while in the West, far more men in urban there is life as a beginning, there is death as an areas commit suicide, it is the exact opposite in ending.” China, where suicide is more common among The people of China have historically believed women; indeed, 50 percent of all suicides among in immortality, that the dead live on. They burn women in the world occur in China. The suicide paper money in order to provide the deceased rate is particularly high among Chinese women with spending money in the “other world,” and age 16 to 26. And since 70 percent of China’s 1.2 children in years past would sell themselves as billion people live in rural areas, it is not surpris- slaves so as to give parents a good funeral. When ing that 90 percent of the suicides occur in the the time came to cover the casket, the living countryside. would turn their backs toward the casket, so evil Women probably always have been at high spirits that might hover around the dead would risk for suicide in Chinese society, where their not follow them home. For similar reasons, the innate worth is considered to be low. However, Chinese preferred a patient to die in the hospital their suicide rate today seems to be related to rather than at home, because the house might social changes, as well as to continuing social be haunted if a family member died at home. To problems. The paternalism in Chinese families elderly Chinese, the hospital is still the best place has often led to abuse of women (especially to die. young women) in the past, which has been Suicide was common in pre-Communist intensified by economic developments of the last China—so common, in fact, that 19th-century two decades that have worsened the situation of missionaries were appalled. Deliberate overdoses rural women. Another factor for the high suicide of opium and drowning were the two most rate among Chinese women could be the one- preferred methods because they left the body child-per-couple policy in China. While this undisfigured for the afterlife. Committing sui- reduces the risk of a population explosion, it can cide on an enemy’s doorstep was the ultimate be a major blow to disempowered young women revenge because it rendered the house unin- in many rural areas who need to have more sons habitable and unrentable. Everyone believed and grandsons to raise their inferior status in a the house would be haunted by the of the world still ruled by patriarchal values. suicide. 44 cholesterol-serotonin hypothesis cholesterol-serotonin hypothesis A theory viating depression, and cholesterol appears to that suggests a link between suicide and low lev- directly affect serotonin levels. For example, els of cholesterol and a brain chemical called some studies have shown that lowering and rais- serotonin. Serotonin is also believed to be one of ing cholesterol levels in monkeys significantly the primary biological triggers of DEPRESSION. lowers and raises serotonin activity. So although Several studies have reported an association lowering cholesterol levels in humans does between lower cholesterol (and subsequent low reduce heart attacks, it may raise the risk of serotonin) and increased incidence of violent dying from other causes, including suicide. acts, including suicide. Scientists are clearly Recently, European researchers found a divided over this controversial finding. Given genetic mutation that appears to increase a per- the major impetus to prevent cardiovascular dis- son’s odds of committing suicide more than ease by using cholesterol-lowering drugs, not threefold. The gene affects the levels of the surprisingly cardiologists have been particularly chemical serotonin in the brain. The serotonin alarmed. They dismiss the aggression findings by levels are affected because the mutation reduces quoting the results of two large studies of cho- the ability of brain cells to absorb serotonin. lesterol-lowering drugs that found no link to It is well known that defects in serotonin accidents or suicide. However, other studies— uptake can cause depression, eating disorders, particularly a large analysis of several coronary and other mental illnesses. These genetic data disease primary prevention trials—showed that are consistent with a correlation between low lowering cholesterol via drugs and diet was serotonin uptake activity and violent behavior, associated with more suicides, accidents, and including violent suicidal behavior. violence. See also MENTAL ILLNESS. Several studies over the past five decades have reported that low cholesterol is associated with depressed mood. A link between choles- Christianity Self-destruction was common- terol-lowering and brain serotonin may have place in both Greece and Rome when Christian- direct relevance for a potential association ity was born. Suicide at the time was tolerated between low cholesterol and increased likeli- and, in some instances, actually encouraged by hood of suicidal acts. the Stoics, the Cynics, the Cyrenaics, and the Serotonin is a brain neurotransmitter that is Epicureans. Early Christians seem to have involved in the regulation of mood, appetite, accepted the prevailing attitudes of that era. The and impulse control; and problems with the Roman emperor Nero began the persecution of serotonin system have been linked to major the Christians. Because the life of an early Chris- depression and also with suicidal behavior. tian in the Roman Empire was intolerable, the Lower levels of serotonin function are associated Church’s promise that death would lead to ever- with an increased likelihood of, and increased lasting glory and redemption paved the way for severity of, suicidal acts during a depressive a flood of suicides and martyrdom, which would episode. not abate until a powerful religious figure arose Studies suggest that serotonin in the brain in the fifth century. may act as a kind of “restraining” neurotrans- In A.D. 413, the man who would become St. mitter. In healthy people the serotonin system Augustine—Augustinus, Bishop of Hippo in will discharge to suppress harmful impulses, but Roman Africa—began a comprehensive over- people with low levels of serotonin fail to ade- view of Christian theology. It was a project that quately suppress negative impulses. would take 13 years to complete. Encompassing Antidepressants that boost the level of sero- 22 books, The City of God Against the Pagans begins tonin in the brain can be very successful in alle- in the first book with the subject of self-murder. Christianity 45

Although the Old Testament mentions suicides there had been no official church position without adverse comment, Augustine takes the against it. Then, in 533, the Second Council of Fifth Commandment (“Thou shalt not kill”) at Orleans expressed the initial organizational its word. He also criticizes Judas for committing disapproval of self-destruction. In 563, the a second crime by hanging himself, even though Fifteenth Canon of the Council of Braga denied he was atoning for the earlier crime of betraying suicides the funeral rites of the Eucharist and the Christ. Ultimately, Augustine agrees with Plato’s signing of psalms. In 673, the Council of Here- argument that life is a gift of God and bearing ford withheld burial rites to any who committed suffering, instead of shortening it by suicide, is a suicide. And in 1284, the SYNOD OF NIMES refused measure of the soul’s greatness. suicides burial in holy ground. Voluntary martyrdom was common among Saint Thomas Aquinas (see AQUINAS, SAINT the early Christians, particularly when persecu- THOMAS) opposed suicide on the basis of three tion made life unbearable. Eusebius (ca. A.D. postulates, stating a belief that all life was a 260–ca. 340), bishop of Caesarea, tells of Chris- preparation for the eternal. Aquinas stressed the tians about to be tortured who committed sui- sacredness of life and absolute submission to cide, “regarding death as a prize snatched from God. the wickedness of evil men.” In fact, there was Four centuries later, JOHN DONNE, then dean virtually a pathological element present in the of St. Paul’s Cathedral, reacted to the church’s craving for martyrdom as expressed by Ignatius existing strict attitudes toward self-destruction. of Antioch in his letters, such as that written He believed suicide was neither a violation of to Rome’s Christian community. “I beseech church law nor against reason. His position was you . . .” he wrote, “Suffer me to be eaten by the soon supported by such secular philosophers as beasts that I may be found pure bread of Christ. DAVID HUME, Montesquieu, Voltaire, and JEAN- Rather entice the wild beasts that they may JACQUES ROUSSEAU. They insisted on greater free- become my tomb, and leave no trace of my dom of the individual against church authorities. body, that where I fall asleep I be not burden- “In modern times,” writes Rabbi Grollman in some to any. Then shall I be truly a disciple of Suicide, “Dietrich Bonhoeffer viewed suicide as a Jesus Christ, when the world shall not even sin in that it represented a denial of God.” Yet see my body. Beseech Christ on my behalf, that Bonhoeffer, the German Lutheran theologian I may be found a sacrifice through these in- who was hanged by the Nazis in 1945 at age 39, struments.” qualified his position to accommodate prisoners The Christians, then, saw their religion as of war who might commit suicide rather than offering a chance of martyrdom and an opportu- give out classified information that could injure nity to die as a blood-witness to Jesus Christ. or destroy the lives of others. Martyrdom, with its exalted emotionalism, Modern-day views and attitudes by Christians characterized large groups in the Roman Empire toward suicide are just as confused and contro- between the reigns of NERO and Julian (A.D. versial as were those of earlier times. Even 54–363). with the arrival and application of sociology, The Apostles did not denounce suicide; the psychology, psychiatry, and anthropology to the New Testament touched on the question of self- problem, Christian attitudes still vary widely. destruction only indirectly, in the report of Suicide is no longer a crime in any state, but aid- Judas’s death. So for several centuries, the lead- ing and abetting a suicide is against existing laws ers of the church did not condemn this wide- in 25 states. (States having specific laws regard- spread practice. ing assisting suicide are: Alaska, Arizona, Cali- Augustine (see also AUGUSTINE, SAINT) was the fornia, Connecticut, Delaware, , Hawaii, first to denounce suicide as a sin. Until then, Indiana, Kansas, Maine, Minnesota, Mississippi, 46 chronic suicide

Montana, Nebraska, , New Jer- Today, ethical-religious approaches are sey, New Mexico, New York, Oklahoma, Oregon, counter-balanced with the broader perspectives Pennsylvania, South Dakota, Texas, Washing- of the social sciences, according to Grollman. ton, and Wisconsin.) And Christian church Increasingly, suicide is being recognized not only authorities of varying faiths continue to regard it as a religious question, but as a major medical as a sin against God. Suicide is still covered up by problem. many, whispered about, and concealed in many instances. The Christian faith has always extolled the chronic suicide Term coined by Dr. KARL virtue of suffering, with its “ennobling” effects, MENNINGER, noted psychiatrist and the best- as DORIS PORTWOOD points out in Common-Sense known proponent of Freud’s theory that suicide Suicide: The Final Right. Catholic spokesmen con- is aggression turned upon the self. Menninger, in tinue to often call suffering “the greatest possible his 1938 book Man Against Himself, called source of heroism, purification and redemption.” “chronic suicides” those individuals who might Protestant clergy continue in many cases to cite find the idea of killing themselves to be repug- Job’s rejection of suicide, despite his trials, as nant, but who nevertheless choose to destroy evidence that the Bible is opposed to self- themselves slowly by way of drugs, alcohol or destruction. other methods. Behind their denial syndrome Portwood contends that “The analysis of they justify their actions by, in Dr. Menninger’s Christ’s death on the cross also is variable.” She words, “claiming that they are only making life writes that “many people, within and without more bearable for themselves.” the Church, consider Christ’s death a premedi- tated suicide—a deliberate sacrifice that, given chronic suicider A person who attempts his powers, he certainly could have avoided.” repeated acts of suicide. Others, obviously, consider such an analysis as blasphemy. There are today a number of “progressive” classification of suicides The idea that there Christian denominations that distribute study lit- are different types of suicidal behavior. erature on the option of EUTHANASIA. Nor is sui- ÉMILE DURKHEIM, a 19th-century sociologist, cide consistently rejected as an alternative to life conducted a pioneering study of the sociology of by some churchmen, even for themselves. One suicide. His detailed work, Le Suicide, was pub- such instance was the now famous attempted lished in 1897. Durkheim maintained that sui- double suicide of Dr. Henry Pitney Van Dusen cide was more easily understood and explained and his wife in 1975. He had been head of the as a reaction by the suicide to the peculiarities of Union Theological Seminary and enjoyed world society. Durkheim identified four types of suici- recognition. In 1970, Dr. Van Dusen suffered a dal behavior, basically falling at the extremes of stroke and lost the speaking facility that played two groups. The first is characterized by the such a key role in his professional life. His wife extremes of integration, and the second group suffered from arthritis. In late January 1975, they by extremes of regulation. took massive doses of sleeping pills. Mrs. Van At one extreme of the integration concept lie Dusen died peacefully, but her husband was hos- the “egoistic suicides,” which occur, according to pitalized and lived until mid-February of that Durkheim, when a person feels alienated from year. The famous couple’s own simple note said, society and has few binding ties to family, “Nowadays it is difficult to die,” and added, “We church, business, education, or social groups. feel that this way we are taking will become The egoistic suicide victim is usually lonely, more usual and acceptable as the years pass.” unmarried, and unemployed. But sometimes it Cleopatra 47 maybe represented by the self-destruction of a cide was the most logical and desirable of all teenage runaway who finds herself alone and ways to die. After Zeno hanged himself at age friendless in a strange town. 98—a true Stoic—Cleanthes took over as leader “Altruistic suicide” is at the other extreme and of the Stoic school. is the opposite of egoistic self-destruction. It Cleanthes was originally a wrestler, and in comes about with people so caught up with a this capacity he first visited Athens, where he particular cause of the ongoing values of their became acquainted with philosophy. Although society that duty takes precedence over their poor, he was determined to study with an emi- own individual needs. The young Japanese nent philosopher, and chose Zeno. For many PILOTS during World War II are a clas- years Cleanthes was so poor that he was sic example of altruistic suicides. They sacrificed compelled to take notes on Zeno’s lectures on their lives to crash their planes into Allied war- shells and bones, since he could not afford to ships. The national military authority over the buy better materials. He remained a pupil of kamikaze pilot was so pronounced that he lost Zeno for 19 years. his own personal identity and instead wished to At the age of 99, Cleanthes developed a boil sacrifice his life for his country. on his gum, and was advised by a doctor not to Along the other continuum, that of regula- eat for two days to allow the boil to heal. After tion, at the two extremes are ANOMIC SUICIDES fasting, he decided that since he had come that and FATALISTIC SUICIDES. Durkheim never fully far on the road toward death, he might as well developed the concept of fatalistic suicides, go all the way, and so he starved himself to which referred to suicides as a result of exces- death. sive constraints and repressive regulations in society that limited choice and reduced oppor- Cleombrotus Greek philosopher said to have tunity. been inspired by Plato’s Phaedo to commit suicide Durkheim’s category of anomic suicides, how- by drowning. It was in Phaedo that PLATO made ever, was expounded fully, and referred espe- SOCRATES repeat the Orphic doctrine—before he cially to the confusion and sense of loss when drank hemlock—that suicide was not to be tol- traditional values and mores underwent marked erated if it seemed like an act of wanton disre- or rapid change. Talcott Parsons, a noted sociol- spect to the gods. Plato used the simile of the ogist, writing in International Encyclopedia of the soldier on guard duty who must not desert his Social Sciences, says that in this state of the social post, and also that of man as the property of the system, some or many of its members reach the gods, who are as angry at our suicides as we point where they “consider exertion for success would be if our chattels destroyed themselves. meaningless, not because they lack capacity or opportunity to achieve what is wanted, but Queen of Egypt who because they lack a clear definition of what is Cleopatra (69–30 B.C.) killed herself, most likely by the bite of an asp. desirable. . . . It is a pathology of the collective Cleopatra was born in 69 B.C. in Alexandria, nominative system.” Egypt, and inherited the throne when she was See also TERRORISM AND SUICIDE. 18 upon the death of her father, Ptolemy Auletes. Cleopatra was a strong-willed, brilliant Cleanthes (331–232 B.C.) Philosopher and Egyptian queen who dreamed of a greater world successor to ZENO, founder of the STOICS, a philo- empire. sophical school that taught that pain and plea- Married to her young brother to fulfill Egypt- sure, poverty and riches, and even sickness and ian law, Cleopatra eventually had liaisons with health, were equally unimportant, and that sui- both Caesar and MARK ANTONY. After Antony 48 clergy and suicide prevention was defeated by Octavian during the defense of treating suicidal people after they had tried to kill Alexandria, he was given a false report of Cleo- themselves rather than attempting intervention patra’s death, and committed suicide by falling beforehand. The Salvation Army’s antisuicide on his own sword in 30 B.C. department exists to this day, though much of its After Antony’s death, Cleopatra was taken to work has been taken over by other organizations Octavian, where she was told she would be dis- in England. played as a slave in the cities she had once ruled. Another major suicide prevention organiza- Unable to face this humiliation, Cleopatra had tion started in England in 1953, and now oper- an Egyptian cobra called an asp brought to her, ating centers in 26 countries of the world, is the hidden in a basket of figs. The Egyptian religion SAMARITANS. The Reverend CHAD VARAH started declared that death by snakebite would secure the organization in London in 1953 with the immortality, which was her dying wish. notion of “befriending” suicidal people. Today, all of the Samaritan centers, both in the Com- monwealth and in the United States, are staffed clergy and suicide prevention Members of by volunteers who act as substitute families or the clergy have been a valuable resource in the close friends to people who come to them, offer- area of suicide prevention. Frequently when a ing love, care, compassion, and companionship. parent or a teacher suspects that a young person The inspiration for the various Samaritan pro- is having problems, the pastor, priest, or rabbi is grams is not spiritual—they gain only their the first person to whom they turn. The poten- name from the parable of the Good Samaritan— tial suicide will often confide in a clergyman or and their approach is always secular, pragmatic, woman before they will anyone else—because and nonsectarian. they view them as people who understand their At the time the Samaritans was founded, futility and anguish, yet won’t betray their con- Chad Varah was rector of St. Stephen Wal- fidence. brook, one of the City of London’s historic Spread throughout the United States are churches. An honors degree in philosophy from about 250 suicide prevention and crisis centers Oxford University, considerable success as a that help suicidal people cope with life crises. professional journalist, and the care of a num- Many of the trained volunteers and coun- ber of Anglican parishes all helped to prepare selors who work at such centers are members of the Reverend Varah for his work with the the clergy. They provide a lifeline for those dis- Samaritans. traught people who call them on hotlines. A suicide prevention service network that has Clergy volunteers take part in the same inten- a more directly religious orientation is Contact sive training program as others to learn how to Teleministries USA (see CONTACT USA). The orga- handle emergency problems they constantly nization boasts more than 100 telephone coun- face. They do not attempt long-term therapy, but seling ministries throughout the United States. concentrate only on coping with emergencies They try to listen to and help any suicidal person and immediate crises. For extended therapy, the in distress. Contact Teleministries USA is a Chris- clergy volunteers usually refer callers to profes- tian ministry whose aim is “sharing the goodness sional psychiatrists, psychologists, social work- of God’s compassionate love with each and ers, or other qualified counselors who work with every person.” They ask their telephone volun- particular centers. teers to “undertake to counsel in accordance It was the clergy who first developed the idea with Christian insight.” Contact is an American of a community center to help prevent suicide. affiliate of Life Line International, a worldwide In 1906, a center was established in England by organization with the same mission (in Canada members of the SALVATION ARMY. It aimed at called Tele-Care). clues of suicide 49

In Boston, Massachusetts, Father Kenneth B. • Changes in school performance, lowered Murphy organized Rescue, Incorporated, in grades, cutting classes, dropping out of activi- 1959. The nondenominational agency, located at ties Boston’s City Hospital, uses the volunteer ser- • Personality changes, such as nervousness, vices of over 70 clergymen and women and also outbursts of anger, or apathy about appear- the help of medical professionals. ance and health For the person who is threatening suicide, the • Use of drugs or alcohol various suicide prevention and crisis center orga- nizations extend life-saving assistance, compas- • Recent suicide of a friend or relative sion, and support. • Previous suicide attempts Pastoral volunteers and counselors who have taken special training in social work, psychology, Three-fourths of those who kill themselves and suicide prevention techniques can be ex- have seen a physician within at least four tremely helpful to the suicidal person, but un- months of the day on which they commit sui- trained members of the clergy working at suicide cide. People who threaten suicide usually mean prevention centers do not pass themselves off as it, at least unconsciously. They just haven’t yet substitutes for effective psychotherapists. decided on the how or when. If conditions in that Suicide prevention and crisis centers accred- person’s life fail to change, he or she will soon ited by the American Association of Suicidology set a time and choose the method of self- (AAS) are listed in Appendix II. destruction. See also SUICIDE PREVENTION ADVOCACY NET- When people are suicidal, there is no single WORK. trait by which all of them can be characterized. Always, however, they are disturbed and often they are depressed. The various verbal or behav- clues of suicide Most people who seriously ioral “hints,” some obvious, others subtle, intend suicide leave discernible clues to their should be taken seriously. A suicide attempt, no planned action. At times, the warnings take the matter how feeble or unlikely to succeed, is stark form of broad hints; at other times, there are testimony of the suicidal state. Suicide attemp- merely subtle changes in behavior. But the sui- tors do want attention and, without it, they may cide decision is seldom impulsive; usually, it is well succeed in their next attempt. premeditated. Four out of five persons who succeed in tak- The following are clues or warning signs of a ing their lives have previously given clues of potential suicide: their imminent action. Even the vague clues often predict a suicide accurately. Once a person • Preoccupation with themes of death or has finally decided to kill himself, he begins to expressing suicidal thoughts act differently. • Giving away prized possessions, making a will, Those “different” actions, both verbal and or other “final arrangements” behavioral, become the clues or warning signs of a potential suicide. • Changes in sleep patterns (either too much or Though these clues to suicide are not espe- too little) cially difficult to recognize, it is not that easy to • Sudden and extreme changes in eating habits, determine just how close the disturbed person losing or gaining weight may actually be to a suicide attempt. Trained • Withdrawal from friends and family or other professionals or volunteer staff members of any major behavioral changes, accompanied by suicide prevention center or service can predict a obvious depression suicide with more than chance accuracy. 50 cluster suicides

See also DEATH WISH; EATING HABITS; FRIENDS; tiveness of the individual whose death is being IMPULSIVENESS; INSOMNIA; IRRATIONALITY; MOOD reported and the amount of publicity given to SWINGS; RECKLESS DRIVING AS SUICIDE CLUE; WILL, the story. LOSS OF; WITHDRAWAL. Prevention The CENTERS FOR DISEASE CONTROL developed cluster suicides A chain of completed suicides guidelines for a community response to a suicide by people in neighboring geographic areas. cluster. The recommendations include: Every year, 100 to 200 American youngsters die in suicide clusters, and there are signs that the • creating a coordinating committee from com- rate is rising. These estimates do not include munity: education, public health, mental clusters of attempted suicides, since there is no health, local government, and registry of suicide attempts. centers Still, suicide clusters in general—whether • responding in a way that minimizes sensa- multiple simultaneous suicides or a series of sui- tionalism and avoids glorifying the suicide vic- cides occurring close together in time—may tims account for no more than 1 percent to 5 percent of all youth suicides. Nevertheless, when a sui- • evaluating and counseling close friends of the cide cluster does occur, an extraordinary amount deceased and suicide attempters who may be of community effort and resources is temporar- at high risk. ily devoted to suicide prevention. Suicide contagion is not a new phenomenon. In the past, other groups have seen waves of Evidence of suicide clusters has been reported in suicides, including Roman circus performers, accounts from ancient times through the 20th early Christian church followers, and Viking century. Concern about suicide clusters has warriors. Early in 1987, south Florida counted deepened after a number of highly publicized eight elderly murder-suicides. But for a problem suicide outbreaks among teenagers and young that has been around since at least the fourth adults in recent years, and because of new evi- century B.C., when a series of self-inflicted hang- dence that a significant number of suicides ings took place among the young women of the appear to be associated with suicide stories in the Greek city of Miletus, all evidence points to the mass media. youth suicide cluster phenomenon being on a Suicide clusters have been reported among dramatic increase during the 1980s. psychiatric inpatients, high school and college stu- Sometimes called the “Werther syndrome,” dents, Native Americans, Marine troops, prison after the 1774 novel The Sorrows of Young Werther inmates, and religious sects, although U.S. suicide by JOHANN WOLFGANG VON GOETHE (which re- clusters occur predominantly among teenagers sulted in many young men committing suicide and young adults. While clusters have included in imitation of the book’s central character), friends or acquaintances in the same school or clustering is thought by some authorities to be church, it is not necessary for those who complete triggered by the media. Other experts openly suicide in a cluster to have direct contact with one speculate that such TV movies as ABC’s “Surviv- another: sometimes knowledge of the first sui- ing,” might also play a key role in young people’s cides was obtained through the news media. suicidal behavior. Scientists generally agree that prominent media coverage of a suicide increases suicide Cobain, Kurt (1967–1994) Musician, leader behavior in those who view the coverage. The of the grunge band Nirvana who took his life at magnitude of the increase is related to the attrac- age 27. Cobain was a driving force behind the college students 51 grunge music scene, but struggled with chronic Suicide among this age group is extremely dif- health problems, depression, and substance ficult to investigate, and because so few college abuse. students kill themselves, the small studies that Born in Aberdeen, Washington, Cobain examine the problem can suggest only tentative dropped out of high school and left home in his conclusions. Despite their limitations, however, late teens. He married Courtney Love on Febru- some of these studies do suggest that certain stu- ary 24, 1992, and shot himself two years later. dent groups may have much higher rates of sui- cide, and that suicide may be more prevalent cocaine Cocaine use is associated with a among students attending some elite schools in much higher risk of suicidal behavior and suici- the United States, ENGLAND, and JAPAN. For ex- dal thoughts in depressed people. Cocaine abuse ample, foreign students in American and British is also one of the top predictors of suicide among schools have a much higher suicide rate. In the teenagers. Moreover, teens having parents with 1950s, when these studies were done, foreign cocaine use disorder were 3.5 times more com- students had a suicide rate of 80 per 100,000— mon among those in the suicide attempter group many times higher than the rate of their nonfor- than among those in the non-attempter group. eign peers. Researchers suspected that social Although no statistics are available to indicate isolation, which is a particular problem for these a direct correlation between suicide rates and foreign students, may have been the cause for their higher rate. use of the illegal and addictive drug cocaine, The most common factor among college authorities do know that drug overdoses in gen- suicide is mental illness—in particular, mood eral claim about 7,000 lives in the United States disorders such as clinical DEPRESSION and BIPOLAR annually. In 1984, the U.S. drug overdose death DISORDER. And while suicide is not more fre- figure was projected at 6,994, according to fed- quent in any of the four years of college, it does eral government sources. occur more often with students who take more Cocaine leads from a quick high to a crash than four years to earn their degrees, perhaps that most users relieve by taking either heroin or because this group includes many students more cocaine—then more and more as tolerance whose studies were interrupted by serious for the drug increases. People have become sui- depression or other emotional problems. cidal during the “down” periods following The impact of mood disorders, which often cocaine use, as they have when “crashing” from appear between age 18 and 25, is heightened other drug use. This is usually a time of extreme by drinking—a staple of college life. Many depression, and some users have also become people with depression drink or use drugs to suicidal as a result of losing touch with reality ease their symptoms. But alcohol and drugs and imagining themselves capable of unrealistic more often worsen the pain they were feats and immune from all danger. intended to alleviate. Substance abuse under- mines the students’s willingness to seek out and college students Suicide is the third leading receive good clinical care and sabotages the cause of death among young people. For those effectiveness of treatment. Substance abuse of college age, it is the second leading cause reduces inhibitions and increases risk-taking, (after accidents). In addition, the suicide rate is reinforcing tendencies toward self-destruction. higher among 19- to 24-year-olds enrolled in One recent study of campuses showed more college than it is for those who aren’t enrolled. than half the students completing suicide were Since 1950, the suicide rate among college-age intoxicated, and a slightly larger number were women has more than doubled, while the rate thought to have a significant substance use among college-age men has tripled. problem. 52 Common Sense Suicide: The Final Right

In addition, college students who complete Common Sense Suicide: The Final Right A suicide have different personality traits from nonfiction book by the late DORIS PORTWOOD that other students. While most young adults who is a carefully researched examination of what complete suicide have impulsive, high risk-tak- has been called “the last taboo” in our society: ing personalities, and abuse drugs and alcohol, suicide. The book is a thought-provoking state- college students who kill themselves are usually ment of the right to suicide for certain members depressed, quiet, socially isolated young people of society. She addressed the audience of which who do not abuse alcohol or drugs. Many col- she was herself a member: the aging. lege students feel depressed and rejected by their Her theme: Increased longevity has its families, and struggle to be accepted by doing rewards, but when the penalties get too high, well in school or athletics. the self-destruct mechanisms built into all living Many suicidal students experience anxiety organisms should be freed for people, and it and insomnia, although these may disappear must be our choice what price we, sane and shortly before the suicidal act, as the plan to long-living, ought to pay for the time we do or complete suicide provides a seeming solution to do not linger. their psychic pain. When they do go for help, few report their suicidal intentions or get any communication of suicidal intent Before psychiatric treatment, even though nearly half their attempted death, suicidal people leave a the suicidal students seek some medical treat- discernible trail of hints—sometimes subtle, ment in the months before completing suicide. often obvious—of their intentions. Every suicide Experts suggest that schools should prepare attempt is a serious cry for help. If the cry is plans in case a suicide does occur on the campus, heard and duly acted upon, suicide can usually focusing on outreach to survivors and on pre- be prevented. Most obvious communications are venting suicide contagion by managing the the cries of those who threaten, “I’m going to kill information that is presented to the press and myself.” They should be taken seriously, as public. As few suicides occur on each campus, should such angry asides as “I wish I were dead,” however, few schools have prepared such plans or “Everyone would be better off without me.” for managing the acute disruption in campus life All such dejected or rage-filled remarks are real that follows a suicide. communicative clues to suicide intent. All too Authorities attribute a number of reasons to seldom are they taken seriously. the college suicide rate: living away from home for the first time; stress and tension caused by verbal direct: “I will shoot myself if you leave academic pressures; competition for jobs upon me.” graduation; alcohol and/or drug abuse; loss of verbal indirect: “A life without love is a life self-esteem and self-worth; feeling unloved and without meaning.” unwanted; pessimistic outlook concerning the behavioral direct: Hoarding pills by a chroni- future; sense of failure; alienation; emotional cally ill, severely disabled person. emptiness and/or confusion; lack of self-confi- behavioral indirect: Giving away prized pos- dence; and general feeling and attitude of sessions, loss of appetite, insomnia. despair and hopelessness. One study found that in a random sample of The indirect communications, both verbal and 792 college students, 30 percent had entertained behavioral, become significant when evaluated suicidal thoughts during an academic year. One in context; that is, they are not in and of them- study of college freshmen shows 70 percent had selves a communication of suicidal intent but actually experienced suicide thought(s) in a become so when they occur along with other given school year. clues and communications. Compassionate Friends 53

In addition, “blocked communication” is a Method Restriction factor in suicide cases. In one study, 90 percent Preferred methods for suicide differs among men of teenage suicidals admitted they could not talk and women, and among different countries and with their parents. Researchers concluded that cultures. In the United States, the most common the most common factor in the continuing method for completed suicide is by firearms; chaos and unhappiness in the young person’s it has been suggested that reducing firearms life is the lack of parental appreciation or under- availability will reduce the incidence of suicide. standing. Indeed, studies show that one of the However, an experiment in Great Britain sug- two factors that indicate serious trouble ahead gests this is unlikely. The favored suicide method for suicidal children was poor or disordered there at one time was asphyxiation with coal parental communication. (The other factor: gas, but this became impossible after the intro- “overly critical, overly involved or actively hos- duction of natural gas. This resulted in a marked tile parenting style.”) but short-lived decline in the suicide rate. As Dr. Mary Giffin says in A Cry for Help, “The Within a decade, however, the suicide rate had child who can talk about his pain—and his plans returned to previous levels, as suicides were —to someone who is really listening can usually being completed by other means. work out or, at least, work on his problems. The Therefore, while reducing access to firearms child who can’t talk is the child who may commit with gun-security laws reduces accidental deaths suicide.” Giffin adds, “Remember, teens who from firearms, there is no evidence to date that need help don’t ‘grow out of it.’ They become such laws have a significant impact on suicides adults who need help—if they live that long.” attributable to firearms. Any temporary decrease See also CLUES OF SUICIDE. in suicide rate by firearms would probably be reversed as people chose alternative means of community-based suicide prevention Most killing themselves. public health approaches to suicide prevention have included CRISIS HOTLINES, restrictions on Media Counseling access to suicide methods, and media counseling Even though it appears prudent for reporters to minimize imitative suicide. and editors to minimize coverage of youth sui- cide in general and attention to individual sui- Crisis Hotlines cides, there is as yet no evidence that these Although crisis hotlines are available almost guidelines, issued by the CENTERS FOR DISEASE everywhere in the United States, research has CONTROL AND PREVENTION, are effective in reduc- failed to show that they reduce the incidence of ing the suicide rate. suicide. Perhaps actively suicidal individuals do not call hotlines because they are acutely dis- turbed, preoccupied, or intent on not being community resources See SUICIDE PREVEN- deflected from their intended course of action. TION CENTERS. In addition, hotlines are often busy, and there may be a long wait before a call is answered, so Compassionate Friends A national nonprofit, that callers disconnect. Moreover, the advice a self-help support organization that offers friend- person gets after calling a hotline may be stereo- ship and understanding to bereaved parents, typed, inappropriate, or perceived as unhelpful grandparents, and siblings. There is no religious by the caller. affiliation, and there are no membership dues or And while men are at highest risk for com- fees. The Compassionate Friends helps families mitting suicide, gender preferences in seeking deal with grief after the death of a child of help mean that most callers are women. any age, and offers brochures and information, 54 competition sponsors an annual conference, and maintains Children in Japan do not get a second or third an active website. chance; in fact, they must even pass a written The Compassionate Friends was founded in examination to enter a “good” kindergarten. The Coventry, England, in 1969, after the deaths of latter is a must to enter into a good primary two young boys, Billy Henderson and Kenneth school which, in turn, becomes a prerequisite Lawley. Billy and Kenneth had died just three for a good high school and ultimately to a good days apart, and a bond was formed between university. the two sets of parents as they shared the memo- Thus, it isn’t surprising that the suicide rate in ries and the dreams that had died with Billy and Japan rises every February as students write Kenneth. They continued to get together regu- their various entrance examinations. Failure to larly, slowly adding other grieving parents to their get through “examination hell,” so called by the group, until they decided to organize as a self- youngsters, means shame for the student and his help group and actively begin reaching or her family because chances for later-life suc- out to newly bereaved parents in their commu- cess are thereby greatly reduced. nity. Because the word compassionate kept coming Suicide rates for young people run higher in up, they called the new organization “The Society Japan than in the United States, but the rate for of the Compassionate Friends.” Word of the orga- young men in the United States has lately sur- nization spread rapidly around the world, via passed Japan’s rate. In 1964, there were 9.2 sui- interest generated by TV coverage and the cides per 100,000 men in the 15 to 24 age group columns of Dear Abby and Ann Landers. The in the United States. The rate in Japan was 19.2. Compassionate Friends was incorporated in the But in 1977, the Japanese rate was unchanged United States as a nonprofit organization in 1978. while the U.S. rate had soared to 21.8. In 1982— There are now Compassionate Friends chap- the last year for which data are available for both ters in every state in the United States—almost countries—the Japanese rate was 14.5 compared 600 altogether—and hundreds of chapters in to the higher U.S. rate of 19.8 suicides per CANADA, Great Britain, and other countries 100,000 males in the same 15 to 24 age group- throughout the world. In the United States, ing. Experts see this as an indication that career chapters are open to all bereaved parents, sib- and grade competition is becoming more intense lings, grandparents, and other family members in America. who are grieving the death of a child of any age, Germany also has a high youth suicide rate, as from any cause. well as educational competition similar to that in Japan. In 1982, the suicide rate for men in the 15 to 24 age group was 20.9; the rate dropped competition It appears that intense competi- slightly to 19.4 in 1984. For women, age 15 to tion affects the suicide rate of every age group in 24, the 1982 suicide rate per 100,000 was 6.3; many countries, including the United States and that was reduced to 5.2 in 1984. particularly in JAPAN, where cultural tradition According to reports for German students has come to mean that a family’s prestige hinges under 18, the suicide rate is 50 percent higher on a child’s academic performance, both grade than for U.S. students. The country has a pun- and career competition is extremely fierce. ishing system of preselection for higher educa- Tokyo newspapers and other media have tion, which means that the student who doesn’t recently editorialized about the “annual slaugh- do well from the start will have no academic ter of innocents” as that country’s children jump future. off buildings, hang and gas themselves, and leap Business experts in the United States report in front of speeding trains—because of failure to that the phenomenon called “winner depres- achieve a certain rung on the academic ladder. sion”—a feeling that despite great competitive compulsory suicide 55 success, professional accomplishments are some- India; and similar behavior was expected of a how inadequate—is appearing with greater fre- dead emperor’s favorite courtiers in ancient quency in the world of business and commerce. China. Such practices, now largely extinct, most It appears that mergers, acquisitions, the intro- likely developed from the ancient, widespread duction of new technology, plus rising competi- custom of immolating servants and wives on the tion from abroad—all are placing new pressure grave of a chief or noble. on and causing greater tension for managers and Self-murder may also be encouraged for the executives. Particularly vulnerable are managers welfare of the group. For example, among pre- who have lost jobs as a result of corporate industrial people, an elderly person who could restructuring and reorganization. no longer gather his own food would be These same experts see winner depression expected to kill himself. (which has sometimes led to suicides) cropping Finally, compulsory suicide may be offered to up more often in tradition-bound fields where a favored few as an alternative to execution, as competition is now intense. among the feudal Japanese gentry, the Greeks Until recently, depression was a taboo subject (such as SOCRATES), the Roman nobility, and in the fiercely competitive business world. high-ranking military officers such as Erwin Today, however, as a result of the victims of win- Rommel, who had been accused of treason. ner depression, many firms take a more con- In traditional Japanese society, in certain sit- structive view. Companies use consulting firms uations suicide was seen as the appropriate to help staff people experiencing psychological moral course of action for a man who otherwise and emotional problems. The consulting services faced the loss of his honor. Compulsory say such employee-assistance programs are (also known as hara-kiri) was declared illegal in effective and have a high recovery rate. Japan in 1868. The custom had been reserved for the nobility and members of the military caste, who would plunge a ceremonial knife Comprehensive Textbook of Suicidology into the stomach when disgraced. The word sep- An important textbook of the field of suicidol- puku is the only Japanese rendering of the Chi- ogy that presents an overview of scientific nese reading of two characters meaning “cutting knowledge about suicide and suicide prevention of the stomach.” The same two characters in for professionals. Multidisciplinary and compre- reverse order can also be pronounced “hara hensive, the book provides a solid foundation in kiri”—and the latter is more common in spoken theory, research, and clinical applications. The Japanese. book was written by Ronald W. Maris, Ph.D., of Self-killing also may be practiced by people the Center for the Study of Suicide at the Uni- who don’t really have a code of laws; for exam- versity of South Carolina, Alan L. Berman, ple, the Trobriand Islanders hurl themselves cer- Ph.D., director of the AMERICAN ASSOCIATION OF emonially from the tops of palm trees after a SUICIDOLOGY, and Morton M. Silverman, M.D., serious public loss of face. In these situations, the of the psychiatry department of the University line between social pressure and personal moti- of Chicago. vation blurs. Today, self-destruction as a military, paramil- compulsory suicide A type of suicide per- itary, or political act (although not always com- formed out of loyalty to a dead master or spouse, pulsory) brings veneration among certain or when commanded by the government for dis- terrorist groups and some Middle Eastern coun- graced officials. tries, even though in Islam, suicide is the Compulsory suicide out of loyalty to a dead gravest sin, which is expressly forbidden in the master or spouse is characterized by SUTTEE in Qur’an. 56 concentration, loss of concentration, loss of Loss of concentration became the first center in the United States. A is considered one of the several warning signs year later, the Council for Telephone Ministries or distress signals given by potentially suicidal was formed to develop CONTACT centers persons. Sometimes the signal is hard to detect throughout the United States. During the next at first, but then it grows progressively more three years, under the leadership of Rev. Ross apparent. Whetstone and the support of the United Any sudden change in a person’s personality Methodist Church, 36 communities began the is usually a warning sign. Ordinary daily tasks process of starting a center. become difficult to carry out. There is often las- Today, CONTACT USA has expanded to more situde and lack of energy. Even the simplest than 60 centers in 21 states, with 10,000 volun- decisions become difficult to make. With lack of teers responding annually to 1.2 million callers concentration, depression usually begins gradu- per year. As the only national network of tele- ally. The person often talks less, prefers to be phone helpline centers in the United States, alone, and there is a marked decline in the level CONTACT USA is committed to a vision of of interest as well as concentration. reaching all who seek someone to listen. For contact information, see Appendix I. constriction The narrowing of a suicidal per- son’s outlook, thinking, and options. contagion The risk arising from exposure to suicidal behavior in a family, peer group, or the CONTACT USA A human service organiza- media. It results in what is called CLUSTER SUI- tion that operates a network of crisis interven- CIDES, where one suicide seems to be the trigger tion and telephone helpline centers across the for others, most often among adolescents. nation. Conceived in 1967 as a response to the For example, Yukiko Okada, 18, jumped to growing social issues of a changing nation, CON- her death in 1986 from the seventh floor of her TACT has evolved into a network of centers in recording studio after receiving an award as 20 states, exploring new ways in which to serve Japan’s best new singer. In the wake of intense their individual communities. More than 10,000 media attention, 33 young people (one only volunteers commit their time to serve their com- nine years old) killed themselves in the next 16 munity through work at a CONTACT center. days—21 by jumping from buildings. The organization was founded on March 16, Even fictional accounts of suicide may be 1963, by Rev. Dr. Alan Walker, minister in the enough to trigger contagion, as in a claimed Methodist Church, Sydney, Australia. Called Life spurt of Russian roulette deaths shortly after the Line, the original organization operated a release of the film The Deer Hunter, which con- unique program designed to train volunteers to tained a disturbing scene about Russian roulette. be available by telephone to callers 24 hours a day. Two years later, Rev. John Brand of Dallas Intervention After a Suicidal Death brought the program to the United States, using of a Relative, Friend, or Acquaintance his church as the location for the first center. Studies have shown that the suicide of a Since the name of Life Line was being used in relative or friend may increase the risk for Texas by a nationally broadcast radio program, childhood or adolescent suicidal behavior. CONTACT was chosen as the name of this new Counseling can help a child realize that suicidal ministry. behavior is not an effective coping strategy in In autumn 1966, a class of 150 began the six- dealing with adversity, and may reduce the risk month training as telephone helpline volun- for suicidal behavior in these circumstances. teers; on March 27, 1967, CONTACT Dallas Intervention may also be needed to decrease 57 the child’s personal sense of guilt, trauma, and the investigation of violent, unexplained, or sus- social isolation. This treatment can be given in picious deaths. They were also responsible for individual meetings, at group sessions with disposing of property that became available other teens, or with parents who need help to under the existing laws after a homicide or sui- support the adaptive capacities of their children cide. The Latin word for crown is corona. and adolescents. School professionals some- The disparity between official suicide rates per times offer programs of this kind and can be 100,000 persons and the actual number of sui- invaluable in identifying grieving friends who cide victims exists for a number of reasons. Gen- may need help. erally, coroners list suicide as a cause of death only when circumstances unequivocally justify such a determination such as, when a suicide coping mechanisms The characteristic man- note is left by the victim of sudden death, when ner in which individuals deal with their physical the person has a history of suicidal tendencies or and social environment, particularly as they has tried suicide before, or when cause of death mobilize their resources to handle stress. For simply cannot be other than suicide. example, people with healthy coping mecha- When such obvious clues are absent, most nisms can deal satisfactorily with the stressors of coroners admit that they are reluctant to rule the daily frustrations and even periodic tragedies. death a suicide. In fact, some coroners or med- Those who have not acquired and developed ical examiners indicate that in many small towns healthy coping mechanisms, who do not dis- and communities, suicide is seldom listed as such play “normal” coping behavior, may exhibit on a death certificate. This practice, they con- totally inappropriate responses to stress (or a tend, is the pragmatic action for a coroner, combination of stresses) that indicate warning because life pressures in a small community dic- signals or distress clues of potential self-destruc- tate certain unwritten rules of conduct. Many of tive behavior. these coroners also act as personal physicians for See also CLUES OF SUICIDE. members of the community, and cannot afford to jeopardize their income by antagonizing cop suicide See POLICE SUICIDE. patient-clients. Many traffic deaths, especially those involv- ing one person in a single car collision with a sta- Duplications of a suicide due tionary object, are suspected “AUTOCIDES,” or to repeated accounts or depictions of the original impulsive, spur-of-the moment suicides. One suicide on television and other media. The well- estimate places such autocide explanations at 75 publicized suicide serves as a model to the next percent of this type of accident. Authorities who suicide, and occasionally spreads through a use this interpretive theory have often set the school system, a community, or—in terms of a actual number of suicides at twice the official celebrity suicide wave—across the nation. U.S. figure. See also CLUSTER SUICIDES; CONTAGION. Finally, there are also many and varied forms of self-destructive behavior (CHRONIC SUICIDES) coroner An elected official responsible for that may ultimately end in or determining the manner and the cause of death death due to chronic health problems. Chronic in all cases of suicide. The office of coroner was suicides are long-term self-destruction by people developed in England at about A.D. 1100 or 1200. who consciously or subconsciously have been Coroners were originally referred to as “crown- killing themselves over a period of time. Such ers,” the name given to those persons appointed cases are never listed as suicides by coroners. by the Crown to represent the king’s interest in Victims of such chronic suicides are more likely 58 Council of Orleans to be listed among the nation’s mortality statis- counseling Hundreds of suicide prevention tics for heart disease, cirrhosis of the liver, pneu- and crisis centers, teleministries, and counseling monia, or “accidental death” due to drug groups indicate nations are well aware of the overdose, drowning, automobile accident, fire, enormity of the problem of suicide. Today, there falls, poisoning, or accidental gunshot wounds. are many self-help organizations designed to Coroners say they generally will consider the help all those who are victims of suicide and sui- following as likely suicide: cut throat, hanging, cidal behavior. This includes services not only for self-immolation, crushing under a train, and car potential suicides, but counseling for survivors of exhaust poisoning. The following are given the suicide. An example of the latter type group is benefit of the doubt by many coroners and/or LOSS (LOVING OUTREACH TO SURVIVORS OF SUICIDE), medical examiners and considered as problem- sponsored by Catholic Charities, which has atic (unless other unequivocal proof exists): fall autonomous groups in most areas of the coun- from a height, drowning, firearms, poisoning, try. Such self-help groups have proved valuable and even drug overdose. for suicide survivors because they offer mutual The question remains how best to assess a support. Members are able to talk as well as lis- dead person’s motives. ten as they learn to live with their tragedy and The chief method used widely today is that of can see that suicide happens to average people the PSYCHOLOGICAL AUTOPSY. Developed by psy- from average families. The sense of shared com- chologists Edwin Shneidman and Norman L. munity and hope that members experience in Farberow after they began the LOS ANGELES SUI- these self-help groups usually extends beyond CIDE PREVENTION CENTER in 1958, the important the meetings themselves. research tool is a method to assist coroners and Family service agencies are community medical examiners to determine the cause of an sponsored and have qualified social workers uncertain death by gathering data on the victim on staff; in addition, most have at least one based on psychological status and personality psychiatrist who serves as a professional con- characteristics. sultant. Sometimes these agencies are denomi- Investigation teams interview relatives and national, such as the Jewish Children’s Bureau friends, coworkers, teachers, and anyone else and Catholic Charities (sponsors of the LOSS who perhaps played a significant role in the groups for suicide survivors). Lutherans also deceased’s life. The purpose is to reconstruct the support several hospitals that provide services final days and weeks of life by gathering facts similar to those offered by other Family Service and opinions about a recently deceased person Agencies. in an effort to understand the psychological The Family Service Association of America, components of death. with its chain of member agencies nationwide, offers low-cost individual and family counseling, family life education programs, special groups Council of Orleans (Second) Held in A.D., for teens, and family advocacy activities. 533 the Council expressed the first institutional The SAMARITANS, one of the major suicide pre- disapproval of suicide by the Catholic Church vention organizations in England, now has cen- which it determined was the most serious and ters in many parts of the world. heinous of transgressions. However, it was not See also COMMUNITY RESOURCES; HELP FOR SUI- until 563 and the Council of Braga (the Fifteenth CIDAL PEOPLE; PREVENTION (OF SUICIDE). Canon) that there was institutional denial for suicides of funeral rites of the Eucharist and the singing of psalms. Craig and Joan A book by Eliot Asinof that See also ATTITUDES. deals with the true story of two New Jersey crime 59 teenagers who killed themselves in 1969 to Upon being awarded a Guggenheim fellowship protest the Vietnam War. Joan Fox and Craig in 1931 to complete a series of poems about the Badiali, both 17, asphyxiated themselves after Aztec, he temporarily settled in Mexico. Yet leaving behind 24 suicide notes that explained things did not go well south of the border, where their political protest of the war. Their suicide Crane found himself a gay male in a culture that pact generated a great deal of national publicity. was largely homophobic. See also TEENAGE SUICIDES. He had discovered he was a homosexual after an affair in 1919 in Akron, when he was work- ing as a clerk in one of his father’s candy stores. A prize- Crane, Harold Hart (1899–1932) In the spring of 1924, he met a ship’s purser winning U.S. poet who produced several vol- named Emil Opffer, forming an intense emo- umes of poetry and then killed himself by tional relationship. Unfortunately, Crane never jumping off a steamship. Hart was born in 1899 found a partner with whom to share his life. in Garrettsville, Ohio, the only child of Grace After Opffer, his affairs were temporary, anony- Edna Hart and Clarence A. Crane, a candymaker mous, and sometimes violent. and original manufacturer of the Lifesaver, who As he returned to New York from Mexico, tried to dissuade him from a career in poetry. years of drink had almost certainly ravaged his Crane was a high-strung, volatile child who physical condition, undermining his ability to began writing verse in his early teenage years. control his mental stability. Tormented by a He never completed his final year of high sense of failure after his torturously produced school, but at the age of 17 persuaded his pieces, Crane committed suicide by jumping recently divorced parents to let him live in New overboard from the steamer SS Orizaba off the York City to prepare for college. He wandered coast of Florida on his way home. back and forth between Cleveland and New York, briefly working in Cleveland as a cub reporter and as a menial in his father’s candy crime In America over the past two decades, factory, and in New York as a copywriter for there has been astonishing rise of almost mail order catalogs and ad agencies. He lived a 300 percent in both suicide rates and homi- nomadic life, in and out of apartments and cide rates among young white males age 15 rooms in New York City and southern Con- to 19. necticut, where he shared farmhouses with The United States now ranks among the friends. In New York, he associated with the highest of countries in the world in both suicide literati of the time, including Allen Tate, Kather- and homicide rates. As a group, people who kill ine Anne Porter, E. E. Cummings, and Jean themselves have committed homicide at a much Toomer. However, his alcoholism and instability higher rate than has the general population, interfered with lasting friendships. and persons who have killed others have a His major poems were published as White much higher suicide rate than has the overall Buildings (1926), The Bridge (1930), and Collected population. Poems (1933), a slim body of intense, sensitive, The relation between homicide and suicide in modernistic poetry. Most of the poems in The the United States is dramatized by the fact that Bridge were written on the Isle of Pines off the guns, used in more than 60 percent of the homi- coast of Cuba, where his family owned a vaca- cides, are used as well in some 55 percent of the tion cottage. When he was struggling to com- suicides. Despite the impersonal nature of cer- plete The Bridge, Crane sought inspiration by tain , in four out of five homicides the traveling to Europe, but once the book was pub- victim is a relative, lover, friend, or acquaintance lished, he received instant notoriety and fame. of the murderer. 60 Crisis: The Journal of Crisis Intervention and Suicide

Murder, like suicide, is for the most part a per- The help may come from understanding sonal matter: both suicide and homicide usually family and friends, from suicide prevention have destructive consequences to a number of or crisis center personnel, or, as is often neces- people involved. sary, in the form of professional treatment by a trained psychiatrist, psychologist, social work- Crisis: The Journal of Crisis Intervention and er, or physician aware of and sensitive to such Suicide A journal published quarterly under conditions. the auspices of the INTERNATIONAL ASSOCIATION See also COMMUNICATION OF SUICIDAL INTENT. FOR SUICIDE PREVENTION. suicide Mass suicide as directed by a reli- crisis hotlines Although crisis hotlines are gious leader or group. A number of large cult- available almost everywhere in the United related suicides have occurred in the past 20 States, evidence that they reduce rates of com- years. These include: pleted suicide is unclear. The lack of clear bene- HEAVEN’SGATE The bodies of 39 young peo- fit could be related to the fact that actively ple who were part of a religious cult died in suicidal individuals do not call hotlines as they March 1997 in a mansion near San Diego. The are acutely disturbed, preoccupied, or intent on victims, who were all between 18 and 24 years not being deflected from their intended course of old, drank a lethal mixture of phenobarbital and action. In addition, hotlines are often busy, and vodka and then settled to die over a three-day there may be a long wait before a call is period. Twenty-one victims were women; 18 answered, so that callers disconnect. Moreover, were men. The victims apparently believed their the advice a person gets after calling a hotline deaths would lead to a rendezvous with a UFO may be stereotyped, inappropriate, or perceived hiding behind Comet Hale-Bopp. as unhelpful by the caller. Solar Temple Members of the Solar Temple While men are at highest risk for committing believe that ritualized suicide leads to rebirth on suicide, gender preferences in seeking help a planet called Sirius. In three years, murder-sui- mean that most callers are women. cides by Temple followers have resulted in 74 deaths in Europe and Canada. The charred bod- crying Crying is considered a distress signal ies of three women and two men were found on for the potentially suicidal, especially in cases March 23, 1997, inside a house in Saint Casimir, where the person feels depressed and wants to . Two years earlier, in December 1995, 16 be alone much of the time. Such persons will Solar Temple members were found dead in a often withdraw from family and friends, lose burned house outside Grenoble, in the French their sense of humor, and may cry for no Alps. The year before that (October 1994) the apparent reason—or for the most trivial rea- burned bodies of 48 Solar Temple members were sons. Conversely, when the depression be- discovered in a farmhouse and three chalets in comes especially severe, potential suicides find Switzerland. At the same time, five bodies, in- themselves incapable of crying even when they cluding that of an infant, were found in a chalet want to. north of Montreal. Crying is another clue, warning or distress sig- Branch Davidian On April 19, 1993, at nal of the overwrought, anxious, unhappy indi- least 70 Branch Davidian cult members died vidual who probably exhibits a cluster of clues after a fire and a shootout with police and fed- that may indicate the potentially suicidal. These eral agents ended a 51-day siege of the com- suicide-prone persons, experts agree, need help pound near Waco, Texas. The government called immediately. the deaths a mass suicide in fires set by cult Czech Republic 61 members. The sect’s leader, David Koresh, who culture Since the beginning of recorded his- had preached a messianic gospel of sex, freedom, tory and man’s discovery that he could kill him- and revolution, had told followers he was Jesus self as well as other living creatures, attitudes Christ. Koresh died of a gun-shot wound to the toward suicide have differed in various societies head sometime during the blaze. and cultures, and are generally linked with ide- Vietnamese Suicide In October 1993, 53 hill ologies of death and afterlife. Cultural attitudes Vietnamese tribe villagers committed mass sui- toward suicide seem to be as ambivalent and cide with flintlock guns and other primitive divided today as in ancient Greece and Rome. In weapons in the belief they would go straight to recent times, there have been apologists for sui- heaven. Officials said they were the victims of a cide even among the clergy. Prestigious philoso- scam by a man who received cash donations for phers and writers have defended man’s right to promising a speedy road to paradise. end his own life, whereas eminent others have Mexican Cult In December 1991, Mexican decried such a right with equal conviction. minister Ramon Morales Almazan and 29 fol- The suicidal acts by terrorists in the Middle lowers suffocated after he told them to keep East, some of whom are Muslims are under- praying and to ignore toxic fumes filling their taken despite the QUR’AN decrying suicide as an church. act worse than homicide. Shiite Muslims believe Tijuana Cult On December 13, 1990, 12 that to die in a Jihad, or holy war, assures them people died in a religious ritual in Tijuana, after of a place in Heaven. drinking fruit punch tainted by industrial alco- The collective representations through which hol. It was never clearly established if this was a individuals view suicide seem to have changed. suicide, and authorities speculated the deaths Not a few authorities postulate that the “permis- might have been accidental. siveness” of modern society in general, which Massacre Rev. led reflects a growing tolerance of deviant behavior, more than 900 followers to their deaths on No- may be responsible for the rising suicide and sui- vember 18, 1978, at Jonestown in , by cide attempt rate. The various world societies drinking a cyanide-laced grape punch. Cult appear to be less moralistic and punitive toward members who refused to swallow the liquid suicidal behavior today than a generation ago. were shot. Jones, who was found dead with a Whether or not this societal attitude implies a bullet wound in the head, had led the Peoples greater readiness to understand than condemn, Temple in San Francisco and moved it to a lack of value commitment, or merely general Guyana. apathy, remains to be seen. Yet the tendency to Falun Gong Seven Chinese Falun Gong conceal suicidal acts still prevails in most cul- practitioners tried to kill themselves in Tian’an- tures, even though the reasons for this reaction men Square in January 2001 by setting them- are not the same as at those times in history selves on fire. Five practitioners, including a when suicide, or even attempted suicide, was 12-year-old girl, soaked themselves in gasoline considered a crime and a sin. and set themselves on fire at around 2:40 P.M.on Suicidal acts will continue to be committed, the eve of China’s lunar New Year. One died on but the world’s various societies and cultures the spot, and the four others were injured. Police will, it appears certain, view this peculiarly on duty at the time rushed to the rescue and human problem in different ways and for differ- immediately sent the injured to a local hospital. ent reasons. Two others planning a suicide attempt were found by the police and stopped. Czech Republic The Czech Republic, toge- See also MASS SUICIDE. ther with the other countries of Central Europe, 62 Czech Republic form a geographical region with a high suicide higher than in smaller towns and villages, but rate, in spite of its predominantly Catholic pop- these rates are now tending to draw closer. ulation. Statistical data indicate, however, that As high as the suicide rate in Czechoslova- the suicide rate in the area of the former Cze- kia was in 1983, it was nowhere near the aston- choslovakia has declined during the last 20 ishing, world-leading rate in nearby Hungary, years. In 1999, the Czech Republic reported a with its 45.9 percent rate total per 100,000 suicide rate of 15.9 per 100,000 (25.7 for males, population. 6.2 for females). Asked about the fact that Hungary has for The rate of suicides has always been higher in several years been the world’s most suicide- the Czech Republic than in Slovakia, although prone nation, Dr. Geza Varady, director of the the rate at the beginning of the 1990s was the Institute for Mental Health in Budapest, told an lowest of the postwar years. The greatest decline interviewer: “The phenomenon reflects the has been noted for the age groups 15 to 24 years Hungarian temperament, which is volatile and and 40 to 59 years. As in most countries, the likes dramatic gestures.” Many suicidologists male suicide rate is much higher than for contend that figures such as the World Health females, especially in Slovakia, and the differ- Organization statistics do not say as much about ence is still increasing. national characteristics as they do about the way In the ’60s and ’, the suicide rate of the facts are gathered or covered up in the various capital cities of Prague and Bratislava was much reporting nations. D

Dada Short-lived European literary and art when he was nine, and he grew infatuated with movement that reflected disillusionment with all her. She grew impatient with the attention he conventions and World War I. Dada is French paid other women, and she eventually married a baby talk for “anything to do with horses.” The banker. She died at a young age in 1292. two founders of the movement were German Perhaps the greatest of Italian poets, his chief poets Richard Huelsenbeck, and Hugo Ball. Dada work is one of the world’s poetic masterpieces was representative of the extreme, violent, and (The Divine Comedy). For Dante, there appears to self-destructive impulse against everything, not have been no recognition or acceptance of simply against the establishment and the bour- extenuating circumstances regarding suicide. geoisie which was the artists’ audience, but also In Canto XIII, Dante writes about the Wood of against art, even against Dada itself. For the the Suicides, explaining that when a soul is Dada purist, suicide was inevitable. forced from its body in the violence of suicide, The movement was a precursor to surrealism Minos sends it down to the Seventh Circle. The and subsequent radical art doctrines. Dada soul, wherever it lands, falls into the ground, negated all formalism in art and produced sprouts, and grows into a sapling and then a “paintings” that were primarily collages made of tree. The Harpies feed on the leaves and such materials as newspaper bits, buttons, and branches, causing great pain. After Judgment photographs. Day, when all sinners’ bodies are reunited with Its reign began with a suicide, ended with their souls, the bodies of the Suicides will hang one, and included others in its progress. Like so from the thorns of the trees. Dante, indeed, put many of the Dadaists, Dada died by its own suicide in the Seventh Circle of Hell, below the hand. Jacques Rigaut, whose suicide in 1929 is heretics and the , to express his moralis- thought by many to mark the end of the Dada tic horror of suicide. era, believed that “suicide is a vocation.” Other Dadaists who committed suicide included Arthur daredevils Suicide is the number-three killer Craven and Jacques Vaché. of young people; for those of college age, it is the second leading cause of death. Many suicidolo- Dante Alighieri (1265–1321) Born in Flo- gists believe that suicide is actually the number- rence in 1265 into an aristocratic family, Dante one killer of young people, and that many was schooled by the Franciscans. Among his homicide and accident victims are suicides in teachers was Guido Cavalcanti, a poet of local disguise. fame who died in 1300. Dante later began writ- These CHRONIC SUICIDES include the daredevil ing love poetry, especially sonnets, at an early who shouts “Look, no hands” as he speeds on his age, and devoted much of them to a Florentine motorcycle on a narrow road; the preteen boy, woman, Bice, whom he called Beatrice (“the dressed in Superman cape, who jumps from the bringer of blessings”). They met for the first time roof; or adolescents abusing drugs and alcohol.

63 64 David of Augsburg

Sigmund Freud, pioneer in the study of the During the medieval period, there was a unconscious mind, concluded that everyone has growing recognition that mental and emotional a desire to harm or even totally destroy them- disorders could lead to suicide. Such states and selves. Some people, because of their unfortu- their potential consequences are often related to nate life circumstances, are driven to suicide the concept of melancholy or acedia (spiritual openly and consciously. Others seek more subtle sloth). In his writing, David distinguished among means without comprehending why or what three types of acedia, one of which be thought they are doing. Fortunately, most persons seem could lead its victim to suicide when oppressed able to perceive the consequences of their self- by unreasonable grief. This type of sorrow, David destructive behavior and change direction. Most believed, might be triggered from a previous people, in fact, control these negative urges or impatience, from frustration, or from an abun- impulses. dance of “melancholic humors” that require a But there are still far too many people, espe- doctor to cure. cially among the young, who either do not rec- ognize their own self-destructiveness or deny it Dean, James B. (1931–1955) An actor killed till it is too late. They are the ones who drive too at age 24 when he was speeding along in his new fast, drink excessively, smoke three packs a day, silver Porsche Spyder sports car and slammed mix drugs and alcohol, and play Russian into another auto at an intersection. He died roulette with loaded guns. They are the “dare- instantly. Some suicide authorities suggest that devils.” Dean’s death might come under the heading of Some suicide experts suggest this as a possible CHRONIC SUICIDE, a term attributed to Dr. KARL cause of actor JAMES DEAN’s death, at age 24, in a MENNINGER. Menninger interpreted most acci- car accident on a lonely California highway. On dents to be the result of unconscious self-destruc- September 30, 1955, Dean—a heavy drinker tive drives. Recent studies indicate that suicidal and drug user at the time—was driving at a reck- fantasies and “death wishes” do lie at the root of less 85 mph in his silver Porsche on Highway 41 some traffic and other kinds of accidents. Many at Chalome, near Pasa Robles. He was en route others appear to be related to brash, impulsive, to a sports car race at Salinas when he smashed spur-of-the-moment behavior—a “daredevil” into another car, and was pronounced dead on defiance of fate that Dr. Menninger still considers arrival at the Pasa Robles Hospital. To compound as self-destructive or “chronic” suicide. the tragedy, some grief-stricken fans committed James Dean, born in tiny Fairmont, Indiana, suicide. had a reputation as a sullen, unfriendly, moody See also CELEBRITY SUICIDES. person to those in power, a man who would not give ground if he thought he was right. His few David of Augsburg (?–1272) Medieval Ger- close friends thought him warm and loyal. In an man mystic born probably at Augsburg, Bavaria, interview not long before his death, Dean is early in the 13th century, who wrote about the quoted as saying, “If a choice is in order, I’d emotional and mental problems that could lead rather have people hiss than yawn.” At famed to suicide. Chasen’s restaurant, he often accompanied rude He entered the Franciscan Order probably at requests for service by table-banging and silver- Ratisbon, where a monastery of this order was clanging. He reputedly drank heavily and used located as early as 1226; the Franciscan drugs abusively at times. On the eve of his monastery at Augsburg was not built until 1243. death, he had attended a party at Malibu, which At Ratisbon, David served as master of novices had ended in a shouting match with another and wrote his celebrated “Formula Novitiorum.” person. Death of Peregrinis, The 65

Yet, Dean’s sudden death touched off the tificate. Because suicide is particularly subject to greatest wave of posthumous hero worship in inaccurate determination, the incidence of sui- Hollywood since the untimely death of cide may be conservatively estimated at a mini- Rudolph Valentino. Some fans committed sui- mum of 10 percent. Unfortunately, suicide data cide. Many of his fans refused to accept his are sometimes quoted without either qualifica- death. Today, more than 40 years after his tion or recognition of the incomplete nature of death, fan mail for Dean keeps arriving, mostly the death certificate information. from teenagers across the country who identi- fied with the troubled youngster, the man-boy death education Discussion of grief, be- anti-hero, played by the actor in Rebel Without a reavement counseling, and death as a human Cause. experience. Proponents of death education say it is beneficial and long overdue. Critics, on death certificates In the United States, a the other hand, claim such courses are often coroner or usually determines introduced haphazardly by unqualified teach- whether a death is a suicide, and records that ers and point to cases of negative, damaging decision on the death certificate. For each death information affecting young people. In fact, certificate filed in the United States, the certifier the suicides of former death-education students must indicate the cause of death and the manner and the traumatic reactions of others have gen- of death as “natural,” “accident,” “suicide,” erated increasing criticism of death education “homicide,” or “undetermined.” Laws guiding classes. these decisions differ by state and sometimes by Conservatives complain that the practice country. usurps the prerogatives of home and church. In Several factors, including uncertainty about Oklahoma, conservative legislators tried un- what evidence is necessary and pressures successfully to introduce a bill that would ban from families or communities, may influence a death education altogether. Some critics worry coroner or medical examiner not to certify a that in the hands of unskilled and overenthusi- specific death as a suicide. Because the extent astic teachers, death education may in fact to which suicides are underreported or mis- inspire more anxiety, depression, and fear than it classified is unknown, it has not been possible reduces. to estimate precisely the number of suicides, Some schools have asked students taking such identify risk factors, or plan and evaluate pre- courses to write their own , their own ventive interventions. Some suicidologists epitaphs, or even to visit funeral homes and cre- believe that death certificates do not provide matoria. Others have had students lie down in enough (or the right kind of) information to be empty coffins, plan their own funeral services, helpful. and attend death education classes held in For example, accurate estimates correlating cemeteries. the risk of suicide with religious affiliation can- Serious thanatologists believe that if death not be easily obtained, since religion is not education is to become a truly meaningful part recorded on death certificates. And yet, religious of school curricula, it must be standardized and affiliation is known to affect a person’s risk of professionalized. suicide. In addition, suicide statistics are grossly Death of Peregrinis, The An essay written underestimated. In suspected suicide or homi- by Greek satirist LUCIAN after he personally wit- cide cases, state laws usually require a medical nessed the fiery death by immolation of Peregri- examiner or coroner to complete the death cer- nis Proteus, a Cynic philosopher. Peregrinis, 66 death wish who early in his life left home under suspicion death with dignity See EUTHANASIA. of having strangled his wealthy father to get his hands on the family fortune (it was never actu- Decalogue Article The Decalogue (Ten Com- ally proven), in A.D. 165 ended his restless, mandments) was the primary source for St. wandering life before a large crowd at the AUGUSTINE’s denouncement of the act of suicide. Olympic festival by cremating himself on a pyre At the time there was no official Catholic in the Indian manner. Peregrinis instructed his Church position on suicide. He asserted that the disciples to establish a cult in his honor after his act could not be condoned, even in the case of a death; this was done in his native town of Par- woman whose honor was endangered, because ium, on the Hellespont. It is said that the statue suicide is an act which precluded the possibility set up in his honor worked and of repentance, and it is a form of homicide and attracted many pilgrims. Just before jumping thus a violation of the Fifth Commandment, into the fire, he exclaimed: “Gods of my mother, “Thou shalt not kill.” gods of my father, receive me with favor.” The time of Peregrinis was a period when many Definition of Suicide A book that outlines 10 were filled with contempt for the human con- characteristics common in suicide, written by dition, felt themselves to be aliens in this EDWIN SHNEIDMAN, Ph.D., professor of thanatol- world, and asked the question, “What are we ogy at the UCLA School of Medicine. Shneid- here for?” SENECA (ca. 5 B.C.–A.D. 65) in his Epis- man provides detailed explanations of these tles says that a desire possessed many, a longing “Ten Commandments of Suicide” that together for death. EPICTETUS (ca. A.D. 50–120) also noted offer an intimate portrait of the suicidal person’s this death wish among young men and tried to emotions, thoughts, internal attitudes, desires, restrain it by urging them not to commit sui- actions, and inner stresses. cide. The author, cofounder and formerly codirec- tor, with Dr. Norman L. Farberow, of the LOS death wish The (often unconscious) desire to ANGELES SUICIDE PREVENTION CENTER, uses exam- end life, almost as a way of approaching life. Sui- ples of actual suicide to construct a deeper, cidal adolescents will often seem to have a clearer understanding of the driving forces “death wish.” They amble across busy streets, behind the act itself. speed around icy corners on motorbikes, and Definition of Suicide is considered by authorities mix drugs and alcohol without knowledge of as both a major theoretical treatment of self- their synergistic effect. Other suicidal behavioral destruction and a practical first-aid manual and hints sometimes include repeated auto acci- guide for preventing suicidal deaths. dents, driving bicycles into stationary objects, and picking fights with bigger youngsters and “Dejection: An Ode” Written by Samuel sometimes even with police. Taylor Coleridge in 1802, this autobiographic This kind of attitude reflects an abnormal pre- poem resulted from his unhappy love for occupation with death and usually means the Wordsworth’s sister-in-law, Sara Hutchinson. It person is trying to send parents or significant is an intensely moving confession of his poetic others a message. sterility, a recognition of the death of his creativ- Almost everyone who seriously intends sui- ity as a kind of suicide. cide leaves clues to their imminent action. Samuel Taylor Coleridge was born in Ottery Sometimes there are broad hints; sometimes St. Mary on October 21, 1772, youngest of the only subtle changes in behavior. But the suicide ten children of John Coleridge, a minister, and decision is usually not impulsive. Ann Bowden Coleridge. He was often bullied as dentists and suicide 67 a child by Frank, the next youngest, and so Demosthenes’s end came in the famed temple Coleridge ran away at age seven. of Poseidon. In completing suicide, the great His brother Luke died in 1790 and his only Greek orator joined the company of some of the sister, Ann, in 1791, inspiring Coleridge to write ancient world’s most distinguished men. “Monody,” one of his first poems, in which he likens himself to Thomas Chatterton. Coleridge High rates of suicide are reported in was very ill around this time and probably took Denmark, Sweden, and Austria, lower rates occur laudanum for the illness, which triggered a life- in the United States, England, and France, and long opium addiction. the lowest rates are in Ireland, Italy, and Spain. He went to Cambridge in 1791, poor in spite According to the most recent suicide figures of some scholarships, and rapidly worked him- from the World Health Organization (1996), self into debt with opium, alcohol, and women. there were 34.1 suicides in Denmark per 100,000 Four years later, Coleridge married a woman people—a slight decrease from the year before named Sarah Fricker, but soon afterward he met (35.4), yet significantly higher than a decade William Wordsworth, who introduced him to earlier (28.6 in 1983). his sister-in-law, Sara Hutchinson. Coleridge fell The suicide rate in 1996 among Danish men in love with Sara almost immediately, putting an was 24.3 per 100,000, and the female rate was extra strain on an already troubled marriage. 9.8. This represents about an equal number of In 1806, he divorced Sarah, but his paranoia suicides in 1995 and 1996 among men, but is a and mood swings, brought on by the continual decrease among women when compared to a opium use, were getting worse, and he was rate of 11.2 in 1995 and 12 in 1994. hardly capable of sustained work. He was still By far the highest suicide rate among various haunted by his inability to stop using opium, Danish age groups is in the over 75 group, with however, and so he moved into the house of an 90 suicides per 100,000. The suicide rate among apothecary named James Gillman to help cut Danish teenagers is 15.6 per 100,000. back his opium dose. Unfortunately, this did not work, and like all addicts, Coleridge quickly had an alternative supply arranged. dentists and suicide There is little valid evi- He died peacefully on July 25, 1834, leaving dence that dentists are more prone to stress- only books and manuscripts behind. His sym- related suicides than the general population, bolic suicide over many years—his creative according to an article in the June 2001 issue of death by opium—was to become one of the the Journal of the American Dental Association romantic alternatives for those not lucky enough (JADA). (in the romantics’ eye) to die prematurely. Since 1933, both the public and professional media have repeatedly portrayed dentists as being suicide-prone, and this message was Demosthenes (384?–322 B.C.) One of the repeated casually and accepted without support- greatest Athenian orators of all time. He based ing data. There have been few formal attempts his political career on enmity against the Mace- over the last two decades to statistically verify donians, and was ultimately exiled (in 324) on this alleged risk on a national basis. charges of financial corruption brought by the An estimated 31,000 Americans, including pro-Macedonian faction in Athens. Returning in health care workers, died in 1996 from self- 323, after the death of Alexander the Great, inflicted injuries, according to the National Demosthenes organized an unsuccessful revolt Center for Health Statistics, but there is no reli- and took poison from a pen while fleeing able information on the number of suicides by Antipater, who captured Athens in 322 B.C. dentists. 68 departing drugs

For the JADA article, researchers evaluated who complete suicide have had a mood disorder current literature on stress and suicide in health such as major depression or BIPOLAR DISORDER professionals in an effort to verify or refute the (manic depression), and about nine out of 10 widely held belief that dentists and other health people who kill themselves have at least one care professionals are at higher risk of commit- mental illnesses. Younger persons who kill ting stress-related suicide. They found no consis- themselves often have a substance abuse disor- tent statistical evidence available to prove that der in addition to being depressed. dentists are suicide-prone, and most reliable data However, no one theory can account for the suggest the opposite. many and varied forms of suicidal behavior. Cer- It is unclear whether those dentists who kill tainly not all severely depressed persons commit themselves do so because of occupational stress, suicide; nor do all those who kill themselves suf- or because of other factors such as malpractice fer from depression. suits, divorce, alcohol abuse, unfulfilled expecta- Still, depression is a warning sign that should tions, or DEPRESSION. not be ignored, and ranks high on the list of pre- The ADA offers a Dentist Well-Being Program disposing factors for suicidal behavior. Among to those dentists experiencing personal prob- the mental disorders, depressive illness carries lems, including alcohol or substance abuse, the highest suicidal risk, since depression is char- stress, burnout, and depression. acterized by a feeling of worthlessness and despair and a wish to die. Since the risk of a severely depressed person departing drugs The term popular among committing suicide is so pronounced, it is essen- those in the EUTHANASIA movement for lethal tial to recognize the signs of depression. Some of medications used to bring about death. the many warning signals depressed people usually exhibit in varying degrees include: sad- depression About half of all suicides each ness, apathy, expression of feeling empty and year in the United States are said to be victims of numb, inability to enjoy anything, pessimism, depression. Although most people who are feelings of hopelessness and worthlessness, guilt depressed do not kill themselves, having major and anxiety, indecisiveness, memory and con- depression does increase a person’s suicide risk. centration problems, and often, preoccupation The more severe the depression—especially if with suicidal thoughts. Other warning signs untreated or inadequately treated—the greater include persistent sadness, withdrawal, head- the suicide risk. New data on depression suggest aches, stomachaches, insomnia, fatigue, and, at that about 2 percent of those people treated for times, aggressive behavior. There is more often depression in an outpatient setting will die by than not a decline in sexual drive as well. suicide, rising to 4 percent for those treated as Because the primary risk of depression is sui- inpatients. Moreover, those treated for depres- cide, a good diagnosis and effective treatment sion as inpatients after having suicidal thoughts are critical. At least 80 percent of people who or making a suicide attempt are about three commit suicide never got that treatment. While times as likely to die by suicide as are those who about 30,000 Americans kill themselves each were treated only as outpatients. year, at least 10 times that number make unsuc- There are also dramatic gender differences cessful attempts. when it comes to suicide risk among depressed Most experts believe that depression does not people. Whereas about 7 percent of men with a have one specific cause, but is the result of a col- history of depression will kill themselves, only 1 lision between genetics, biochemistry, and psy- percent of depressed women will die by suicide. chological factors. The biological basis for It is estimated that about 60 percent of people depression can be found in nerve cells in the part distress centres 69 of the brain responsible for human emotions. life on his country’s behalf, or for the sake of his When levels of certain messenger chemicals friends, or if he suffers intolerable pain, mutila- called neurotransmitters are too low, communi- tion, or incurable disease. cation in the brain slows down. While there are It was Diogenes who, seeing that Antisthenes as many as 100 different kinds of neurotrans- was overcome by a distaste for life, offered a dag- mitters, there are three that seem to be of partic- ger to his friend and said: “Perhaps you have a ular importance in depression—norepinephrine, need of this, friend?” ANTISTHENES replied: “I serotonin, and dopamine. It is clear that these thank you, but unfortunately, the will to live is neurotransmitters are related to depression also part of the world’s evil, as it is part of our because drugs that boost levels of these chemi- nature.” cals also ease depression. In addition to biochemical reasons, most cases direct and indirect self-destructive behavior of depression seem to be triggered by a serious (ISDB) Both classifications end in death, but loss or unpleasant experience that pushes a per- direct suicide death is quick and more obviously son into depression who may be genetically or what has traditionally been termed “suicide.” psychologically vulnerable. At other times, a ISDB is considered a slow form of suicide which depression may appear to occur spontaneously, hastens death, but is not clearly what is usually perhaps triggered by hormonal changes or a meant by the word “suicide.” ISDB examples physical illness. might include: overeating and chronic obesity, Treatment smoking, alcoholism or other drug overuse or Fortunately, as many as 90 percent of people abuse, risk-taking, accident proneness, and not with depression can be successfully treated with adhering to behavior regimens that would sus- a combination of antidepressant medication and tain and/or prolong health and life. psychotherapy, usually within three months. To date, experts have failed in their efforts to come up with a term, definition, or classifica- tion that satisfactorily covers the complex group- diabetes There have been cases where dia- ing of behaviors that have been put forth as betes victims consistently “forgot” to take their “suicidal.” medication and, as a result, became dangerously sick. Complications from such destructive behavior have sometimes led to diabetics’ death. distress centres (Canada) CANADA, like the In such situations, people seldom think to con- United States, has a nationwide network of sui- nect the self-destructive behavior directly to sui- cide hotlines (called “distress centres” in cide. They are simply, tragically, examples of the Canada). Distress centres nearly always have kind of “uncounted suicides” described by Dr. telephone numbers listed on the inside front KARL MENNINGER as CHRONIC SUICIDE. cover of the local phone book, along with other emergency numbers. If no phone book is avail- able, telephone operators have numbers for cri- Increasingly rigid dichotomous thinking sis services of all kinds, including suicide thought processes and loss of ability to see any prevention. In larger population centers of options to death by a suicidal individual. Canada, as in the United States, one can also dial 911 for emergency services. Diogenes (?412–323 B.C.) Greek philoso- Canada suicide prevention services are also pher and principal exponent of the Cynic school available to anyone at Salvation Army agencies of philosophy who believed that the wise man and at branches of the SAMARITANS and CON- will for reasonable cause make his own exit from TACT (in Canada, called Tele-care). In addition, 70 distress signals there are Canadian Mental Health Association father as well. It is still typical that mothers (CMHA) branches throughout the country, become the custodial parent, so that generally including the remote Northwest Territories and speaking, men lose the role of being a father in the Yukon Territory. a way that women do not lose the role of being The SUICIDE INFORMATION AND EDUCATION CEN- a mother. TRE (SIEC), which is international in scope, has a Making the problem worse, men often feel comprehensive data bank of articles, newspaper as if they’re responsible for the failure of a and magazine clippings, books, films, cassettes, marriage. And typically, men tend to cope more etc., about suicide. destructively with stress, such as drinking too much. distress signals Almost everyone who seri- Divorce statistics also reveal that in one study ously intends suicide leaves clues to his or her of 13 European countries conducted by the imminent action ranging from broad hints to regional European office of the WORLD HEALTH subtle changes in behavior. But the suicide deci- ORGANIZATION found that divorce was the only factor linked with suicide in every one of the 13 sion is usually not impulsive. countries. The study showed that factors such as Called risk factors (see RISK OF SUICIDE), early- poverty, unemployment, and disability were warning clues or distress signals, these changes associated with divorce in some of the countries, of behavior represent very important warning but that disruption of the family was the only signs to trained suicide prevention authorities. factor linked with divorce in all 13. At the same time, the statistics for divorce and divorce and suicide Divorced people are for teen suicide are closely related. In the past three times as likely to commit suicide as people several decades, both the number of divorces who are married, according to federal re- and the number of young suicides have tripled. searchers. Moreover, children of divorce are at Indeed, a number of reliable studies indicate that higher risk for committing suicide when they most young suicides are children of divorce. In grow up; adults who reported having had par- one study, 71 percent of young suicide at- ents who divorced or separated during child- tempters came from broken homes. hood were also nearly twice as likely to report a Another study found that of young at- later suicide attempts. tempters, 72 percent had at least one natural Divorce now ranks as the number one factor parent absent from the home, 84 percent of linked with suicide rates in major U.S. cities, those with stepparents wanted them to leave, ranking above all other physical, financial, and and 58 percent had a parent who had been mar- psychological factors. However, divorced men ried more than once. and women don’t commit suicide at the same In another study of young suicide attempters rate. Divorced and separated men are two and treated over a seven-year period, more than half a half times more likely to commit suicide than of the families of the suicide attempters had an married men. But divorce doesn’t seem to lead absent parent, while in one quarter of these fam- more women to commit suicide. The difference ilies, both parents were absent. could be in the social bonds for men and women. Because women are socialized to doctor-assisted suicide See PHYSICIAN- have deeper friendships, when a divorce ASSISTED SUICIDE. occurs, women tend to have more of a social support network. In addition, men may have trouble coping with divorce because they not doctors Among the professional disciplines, only lose the role of husband, but often of doctors are twice as likely to kill themselves as Donatists 71 the general population. However, the true the problem of suicide and suicide attempts by higher rate of suicide is really among women member-colleagues. physicians. For example, in one study, white men over age 25 had a suicide rate of 34.6 per 100,000, which is very close to the suicide rate Donatists The Donatists were a schismatic for men physicians of 35.7. But the general pop- sect of especially rigorous Christians living in ulation of women over age 25 shows an 11.4 North Africa from the fourth to the seventh cen- rate of suicide, whereas women physicians turies, who elevated suicide to a religious expe- attained a rate of 40.7. rience. The Donatists, named after their bishop Researchers speculate this may have some- Donatus, had split from wider Roman Catholi- thing to do with the changing roles for women, cism in their theology of the church. Donatism in addition to the high stress of their jobs and was basically a response to alternating periods of easy access to drugs. persecution and toleration, culminating in the Other studies have identified psychiatry, anes- formal legalization of Christianity by Constan- thesiology, and ophthalmology as specialties at tine in the fourth century. The Donatists greater risk for suicide, with pediatrics the least believed that Christians who had given in to per- risk. In some studies, psychiatrists were found to secution were no longer fit to occupy positions kill themselves twice as often as other specialties. of leadership in the church, and could no longer administer sacraments. Risks As time went on, the Donatists began to Physicians at risk for suicide often send out indi- believe not only that the clergy needed to be rect calls for help to their colleagues, and espe- holy and in a state of grace but also that the cially to their own personal physicians. entire church needed to be holy and in a state of The following events can signal a higher risk grace—and any member who did not remain for physicians to commit suicide: holy faced expulsion from the church. At this point the Donatists began to embrace a cult of martyrdom, greeting one another with the wish • transition from residency to independent “may you gain your crown.” practice The Donatists were so extravagant in their • approach of retirement horror of life and so desirous of martyrdom that • when parents become terminally ill they inspired their contemporary, ST. AUGUSTINE, • when children leave home to the view “ . . . to kill themselves out of respect for martyrdom is their daily sport.” JOHN DONNE • chronic marital problems noted, with no little embarrassment “that those • intense competition from younger colleagues times were affected with a disease of this natural • substance abusers who experience new desire of such a death . . . for that age was losses growne so hungry and ravenous of it [martyr- dom], that many were baptized only because The AMERICAN MEDICAL ASSOCIATION, the they would be burnt, and children taught to American Medical Student Association, and the vexe and provoke Executioners, that they might AMERICAN PSYCHIATRIC ASSOCIATION all recognize be thrown into the fire.” the growing seriousness of this problem and sub- The Donatists didn’t care how they perished, mit that suicide prevention and intervention so long as their conduct was, in Gibbon’s words, programs are now urgently needed among “sanctioned by the intention of devoting them- physicians. These organizations have established selves to the glory of the true faith and the hope special task forces and committees to deal with of eternal happiness.” When all else failed, they 72 Donne, John would, in the presence of relatives and friends, was neither a violation of the law nor against plunge headlong from some lofty rock, and, reason. writes Gibbon, “many precipices were shown, Other noted secular writers and philosophers which had acquired fame by the number of (Hume, Montesquieu, Voltaire, and Rousseau) these religious suicides.” later echoed Donne’s position, arguing that sui- During Donatus’s lifetime Donatism became cide was indeed defensible under certain condi- the dominant Christian church in North Africa, tions. They wrote notable essays stressing the but it faded in importance by the third genera- need for greater freedom of the individual tion. Early in the fifth century, St. Augustine against the ecclesiastical authority. rose to power and spent time addressing the In the end, suicide for the famed poet- problem of Donatism. At Augustine’s death, preacher was not a possibility, because Donne’s both Catholic and Donatist Christians suffered Christian training and devotion were ultimately under the Vandal invaders, which probably stronger than his despair. encouraged both sects to accept one another more easily. Although Donatism became more Dostoevsky, Feodor Mikhailovich (1821– popular again in the sixth century, the entire 1881) Russian novelist who became involved North African Church was weakened and com- with a semirevolutionary group, was arrested promised by infighting, and was unable to with- and condemned to death, and at the last stand the attractions of ISLAM in the seventh moment reprieved and sent to Siberia. There he century, when the Christian church disappeared underwent the torments reported in many of his entirely from western North Africa. later novels. In his novel The Possessed (1871–72), Dostoevsky’s graphic treatment of nihilism, the Donne, John (1572–1631) English poet antihero Alexsey Nilich Kirilov kills himself, he who entered the Church in 1615 and became says, to show that he is God. Secretly, however, dean of St. Paul’s in London. As a young man, he he kills himself because he knows that he is not was considered the foremost metaphysical poet God. He commits, by shooting himself, what the in Britain, noted for his beautiful, witty love author calls a “logical suicide,” self-destructing lyrics. triumphantly. Donne, who was chaplain to King James I, Off and on throughout 1876, Dostoevsky re- removed suicide from the realm of religion and portedly stewed over the suicide question, pur- morality. To him, suicide was the act of a person suing the subject in newspapers, official driven by personal motives. He wrote a defense government reports, and in conversation with of suicide as a young man in which he candidly friends. In The Diary of a Writer he wrote: “It is admitted that he had contemplated taking his clear, then, that suicide—when the idea of own life. It was because of such extreme per- immortality has been lost—becomes an utter sonal revelations that he refused to publish his and inevitable necessity for any man who, by his essay on suicide, BIATHANATOS. Written in 1607 or mental development, has even slightly lifted 1608, the book was not published until 1646, 15 himself above the level of cattle.” years after his death and nearly 40 years after it But Dostoevsky, in the last analysis, clings to was written. his traditional beliefs in Christianity and its Donne’s defense of suicide was one of the attendant love and charity. first reactions against prevailing Church atti- tudes. He agreed that self-destruction was double suicide A suicide that is completed by contrary to the law of self-preservation, but spouses, a couple, or by two friends, also known no more than that. He postulated that suicide as dyadic death. drug abuse 73

Douglas, Jack D., Ph.D. Author of the well- but the use of acetaminophen to commit suicide known sociological study of suicide, The Social is increasing. While most people think of aceta- Meanings of Suicide. minophen as a safe painkiller, in fact an over- Douglas is also known for outlining the fun- dose can be very dangerous. damental dimensions of meanings required in One study of 100 young adults from New the formal definition of suicide. These are: York City’s Upper East Side who had tried sui- cide found that each suffered from some form 1. The initiation of an act that leads to the death of psychiatric illness, primarily depression. The of the initiator. most frequently given reason for attempting 2. The willing of an act that leads to the death of self-destruction was a feeling of utter hopeless- the willer. ness brought about by the threatened or actual 3. The willing of self-destruction. loss of an important person in their lives. Some 4. The loss of will. of the group blamed their attempts on alco- 5. The motivation to be dead (or to die) which leads hol and/or drug abuse; fearful of psychiatric to the initiation of an act that leads to the symptoms, they became hopeless and isolated death of the initiator. themselves. 6. The knowledge of the actor that actions he ini- Psychiatrist HERBERT HENDIN studied college tiates tend to produce the objective state of students abusing drugs as part of a psychoana- death. lytic study he conducted at for his book The Age of Sensation. He discovered that while some drug abusers mixed the drugs drop-in centers Name given by the Chicago they used, others favored one or another group area’s North Shore suicide workers to suburban of drugs depending upon their emotional prob- places where young people drop in to listen to lems and needs. music, do their homework, play cards or just LSD and other psychedelic drug abusers talk. The important thing is that staff workers wanted to escape feeling emotions. These stu- get to know the adolescents and can observe dents grew up feeling rejected and lonely; they them over a period of time. Drop-in centers pro- didn’t allow themselves to get close to others vide a source of crisis support for youngsters because it might prove too painful. who lack caring communication and feel alien- Amphetamine abusers in the Hendin study ated from school, their peers, often even their were mostly women students. Most of these own parents. users wanted desperately to please their par- ents, to fulfill the goals their parents had set for drug abuse One of the strongest risk factors them. These pleasers ignored their own needs, for suicide is drug abuse. The potential for sui- kept themselves high on amphetamines, so cide is in everyone; whether or not the potential they would have no time left to think about grows and rises to the surface depends on how how they felt or what they wanted. Having well one’s individual system of checks and bal- destroyed their true selves, these young women ances continues to function. programmed themselves to be efficient ma- While there is no single explanation for sui- chines. But at times when the programming cide, certainly drugs play a key role in many sui- failed and the machinery broke down, they cide attempts and “completed” suicides. Use of became openly suicidal. barbiturates has decreased to less than 5 percent Until recently, the most despairing, self- of cases, but use of other psychoactive drugs is destructive drug misusers and abusers have been increasing. Use of salicylates has decreased from heroin users, who had usually suffered early and less than 20 percent of cases to about 10 percent, deep hurt in their lives. They abused drugs to 74 drug treatments for suicide prevention prevent further hurt, to dull all feelings, and ever, among depressed adults, the newest anti- keep everybody at a safe distance. depressants—SSRIs such as Prozac and Zoloft— At least 1 million people in the United States have been found to reduce suicidal thoughts and have tried crack, creating a new wave of cocaine the frequency of suicide attempts in nonde- addiction. pressed patients who had previously made at Paranoia and extreme agitation caused by the least one suicide attempt. crack “high” have, in many cases, led to violent In a controlled trial of the experimental neu- crime and suicidal behavior. Crack destroys the roleptic drug flupenthixol, researchers noted a user’s mind and body, causing convulsions, brain significant reduction in suicide-attempt behavior seizures, heart attacks, respiratory problems, and in adults who had made numerous previous severe vitamin deficiencies. Addicts suffer attempts. Similar studies have not yet been con- depression and suicidal or homicidal thoughts ducted on teens, although antidepressant studies when they crash. in depressed teens suggest that these drugs are Despite its relatively low per-unit cost, addicts effective for treating DEPRESSION and for reducing end up spending thousands of dollars on binges, suicidal ideas in this age group. smoking the contents of vial after vial in crack or Because controlled studies of tricyclic antide- “base” houses—not unlike modern-day opium pressants have not been found to be helpful in dens—for days on end without food or sleep. depressed children and adolescents, SSRIs Authorities say users will do anything to repeat instead are considered to be a first choice in the brief high, including robbing their parents, treating depressed suicidal children and adoles- relatives, and friends, selling their possessions cents. Unlike tricyclics, the newer SSRIs have a and their bodies. lower likelihood of being fatal if taken in over- Crack, like other addictive drugs—including dose. some over-the-counter prescription drugs— In adults with major depressive disorder, con- leads all too quickly to serious trouble, from a trolled research suggests that lithium reduces euphoric high to a startling crash that many peo- suicide risk, but this has not yet been shown in ple relieve by taking more . . . then more and children and adolescents. more. Users gamble with their lives again and Doctors should be careful about prescribing again. medications that may reduce self-control, such Authorities report that thousands of teenagers as benzodiazapines, amphetamines, and pheno- and other young people (in the 20 to 26 age barbital. Also, these drugs are highly lethal if group) have plunged so deeply into drug abuse taken in overdose or mixed with alcohol. that it has cost them their lives. Unfortunately, thousands of others are now living lives where “accidental” death or suicide become daily druids Priests of the Celtic people who occurrences. Some experience the agonizing, believed that there is another world beyond this slow death of mental, emotional, and physical one, and they who kill themselves to accompany deterioration, while untold numbers die or their dead friends, will live with them there. become crippled or disfigured for life because of This belief is similar to a custom once com- highway crashes caused by reckless driving or mon among certain African tribes in which driving while in a drugged stupor. warriors and slaves put themselves to death when their king dies, in order to live with him in paradise. drug treatments for suicide prevention There is very little research on the usefulness of medication for reducing suicidal thoughts or Du Suicide et de la Folie Suicide The first preventing suicide in children and teens. How- important psychiatric study of suicide written by Durkheim, Émile 75 the French physician Charles-Henri Brierre de are understated by as much as one-fourth to Boismont (1798–1881). The book, which was one-third. published in 1856, made extensive use of statis- tics in addi-tion to information obtained by Durkheim, Émile (1858–1917) French so- questioning 265 people who either had planned cial philosopher and pioneer in or tried to commit suicide. whose monumental book Le Suicide (1897), After an extensive analysis, de Boismont con- established a model for sociological investiga- cluded that not all suicides are due to insanity, tions of suicide. One of the most important and although many are caused by mental illness. prolific sociologists in the history of the field, Other causes he discovered include alcoholism, Durkheim is credited with making sociology a illness, family problems, love problems, and science by using an empirical methodology in his poverty. own studies, especially in regard to his study of He also discovered a higher proportion of suicide rates and issues of European nations. unmarried people, old people, and men among David Émile Durkheim was born on April 15, the suicides he studied. He came to believe that 1858, in Epinal, in Lorraine. His mother, suicide was the result of a changing society that Mélanie, was a merchant’s daughter, and his led to social disorganization and widespread father, Moïse, had been rabbi of Epinal since the alienation. 1830s. Émile, whose grandfather and great- grandfather had also been rabbis, appeared des- tined to follow in their footsteps. He was sent for dual suicide A type of suicide in which two part of his early education to a rabbinical school, people kill themselves. It usually includes but Durkheim soon realized he was not inter- sub-categories such as parent-child suicide, ested in the rabbinate. Indeed, soon after his MURDER-SUICIDE, murder-suicide between lovers, arrival in Paris, Durkheim abandoned Judaism suicide after the death of a spouse, and love pact altogether, although he always remained a part suicide. of a close-knit, orthodox Jewish family with See also . roots deep in the Jewish community of Alsace- Lorraine. Dublin, Louis I. Author of Suicide: A Sociologi- An outstanding student at the Collège cal and Statistical Study, The Facts of Life from Birth d’Epinal, Durkheim skipped two years, easily to Death, and with B. Bunzel, To Be or Not to Be. obtaining his baccalauréats in Letters (1874) and ÉMILE DURKHEIM’s Le Suicide established a model Sciences (1875). Intent on becoming a teacher, for sociological investigations of suicide; there Durkheim left Epinal for Paris to prepare for have been a number of subsequent studies of admission to the prestigious École Normale this genre. Supérieure. However, he was miserable in Paris, Dublin’s work falls within the sociological tra- worried over his father’s illness and his family’s dition. He is considered one of the principal financial security. A provincial alone in Paris, his demographers of suicide this century, whose scientific interests did not help him prepare for valuable summary of suicide rates showed the the study of Latin and rhetoric he needed to be wide variation in those rates during the period admitted to the école. After failing in his first 1900 to 1960. two attempts at the entrance examination, Dublin noted the inverse association be- Durkheim was at last admitted near the end of tween economic prosperity and suicide and 1879. Despite constant fears of failure that the positive association between depression plagued him throughout his life, Durkheim par- and suicide. He also suggested that recorded ticipated in the political and philosophical suicide figures in cause-of-death certification debates at the école. 76 dutiful suicide

Though ill through much of 1881–82, he • EGOISTIC SUICIDES, in which the person has too passed his exams and began teaching philosophy few ties with the community, with little reli- in 1882. Durkheim was appointed in 1887 as gious, family, political, or social controls. “Chargé d’un Cours de Science Sociale et de Péd- • ANOMIC SUICIDES, which occur when the indi- agogie” at Bordeaux, and sociology first entered vidual simply cannot adjust to social change. the French university system. This appointment • fatalistic suicides, which result from excessive of a young social scientist to the predominantly regulation (such as, among prisoners or humanist Faculty of Letters at Bordeaux was not slaves). without opposition, and Durkheim made this worse by emphasizing the value of sociology to Durkheim was devastated by the death of his the more traditional humanist disciplines of phi- beloved son Andre in World War I, withdrawing losophy, history, and law. into silence and forbidding friends to mention His groundbreaking 1897 study of suicide his son’s name in his presence. Burying himself focused on the advent of technology and mech- in the war effort, he collapsed from a stroke after anization that he believed was endangering eth- speaking passionately at a committee meeting. ical and social structures and triggering suicidal After resting for several months, he began to tendencies. Since then, more and more scientific work on La Morale; but on November 15, 1917, studies of what was once called “self-murder” he died at the age of 59. were completed each year, and today the subject of suicidology is studied at major medical insti- tutions around the world. dutiful suicide Suicide understood as a cul- Within 10 years of Durkheim’s study, the SAL- turally defined obligation. VATION ARMY established an anti-suicide bureau and American minister Henry Warren started Dying with Dignity A registered Canadian the National Save-a-Life League. In 1910, SIG- charitable society whose mission is to make MUND FREUD’s VIENNA PSYCHOANALYTICAL SOCIETY dying with dignity an option available to any- held a symposium on suicide, and investigation one, to protect patients and doctors alike, to seek into suicide took a new turn. legal reform, and to introduce safeguards regard- Durkheim, who also is considered a pioneer ing voluntary EUTHANASIA. in the origins of religion, analyzed his French To accomplish these goals, the group provides data on suicide and then proposed four kinds of counseling and advocacy services, and provides suicide, each emphasizing the strength or weak- Living Wills, powers of attorney for personal ness of the individual’s relationship or ties to care, and other advance health care directives. society. They are: For contact information, see Appendix I.

• ALTRUISTIC SUICIDES, in which a group’s au- thority over one individual is so strong that dysphoria Depression accompanied by anxi- the person loses his own identity and wishes ety: A feeling of malaise or nonspecific illness or to sacrifice his life for the community (such as, general discomfort that often accompanies a soldiers who willingly give their lives for their hangover or withdrawal. country). E

East, John P. (1931–1986) U.S. Republican family was plunged into poverty. George contin- senator from North Carolina for five and a half ued school until he was 14, when he was forced years, who was found dead on the floor of the to get a job as a messenger with an insurance garage of his home in Greenville, North Car- firm to support the family. Through his own ini- olina. The county medical examiner ruled the tiative, he soon took charge of policy filing and death a suicide. Police said the garage was sealed even wrote policies. But his income was not and full of fumes from a running station wagon enough, so he studied accounting at home in the inside. evenings to get a better job. After five years in East, who had contracted polio in the 1950s the insurance business, he was hired as a junior and consequently had to use a wheelchair, had clerk at the Rochester Savings Bank, tripling his many physical problems and was being treated salary. for DEPRESSION, factors that may have con- Planning a vacation to Santo Domingo at age tributed to his 1986 suicide by carbon monoxide 24, Eastman bought a camera and wet plate to asphyxiation. make a record of the trip. The camera, which Senator East had announced in 1985 that he was as big as a microwave, required a heavy tri- would not seek a second term in office because pod and a tent to protect and develop the glass of ill health. plates. The paraphernalia required included chemicals, glass tanks, a heavy plate holder, and Eastman, George (1854–1932) A brilliant a jug of water. While Eastman never made it to scientist who revolutionized photography with Santo Domingo, he became fascinated with his inventions of dry-rolled film and the hand- photography and sought to simplify the compli- held cameras that used it, but who ended his life cated process, experimenting at night in his by his own hand when illness overtook him. mother’s kitchen. By 1880, he had patented not Eastman was born on July 12, 1854, to Maria only a dry plate formula, but also a machine for Kilbourn and George Washington Eastman, the preparing large numbers of the plates. His youngest of three children, in Waterville in up- inventions were phenomenally successful and state New York. The house on the old Eastman made him a wealthy man. Thanks to the profits homestead, where his father was born and of the company he founded to produce his cam- where George spent his early years, has since eras and film, Eastman Kodak, he was able to been moved to the Genesee Country Museum in contribute $100 million to various educational Mumford, New York, outside Rochester. institutions. When George was five years old, his father Plagued by progressive disability resulting sold a nursery business and moved the family to from a hardening of the cells in the lower spinal Rochester, where the elder Eastman established cord, Eastman became increasingly frustrated at Eastman Commercial College. Sadly, George’s his inability to maintain an active life. He com- father died suddenly, the college failed, and the mitted suicide on March 14, 1932, at the age of

77 78 eating habits

77. His suicide note read: “To my friends: My occur when a person is not properly integrated work is done. Why wait?” into society, but is dependent instead upon per- sonal resources. eating habits A noticeable, often dramatic, change in a person’s eating habits is a warning egotic suicide A type of suicide triggered by sign or distress signal of possible suicide. Experts an intrapersonal problem. believe most suicidal children will show changes in eating habits that can be one of many early signs of trouble. A few children (almost always Egypt A devout country where suicide is con- girls) will show extreme eating disorders that sidered by most people to be a mortal sin. As a usually last several years and come to monopo- result, Egypt has a correspondingly low suicide lize their lives. rate, the lowest in the world. Parents, teachers, friends, and counselors The most recent statistics provided by the should consider eating disorders, especially ano- World Health Organization were reported in rexia nervosa and bulimia, as urgent warning 1987, when the rate was allegedly 0.1 per signs. Experts believe such behavior is really an 100,000 for men. According to the statistics that attempt at slow suicide, rather than an instant were reported, not one Egyptian woman com- attempt with a bullet through the brain or a rope mitted suicide. These statistics, some experts around the neck. believe, say less about national character than See also ANOREXIA NERVOSA and BULIMIA. the way facts are gathered or covered up. While highly industrialized and prosperous countries tend to have comparatively high suicide rates, economic class Statistics show that suicide they also tend to have more sophisticated meth- occurs equally among rich and poor alike, and ods of collecting the information on which sta- among adults as well as adolescents. Suicide is tistics are based, and comparatively few usually caused by a combination of forces one of prejudices against doing so. which may be economic fluctuations. Religion is a factor here, as well, since Mus- lims are strongly opposed to self-destruction. Egbert, Archbishop of York (?–766) Eighth The QUR’AN, the sacred scripture of the Muslims, century archbishop who made burial allowances decries suicide as an act worse than homicide. to those suicide victims who had mental and In ancient Egypt, suicide was viewed as a emotional disorders. Egbert made an exception neutral event, because death was merely a for the insane concerning burial in consecrated passage from one form of existence to an- ground. other. It was simply a way to avoid disgrace, See also CHRISTIANITY. abandonment, guilt, cowardice, or loss of a loved one. The oldest known reference to suicide is Suicide committed by people egoistic suicide Egyptian: “Death is before me today, Like the who feel alienated from others and who lack recovery of a sick man . . . Like the longing of a social support. As defined by sociologist ÉMILE man to see his home again. After many years of DURKHEIM, egoistic suicide is an attempt to anni- captivity . . .” (Man Disputing over Suicide with his hilate the self because the individual feels Soul, Egypt, ca. 2100 B.C.). extremely alienated from others and from soci- ety. According to Durkheim, most suicides are egoistic, committed by those with few commu- Elavil (amitriptyline) The brand name for nity ties. Experts believe that egoistic suicides one of a group of antidepressants called tricyclics. elder suicide 79

Before popular antidepressants such as Prozac, nonwhite men across the age spectrum, and the tricyclics were the first line of defense against white men over age 80 have the greatest risk of encroaching DEPRESSION. Today tricyclics are a all age, gender, and racial groups. The suicide less popular choice than the new generation of rate for this group is six times the current over- antidepressants, but they are still an important all rate and three times the rate of African- weapon for those patients who do not respond American men over 80 years old. This high rate to any other drug. among white men over 80 is important because Cyclic antidepressants work by beefing up the the very elderly age group (85 years and older) brain’s supply of norepinephrine and serotonin is the fastest-growing sub-population of elderly levels, chemicals that are abnormally low in adults in the United States. The widowed, many depressed patients. This allows the flow of divorced, and recently bereaved are at especially nerve impulses to return to normal. Unfortu- high risk, as are depressed individuals and those nately, cyclics also interfere with a range of other who abuse alcohol or drugs. The suicide rates for neurotransmitter systems. Used with central women peak between the ages of 45 to 64, and nervous system depressants such as alcohol, it do so again after age 75. can have an addictive effect. Abrupt cessation Experts suspect that rates are so high for this can result in nausea, headache and malaise, but group because older people are less likely to sur- these withdrawal symptoms are not necessarily vive attempts because they are less likely to indicative of addiction. recuperate. More than 70 percent of older sui- Patients who are potentially suicidal should cide victims have seen their primary care physi- not have access to large quantities of the drug, as cian within a month of their death, many with a severe overdosage can cause convulsions, con- depressive illness that was not detected. gestive heart failure, coma, and death. Minimum estimates of suicides among the elderly in the United States range from 6,000 to 10,000 annually, but the actual rate for the eldercide See ELDER SUICIDE. elderly is probably a good deal higher, since many deaths from suicide are never investi- elder suicide Completion of suicide by an indi- gated, and are reported mistakenly as accidents vidual aged 65 or over. While suicide can occur at or deaths from natural causes. Many are com- almost any stage of life, it becomes a much more mitted by isolated, lonely, older people. In some serious problem in the United States after age 65, cases, there are no friends or family members when the suicide rate increases abruptly. who care about the person’s cause of death; in About every 83 minutes, one adult over age other cases, they may be too afraid to ask 65 commits suicide in the United States. The sui- because of the stigma attached to this kind of cide rate for this general age group rose by 9 per- death. cent between 1980 and 1992. During that Additionally, suicides are often mistaken for period, there were 74,675 suicides by elderly natural deaths, especially in cases of medicinal people. In 1993, suicide rates ranged from 15 per overdosing, because many older people take 100,000 population among those 65 to 69 years many medications. old, to 24 per 100,000 population for persons 80 However, the rate for women is relatively to 85 years of age, a rate that is double the over- under-reported, since they tend to use methods all U.S. rate. (such as a drug overdose) that leave room for Among elderly Americans, white men are the other verdicts. Since American men most often most likely to die by suicide, especially if they use guns, these deaths are harder to attribute to are socially isolated or live alone. In fact, white “natural causes.” Nevertheless, that American men are at nearly 10 times the risk for suicide as male suicide rates peak in old age while female 80 electroconvulsive treatment rates are at their maximum during middle age is Methods difficult to explain. The unpleasant realities of Older adults tend to use highly lethal means to old age—increasingly poor health, death of a commit suicide. In 1988, nearly eight out of 10 spouse, relegation to a nursing home—fall more suicides committed by men 65 years and above frequently on women than men, since women used a firearm. Hanging and poisoning were the tend to live much longer. second and third leading causes of suicide in this On the other hand, women are generally bet- group. ter than men at maintaining social and family contacts. And men, due to the higher status and Suicide Attempts more competitive nature of their activities, lose For the population as a whole, there are about more social standing as they age than do 25 suicide attempts for every suicide completion. women. For elderly people, the ratio of attempts to com- pleted suicides narrows dramatically to 4:1. This Risk Factors means that an older person who contemplates Risk factors for suicide among the elderly suicide is more likely to complete the act. include the presence of a mental illness (espe- Elderly people often choose lethal methods cially depression and alcohol abuse), being sick, when attempting suicide, and because they tend being socially isolated (especially widows), and to be more frail, they are less likely to recover having guns in the home. Elderly widowers are from a suicide attempt. a very high-risk group, probably because they Suicide notes left by the elderly tend to show are more socially isolated and because of the loss a desire to end their suffering, rather than of emotional and social support provided by dwelling on interpersonal relationships, intro- their wives. spection, or punishing themselves or others, Between 60 and 85 percent of elderly suicides which are common themes in younger suicides. had significant health problems, and in four out of every five cases this was a contributing factor Prevention to their decision. On the other hand, nonsuicidal Maintaining close family ties with available rela- elderly had similar rates of physical illness as the tives, involvement in community groups suicidal. such as volunteer organizations, and access to Life events commonly associated with elderly good medical and mental health care provide suicide include: substantial protection from suicide by the elderly. Careful monitoring of prescription drugs • death of a loved one and observing any signs of substance abuse also • uncontrollable pain help prevent suicide, as do bereavement support • fear of dying a prolonged death that damages groups for the elderly who have lost loved ones. family members emotionally and economi- cally electroconvulsive treatment (ECT) A form • loneliness of treatment for DEPRESSION consisting of the • major changes in social roles, such as retire- application of a weak electric current to the head ment in order to produce convulsion and uncon- sciousness. While often effective for severe Most elderly patients who complete suicide depression, ECT has caused a great deal of con- visit their doctors within a few months of their troversy because of its frightening reputation death; more than a third consult a physician and tendency to trigger memory loss in many within the week of their suicide. patients. emergency rooms, help in 81

The modern practice of electric shock treat- ment at the University of North Carolina, Chapel ments is less than 65 years old. Because it was Hill. Almost 6,000 from a total of 139,000 work- cheap and easy, the use of ECT soon spread; by ers were selected for detailed study. the 1950s it was the primary method of treat- Out of the 6,000 workers studied, there were ment for depression until the discovery of anti- 536 deaths from suicide. These suicide deaths depressants led to a substantial decline in its use. were twice as high among those whose work Today, about 100,000 people a year are treated regularly exposed them to extremely low- with ECT. frequency (EMF) electromagnetic radiation. Sui- In a typical ECT treatment, the patient is cide risks were considered for electricians, line- given an anesthetic and a muscle relaxant before men, and power plant operators, the three most padded electrodes are applied to one or both of common jobs with increased exposure to mag- the temples. A controlled electric pulse is deliv- netic fields among the five utility companies. ered to the electrodes until the patient experi- (Only men were studied because women rarely ences a brain seizure; treatment usually consists worked in jobs where they were exposed to of six to 12 episodes (two or three a week). After EMFs.) the treatment, the patient may experience a The researchers suggest that electromagnetic brief period of confusion, which is later forgot- fields may reduce the production of melatonin, a ten, and a brief period of amnesia covering the hormone that maintains daily circadian period of time right before the treatment. rhythms, including the sleep and wake cycle. While serious depression in teens can lead to Reduced levels of melatonin are associated with suicide, ECT is rarely considered for these depression. younger patients, and there have been no con- What scientists found particularly interesting trolled studies for this age group. There is a risk is that the greater the amount of exposure to of prolonged seizure in younger patients, who EMFs, the greater the likelihood that the worker are more susceptible to seizures than are adults. would commit suicide. Researchers also noted Likewise, ECT in elderly patients who are that the younger workers seemed to be more depressed and demented is not recommended affected by the EMF radiation. because the treatment can worsen their con- Established risk factors for suicide are history dition. of mental and addictive disorders, abnormalities in the serotonin system, and disrupted family environment. Unfortunately, information about electromagnetic fields Prolonged exposure these risk factors was not available from person- to extremely low-frequency electromagnetic nel records at the companies. fields such as those emitted by large power lines The authors concluded that there is an asso- may double the risk of suicide, according to a ciation between cumulative exposure to ex- study from the University of North Carolina. The tremely low-frequency electromagnetic fields highest risk of suicide was found among those and suicide, especially among younger workers, with the highest levels of exposure, particularly and physical impairments among older workers. in the year preceding death. The association was The study was published in the Occupational and even stronger among those whose death Environmental Medicine Journal. occurred before the age of 50. The health records of all electricians and field technicians at any of the five major electric emergency rooms, help in Suicidal persons power companies in the United States between who survive a serious attempt are usually 1950 and 1986 were studied by Dr. David Savitz, rushed by EMS or paramedic teams to a hospital professor and chair of the depart- emergency room. Authorities urge parents and 82 Empire State Building relatives to make certain the patient is evaluated and women, and young and old persons. Their and treated (where possible) by a professional study showed the rate increased more for high therapist. status groups (whites, men, and younger indi- Parents or relatives cannot rely on the emer- viduals) during economic depressions than for gency room staff of a hospital to refer a suicidal low-status groups. They concluded that the data patient for psychiatric care. There are times indicate high-status groups are more sensitive to when the staff will call in a hospital psychiatrist the frustrations produced by business cycles. or psychologist for consultation on an attempted In the United States, other studies show that suicide victim. When this happens, the patient is rates of suicide are highest among laborers, often transferred, after recovering from the while in Great Britain both professional and attempt, to a psychiatric ward. But a family can- laborer groups had higher rates than other occu- not count on this always happening; emergency pational groups. Experts caution that occupation room staff personnel are simply too busy (or may be an important factor in assessing suicide uninterested) to follow through with psychiatric rates not only because of the work involved, but consultations. also because of the lifestyle outside of work Unfortunately, once the person—and espe- established by persons in particular occupations. cially the adolescent—checks out of the hospital, During rapid rises in the business index, sui- statistical studies indicate that the majority fail to cides tend to fall. With only slight business index seek additional professional assistance. It is up to increases, during the final phase of increase, the the suicide attempter’s family to make certain he suicide rate does increase—but primarily among or she receives therapy by a certified professional. females, particularly among those least involved in the machinations of the economy. Generally, business cycles are more highly correlated with The tallest building in Empire State Building male suicides than with the suicide of women. New York City that was for many years the site But the suicide of black women is more closely of many spectacular suicides. The last time a per- linked to business fluctuations and employment son jumped off the Empire State Building was in than is the suicide of black men. 2000, but there have been more than 30 suicides It’s clear that suicide rates vary in response to at the 1,250-foot skyscraper since it opened in economic conditions. In the United States, for 1931. Most of those who have leaped to their example, rates declined during the prosperous deaths never made it to the street, landing years of World Wars I and II but rose during the instead on one of the building’s setbacks. Great Depression. After World War II as the Over time, protective barriers were built country prospered, the rates remained low. higher around the observation platform to pre- European countries in general showed similar vent suicides. Today the barriers, plus sharp- trends. eyed guards, make the top of the Empire State Building virtually suicide-proof. England Suicide in England has for centuries been regarded with significant disfavor. The ris- employment There is an inverse association ing rate of suicide among men in England and between economic prosperity and suicide and Wales observed in the 1970s and ’80s has the positive association between depression and reversed, and the suicide rate for both sexes is suicide. now decreasing, according to an analysis of Andrew F. Henry and James F. Short, trying to suicide data from the British Office for National determine more clearly how economic cycles are Statistics. related to suicide, analyzed separately the trend Between 1990 and 1997, the suicide rate for in suicide rates for whites and nonwhites, males men and women decreased in all age groups. England 83

There were also changes in the methods used to young children from the harshly cruel penalties commit suicide. Rates of self-poisoning with imposed by Anglican Church law. solids and liquids leveled off for men between When a suicide did take place, townspeople these years, and rates fell by 22 percent for often dragged the degraded body through the women. Poisoning by gases and vapors (includ- streets to be spat upon or hanged from public ing car exhaust fumes) fell by 61 percent in men gallows. Sometimes the victim was buried on the and 60 percent in women. However, suicides by spot where he or she had committed suicide; at hanging and strangulation increased in men. other times, the body remained unburied in the The fitting of catalytic converters onto cars area of town reserved for public executions. accounted for some of the fall in male suicides, Often the suicide’s body was buried at a cross- according to Guy McClure, M.D., consultant roads with a stake driven through its heart and a psychiatrist at the Chelsea and Westminster Hos- stone placed on the face to prevent the dead per- pital in London and author of the study. All gas- son’s spirit from rising. powered cars sold in the since In England as recently as 1823, the body of a December 31, 1992, have had to have convert- man who killed himself was dragged through ers, which reduce the carbon monoxide content the streets of London and buried at a crossroads. of the exhaust gas. He was the last suicide in England whose body However, since only 36 percent of cars had was so mistreated; Parliament passed a law converters by 1997, there may be other possible shortly thereafter authorizing private burial of a explanations for the fall. Levels of psychosocial suicide in a churchyard or in a private burial stress may have declined in men and women ground. between 1990 and 1997 as the national econ- In 1961, a new law repealed all previous civil omy and unemployment statistics improved. A rulings about suicide—rulings that had been move toward psychiatric care in the community based on early Anglican Church doctrine. may also have had an impact. Today it is no longer a crime to attempt or Attempts had been made to limit the avail- successfully to commit suicide in England. ability of certain suicide methods, such as detox- Famed poet-preacher JOHN DONNE, who became ifying domestic gas, reducing the prescribing of dean of St. Paul’s Cathedral in London, was barbiturates, and fitting catalytic converters. highly influential in changing public’s attitudes Recent legislation reducing the number of avail- by his defense of suicide in the book BIATHANATOS, able paracetamol (Tylenol) pills per packet has published in 1644. About 100 years later, Scot- been shown to decrease suicide by paracetamol tish philosopher DAVID HUME argued convinc- by eight percent in one year after the law passed. ingly against treating suicide as a crime in his Therefore, the rates for hanging may have short essay “On Suicide.” Suicide was regarded increased because it is not possible to limit the at the time as so widely prevalent that many availability of rope. believed the problem constituted a national The teachings of ST. AUGUSTINE and other early emergency. church leaders became incorporated into the The World Health Organization (WHO) statis- laws of the Roman Catholic Church and later the tics on suicide and self-injury includes Wales’s Anglican Church. Suicide was declared an act figures with England (Northern Ireland and inspired by the devil, as church councils deemed Scotland are listed separately). Most recent sta- it a mortal sin. Bodies of suicides were denied tistics (1997) show a suicide rate per 100,000 Christian burial, and even suicide attempters population totaling 13.2, a slight drop of .2 since were excommunicated. Church laws did distin- 1996. guish, however, between the self-destruction of The male suicide rate is 10.3 as opposed to the sane and insane persons, and also excluded much lower female rate of 2.9. Highest rate for 84 English Malady, The specific age groupings is that for 75+ years case histories of adult and adolescent suicides, of age; for males, it is 16.9 per 100,000 popula- and clarifies the various motives for completing tion. Highest female age group rate is the 45–54 suicide. category, where the rate is 4.4 per 100,000 population. Enlightenment, Period of The mid-18th-cen- tury era when new views led to more tolerant English Malady, The Book presenting suicide attitudes and opinions about suicide. Leaders of as a medical problem, written by Scottish physi- the “Enlightenment” included Voltaire, JEAN- cian George Cheyne (1671–1743) in 1733. JACQUES ROUSSEAU, and DAVID HUME among oth- Cheyne opened a practice in London in 1702, ers. They and their allies condemned the where he published a number of medical trea- traditional cruel treatment of suicides. tises. In 1715, he argued that life cannot be cre- ated from inorganic matter; all living things, he environment The idea that a person’s sur- reasoned, “must of necessity have existed from roundings can influence a person’s desire to all eternity.” commit suicide can be traced to antiquity. Early In The English Malady, Cheyne wrote that physicians, writers, and philosophers began to melancholy was caused by “the moist air of discuss the role of environmental factors such as these islands, our variable weather, a too-rich air, diet, and temperature on both social and diet and overpopulation.” Cheyne’s text offered medical problems. These discussions became so a new perspective on the problem of melan- common and widespread in the 18th century choly. He linked suicide to the social conditions that they led to the opposition of sanctions that prevailed in England in the early 18th cen- against suicide, and the development of tolera- tury, rather than to the particular moral attrib- tion for such acts. utes of the sufferer of melancholy. The change is Henry Morselli, an Italian professor of psy- subtle but of utmost importance to the history of chological medicine, was an early researcher of subjectivity. the subject. In his book Suicide: An Essay on Com- According to Cheyne, melancholy was caused parative Moral Statistics (first published in Milan in by the luxurious lifestyle of wealthier English 1879, reprinted in 1975 by Arno Press, New people of the day. Many later sociological terms York), Morselli studied endless statistics and, for similar states of psychological distress were among other things, tried to relate “cosmico-nat- developments of Cheyne’s cultural approach to ural” influences such as climate, geological for- psychic ailments, such as alienation, chronic mations, and so on to suicide. He also considered boredom, anomie, neurosis, anxiety, disen- biological factors, social conditions of the suicidal chantment, depression, nerves, and so on. The person and individual psychological influences. full title of the book was: The English Malady: Or Many, if not most, of Professor Morselli’s con- a Treatise of Nervous Diseases of all Kinds, as Spleen, clusions would be challenged today (such as the Vapours, Lowness of Spirits, Hypochondriacal, and frequency of suicide in various parts of Italy gen- Hysterical Distempers, Etc. (London: G. Strahan erally is in a direct ratio with stature, and the and J. Leake, 1733). inclination to self-destruction increases from south to north as the stature of Italians gradually Enigma of Suicide, The A deeply compas- increases). Yet, if Morselli’s correlations seem sionate treatment of suicide that examines sui- strange, consider that there was a study in the cide from the historical, moral, sociological, and spring 1977 issue of Suicide and Life Threatening psychological angles, written by Life magazine Behavior that attempted to correlate the rate of writer George Howe Colt. The book includes suicides with the moon’s position. The only rela- Epictetus 85 tionship appeared to be a slight increase in the lived and worked first in Rome, and then as a number of suicides during the new moon phase, teacher with his own school in Greece. suggesting perhaps that a small percentage of The philosophy of Stoicism was among suicide-prone people are influenced by lunar several at the time that accepted and even rec- changes. ommended suicide under certain conditions— It has also been postulated by some authori- particularly as an escape from evil. Epictetus also ties that geography may affect people who live endorsed suicide in some cases. The principal in isolated areas, in regions where days are short moral theme of Stoic philosophy is that humans and the nights long, and/or where climate is should resign themselves to whatever fate has in gloomy. Northerly countries such as SCANDINAVIA store. For some of us, Epictetus suggests, there show higher suicide rates than do tropical may be limits to what we can endure in this life regions. In the United States, suicide frequencies and, so, when things become intolerable, we rise as one travels from east to west (Nevada has may wish to end our lives. He describes our the country’s highest suicide rate per 100,000 options by saying: population with Arizona and Alaska close “... Above all, remember that the door behind). stands open. Do not be more fearful than chil- Others theorize that spring is the deadliest dren. But, just as when they are tired of the time of year for suicides and winter the least game they cry, ‘I will play no more,’ so too when deadly. One researcher notes that people of you are in a similar situation, cry, ‘I will play no slight physique tend to commit suicide in early more’ and depart. But if you stay, do not cry.... spring, those more stockily built, toward the end Is there smoke in the room? If it is slight, I of spring. More suicides are said to occur on cer- remain. If it is grievous, I quit it. For you must tain days of the week—Monday is the favored remember this and hold it fast, that the door day. Also, suicides are said to prefer certain stands open.” [Discourses, Book 1, Ch. 24, 25] hours of the day, usually in late afternoon or Although Epictetus based his teaching on the early evening, presumably when they know works of the early STOICS including thought, other family members are at home. logic, and ethics, he emphasized ethics. The role Some of these environmental correlations of the Stoic teacher was to encourage his stu- obviously play a part in the frequency and moti- dents to live a philosophic life of reason, whose vation of suicidal persons, but other circum- end was happiness. For Stoics, being happy stances and statistics vary so greatly that it is meant living virtuously and according to nature. impossible to draw any useful conclusions. The task of a Stoic is to live according to nature, Environments in which there is crime, vio- which means intelligently responding to one’s lence, alcohol and/or drug abuse, divorce, or own needs and duties as a sociable human unemployment, appear to make some individu- being, but also wholly accepting one’s fate and als especially vulnerable. the fate of the world as coming directly from the divine intelligence. Epictetus, along with all other philosophers of Epictetus (ca. A.D. 55–ca. 135) Greek the Hellenistic period, saw moral philosophy as philosopher and an eminent exponent of Sto- having the practical purpose of guiding people icism who approved of suicide in some cases. toward leading better lives. The aim was to live Born about A.D. 55 in Phrygia (now central well, to secure happiness. Epictetus encouraged Turkey), as a boy he came to Rome as a slave. his students to think of life as a festival, arranged While still a slave, he studied with a Stoic for their benefit by God, as something that they teacher. He lived about 400 years after the Stoic can live through joyously, able to put up with school of ZENO was established in Athens. He any hardships because they have an eye on the 86 Epicureans larger spectacle that is taking place. Epictetus Society is seen as a necessary protection did not marry, had no children, and lived to an from injustice, and the ultimate happiness is old age. peace. His motto was lathe biosas (“live unob- trusively”). Epicureans Adherents of a philosophical school of thought in ancient Greece that taught epilepsy Research suggest that patients with that pleasure was the goal of life, and could be epilepsy (especially temporal lobe epilepsy) attained by moderation. Epicureans considered attempt suicide at a rate about four, five, or suicide an appropriate escape from the sufferings seven times as high as that of the general popu- of this world, especially physical illness and lation, depending on the study. The last 10 years emotional frustration. For the Epicureans, it was of suicidology literature continues to report both better by far to have a few friends with whom to higher suicide rates among people with epilepsy, serenely contemplate the universe and with and the fact that many use antiseizure medica- whom to enjoy moderate and secure pleasures. tions to kill themselves. Expounded by Lucretius, the philosophy There is also an increased risk for suicidal was much followed in Rome and during the behavior in children with epilepsy, who are Renaissance. more likely to complete the attempt. The higher Epicureans opposed suicide because self- risk for these patients is attributed to their destruction simply did not fit their concept of the problems with housing, schooling, work, social calm life, with its primary quality of joy. relationships, psychiatric disturbances, and anti- convulsant drugs. The risk can be lessened by education, watching for psychiatric disturbances, Epicurus (?342–270 B.C.) Greek philosopher who opposed suicide and whose work was pop- and monitoring their medication level. ularized by the Roman poet Titus Lucretius Other studies have noted more suicidal Carus. Epicurus was born on the island of Samos thoughts and impulses and higher risk factors for in Ionia, going off at age 19 to Athens to study at suicide in three samples of epileptics studied in the Academy. metropolitan Los Angeles, noting a higher Epicurus had little patience with religion, prevalence of depression and hostility. Unex- which he considered a form of ignorance, but he pectedly, researchers also found the patient fears said that the gods existed, although they lived about seizures played a significant role in actual far away in space and had nothing to do with suicide attempts, and were the reasons for their people on Earth. (Atheism was still illegal in suicidal impulses and fantasies. Athens.) Epicurus believed it was useless to Furthermore, other studies have found that argue over metaphysics, that there was no such incarceration suicide among people with thing as a soul that lived after death, that epilepsy is especially high, especially among humans arrived at their present condition by those who are also depressed. Epileptic prisoners means of evolution, and that people have free tend to be more depressed and suicidal, and to will. have drinking problems. Virtue for Epicurus was a means to an end— and that end was happiness. He believed it was Epistles Seneca, Roman statesman, philoso- good to feel pleasure and to avoid pain, although pher, and author, in his famous Epistles refers to sometimes pain was necessary in order to gain a desire that seemed to possess many at the happiness. On the other hand, he believed that time—a morbid longing for death (affectus qui sometimes pleasure leads to more suffering than multos occupavit, libide moriendi). Seneca was tutor it is worth. and trusted advisor to Emperor NERO until he fell Esprit des lois 87 from Nero’s favor and was obliged to commit considering them, wiser than those who are suicide in A.D. 65. unwilling to die and want to live longer. His See also SENECA, LUCIUS ANNAEUS. Encomium Moriae (The Praise of Folly) was a satire on the state of Europe in his time; it became a equivalents of suicide Actions such as drink- best seller, sometimes called “In Praise of Folly.” ing, smoking, substance abuse and reckless dri- ving that may reflect an unconscious wish to die. Eskimos and suicide The suicide rate for SIGMUND FREUD believed that everyone has a Alaskan Natives is twice that of the U.S. popula- desire to totally destroy themselves. He thought tion, and in western Alaska, the Eskimo suicide that some people are driven to suicide con- rates are even higher. The most common sciously, whereas others seek more subtle meth- method of suicide among many Alaskan natives ods without understanding what they are doing. is hanging, although other Eskimo groups also On the other hand, certain people can perceive use drowning and guns. Motives include illness the consequences of their self-destructive urges or old age, unhappy love affairs, and depression. and control these negative impulses fairly well, Certain Eskimo civilizations practiced suicide to live normal, happy lives. motivated by social concern. Because these peo- Such “suicide equivalents” are sometimes ple lived in regions where the food supply was labeled by experts as a partial suicide, a subin- limited, aged members of the group sometimes tentioned suicide, a submeditated suicide, indi- would deliberately wander off and freeze to rect self-destructive behavior or a suicide death, in order that the others might sustain equivalent, respectively. Authorities such as themselves with whatever food was available. Norman L. Farberow have long insisted that the The Iguliic Eskimos believed that a violent definition of who and what constitutes a suicide death was a guarantee the individual would end should include the numberless, diverse group of up in paradise, which they called the Land of individuals engaged in life-shortening activities. Day. In contrast, those who died peacefully from While these kinds of death are not ruled “sui- natural causes were consigned to eternal claus- cides,” they represent cases where definite, trophobia in the Narrow Land. unconscious lethal intention is involved. See also ABUSE, SUBSTANCE; DAREDEVILS. Esprit des lois Influential book by French writer Charles-Louis de Secondat, baron de la equivocal deaths A death in which the cause Brède et de Montesquieu, who theorized that is uncertain or unclear. The PSYCHOLOGICAL the occurrence of suicide among different people AUTOPSY procedure often makes possible a deci- was due to climate influence combined with cer- sion as to the cause of death. This usually proves tain cultural factors. therapeutic for grieving survivors. The baron was born in the Château de la Brède near Bordeaux on January 18, 1689. His Erasmus, Desiderius (1466–1536) Dutch family was of noble rank; his grandfather was humanist scholar and writer who explains in president of the Bordeaux parliament, his father Funus (The Funeral) why God meant death to be was a member of the royal bodyguard, and his an agony and explains further that he did this mother, who died when he was age 11, traced “lest men far and wide commit suicide.” Yet her ancestry to an old English family. Young Erasmus had said otherwise in his well-known Charles de la Brède, as he was then known, was The Praise of Folly (1509), wherein he commends sent to the Oratorian College at Juilly, where he those who would voluntarily kill themselves to received a classical education in which religion be rid of a miserable and troublesome world, was not important. When, at 25 he returned 88 Esquirol, Jean-Etienne-Dominique home after being called to the bar, he received dred hares save themselves, even in the grey- from his paternal uncle the style and title of hounds’ jaws,” he wrote. Baron de Montesquieu, by which he was after- The French essayist concludes that the only ward known, and became councillor of the Bor- acceptable justifications for suicide are unsup- deaux parliament. portable pain or a worse death. In Esprit des lois, the baron expressed his belief that the English willed themselves to die without reason, seemingly in the midst of happiness, ethics and morality of suicide The controversy while the Romans committed suicide as a result concerning the ethics of suicide has long raged of their education. Montesquieu concluded that not only among philosophers, but among reli- English suicides were the result of a malady gious disciplines as well. ALBERT CAMUS, in his caused by the effect of climate on the body and The Myth of Sysiphus, wrote that “There is but one mind. He reasoned, therefore, that suicide philosophical problem: whether or not to com- should not be punishable. His view reflects the mit suicide.” Sir Thomas Browne, in Religio trends of opinion about suicide that had been Medici (written in 1635 and published in 1642), developing up to his time. stated that: “Herein are they not extreme that can allow a man to be his own assassin and so highly extoll the end by suicide of CATO.” The Esquirol, Jean-Etienne-Dominique (1772–1840) linguist, David Daube, writes in Philosophy and French psychiatrist who described the difference Public Affairs (1972):“. . . the history of the word between mental deficiency and insanity, and ‘suicide’—and a strange one it is, mirroring the who believed suicide was almost always trig- flow of civilizations and ideologies as well as the gered by insanity. He outlined his beliefs on sui- vagaries of the fate and fame of individual cide, in which genetics and a person’s individual authors.” Donald Attwater, in The Penguin Dictio- disposition played a role, in Des maladies mentales. nary of Saints (1965), writes about Saint Pelagia It was the first book to espouse an objective and (ca. 304), a 15-year-old Christian girl who lived rational view of mental disorders. He inter- in Antioch during the persecution of Christians viewed a number of people who attempted sui- by Diocletian. When soldiers broke into her cide, and worked with many inmates in prisons home to seize her, she eluded them and “in to develop his theories. order to avoid outrage,” she jumped to her death from the housetop. She is venerated by Catholics Essais Michel Eyquem de Montaigne, in his as a maiden martyr, an example of death before Essais, wrote that death is “not a remedy for one dishonor, despite once-harsh religious laws with malady only, but for all ills. It is a very secure regard to suicide. haven, never to be feared and often to be As John L. McIntosh states in Research on Sui- sought. It is all one whether man ends his life or cide (1985): “Recently, those controversies have endures it; whether he ends it before it has run been brought to the fore by many forces: its course or whether he waits for it to end; no changes in resuscitation and life-preserving matter whence the end comes, it is always his technologies, longer life expectancies, publicized own; no matter where the thread snaps, it’s the ‘rational’ suicides, and ‘how-to’ manuals (pro- end of the road.” viding explicit and specific information regard- Montaigne, however, ultimately wonders ing methods of suicide) which have been what situations can truly justify the act of killing published in several countries.” oneself. Since there are so many sudden changes In addition, literature and the media have in life, it is difficult to judge at what point a per- provided instances concerning easy and accepted son is really without hope. “I have seen a hun- suicide. euthanasia 89

Indeed, complex ethical, moral, and religious low rates may have more to do with faulty views on suicide, along with legal arguments, reporting rates than actual suicide rates. deal with topics such as the determination of See also GLOBAL SUICIDE. the point of death and life, abortion, and EUTHANASIA. Such ethical and moral dis- Eusebius, Bishop of Caesarea (A.D. 260– agreements continue as both suicide prevention ?341) Catholic bishop and historian who agencies and suicide assisting groups still exist focused considerable attention on church mar- today. tyrs. His history offers many examples treated at Society has not been able or willing as yet to length, and his Martyrs of Palestine was written resolve (and in certain cases even consider) in several editions over a period of years. In these difficult ethical and moral problems as The Ecclesiastical History, he relates tales of Chris- they relate to the issue of suicide. This ethical- tians about to be tortured who chose instead to moral-religious-social ambivalence regarding commit suicide, “regarding death as a prize suicide stands in the way of understanding fully snatched from the wickedness of evil men.” Vol- what Albert Camus called a “fatal game that untary martyrdom was common among the leads from lucidity in the face of existence to early Christians. flight from light.” Eusebius also wrote a number of other works, including theological treatises and works on Europe Despite striking cultural differences in Christian scripture. suicide rates, the basic relationships of the major demographic variables for the United States are euthanasia Term derived from the Greek also found in most European countries. The word meaning “good death” to describe a death motives and methods of suicide victims vary, as caused by someone other than the deceased as a do contemporary cultural attitudes toward sui- way of relieving suffering. Also called “mercy cide. (Attitudes in general are more tolerant killing,” euthanasia is an extremely controversial toward suicide than in the past; still, many cul- act still debated on religious, political, and moral tures and religions continue to view self-destruc- grounds. tion as an abomination.) There is a difference between euthanasia and The nations of Eastern Europe have strikingly ASSISTED SUICIDE. In the former, a person other higher suicide rates than countries in the West. than the deceased performs an act that results in The highest rates occur in the Lithuania (43.7 the person’s death. In assisted suicide, someone per 100,000) followed by the RUSSIAN FEDERA- helps the deceased commit suicide, but the per- TION (37.1 per 100,000), BELARUS (35.5), Estonia son technically dies by his own hand. An exam- (34.0), HUNGARY (33.9), and Latvia (32.8). ple of assisted suicide would be a person who Lithuanian men kill themselves at a rate of 73.8 dies by swallowing pills supplied by a doctor for per 100,000, closely followed by men in the the purpose of causing death. Russian Federation at 62.6. The law permits patients or their surrogates to The highest rates of suicide in Western withhold or withdraw unwanted medical treat- Europe are GERMANY (28.8 per 100,000), fol- ment even if that increases the likelihood that lowed by (24.2), BELGIUM (21.5), SWIT- the patient will die—so people cannot be hooked ZERLAND (20.4), and AUSTRIA (19.5). up to machines against their will. Countries of Europe with the lowest alleged In most cases, the law draws the line at suicide rates include AZERBAIJAN (.65 per actively causing a person’s death. Oregon, Bel- 100,000), ARMENIA (1.8), Tajikistan (3.4), GREECE gium, and the Netherlands are the only three (3.9), and Georgia (4.3). However, extremely places in the world where laws specifically permit 90 Euthanasia Education Council euthanasia or assisted suicide. Oregon permits this concern are medical advances in technology assisted suicide, whereas Belgium and the Nether- that have brought about marked demographic lands permit both euthanasia and assisted suicide. changes in population(s) and a significant In 1995, Australia’s Northern Territory ap- increase in the number of retired/aged persons. proved a euthanasia bill that went into effect in In 1935, the British Voluntary Euthanasia 1996, but was overturned by the Australian Par- Society was formed, followed by the founding in liament in 1997. Colombia’s Supreme Court 1938 of the Euthanasia Society of America. In ruled in 1997 that penalties for mercy killing 1980, the World Federation of Right-to-Die should be removed, but the ruling does not go Societies was founded, with 27 groups from 18 into effect until guidelines (still to be drafted) are countries joining, and by the 1980s the num- approved by the Colombian Congress. ber of pro-euthanasia groups trebled. Prominent Neither suicide nor attempted suicide is crim- U.S. supporters of euthanasia have included Dr. inalized anywhere in the United States or in Walter C. Alvarez, Robert Frost, Dr. Henry many other countries. When penalties against Sloane Coffin, Dr. Harry Emerson Fosdick, and attempted suicide were removed, legal scholars Margaret Sanger. made it clear that this was not done for the pur- pose of permitting suicide. Instead, it was intended to prevent suicide. Penalties were Euthanasia Education Council (EEC) Estab- removed so people could seek help in dealing lished in 1969, the EEC was instrumental in dis- with the problems they’re facing without risk of tributing more than a quarter of a million copies being prosecuted if it were discovered that they of the Living Will in an effort to ensure a had attempted suicide. Euthanasia and assisted patient’s right to a natural death, unencumbered suicide are not legal (except in Oregon) because by heroic efforts or unnecessary resuscitation. they are not private acts. Rather, they involve The Euthanasia Education Council later became one person facilitating the death of another. The known as Concern for Dying; in 1991, the orga- concern by opponents is that assisted suicide or nization changed its name to Choice in Dying, euthanasia could lead to abuse, exploitation, or and then to Partnership for Caring: America’s erosion of care for the elderly or handicapped. Voices for the Dying. Two types of euthanasia are usually men- The organization has evolved into a nonprofit tioned in professional discussions of termination organization devoted to raising expectations and of life. One is typed as “active” or direct—where increasing consumer demand for excellence in life is ended by “direct” intervention, such as care near the end of life. The group operates the administering to a patient a lethal dose of a drug. only national crisis and information hotline The other is called “passive” or indirect—i.e., dealing with end-of-life issues, and provides where death results from withdrawal of life-sup- state-specific living wills and medical powers of port or life-sustaining medications. Dr. Christi- attorney (also called advance directives). aan Barnard, who received international acclaim The group promotes accessibility to high- and recognition for pioneering work in heart quality, comprehensive , including transplant surgery, writes in Good Life, Good hospice care, and distributes publications and Death: A Doctor’s Case for Euthanasia and Suicide videos that offer practical information for con- that: “Indeed, even though many doctors will sumers about how to get the best possible end- not admit it, passive euthanasia is accepted med- of-life care. The group offers education and ical practice—a common occurrence in wards consultation to doctors, nurses, social workers, where patients live out their final hours.” attorneys, and clergy, and trains corporate staff The concept of “death with dignity” is today to help their employees deal with end-of-life an ever-increasing focus of debate. Reasons for decisions. exile 91

In addition, Partnership for Caring tracks and view suicide as an “unforgiveable sin,” and a monitors all state and federal legislation and sig- Lutheran who commits suicide is not denied a nificant court cases related to end-of-life care. Christian burial. Until 1979, the Society for the Right to Die However, in ISLAM, suicide is the gravest of and the EEC operated as separate arms of the sins. Suicide is forbidden in the QUR’AN, which U.S. right-to-die movement. They shared the decries that taking one’s own life is an act worse same offices in Manhattan and concentrated on than homicide. Paradoxically, Muslim suicide passive EUTHANASIA, and focused its efforts on terrorists are not uncommon in their zeal to die enactment of state right-to-die laws, while the in a Jihad, or holy war. In their mind, this nonprofit Council stressed educational and assures them a passport to heaven, despite the philosophical issues of “dying with dignity.” The fact that the Qur’an contains nothing stating close working relationship between the two that killing guarantees a passport to heaven. groups ended in 1979 when the EEC stopped Judaism, too, considers suicide a sin. Al- financial support of the society, primarily though the Hebrew Bible did not specifically because of EEC’s disapproval of “indiscriminate prohibit suicide, subsequent Jewish laws forbade or ill-conceived legislation.” EEC became con- it and denied full religious burial rites to people vinced that such legislation could limit rather who took their own lives. than broaden a person’s decision-making power. JEWS over the years, however, have recog- For contact information, see Appendix I. nized and honored “heroic” suicides—that is, self-destruction to avoid being murdered by ene- excommunication When the teachings of ST. mies, forced into idol worship, sold into , AUGUSTINE and other early church fathers were or sexually abused. In fact, dying with honor to incorporated into the laws of the ROMAN CATH- preserve one’s beliefs and affirm one’s freedom OLIC CHURCH (and later the Anglican Church), to control life and death has continued through- suicide was declared an act inspired by the devil. out Jewish history, from MASADA in A.D. 73 to Church councils proclaimed it a mortal sin, and the Nazi concentration camp in TREBLINKA dur- ruled that the bodies of people who committed ing World War II. suicide be denied Christian burial. Even suicide The Japanese at one time ritualized suicide attempters were excommunicated. through the ceremonial death with honor of SEP- However, church law made a distinction be- PUKU, or hara-kiri as practiced by the samurai, or tween the suicides of sane and insane people, members of the military class. Hara-kiri was offi- and also exempted young children from the cially outlawed in 1868, yet the tradition of sui- penalties of the church laws. cide in the name of honor still influences certain These religious doctrines against the act of Japanese practices. This ancient glorification of suicide still remain in effect in the Roman death with honor (such as the Japanese soldiers Catholic Church and in many Protestant who died as KAMIKAZE PILOTS during World War churches, but today many priests and ministers II) may be responsible, at least in part, for the usually are more tolerant and have found ways high rate of suicide among young Japanese to modify them in most circumstances. today. Increasingly, church officials are coming to recognize suicide as not only a religious ques- tion, but also a major social and medical prob- exile Self-imposed exile in some societies was lem. Groups such as the Anglican Church have an alternative to suicide. These voluntary exiles established special commissions to consider the were socially acceptable for example, the Tixopia revision of harsh religious laws concerning sui- would set out to sea by canoe, a voyage likely to cide. The Lutheran Church in America does not result in death. 92 existentialism existentialism The modern philosophical expendable child syndrome An adolescent movement founded by Søren Kierkegaard, or child’s belief that parents wish the child was developed in GERMANY by Martin Heidegger and dead. Karl Jaspers, and popularized after World War II by Jean Paul Sartre and ALBERT CAMUS in France. explosives Most youths who complete suicide Existentialism which embraces both religious do so with guns and explosives. HANGING is the mysticism (Kierkegaard) and atheism (Sartre), is second most common method, while taking pills a philosophy of crisis. It regards the whole of and poisons is the third. Young girls who kill human and cosmic existence as a series of criti- themselves do so most often with pills and poi- cal situations, each demanding the whole inner sons, but in recent years, guns and explosives resources of the individual for its resolution; cri- have become the second most common method. sis follows crisis to the ultimate end in death. Hanging is the third method most often used by Despair and disillusion are the chief characteris- young girls. tics of existentialism. Camus saw the goal of On the other hand, young men and women existentialism as establishing whether suicide who attempt suicide (but do not succeed) gener- was necessary in a world without God. ally do not use such violent methods as guns, explosives, or hanging. Most attempters (with- existential suicide Completing suicide out fatal results) have taken BARBITURATES or because “life isn’t worth it.” other drugs, poison or slashed their wrists—all methods that allow time for rescue. EXIT Nonprofit Scottish group (formerly the Voluntary Euthanasia Society of Scotland) extended family A particular way of life, in founded in 1935, that then broke away from the which three generations and sometimes even an English society to become independent and to aunt, uncle, and cousins in addition, lived under publish How to Die with Dignity, the first self-deliv- one roof. Many social scientists and suicidolo- erance manual in the world. In 1993, EXIT pub- gists believe that the extended family served to lished Departing Drugs. Both books are not protect each member from self-destructive available to the general public or minors. impulses. Today, the nuclear family (with both From 1992 to 1995 the group sponsored re- parents working or a single-parent family) offers search into living wills, clarifying the pros less support and protection. and cons of such documents, and published Col- Just how much the demise of extended fami- lected Living Wills, the first such international lies influences today’s alarming rise in suicide collection. among young people is difficult to measure. F facilitated suicide Completion of a suicide fallacies about suicide See MYTHS CONCERN- because of clinician indifference. This is also ING SUICIDE. known as an “iatrogenic” suicide. Falret, Jean-Pierre French psychiatrist who facilitating suicide The legal term for helping published in 1822 the first study of suicide that in a suicide completion. made use of statistical data, though admittedly on a small scale. In his De l’hypochondrie et du sui- cide, Falret classified causal factors that may lead Fadlan, Ibn Arab chronicler who in A.D. 921 to suicide under four headings: was sent by the caliph of Baghdad with an embassy to the king of the Bulgars of the Middle 1. Predisposing—heredity, temperament, cli- Volga. Ibn Fadlan wrote an account of his jour- mate; neys with the embassy, called a Risala. This Risala 2. Accidental direct—passions, domestic trou- is of great value as a history, although it is clear bles, etc.; in some places that inaccuracies and Ibn Fadlan’s 3. Accidental indirect—bodily pain, illness; own prejudices have slanted the account. 4. General civilization, civil disorders, religious During the course of his journey, Ibn Fadlan fanaticism. met a people called the Rus, a group of Swedish origin who acted as traders in the Bulgar capital. Falret’s work was yet another step in helping In the Risala, Ibn Fadlan describes a Rus funeral, authorities realize that suicide resulted from the which includes the suicide of a slave girl. interaction of many factors. When a Rus chieftain died, his female slaves were asked who wanted to be buried with him. fame During the 1830s in France, suicide The slave girl who volunteered would then be actually became fashionable among young cared for by two young women for 10 days, who romantics. In the case of one man, charged with watched over her and accompanied her every- pushing his pregnant mistress into the Seine, he where. Garments were made for the dead chief- defended his action by saying, “We live in an age tain as the doomed slave drank and sang every of suicide; this woman gave herself to death.” day. After the 10th day, the slave girl was killed For young poets, novelists, dramatists, painters, and both the chieftain and the slave were then and members of countless suicide clubs, to die by cremated on board a ship. one’s own hand was a sure way to fame. In a This experience is similar to other forms of satirical novel published in 1844, Jerome Paturot institutional suicide practiced among both the a la recherche d’une position sociale, the protagonist Thracians and the Hindus, each with customs in observes that “a suicide establishes a man. Alive which a widow or concubine offered her life one is nothing; dead one becomes a hero . . . All when the husband or master died. suicides are successful; the papers take them up;

93 94 suicide people feel for them. I must decidedly make my dren and teens and to improve family function- preparations.” ing is of some help for children and adolescents without major depressive disorder. Psychoedu- familicide suicide Killing of one or more cational approaches to reduce the extent of family members by a person who then goes on expressed anger may be helpful in lowering risk to commit suicide. for suicidal behavior in children and adolescents. Family therapy is also used to help the sur- viving family members of a person who has family therapy A significant class of risk fac- completed suicide. This type of therapy can help tors for suicide involves family problems such as family members move beyond the death. With poor communication, disagreements, and lack of this type of treatment, family members come to cohesive values and goals and of common activ- see that suicide happens to people from all walks ities. Suicidal children and adolescents often feel of life, to people much like themselves from that they are isolated within the family, show families much like their own. problems in independence, and view themselves as expendable to the family, a perception that is a motivating force for suicide. Family therapy farmers During late 1985 and throughout with suicidal children and adolescents is an 1986, America’s farm belt was being described as important way to treat these problems and to a “time bomb” because so many farmers were improve effective family problem-solving and committing suicide. Debt-ridden midwestern conflict resolution, so that blame is not directed and southern farmers were starting to feel the toward the suicidal child or teen. pressures and that accompanied low Family therapy examines the role of the suici- crop prices, relatively high interest rates, and dal member in the overall psychological well- low land values. These and other more subtle being of the whole family; it also examines the political factors began combining to force people role of the entire family in perpetrating the prob- off farms that, in many instances, had been in lems of the suicidal person. This type of therapy their families for generations. Land was being can be effective because a family’s patterns of lost in forced sales and equipment and livestock behavior influences the individual, and there- was seized. fore may need to be a part of the treatment plan. Farmers are not totally unique in such a situ- In family therapy, the unit of treatment isn’t just ation. There is tremendous stress and pain to the person—even if only a single person is inter- persons when economic and social dislocation viewed—it is the set of relationships in which occurs on a large scale, whether in rural or the person is imbedded. urban areas. But the farmers’ predicament— Family therapy is brief, solution-focused, and which generates an additional stress element—is specific, and has attainable therapeutic goals. that in such crises they not only lose their farms, With family therapy, suicide survivors can be but their businesses as well. Moreover, the taught that the future can bring resolution to farmer who loses his job may lose one that was what may seem an inextricable plight. held by his father, his grandfather, and other Cognitive-behavioral approaches with suici- ancestors for 100 years or more. dal children and adolescents and their families In mid-February 1986, more than 65,000 try to reframe their understanding of family farmers around the country received letters from problems, change the family style of poor prob- the FHA notifying them that they must restruc- lem-solving techniques, and encourage positive ture or renegotiate their farm loan payments or family interactions. Time-limited home-based face foreclosure. The federal agency, with some intervention to reduce suicidal thoughts in chil- 2,000 field offices in the United States, said it Fifth Commandment 95 took the drastic action to recover $5.8 billion in female suicides An American woman at- delinquent loans. tempts suicide every 78 seconds, and succeeds in As financial pressures eased somewhat among taking one life every 90 minutes. Although U.S. farmers into the 1990s, they worsened for many effective treatments exist, suicide in wo- British farmers, who faced continual losses from men remains a much underrecognized, under- mad cow disease and then foot-and-mouth dis- diagnosed, and undertreated problem. ease, followed by floods and storms of biblical Suicide is more common among women who proportions. By the turn of the 21st century, are single, recently separated, divorced, or wid- British farmers were committing suicide in owed, and peaks between the ages of 45 and 54, record numbers. Registered suicides among and again after age 75. The triggering life events farmers, horticulturists, and farm managers look for women who attempt suicide tend to be inter- set to be their worst for more than a decade, and personal losses or crises in significant social or were so high that more than one person a week family relationships. in the industry was registered as a suicide in Experts believe that women attempt suicide 1999. twice as much as men because of higher rates of mood disorders such as major DEPRESSION and fear of punishment In some young people, seasonal affective disorder among women. the fear of punishment (real or imagined) may Indeed, between 60 percent and 80 percent of cause them to think obsessively of suicide as the women experience transient depression, and 10 only solution to their problems. to 15 percent of women develop clinical depres- In families where there is little or no commu- sion during the postpartum period. Experts nication, violence sometimes becomes the only believe women aren’t as likely as men to com- interchange between parent and child. Children plete the suicide attempt because women are who are punished regularly (and often brutally) more likely than men to have stronger social come to think they can do nothing right. They supports, to feel that their relationships are also discover quickly that their parents are easi- deterrents to suicide, and to seek psychiatric and est to live with after they’ve gotten rid of their medical intervention. Some researchers estimate aggression through such abuse. that, among young people, as many as nine These child-victims sometimes become self- times more girls than boys attempt suicide with- destructive. They anticipate their parents’ abuse out completing it. by punishing themselves. Then, tragically, one Although women attempt suicide more often, day they self-inflict the final, lethal punishment. men complete suicide at a rate four times that of For the troubled, overly anxious or depressed women. The 1998 suicide rate among U.S. women young person, fear of separation can become was 4.4 per 100,000, compared to 18.6 for men. quite morbid and totally devastating. Routine separations experienced by most of us in life, Fifth Commandment The fifth (or sixth, per such as going to kindergarten, going off to col- the King James Version) of 10 commandments lege, breaking up with a girl- or boyfriend, mov- (“Thou shalt not kill”) delivered by God to ing to a new neighborhood or town—are Moses on Mt. Sinai, according to the Old Testa- difficult enough, but for the insecure, highly ment of the Bible. sensitive child they can prove debilitating. Organized religions were the first to con- Sometimes the young person affected by demn suicide. Christians believed life to be a these fears leaves clues that indicate potential gift from God, and that only God may take self-destructive action, such as broad hints or life away. Self-death also violated the Fifth subtle changes in behavior. Commandment. 96 Fiji Islands

However, the Judeo-Christian tradition, as The women would actually compete with one well as Islamic tradition, maintains that suicide another in the rush to destroy themselves, believ- in the form of martyrdom was permissible. The ing that the first to die would become the chief- Jewish religion also believes that suicide is tain’s favorite wife in “the world of the spirits.” acceptable if carried out to prevent torture, rape, See also SOUTH PACIFIC ISLANDS AND SUICIDE; or slavery. King Saul, for example, fell on his SUTTEE. sword after defeat in battle. The mass self- destruction to prevent capture of the defenders filicide-suicide Killing one or more offspring of the MASADA, a Jewish fortress besieged by by a person who then commits suicide. Romans in A.D. 72–73, was also considered a heroic action. : The Practicalities of Self-Deliver- ance and Assisted Suicide for the Dying Fiji Islands Fiji Indians have the world’s high- Best-selling book by , founder of est female suicide rates, and the overall figures the HEMLOCK SOCIETY, which was published in are among the highest anywhere as well. Most 1991 in the face of heated controversy and recent statistics suggest that suicide is growing national debate. Final Exit was written as a hand- fastest among adults with dependent children book for people who wanted to end their suffer- and among the children themselves. The latest ing from unbearable pain due to terminal or figures show more than 100 people committed incurable illness. Attempts to ban the book in suicide in the year 2000 and more than 100 oth- the United States, Australia, and New Zealand ers attempted suicide, but experts say actual failed, but Final Exit remains banned in France. numbers are much higher. The concise manual includes descriptions There is speculation in Fiji that the high youth about: suicide rate is a consequence of a school exami- nation system that discriminates against Indians • How to commit suicide with sleeping pills, (44 percent of the population) in the awarding preferably with the aid of a loved one of scholarships and places in schools. • a chart listing lethal doses of 14 drugs Clinical depression associated with suicide in the Western world is mostly absent in Pacific sui- • legal considerations, life insurance, and living cides, and few of the victims are mentally unbal- wills anced. Instead, a major cause of the rise in • finding the right doctor, hospice care, and pain suicides has been the erosion of social structures control and values, leaving many young people insecure. • letters to leave behind Journal of the American Academy A study in the • how to write a self-deliverance checklist of Child and Adolescent Psychiatry noted suicide among native populations is a significant prob- • psychological support groups for the dying lem worldwide—but especially in the Pacific. • suicide hotlines for depression Anthropologically, a common thread among these groups is the relatively sudden contact The book sold more than a million copies world- with Western culture, domination by the West- wide, spending 18 weeks on the New York Times’s ern culture, and greater or lesser degrees of best-sellers list. It has since been published in acculturative stress. translations in every major world language. But suicide has long been a part of the Fiji cul- ture. Early Fiji Islanders forced the many wives of Finland Finland has historically ranked high a tribal chieftain to kill themselves when he died. in both homicide and suicide among the world’s Flaubert, Gustave 97 cultures. WORLD HEALTH ORGANIZATION (WHO) fold; if the gun is unlocked, sixfold, and if statistics for 1998 show the country’s suicide rate loaded, ninefold. The states with the highest sui- per 100,000 population to be 24.2. The male sui- cide rates are Nevada, Montana, Arizona, New cide rate was a very high 38.3, while the female Mexico, and . All are states where guns rate was only 10.1. Highest among listed age are a part of the culture. groups was 45 to 54. The figures for young men States with stricter gun control laws have who complete suicide are particularly high (one lower rates of suicide. The states with the lowest in four suicides are committed by a man under suicide rates are New Jersey, New York, Massa- the age of 35). Nonetheless, the number of sui- chusetts, Rhode Island, and Washington, D.C.— cides, notably those of men, has been declining coincidentally, the states with some of the steadily since the peak year (1990); however, strictest gun laws in the country. the figure for women has remained unchanged. Although most gun owners reportedly keep a Because Finland had one of the highest sui- firearm in their home for protection or self- cide rates in the world, the country participated defense, 83 percent of gun-related deaths in in a 10-year suicide prevention program with these homes are the result of a suicide, often by WHO help from 1986 to 1996. The project’s goal someone other than the gun owner. was a 20 percent reduction in the incidence of And yet, fewer than 10 percent of people who suicide. The final outcome was a 9 percent complete suicide buy a gun with the specific reduction over the entire duration of the project intent of killing themselves. (from 1987 to 1996) and an 18 percent reduc- Emergency rooms across the nation verify tion from 1990—the peak year—to 1996. that suicide attempts with firearms are almost In 1996, a total of 1,247 people (956 men and always fatal. From 1980 to 1992, the suicide rate 282 women) took their own lives in Finland. For for 15-to-19-year-olds increased 28.3 percent, every other woman and one in four men, the and rose among 10-to-14-year-olds by 120 per- means of suicide was poisoning, mostly with cent. For black males aged 15 to 19, the suicide medications. rate increased 165.3 percent from 1980 to 1992. The increased rate of completed suicides may firearms suicide Use of a handgun, rifle, or be attributed to the use of more lethal means shotgun as a way to complete suicide. Firearms during attempts, specifically firearms. For exam- are currently the method most often used to ple, in Oregon from 1988 to 1993, 78.2 percent complete suicide by all groups (men, women, of suicide attempts with firearms were fatal, but young, old, white, nonwhite)—and the rates are only 0.4 percent of suicide attempts by drug increasing. Today, firearms are used in almost 60 overdose were fatal. percent of all suicides, accounting for more than 18,000 deaths each year in the United States. Flaubert, Gustave (1821–1880) French Firearms are now the most common method of writer whose most famous novel, Madame Bovary suicide even for women and for boys and girls (1857), describes Emma Bovary’s attempts to age 10 to 14. More than half of the gun deaths escape her drab existence through adultery and in the United States are suicides, and more peo- finally suicide. The story details the romantically ple die from firearm suicides than from homi- motivated, marital indiscretions of a wife in a cides. French provincial town; it is a condemnation of The odds that potentially suicidal adolescents what he sees as the petty, drab lives of the will kill themselves double when a gun is kept in French bourgeois class. the home. The availability of a gun increases the Flaubert confessed in his letters that as a likelihood of a person dying from suicide five- young man “I dreamed of suicide.” He wrote 98 follow-up, of suicidal persons that he and his young provincial friends, “lived telephone therapist determines who this might in a strange world, I assure you; we swung be: father, mother, wife, lover, or whoever.) The between madness and suicide; some of them idea is to avert the critical moment that will killed themselves . . . another strangled himself drive the caller to the brink of self-destruction, with his tie, several died of debauchery in order then provide the necessary follow-up help as to escape boredom; it was beautiful!” quickly as possible. Gustave Flaubert was a second son; his father Each suicide prevention group necessarily tai- was chief surgeon at the Hôtel-Dieu in Rouen lors its service to its own needs. There is no sin- and his mother was the daughter of a wealthy gle pattern or organization yet proved to be doctor. He began writing at a very early age, and better or more successful than another. Some published his first work when he was only 16. A services operate autonomously; others are a unit solitary boy with a rich imagination, in 1841 of the community’s mental health facility. A ser- Flaubert entered the faculty of Law in Paris. He vice can also be part of an emergency hospital or was forced to withdraw from studies when he tied to the local university. discovered that he was afflicted with epilepsy. The majority of suicidal callers want and need Although he continued to write, none of his help. When questioned a short time after their major works were published during this period. calls, 87 percent of the people said that they had He died suddenly of a stroke; his unfinished been helped. Questioned a long time after their final work, Bouvard and Pecuchet, was posthu- distress calls, 80 percent still maintained that mously published. they had been helped. Twenty-eight percent said The famous novelist was once asked who the that the service had saved their lives; 34 percent real-life Emma Bovary was. The author smiled said the facility “might” have saved their lives. wistfully and said, “I am Madame Bovary.” The suicide prevention center must be thoughtfully created, properly administered, and generously supported in order to extend maxi- follow-up, of suicidal persons The primary mum understanding and assistance. goal of any suicide prevention worker is to stop the caller from killing himself. Remaking the caller’s personality, curing all his troubles, no forfeiture, law of According to Henry de matter how serious, is not the major intention of Bracton, legal authority of mid-13th century in a suicide prevention service. In fact, effective England, an ordinary suicide forfeited his goods, action has a limited goal, to provide an immedi- while a person who killed himself to avoid a ate, ready contact between the highly disturbed felony conviction forfeited both goods and land. person calling a 24-hour “hotline” or “lifeline” This “law of forfeiture” remained in force and the community’s helping agencies that are throughout England into the 19th century. It available. was, however, often circumvented through the Fortunately, people are not permanently sui- claim of insanity. cidal. Even for the most despairing person, the suicidal mood ebbs and flows. In the majority of Forrestal, James (1892–1949) Former U.S. cases, staffers can provide the tension relief banker and cabinet officer in the Franklin D. needed to ease a critical suicidal situation. They Roosevelt and Harry S. Truman administrations, can then “arrange” things for the suicidal caller; Forrestal left banking as America’s entry into that is, set up an interview with a staff psychia- World War II loomed closer. He became under- trist, psychologist, social worker, or volunteer. secretary of the navy (1940–42), secretary of the Sometimes a meeting is arranged between the navy (1942–47) and first secretary of defense suicidal person and a “significant other.” (The (1947–49). France 99

President Truman was unhappy with Forre- According to the French Criminal Ordinance stal’s performance as secretary of defense, and on of August 1670 the body of a suicide was still March 28, 1949, forced him to resign from office. required to be dragged through the streets and Soon afterward, Forrestal, suffering from depres- then thrown into a sewer or the town dump. sion, was admitted to Bethesda Hospital, where Despite the law, however, many such cases were he committed suicide by throwing himself out of overlooked, and such severe penalties were not a 16th-floor hospital window on May 22, 1949. carried out. In Toulouse, for example, the punishment of Foster, Vincent Walker, Jr. Deputy legal dragging the corpse was imposed in 1742 and counsel for President Bill Clinton who was again in 1768, but the suicides occurred in jail found dead in a roadside park from an appar- and the victims were either convicted of or ently self-inflicted gunshot wound at 6 P.M.on indicted for a crime. Spectator revulsion against July 20, 1993. Foster’s body was found in an the practice ended the penalty after 1768, overgrown area at Fort Marcy, a small Civil War although burial in consecrated ground was often park across the Potomac River from Washington, denied the person who committed suicide in this D.C., in suburban Virginia. U.S. Park Police predominantly Catholic nation. found a pistol in Foster’s hand and quickly ruled In 1822, studies of suicide in Paris suggested the death a suicide. Reports of serious depres- that suicide reports were probably understated sion, together with prescriptions for antidepres- for several reasons. First, relatives in certain sants, supported that finding. cases tried to prevent a family disgrace by having However, the nature of his death and his con- the death attributed to some other cause, such as nection to Whitewater, Travelgate, and other insanity, and, reported suicides did not consider political scandals set off a swirl of controversies the large number of attempted suicides. suggesting murder and a politically motivated Another extensive study concerning suicide coverup. Rumors about his death shook the in France was done by Brierre de Boismont, and stock market and dogged the president, as Foster was considered an important contribution to the came to be seen by many as the key to dark problem of suicide in the mid-19th century. In secrets about some of the most powerful people his treatise DU SUICIDE ET DE LA FOLIE SUICIDE, pub- in the world. lished in 1856, de Boismont not only used statis- Foster was a friend of the Clinton family and tics extensively, but he also questioned 265 former law partner of Hillary Rodham Clinton. people who had either planned or attempted Married and the father of three children, Foster suicide. On the basis of his comprehensive study, was the number two White House lawyer. His de Boismont denied that all suicides were caused death stunned the president’s staff members, by insanity. He believed other important causes who said they were unaware of anything that included alcoholism, illness, family troubles, might have caused Foster to take his own life. love problems, and poverty. His findings also brought him close to a sociological explanation France Official, legal and ecclesiastical atti- of suicide. For instance, he discovered a higher tudes toward suicide were conservative in proportion of unmarried persons, of old people, France until well into the 18th century. Suicide and of men. More generally, he saw suicide as a was, in fact, equated with murder in various consequence of changes in society leading to countries in Europe. In France, the corpse was social disorganization and to alienation for many treated accordingly; the body was dragged people. through the streets, head downward on a hur- It is obvious that Brierre de Boismont and dle, and then hanged on a gallows. other 19th-century investigators of suicide were 100 French Criminal Ordinance of August 1670 heading toward ÉMILE DURKHEIM’s now-famous little was known about suicide but that perhaps conclusion stated in Le Suicide in 1897: that sui- the self-destructive action was actually a repudia- cide will not be widely prevalent in a society that tion of life because of the craving for death. This is well-integrated politically, economically, and particular remark, we now know, foreshadowed socially. Freud’s later belief in a death instinct. Recent statistics from 1997 indicate that Sigmund Freud’s paper “Beyond the Pleasure France has a suicide rate slightly lower than that Principle” presents his later theory of suicide. He of other European countries, at 19.2 per 100,000. believed there are two distinct kinds of drives: French men kill themselves at a rate of 28.4 per One is the life instinct, or Eros; the other, the 100,000 compared to a female rate of 10.1. This death, destructive and aggressive drive, or Tha- total overall suicide rate is thus lower than that of natos. There is an ongoing, constant shifting of GERMANY (28.8), BELGIUM (21.5), and AUSTRIA the balance of power between the two instincts. (19.5), but higher than that of ITALY (8.3), PORTU- Eros ages, but ageless Thanatos may assert itself GAL (5.7), and GREECE (3.9). Statistics are pro- “until it, at length, succeeds in doing the indi- vided by the World Health Organization (WHO). vidual to death.” Suicide, as well as homicide, is an aspect of French Criminal Ordinance of August 1670 the impulsive destructive action of Thanatos. Murder, Freud believed, is aggression turned This infamous law required, among other things, upon another; suicide is aggression turned upon that the body of a person who committed suicide oneself. His implied value judgment is that mur- be dragged through the streets and then thrown der should be disapproved and prevented into a sewer or onto the town dump. Despite the because it is highly destructive. Suicide must also law, cases were sometimes ignored and the be disapproved and prevented since it is nothing severe penalties were not applied. The penalty less than murder “in the 180th degree.” was last carried out in Toulouse, in 1768. Freud was born on May 6, 1856, in Freiberg, See also FRANCE. the son of Jacob and his third wife, Amalia. While earning his doctorate in medicine, he Freud, Sigmund (1856–1939) Austrian psy- worked at the Institute of Physiology as a chiatrist of Jewish descent, founder of modern research assistant specializing in . In psychoanalysis. Although much of Freud’s work 1896, he headed the neurological department of was controversial, particularly his theories about the First Public Children’s Hospital. In 1900, he children’s sexuality, his concept of the uncon- wrote The Interpretation of Dreams, which formed scious mind underlies most modern inquiries the basis of his research for the next 40 years. into human behavior and motives. Freud pioneered the idea of the subconscious, Concerning the act of suicide, Freud viewed and at a time when most doctors believed men- the urge to kill oneself as essentially a problem tal illness was caused by poor genes, Freud within the individual. He believed that life and argued that patients could be cured of hysteria death forces are in constant conflict in every per- just by talking with their doctors. son, even though these conflicting forces are Between 1921 and 1938, Freud wrote various unconscious. works detailing psychoanalysis’s effect on the On April 27, 1910, the VIENNA PSYCHOANALYTI- social world. Freud fled Vienna in the 1938 inva- CAL SOCIETY met for a discussion titled “Suicide in sion of Austria, moving to Paris and then to Lon- Children.” Freud said then that in their desire to don, where he continued to write. wean children from their early family life, schools At the end of his life, Sigmund Freud, in ter- often exposed the immature student too abruptly rible pain from an invasive cancerous epithe- to the harshness of adult life. He added that too lioma, murmured to his trusted doctor Max Furst, Sidney 101

Schur, “This makes no more sense,” and so to the stress inherent in adolescence com- Schur injected him with a lethal dose of mor- pounded by increasing stress in the environ- phine on September 23. He was 83. ment. Adolescence is a time when ordinary levels of stress are heightened by physical, psy- friends As they move closer to self-destruc- chological, emotional, and social frustrations tion, presuicidal persons of all ages tend to drop that can lead to violence and aggression. their close friends or deliberately to make them- selves so obnoxious that the friends drop them. See BURIAL (FOR SUICIDES). Suicidal patients will often become either very withdrawn or overly aggressive, an important Funus (The Funeral) In his 1526 colloquy, distress signal or warning sign to parents, Funus, the Dutch scholar ERASMUS explained friends, or associates. why God meant death to be an agony, and said Once people finally decide to complete sui- that he did this “lest men far and wide commit cide, they begin to act differently. suicide. And since, even today, we see so many do violence to themselves, what do you suppose Friendship Line for the Elderly, The A would happen if death weren’t horrible? When- national person-to-person service based in San ever a servant or even a young son got a thrash- Francisco where trained volunteers regularly call ing, whenever a wife fell out with her husband, elderly persons to offer emotional support, med- whenever a man lost his money, or something ication reminders, and safety checks. An off- else occurred that upset him, off they’d rush to shoot of the city’s suicide prevention program noose, sword, river, cliff, poison.” started in 1963, this direct service figures impor- Yet, paradoxically, in his The Praise of Folly tantly in the suicide and mental health educa- (1509), Erasmus had commended those who tion of other minority groups throughout the voluntarily killed themselves to get rid of a mis- Bay Area. erable and troublesome world. His earlier writ- Staff members offer consultation, training, ing, Encomium Miriae (The Praise of Folly), was and seminars to schools, universities, hospitals, intended as a satire on the state of Europe in his and mental health agencies. The program also time. includes two drug lines and a Grief Counseling Program for those who have suffered a loss by Furst, Sidney In a major psychoanalytic arti- suicide or other traumatic circumstances. cle concerning the relationship of suicide The Friendship Line is the only nationwide method versus motive, “The Psychodynamics of toll-free number offering telephone support to Suicide,” Furst and Mortimer Ostrow suggest depressed, isolated, abused, and/or suicidal older that the suicidal method is an expression of a adults. It is available 24 hours a day, 365 days a sexual wish and/or punishment for a fantasized year. crime. The toll-free national number is (800) 971- In Suicide in America, HERBERT HENDIN, M.D., 0016; in San Francisco the number is (415) 752- writes: “Without psychodynamic evidence from 3778. case material, they (the team of Furst-Ostrow) maintain that male homosexuals, if suicidal, will frustration The teenage suicide rate has risen stab or shoot themselves or arrange to be to crisis proportions over the past 20 years, and stabbed or shot as an extreme expression of their experts believe that a combination of frustration wish to be attacked by another man’s penis.” and stress can lead a person to attempt suicide. Hendin concludes that if these writers were cor- The rising rate has been explained as a reaction rect, homosexuality would be a far more impor- 102 Furst, Sidney tant factor in suicide in the United States than native of such unsubstantial speculation . . . psy- elsewhere in the world, since only in America chiatry has settled for the safe but sterile statisti- are guns the major method of suicide. cal approach that has dominated the subject.” Furst and Ostrow also regard falling from Hendin, along with other suicidologists, believes heights as an expression of sexual guilt for that “Psychodynamic study of the suicidal indi- “phallic erection under improper circum- vidual can often provide evidence of the mean- stances.” Dr. Hendin’s rebuttal: “Given the alter- ing of the choice of a particular method.” G

Garroway, Dave The original host of TV’s The Loss of consciousness occurs within a few min- Today Show, Garroway left the show in 1961, and utes, and death follows within a half hour. was replaced briefly by John Chancellor and then Suicide by breathing car exhaust is becoming by Hugh Downs. Largely forgotten by the public, less common with the introduction of catalytic Garroway committed suicide on July 21, 1982. converters, which remove the carbon monoxide from the exhaust. Catalytic converters remove gas Women, more so than men, seem to pre- 90 percent of the carbon monoxide; one man fer a passive means of self-destruction. For in- survived after breathing exhaust fumes for five stance, women will more likely ingest a lethal hours. A drop in suicides was noticed in the dose of drugs, swallow pills or poison, or inhale United States with the introduction of the cat- gas rather than shoot or hang themselves. alytic converter in 1968, although they have Authorities conclude this may be because now risen again. women don’t usually want to shed their blood or Coal Gas disfigure themselves. Several types of gas can be used as a way to The detoxification of domestic gas (from coal gas commit suicide, but these methods are less com- with high carbon monoxide content to natural mon than firearms. Women tend to prefer this gas) might have reduced the suicide rate in method of suicide over more violent means. In nations where the switch had taken place. It has one study of youth suicide, 78 percent of suicide definitely reduced overall suicide rates in the attempts with firearms were fatal, as compared UNITED KINGDOM and AUSTRALIA, although some to 36 percent of attempts with gas poisoning. researchers believe the reduction was tempo- rary, and has been replaced by other methods. Car Exhaust For example, in the 1960s when town gas was Car exhaust is a lethal method of suicide with a widely available in the United Kingdom, using large proportion of attempters dying. The active the gas oven was the commonest method of sui- ingredient in car exhaust (carbon monoxide) is a cide. North Sea gas, which is composed of colorless, odorless poisonous gas that is produced methane, is nontoxic, and its introduction by the internal combustion engine. Carbon resulted in a drop in the suicide rate of one- monoxide binds to hemoglobin better than oxy- third. gen, so the human body thinks it’s oxygen, and breathing continues normally until the person Helium loses consciousness. Breathing carbon monoxide In addition to being odorless, colorless, and non- fumes causes headaches, dizziness, weakness, flammable, helium is also considered nontoxic, sleepiness, nausea and vomiting, confusion and but some people use it to commit suicide. Inhal- disorientation. As the level of the gas in the blood ing helium leads to unconsciousness and death rises, the patient becomes confused and clumsy. after a few minutes. Helium is used to inflate

103 104 gatekeepers balloons, and is therefore inexpensive and • aggressive behavior: Completed suicide is widely available. associated with aggressive behavior that is more common in men, and which may in Nitrous Oxide (NO2) turn be related to some of the biological dif- This method is used by Dr. to ferences identified in suicidality. help patients complete suicide. A cylinder of the • methods: Women in all countries are more deadly gas is connected by a tube to a mask over likely to ingest poisons; in countries where the person’s nose and mouth; a valve must be poisons are highly lethal and where treatment released to start the gas flowing. Depending on resources scarce, rescue is rare and hence the person’s disability, a makeshift handle may female suicides outnumber males. be attached to the valve to make it easier to turn. • help: Experts suggest women are more likely By Kevorkian’s estimates, this method may take to seek help for their problems, such as 10 minutes or longer. Sometimes, patients take DEPRESSION, whereas men are more likely to sedatives or muscle relaxants to keep them calm suffer in silence. In addition, women are as they breathe the gas. socialized to express emotions more freely and The poet SYLVIA PLATH, who had made several accept a dependent position (help-accepting) previous suicide attempts, sealed her kitchen more than men. and turned on the gas, but not before she left a note about how to reach her doctor. A series of Suicide by firearm is the most common method miscalculations—her housekeeper arrived late, for both men and women, accounting for 58 the door was locked, a neighbor had been percent of all suicides in 1997. Seventy-two per- knocked unconscious by the escaping gas, work- cent of all suicides were completed by white men had to force the building door open—cost men, and 79 percent of all firearm suicides were Plath her life. completed by white men. gatekeepers Term used for those involved genetics and suicide There is growing evi- with and engaged in the educational process dence that familial and genetic factors contribute concerning suicide prevention, intervention, to the risk for suicidal behavior. Major psy- and postvention—the physicians, psychiatrists, chiatric illnesses (including BIPOLAR DISORDER, psychologists, pyschotherapists, nurses, social DEPRESSION, SCHIZOPHRENIA, ALCOHOLISM, and workers, clergymen, lay volunteers, and others substance abuse) and certain personality disor- who are most likely to know of persons about to ders that run in families, increase the risk for sui- take their lives. Many of these professionals and cidal behavior. lay volunteer workers are generally in a strategic This does not mean that suicidal beha- vior is inevitable for individuals with this fam- position to identify and do something about a ily history; it simply means that such persons potentially dangerous situation. may be more vulnerable and should take steps to reduce their risk, such as getting evalu- gender differences in suicide More than four ation and treatment at the first sign of mental times as many men as women die by suicide, illness. increasing to about 10 to one in the elderly, but In one recent Danish study of 114 adopted women attempt suicide about two or three times boys (57 with a biological family history of more often than men. Researchers aren’t sure suicide), boys who later completed suicide had why there are such significant gender differences, six times more biological relatives who had but they have several possible explanations: killed themselves than the boys who didn’t com- geographic factors 105 plete suicide. All of the adopted boys had been cidal behavior in relatives of suicides than in raised in families with no history of suicide. controls. In psychological autopsy studies in Recently, European researchers have found Pittsburgh, families of suicide victims showed a genetic mutation that appears to increase a per- higher rates of suicide attempts, depression, and son’s odds of completing suicide more than substance abuse in their family histories. Other threefold. The gene affects the levels of the studies found higher rates of suicidal behavior, chemical serotonin in the brain. The mutation substance abuse, antisocial disorder, and reduces the ability of brain cells to absorb sero- assaultive behavior in the relatives of prepuber- tonin, a neurotransmitter related to mood, emo- tal suicidal inpatients than in the relatives of tion, appetite, and sleep. It is well known that nonsuicidal inpatients and normal controls. defects in serotonin uptake can cause depression, In addition to the obvious genetic inheritance eating disorders, and other mental illnesses. risk, studies also suggest that exposure to These genetic data are consistent with a cor- parental substance abuse and depression may relation between low serotonin uptake activity add an environmental risk to the genetic risk for and violent behavior, including violent suicidal suicide. It is also true that family discord, family behavior. violence, and abuse, while not characteristic of In the study, French and Swiss researchers all families with a suicide, occur more often than compared 51 people who had attempted suicide in other families. It is possible that some of these with 139 comparable subjects who had not. family difficulties might also explain the familial They found that one mutation in the serotonin aggregation of suicidality. transporter gene increased a person’s chances of See ABUSE, SUBSTANCE. attempting suicide by a factor of 3.63. Another less potent mutation in the same gene increased geographic factors Some authorities concede a person’s risk of attempting suicide 1.72 times. that geography may influence people who live Some of the same researchers reported a rela- in isolated areas, in those areas where days are tionship between variations in another sero- short and the nights long, and/or where climate tonin-related gene, involved in synthesizing the is predominantly rainy or cloudy. neurotransmitter, and a person’s chances of In the 18th century, many Europeans held committing suicide. the widespread notion that ENGLAND was a “land Other studies have found a higher risk for sui- of melancholy and suicide.” Natives and foreign- cide in identical twins compared to fraternal ers generally accepted the allegation that ones. Along a similar vein, other studies showed gloominess was a characteristic of the inhabi- an increased rate of suicide in the families of psy- tants of the British Isles, particularly the English. chiatric patients who committed suicide. One This melancholy was more than just a mood; it adoption study showed greater risk of suicide was a disease, a malady of mind and body which among biological than adoptive relatives. And directly affected the imagination and was liable psychiatric patients who had made a suicide to end in self-destruction. The condition was attempt had higher rates of attempts in their rel- linked etiologically with both the physical and atives than patients who were non-attempters. social environment. In one study of Old Order Amish, two pedi- These notions of geographic (or environmen- grees equally loaded for affective disorder tal) influence have been traced back to antiquity, showed one pedigree with no suicides and the with roots in geography and medicine. Hip- other with multiple suicides. pocrates perhaps started such ideas in Airs, In younger populations of suicide victims and Waters, Places. attempters, the results are quite similar. Psycho- During the 16th and 17th centuries, increas- logical autopsy studies reveal greater rates of sui- ing significance was placed on such notions in 106 geriatric suicide many fields of thought, study, and practice. gestured suicide See SUICIDE GESTURES. While considering questions of national charac- ter and cultural differences, writers and scholars gifted children Among the many myths of discussed causal roles of such environmental suicide is that of the stereotypical “genius” who aspects as air, diet, and temperature in medical commits suicide. In reality, every type of per- and social problems. son, Christian or Jew, rich or poor, white or These discussions became even more frequent black, young or old, fat or thin, tall or short, in the 18th century, and the use of such ideas led with high or low I.Q., commits suicide. Yet it is many writers to oppose sanctions against suicide true that many young people who attempt or and to urge a less prejudiced and more tolerant complete suicide fall into the category of gifted view of suicide. students. There does seem to be a global geographical The mistake that parents of these children correlation between location and suicide. North- frequently make is assuming that intellectually ern countries, such as Scandinavia show higher precocious children are also emotionally preco- suicide rates than countries in the more tropical cious. The fourth grader who reads at the climates. However, other factors such as religion twelfth grade level is, emotionally, still in the may also affect the rates. fourth grade. There are significant geographical variations All too often, gifted children who have been evident in America. For instance, Nevada consis- moved ahead in school become loners, prefer- tently leads suicide rate statistics, followed by: ring books or special interests to friends. The Alaska, Arizona, California, Colorado, Florida, more they retreat into themselves and their Montana, New Mexico, Oregon, Washington, intellectual activities, the less chance they will and Wyoming. ever make friends. Intellectually they are years Highest U.S. regional rates are generally those above their peers; socially and emotionally they of the Rocky Mountain and West Coast areas, may be much younger. These gifted children with the South showing the lowest rate, with often end up so miserable they cannot commu- the exception of Florida. nicate with anyone, including members of their It was once thought that the rural suicide rate own families. Alienated, entrapped by minds was much lower than that of urban and subur- that developed so much faster than their bodies, ban areas; however, the rural suicide rate in the their despair leads to hopelessness and misery— United States in recent years is very nearly that and they kill themselves. of urban areas. See also FARMERS. Gisu of Uganda, the In certain societies, sui- cide sometimes appears to be a last resort. geriatric suicide See ELDER SUICIDE. Among the Gisu of Uganda, suicides of the elderly sick usually took place after a variety of Germany World Health Organization (WHO) other means of alleviating their condition had statistics for 1997 show that the total suicide rate been tried and proved ineffective. in this country is 15.1 per 100,000. Suicide rates The Gisu consider suicide as a rational act, a were highest in the over-75 age group—an deliberate and logical choice between life and astounding 45.5 per 100,000. Men in this age death, although subsidiary theories account for group committed suicide at a rate of 70.6; the fact that in the same situations, some people women over 75 had an unusually high rate of may choose death and others will not. 20.5. Historically, Berlin has had one of the The Gisu of Uganda feel that ritual cleansing highest city suicide rates in the world. after a suicide is necessary to protect the suicide’s global suicide 107 close kin from danger and to prevent the conta- Country Year Men Women gion of suicide, causing the suicide of anyone Bahrain 1988 4.9 0.5 passing the spot where the suicide occurred. To Belgium 1995 31.3 11.7 conceal a suicide is thus both dangerous and cul- Belize 1995 12.1 0.9 Brazil 1995 6.6 1.8 pable; moreover, it is not possible to perform the Bulgaria 1999 24.1 8.1 necessary ritual in secret. Canada 1997 19.6 5.1 Chile 1994 10.2 1.4 China (selected areas) 1998 13.4 14.8 global suicide About 850,000 people around China (Hong Kong SAR) 1996 15.9 9.1 Colombia 1994 5.5 1.5 the world died from suicide in the year 2000, Costa Rica 1995 9.7 2.1 according to the WORLD HEALTH ORGANIZATION, Croatia 1999 32.7 11.5 which represents a global of 16 Cuba 1996 24.5 12.0 Czech Republic 1999 25.7 6.2 per 100,000—or one death every 40 seconds. Denmark 1996 24.3 9.8 Moreover, over the last 45 years suicide rates Dominican Republic 1994 0.0 0.0 have increased by 60 percent worldwide, now Ecuador 1995 6.4 3.2 Egypt 1987 0.1 0.0 ranking among the three leading causes of death El Salvador 1993 10.4 5.5 among men and women age 15 to 44. And sui- Estonia 1999 56.0 12.1 cide attempts are up to 20 times more common Finland 1998 38.3 10.1 France 1997 28.4 10.1 than completed suicides. Georgia 1992 6.6 2.1 Although suicide rates have traditionally been Germany 1998 21.5 7.3 highest among elderly males, rates among young Greece 1998 6.1 1.7 Guatemala 1984 0.9 0.1 people have been increasing to such an extent Guyana 1994 14.6 6.5 that they are now the group at highest risk in a Honduras 1978 0.0 0.0 third of all countries around the world. Hungary 1999 53.1 14.8 Iceland 1996 20.8 3.7 While mental disorders (particularly DEPRES- India 1998 12.2 9.1 SION and substance abuse) are associated with Iran 1991 0.3 0.1 more than 90 percent of all suicides, in fact a Ireland 1996 19.2 3.5 Israel 1997 10.5 2.6 person’s wish to die is caused by many complex Italy 1997 12.7 3.9 sociocultural factors. Suicide is more likely to Jamaica 1985 0.5 0.2 occur during periods of socioeconomic, family, Japan 1997 26.0 11.9 Jordan 1979 0.0 0.0 and individual crisis, such as the death of a loved Kazakhstan 1999 46.4 8.6 one, job loss, or shame. Kuwait 1999 2.7 1.6 See ABUSE, SUBSTANCE. Kyrgyzstan 1999 19.3 4.0 Latvia 1999 52.6 13.1 Lithuania 1999 73.8 13.6 GLOBAL SUICIDE RATES Luxembourg 1997 29.0 9.8 Macedonia FYR 1997 11.5 4.0 Suicide Rates (per 100,000) Malta 1999 11.7 2.6 (most recent year available, as of 2002) Mauritius 1998 21.9 7.8 Country Year Men Women Mexico 1995 5.4 1.0 Netherlands 1997 13.5 6.7 Albania 1998 6.3 3.6 New Zealand 1998 23.7 6.9 Antigua and Barbuda 1995 0.0 0.0 Nicaragua 1994 4.7 2.2 Argentina 1996 9.9 3.0 Norway 1997 17.8 6.6 Armenia 1999 2.7 0.9 Panama 1987 5.6 1.9 Australia 1997 22.7 6.0 Paraguay 1994 3.4 1.2 Austria 1999 28.7 10.3 Peru 1989 0.6 0.4 Azerbaijan 1999 1.1 0.2 Philippines 1993 2.5 1.7 Bahamas 1995 2.2 0.0 Poland 1996 24.1 4.6 Barbados 1995 9.6 3.7 Portugal 1998 8.7 2.7 Belarus 1999 61.1 10.0 Puerto Rico 1992 16.0 1.9 108 “goal-gradient” phenomenon

GLOBAL SUICIDE RATES (continued) scholar who, with his good friend Friedrich Suicide Rates (per 100,000) Schiller, was the leading spirit in the Sturm und (most recent year available, as of 2002) Drang period of German literature. His autobio- Country Year Men Women graphical novel, The Sorrows of Young Werther Republic of Korea 1997 17.8 8.0 (1744), was acclaimed throughout Europe. Republic of Moldova 1999 27.6 5.1 Young people everywhere read and wept over Romania 1999 20.3 4.4 Goethe’s story about a young man who commits Russian Federation 1998 62.6 11.6 Saint Kitts and Nevis 1995 0.0 0.0 suicide after being torn apart by uncontrollable Saint Lucia 1988 9.3 5.8 passions. Young dandies began to dress like St. Vincent and Werther, speak like Werther, and even to destroy The Grenadines 1986 0.0 0.0 Sao Tome and Principe 1987 0.0 1.8 themselves like Werther. It became a point of Seychelles 1987 9.1 0.0 status to suffer for one’s genius, to struggle for Singapore 1998 13.9 9.5 art’s sake, and to die young—a hero mourned by Slovakia 1999 22.5 3.7 Slovenia 1999 47.3 13.4 all the world. Goethe’s martyr of unrequited Spain 1997 13.1 4.2 love and unbelievably extreme sensibility cre- Sri Lanka 1991 44.6 16.8 ated a new, idealistic, romantic style of suffering. Suriname 1992 16.6 7.2 Sweden 1996 20.0 8.5 The Romantic stance became suicidal. It was Switzerland 1996 29.2 11.6 young Werther who made the act seem posi- Syrian Arab Republic 1985 0.2 0.0 tively desirable to the young Romantics all over Tajikistan 1995 5.1 1.8 Thailand 1994 5.6 2.4 Europe. Trinidad and Tobago 1994 17.5 5.1 Goethe, paradoxically, recounts how as a Turkmenistan 1998 13.8 3.5 young man he greatly admired the Emperor Ukraine 1999 51.2 10.0 United Kingdom 1998 11.7 3.3 Otto, who had stabbed himself. Goethe finally United States of America 1998 18.6 4.4 decided that if he were not brave enough to die Uruguay 1990 16.6 4.2 in like manner, he wasn’t brave enough to die at Uzbekistan 1998 10.5 3.1 Venezuela 1994 8.3 1.9 all. He wrote: “By this convection, I saved myself Yugoslavia 1990 21.6 9.2 from the purpose, or indeed, more properly Zimbabwe 1990 10.6 5.2 speaking, from the whim of suicide.” World Health Organization, October 2001 Goethe created an epidemic of romantic sui- cides throughout Europe with his novel, yet he “goal-gradient” phenomenon Events dis- was almost 83 years old when he died. He was tant in the future feel small, just as objects dis- buried with Schiller in a mausoleum in the ducal tant in space look small. Their prospect does not cemetery. have the effect on motivational processes that it would have if it were of an event in the imme- Gogh, VIncent van See VAN GOGH, VINCENT. diate future. Psychologists call this the “goal gra- dient” phenomenon. In the case of a person Golden Gate Bridge Famous bridge in San who has suffered some misfortune, this reduc- Francisco that is the number one spot in the tion of the motivational influence of events dis- world for troubled individuals to commit suicide. tant in time means that present unpleasant Since it opened in 1937, more than 1,200 people states weigh far more heavily than probable have jumped to their death from the span. future pleasant ones. (Other popular suicide spots include the Eiffel Tower, the EMPIRE STATE BUILDING, the Space Goethe, Johann Wolfgang von (1749– Needle in Seattle, Mount Mihara in Japan, and 1832) German poet, novelist, playwright, and Pasadena’s Arroyo Seco Bridge.) Greece 109

Cornelia Van Eirland was the first person grades One of the several distress signals of the known to have survived a jump off the bridge, young person who may be considering suicide is on September 3, 1941. Currently, only 26 peo- a slackening interest in school attendance and ple have survived a jump off the Golden Gate school work and consequently, a decline in Bridge; the last survival occurred in February grades. Because school is the major activity in a 1995. child’s life, it is also one of the best barometers of So great is the problem of suicides that the mental health. If a child’s grades fall precipitously, Golden Gate Bridge District installed telephones chances are something is wrong. Adults should on the bridge for emergency purposes, one of have the child talk about what’s bothering him. which is to prevent suicides. There is a direct When a child swerves from a long-established connection to the SAN FRANCISCO SUICIDE PREVEN- pattern, something usually is the matter. TION CENTER. In 1996, the rate dropped dramati- cally after the Golden Gate Bridge Patrol began Great Britain See ENGLAND; IRELAND; SCOT- monitoring the bridge as part of a $111,300 sui- LAND; WALES. cide prevention program. Every day, from dawn to dusk, a patrolman on a scooter drives back and forth across the bridge to stop potential Greece Latest suicide rates available in Greece jumpers before it’s too late. The patrol workers are from 1998, in which 3.9 per 100,000 people study all people on the bridge, looking for clues committed suicide. This breaks down to 6.1 per to identify potential jumpers from among the 100,000 for men and 1.7 for women. This repre- tourists. They note the way people walk, the sents a light increase from the 1997 rate of 3.6 way they hold their heads, what they’re looking per 100,000. at, whether they have cameras. Among different age groups, the highest risk The Golden Gate Bridge District stopped pub- occurs among the elderly Greeks over age 75; lishing the number of suicides in June 1995 the 1997 rate is 13.6 for men and 2.6 for women in this age group. when 1,000 suicide was drawing near, but the The ancient Greeks held no clear-cut attitudes published number of 1,200 has been docu- toward suicide, with Greek city-states differing mented. However, those who work closely with markedly in their views and laws concerning the bridge say the figure is much larger; some self-destruction. In Thebes, for instance, suicides say the yearly average is close to 300. were condemned, and the victim was granted no funeral rites. In Athens, the law decreed that one Göring, Hermann Wilhelm (1893–1946) hand of a suicide would be cut off and buried German politician founder of the Nazi secret apart from the rest of the victim’s body—since it police force. Göring joined the Nazi party in was the hand that committed the dread act. 1922 at age 29 and held many important posts Other Greek communities established special in Hitler’s government before he became eco- tribunals to hear arguments of those citizens nomic dictator (1937) and marshal of the Reich who wished to end their lives. A magistrate who (1940). He was condemned to death for war was convinced by a particularly persuasive argu- crimes at the Nuremberg trials, but two hours ment from an individual could grant permission before his scheduled hanging, he committed for that person to kill himself. Magistrates in suicide by taking a poison capsule. On the wall some areas even supplied poison hemlock to of his office in Berlin, Göring a concerned would-be suicides. Magistrates generally consid- wildlife preservationist, had posted this notice: ered insanity, profound physical suffering, or “He who tortures animals wounds the feelings overwhelming grief and sorrow as grounds suffi- of the German people.” cient to permit suicide. 110 grief, of suicide survivors

Greek philosophers and thinkers considered leads to a cycle of suicide or self-destructive acts the suicide phenomenon from their own points of for survivors themselves. view, in terms of ethics and morals. Perhaps the The grief process is especially extreme when most famed suicide of ancient times was that of survivors must deal with a teen or young adult the Greek philosopher SOCRATES, teacher of PLATO. suicide. Everyone involved with the suicide— Socrates died by his own hand, drinking a cup of parents, brothers, sisters, friends—copes with HEMLOCK, though his death in 399 B.C. was actu- their own kind of suffering. ally a form of execution that had been ordered by SIGMUND FREUD spoke of “grief work” in which the rulers of Athens, who had tried him on the there is abnormal desire for reunion with a lost charge of corrupting the young people of his city- loved one. Immediately after a suicide occurs, state. Plato quotes his mentor as saying before his survivors need the help and intervention of oth- death, “No man has the right to take his own life, ers to do what is called the “mourning work” in but he must wait until God sends some necessity order to continue living meaningful lives and upon him, as he has now sent me.” Like Socrates, avoid their own self-destruction. Plato and his own student, Aristotle, both con- Survivors should be encouraged to seek demned the act of suicide. The Greek Stoic immediate help from a professional whom they philosophers who came later held a much more trust: a psychiatrist, psychologist, social worker, lenient view of suicide. Yet both ZENO, founder of minister, priest, rabbi, or physician; or, in the the stoic philosophy, and his successor, CLEAN- case of youngsters, a school psychologist, coun- THES, supposedly took their own lives. selor, teacher, or administrator. Professionals can assist survivors in getting past the first stages of grief, of suicide survivors After any death of shock and disbelief, and then help them through a loved person, survivors experience what the guilt and anger phases that come next. professional authorities deem a “grief process.” At first there is disbelief (“I can’t believe she’s Griffiths, Abel The last person who commit- gone”), followed by profound grief and sorrow. ted suicide in ENGLAND to be dragged through the Survivors often weep, suffer loss of appetite, and streets of London and buried at a crossroads. have endless sleepless nights. They may feel Abel Griffiths was a 22-year-old law student anger, bitterness, outright rage. Some wonder when he was buried in June 1823 clad only in how they can bear life without the dead loved drawers, , and a winding sheet at the cross- one. At long last, sometimes months later, sur- roads formed by Eaton Street, Grosvenor Place, vivors begin to function normally and focus their and the King’s Road. Wrapped in a piece of Russ- thoughts on the future. This last stage is the ian matting, his bloodied, unwashed body was “healing stage” in the grief process. Survivors quickly dropped into a hole about five feet deep. often feel sadness and a sense of loss for years, The Annual Register for that year reports that but they are able to continue living, and gener- “the disgusting part of the ceremony of throwing ally to enjoy their lives. lime over the body and driving a stake through In the case of suicide survivors, however, grief it was dispensed with.” doesn’t always resolve itself in the same manner Superstitions and the desire to punish self- as in other forms of death. The grief feeds on the murderers were behind these burial customs. anger and guilt and the never-to-be-answered Suicides were buried at a crossroads in GREAT question of “why?” And it grows and spreads BRITAIN because these places represented the sign under the disapproval of society, leaving sur- of the cross, because steady traffic over the grave vivors dragged down by a depression that may could help keep the person’s ghost down, and never be closed off. Sometimes the depression because ancient sacrificial victims had been slain guns 111 at such sites. Since they were considered the vinced that the collective conscience of a group ultimate sinners, people who committed suicide was a major source of control in all societal mat- had been staked to prevent their restless wan- ters, including the phenomenon of suicide. He derings as lost souls. felt that every social group has set of beliefs and Griffiths had killed himself after having mur- sentiments, a totality of social likeness. As dered his father. A chemist who knew Griffiths Ronald Maris, editor of Suicide and Life-Threaten- and who was presumably a reliable witness told ing Behavior explains, for Durkheim the suicide the coroner’s jury that he had a “DEPRESSION in rate depends upon forces external to and con- the brain” and had inquired about leeching; he straining of individuals. “To the degree that the was certain that the man was suffering from societal groups are harmonious,” Maris writes, mental disease. But the jury decided that Grif- “integrated and regulated and the individual is fiths killed himself in a sound state of mind. an active, central member of those societal (Had he been found to have been insane, his groups, then the individual’s suicide potential body would not have been treated with disre- will be low and a population of such individuals spect.) will have a low suicide rate.” Resistance to this seemingly unfair verdict was expected, and on the morning of the burial, group therapy A type of psychotherapy in constables and watchmen were stationed in the which six to 10 clients are led by a mental health area to watch for protestors. expert in discussions of mutual problems. Group Immediately after the Griffiths burial, Parlia- therapy techniques are often used as a way of ment passed a law ordering that within 24 hours stressing that a survivor of suicide, or the friends of an , the corpse of a suicide must be and family of someone who has committed sui- buried privately in either a church yard or a des- cide, are not unique. Members of the group ignated burial ground. Yet because the British reveal their problems for the scrutiny of others, still believed that life was a gift from God and the and discuss them openly as a group. This type of taking of it was God’s prerogative only, the 1823 therapy was especially popular during the 1970s law still contained punitive clauses. A person and early 1980s, but is still used today. It allows who committed suicide was still required to be all members to benefit vicariously from resolu- buried at night without Christian rites, between tion of another person’s mutual problem. the hours of nine and midnight, and the person’s The treatment method is similar to the vari- goods and chattels still had to be turned over to ous “12-step groups” used by such organizations the Crown. as Alcoholics Anonymous, in which people find Ambivalence in this law mirrored the ambiva- a way out of their dilemmas by sharing knowl- lence of English public opinion from the late edge of their own triumphs and setbacks. 18th century throughout much of the 19th. For- feiture was generally waived by the Crown in cases in which a suicide was not committed in Guest, Judith Author of the best-selling novel order to avoid conviction for another felony. Ordinary People, which explores the suicide attempt of a young boy and was later made into a movie. group conscience ÉMILE DURKHEIM, among the first sociologists to collect data on suicide and to present the rates in tabular form, was con- guns See FIREARMS.

H

Hadrian (A.D. 76–138) Roman emperor In 123, while traveling, Hadrian met a lan- who ruled from A.D. 117 until his death by sui- guid, moody boy named Antinous, and for the cide. His reign was considered to be a golden era next seven years, he and the emperor were in- of peace and prosperity for the empire. separable. Then in 130, while the two were in Publius Aelius Hadrianus was born on Janu- Egypt, Antinous drowned in the Nile River ary 24, A.D. 76, in Italica, in present-day south- under mysterious circumstances. Some thought ern Spain. His ancestors were Italian army the boy was murdered by those jealous of his veterans who had settled the area some 200 influence; others suspected that he committed years before, which is the origin of his name suicide because of the nature of his relations (“Hadrian”) from Adriatic. Historians know little with the emperor, or because he was outgrowing of Hadrian’s boyhood years, except that he was the age prescribed for Greek pederastic relations trained in the military, visited Rome, and was an between the older male lover and the boy. Oth- enthusiastic hunter. His early career included ers think he deliberately threw himself into the stints as military tribune with different legions, river as part of some sacred sacrifice to protect until his guardian and uncle Trajan was adopted the emperor’s fortunes, or perhaps to cure the by the aging emperor Nerva. When in the fol- emperor of an illness. lowing year Trajan succeeded him as emperor, What is clear is that Hadrian was devastated, Hadrian suddenly found himself in the inner cir- ordering Antinous deified and founding the city cles of imperial power. In A.D. 100 he further of Antinopolis, where every year special games secured his position by marrying Vibia Sabina, were held in the young god’s honor. Cults of Trajan’s grandniece, and by 107 he was a provin- Antinous sprang up all over the empire; he was cial governor. Eventually he moved to Athens, the last god of the ancient world, and much vil- where he fell in love with the city and with ified by the early Christians. More than 500 stat- Greek culture. (His enemies in Rome derided ues celebrating his sensuous, melancholy beauty him as “the Greekling.”). On August 9, 117, still survive. Hadrian learned that Trajan had adopted him, Besieged by inconsolable grief, Hadrian tried meaning he was to be Trajan’s successor, and to kill himself three times. He first commanded a two days later the emperor died. slave to kill him with a sword, but the slave ran Hadrian was one of the greatest of the Roman away, upset; then Hadrian begged a doctor in emperors, and he concentrated on building up vain to poison him. Finally, Hadrian tried to stab frontier defenses such as the massive Hadrian’s himself to death, but was overwhelmed by his Wall in Great Britain, but he also built roads, guards. At this point, he lamented that he bridges, harbors, and aqueducts. During his should have the power to kill others but not reign, he made two extensive tours of the himself. Empire, traveling to the western provinces in Meanwhile, the summer had begun and an op- 121–123, and to the east in 123–126. pressive heat made the stay in Tibur intolerable,

113 114 hanging so Hadrian went to a seaside resort at the Gulf of “Let us relieve the Romans of the fear which Naples where he died on July 10, 138. He wrote has so long afflicted them,” he said, “since it his own epitaph whose elusive wordplay nearly seems to tax their patience too hard to wait for defies translation: an old man’s death.”

Little soul, gentle, wandering, A ritual Japanese form of suicide Guest and friend of the body hara-kiri In what place will you now abide (SEPPUKU) to expiate public shame, which is Pale, stark, bare, restricted to the samurai class of warriors, syn- Unable, as you used, to play. onymous with its Chinese equivalent. Hara-kiri was practiced by Japanese feudal (Animula, blandula, vagula warriors in order to prevent themselves from Hospes comesque corporis falling into enemy hands. In the 16th century, it Quae nunc abibis in loca became a privileged alternative to execution that Pallidula, rigida, nudula, was granted to warriors guilty of disloyalty to Nec ut soles dabis iocos?) the emperor. The condemned man received a jeweled dagger from the emperor, chose a friend hanging Hanging is the second most common to be his “second,” received official witnesses, suicide method in the United States among boys and then plunged the dagger into the left side of and men, following firearms; and the third most his abdomen, drew it across to the right, and common among girls and women. It is the lead- made a slight cut upward; the “second” then ing method world-wide. beheaded him with one stroke of a sword, and In 1999, 5,427 Americans killed themselves the dagger was returned to the emperor. By the by hanging. Hanging is far more common among 18th century, it became permissible to go men than women; 19.1 percent of all suicides in through a semblance of disembowelment before men are from hanging, compared to 16.3 per- beheading. cent for women. Far more women kill them- Voluntary hara-kiri was chosen after a private selves by poisons (30 percent) compared to men misfortune, out of loyalty to a dead master, or to (7 percent). protest the conduct of a living superior. Obliga- In many societies, it is rare to find suicide by tory hara-kiri was abolished in 1868, but its vol- poison or drugs. Some methods such as hanging untary form has persisted. It was performed by require a steadfastness of purpose that makes 40 military men in 1895 as a protest against the the labeling of death by suicide unequivocal. return of conquered territory to China; by Gen- eral Nogi on the death of Emperor Meiji in 1912, and by many Japanese soldiers instead of sur- Hannibal (247–183 B.C.) Commander of the initially successful Carthaginian army against rendering during World War II. Rome during the Second Punic War (218–201 B.C.). Hannibal was forced eventually to with- Harvard Medical School Guide to Suicide draw to Africa, where he was defeated at Zama Assessment and Intervention A compen- in 202 B.C. After the defeat of King Antiochus III dium of current research and thought edited by of Syria, whom he was counseling on how to Douglas Jacobs to help health professionals conduct his war against Rome, Hannibal fled to determine risk and prevent suicide. The book Asia Minor, where a detachment of Roman sol- explains methods for determining the risk level diers surrounded his hideout. Hannibal then for suicidal patients, recommends a suicide took out the vial of poison that he always carried assessment protocol, and provides intervention with him and drank it. guidelines. The book discusses specific groups help for suicidal people 115 such as adolescents, the physically ill, and those Old nor the New Testament prohibits suicide, with major mental illness, alcoholism, and bor- however, and suicidal behavior is not con- derline personality disorder. demned. In fact, there is no specific word for the act itself. In the Western world, the pervasive moral Heaven’s Gate The CULT SUICIDE of 39 cult members in San Diego, California, in 1997, one ideas condemning suicide are Christian, dating of the largest mass suicides in U.S. history. The from the fourth century A.D., detailed by ST. AU- victims were all between 18 and 24 years old; 21 GUSTINE (354–430) for essentially nonreligious victims were women; 18 were men. The victims reasons. St. Augustine was concerned primarily apparently believed their deaths would lead to a about the decimation of Christians by suicide rendezvous with a UFO hiding behind Comet and condemned suicide by Christians who chose Hale-Bopp. death only for reasons of martyrdom or religious Investigators believe the 39 members of the zeal hoping for immediate entrance into heaven. Heaven’s Gate cult drank a lethal mixture of Old Testament figures who committed suicide phenobarbital and vodka and then settled to die include: Samson, Saul, Saul’s armor bearer, Ahi- over a three-day period. Authorities believe tophel, Zimri, Razis, and Abimelech. In the New members mixed the drug with applesauce or Testament, Judas Iscariot is the only recorded pudding, then washed it down with vodka. Plas- suicide. tic bags may have then been placed over their heads to suffocate them. Hegesias (320–280 B.C.) A philosopher also Inside the house, investigators found a docu- known as the “Death-Persuader” or the “Advo- ment labeled “The Routine” that outlined a cate of Death,” who belonged to the Cyrenaics, process by which a group of 15 people would kill one of the minor schools of Greek philosophy themselves, helped by eight others. Then a sec- that flourished in the late fourth and early third ond group of 15 would die, also assisted by eight century B.C. Cyrenaic philosophy taught that people. Given that 39 victims were found, that present individual pleasure is the highest good, would have left a final group of nine. and was therefore an early version of hedonism. The cult members had lived in a palatial home Hegesias, an historian in Alexandria during near San Diego, where they had operated a suc- the reign of Ptolemy II, was far from a happy cessful business designing websites for busi- man, however. Instead, he taught that a happy nesses. Both male and female members of the life is pure illusion and that the complete sup- celibate Heaven’s Gate group sported a unisex pression of pain—that is, death—is the only end look, with buzz-cut hair and shapeless clothes. worth pursuing. His lectures were so successful They had published a book in 1996 discussing a that many listeners actually did commit suicide mixture of Christianity and UFO lore, posting it after hearing him speak. Eventually, his power on their Heaven’s Gate website. to induce suicide became so great that he was According to reports, the cult’s leader, Mar- forbidden to speak. shall Applewhite, had experienced a near death experience while being treated for heart prob- help for suicidal people Scattered through- lems during the 1970s—an experience that out the United States are more than 250 suicide changed his life and led him into the cult. prevention centers accredited by the AMERICAN ASSOCIATION OF SUICIDOLOGY (AAS). Almost all of Hebrew Bible Biblical suicides are rare, with these 24-hour, seven-day-a-week crisis facilities only seven instances reported in the Old Testa- offer emergency telephone services designed to ment and one in the New Testament. Neither the give help quickly. Some have emergency rescue 116 Hemingway, Ernest squads to assist callers after they have tried to The son of a country doctor, Hemingway commit suicide. Others are linked to hospital graduated from high school in 1917. He started emergency services that can provide help as working as a reporter for the Kansas City Star, quickly as possible. heading to Europe during World War I, where In addition, there are hundreds of self-help he served as an ambulance driver in France and or mutual-aid groups in both the United States in the Italian infantry, getting wounded just and Canada not only to help those at risk of before his 19th birthday. Soon he found himself suicide, but also to extend help to survivors of in Paris as Toronto Star correspondent, where he suicides. became involved with the expatriate literary and Help is also available from professionals in artistic circle surrounding Gertrude Stein. Dur- private practice, in community mental health ing the Spanish civil war, he served as a corre- clinics, hospital emergency rooms, national spondent on the loyalist side, fought in World agencies such as the NATIONAL INSTITUTE OF War II, and then moved to Cuba in the 1940s. MENTAL HEALTH and the NATIONAL MENTAL HEALTH Here he bought Finca La Vigia, a bright and ASSOCIATION, international suicide-prevention breezy mansion overlooking San Francisco de groups such as CONTACT and the SAMARITANS, Paula, a village about 10 miles southeast of and the New York-based National-Save-A-Life Havana. The writer spent most of his last 20 League. years in the house, the only place he said he Canada, like the United States, has a nation- every felt at home. wide network of suicide hotlines. Suicidal callers Yet much like his father, Ernest Hemingway should consult an updated telephone book or was a tormented man, grappling with drinking, dial either “0” for operator information or 911. insomnia, violent outbursts, free-floating feel- In Canada, the SALVATION ARMY operates its own ings of dread, and guilt over his behavior. It was suicide prevention facilities. Canada also has at Finca that Hemingway first rehearsed his sui- branches of the Samaritans and Tele-Care. cide in front of his friends and doctor. Seated in In nonemergency situations, help and advice his armchair, he braced the barrel of his is available to anyone through the facilities of Mannlicher Schoenauer .256 against the roof of the CANADIAN MENTAL HEALTH ASSOCIATION, which his mouth and pressed the trigger with his big has branches countrywide. Information is also toe. “The palate is the softest part of the head,” readily available from the SUICIDE INFORMATION he told them. AND EDUCATION CENTRE in Alberta. In 1954, Hemingway was awarded the Nobel See also AMERICAN PSYCHIATRIC ASSOCIATION; Prize in literature. After Castro ejected him from AMERICAN PSYCHOLOGICAL ASSOCIATION; INTERNA- Cuba, he moved to Idaho, where he was increas- TIONAL ASSOCIATION FOR SUICIDE PREVENTION; ingly plagued by ill health, depression, and men- NATIONAL ASSOCIATION OF SOCIAL WORKERS. tal problems. See also Appendix I. When Ernest Hemingway’s father committed suicide in 1928, the writer had branded him Hemingway, Ernest (1899–1961) U.S. writ- a coward, but 33 years later—in July 1961— er whose longer works of fiction include The Sun Hemingway himself swallowed the muzzle of a Also Rises (1926), For Whom the Bell Tolls (1940), 12-gauge shotgun and pulled the trigger. Two of and The Old Man and the Sea (1952). An avowed his siblings also killed themselves; a sister over- sportsman and hunter, Hemingway extolled dosed in 1966 and a brother shot himself in 1982. machismo, courage, and stoicism in his short stories and novels, which were written in a sim- Hemingway, Margaux (1955–1996) Model ple, terse style. and actress who deliberately killed herself with Hemlock Society 117 an overdose of phenobarbital in her Santa Mon- most toxic when the plant is flowering, but all ica, California, apartment on July 1, 1996, parts of the hemlock are deadly. according to the Los Angeles County coroner. The most famous suicide victim of hemlock The 41-year-old actress was the fifth person in was Socrates, who was tried on the charge of her family to commit suicide. Her death ended a corrupting the young people of Athens. Found Hollywood career dogged by alcohol, epilepsy, guilty, he was sentenced to death by drinking bulimia, and life in the shadow of her more hemlock. famous sister Mariel. Typically, Greek city-states differed consider- Santa Monica police investigators had said ably in their laws about suicide. Magistrates in they found no illegal drugs or suicide note in the some areas went so far as actually to provide apartment. The final determination of death by would-be suicides with hemlock so they could suicide was made after toxicological tests. kill themselves. Typically, magistrates considered Hemingway’s career soared in the 1970s several problems to be sufficient cause for sui- when she worked as a top model with compa- cide, including insanity, profound physical suf- nies like Fabergé, followed by a movie career. In fering, or overwhelming sorrow. 1976, the six-foot actress starred with her younger sister, Mariel, in the film Lipstick, but Hemlock Society Oldest and largest organi- later movies were not critical or commercial suc- zation advocating the “right to suicide.” The cesses. society has almost 25,000 members in 70 chap- Hemingway was the oldest granddaughter of ters across the country, who believe that people writer Ernest Hemingway, who had used a shot- should be able to have choice and dignity at gun to commit suicide nearly 35 years earlier to the end of life. The primary way to accomplish the day. His brother, sister, and father also killed this is with legally prescribed medication as themselves. Margaux was the fifth to kill herself part of the continuum of care between a patient out of four generations of Hemingways tor- and a doctor. The Patients’ Rights Organiza- mented by mental instability and manic-depres- tion (PRO-USA) is Hemlock’s legislative arm sion. (Margaux’s older sister, Joan, whose working to change laws to legalize assisted nickname is Muffet, has been in and out of men- suicide. tal institutions since age 16.) According to the society, the law they would On July 6, 1996, Margaux’s ashes were like to enact would protect patients and doctors, buried in Ketchum, Idaho, in the shadow of a allowing mentally competent patients to hasten memorial to her grandfather ERNEST HEMINGWAY, their death with a doctor’s help. Safeguards one of the 20th century’s most celebrated liter- would include: ary figures. • a diagnosis of terminal or irreversible illness hemlock () The ancient that severely compromises the quality of life, poison drink of the Greek philosopher SOCRATES, confirmed by two independent physicians this plant (which resembles a carrot) is rapidly • an evaluation by a mental health professional fatal when ingested. Its large lacy leaves are as if there is reason to suspect clinical depression much as four feet long, producing a disagreeable or mental incompetence garlicky odor when crushed. It is found in South • a written, witnessed request America, northern Africa, and Asia, and in the • a waiting period United States and Canada. In Europe, it’s called “fool’s parsley.” Hemlock contains coniine, a • voluntary assistance on the part of the doctor muscle relaxant similar to curare. Leaves are • revocable by the patient at any time 118 Hendin, Herbert

• medication prescribed by the doctor and self- the time of her death, she was suing her former administered by the patient husband, charging libel and slander for com- • no criminal liability for a physician or family ments he made about her mental state. Her sui- member who helps cide made headlines worldwide, in part because of her allegation in her suicide note that she was • no effect on insurance driven to kill herself by Derek. • monitoring by a state health department. Derek continued to serve as Hemlock’s national executive director until 1992, when he The society considers suicide only for those suf- retired to concentrate on writing, lecturing, and fering from irreversible illnesses with unbearable advising patients considering EUTHANASIA. He is suffering, who want access to a peaceful way to currently president of the Euthanasia Research & hasten their death. The society opposes suicide Guidance Organization (ERGO!), a nonprofit for emotional, ideological, or financial reasons, group specializing in right-to-die guidelines, help- opposes violent suicide for any reason, and ing dying patients and families with information strongly supports suicide prevention programs. and advice, and briefing news media on end-of- The society does not distribute the means to a life issues. He has continued to write books on the peaceful death, but makes available written euthanasia theme, including Dying with Dignity: materials on suicide. Understanding Euthanasia (1993) and Lawful Exit: The society was founded in 1980 in Los Ange- The Limits of Freedom for Help in Dying (1994). les by DEREK HUMPHRY and and his second wife, The Hemlock Society believes that since sui- Ann Wickett, coauthors of The Right to Die: Under- cide is no longer a crime, assistance in suicide standing Euthanasia. The two also wrote Jean’s should also be decriminalized where a termi- Way, an account of how Humphry helped his nally ill or seriously incurably ill person requests critically ill first wife take her own life. this help. Humphry’s first wife, Jean, was diagnosed The society strives to help campaign for better with breast cancer and died in his arms in 1975 understanding of euthanasia and to work toward after she drank a cup of coffee that she knew he improved laws in this area. It publishes a newslet- had laced with secobarbital and codeine to end ter, Hemlock Quarterly, that updates members on her suffering. Less than a year later, Humphry ethical, legal, and operating developments. married Ann. In the next decade they built a powerful national organization with 30,000 Hendin, Herbert The medical director of the members and gross revenues of nearly $1 mil- AMERICAN SUICIDE FOUNDATION and author of sev- lion a year, mainly from dues and book sales. eral books in the field, including Suicide in Amer- In 1989, his second wife, Ann, also was diag- ica; Suicide and Scandinavia; Black Suicide; and The nosed with breast cancer. Three weeks after her Age of Sensation. He received the Louis I. Dublin surgery and four days after Ann began a regimen award in 1982. Dr. Hendin is an international of radiation and chemotherapy, Derek Humphry authority in the field of suicidology and has spe- telephoned home during a business trip to say cialized in integrating the psychological and he was leaving her. What followed was a vicious social aspects of suicide. and very public battle between the two, ending in divorce in 1990 after a highly publicized bitter separation. hereditary factors See GENETICS AND SUICIDE. The next year, Humphry married Gretchen Crocker, youngest daughter of an Oregon farm- Herodotus (ca. 484–425 B.C.) Greek histo- ing family; later that year Ann traveled into the rian, born in Halicarnassus, Asia Minor. He lived Oregon wilderness and committed suicide. At for some time in Athens, then traveled in 443 Hispanics and suicide 119

B.C. as an Athenian colonist to Thurse in Italy. hidden suicide Indirect self-harming behav- There he is supposed to have spent the rest of his ior, also called subintentional suicide or indirect life, writing The Persian Wars. self-destructive behavior. This type of indirect Herodotus describes the custom among Thra- self-harming behavior should be suspected in cians of a form of institutional suicide in which a patients who refuse to eat, don’t take prescribed man’s widows (the Thracians practiced poly- medication properly, and who refuse to social- gamy) vied for the honor of being the one the ize. Older people, who may be taking medica- deceased had loved most. The wife accorded this tion for serious illnesses, are more likely than honor was then slain over the grave and buried younger people to have the opportunity for with her husband. The Greek historian also indirect suicide. described at length the suicide of Cleomenes, king of Sparta (end of the sixth century B.C.). Hippocrates (460–377 B.C.) The central his- torical figure in Greek medicine considered to be heroin and suicide Studies suggest there is a the “father of medicine.” The events of his life strong association between heroin dependence are shrouded in uncertainty, yet he provided an and suicide. Heroin-dependent individuals are example of the ideal physician after which oth- 14 times more likely than their nonaddicted ers centuries later patterned their existence. peers to die by suicide. Some researchers suggest The most famous document attributed to Hip- that the link between heroin and suicide indi- pocrates is the Hippocratic oath, which has cates that some heroin overdoses may in fact be served as a model of professional conduct and suicide attempts. for the ethical practice of medicine ever since. In In one study, 40 percent of methadone addicts the Hippocratic oath for which he was famous, reported a history of at least one suicide attempt. Hippocrates condemned suicide and ASSISTED Women were more likely than men to have SUICIDE: “I will neither give a deadly drug to any- attempted suicide (50 percent vs. 31 percent). body if asked for it, nor I will make a suggestion Ten percent had attempted suicide since enroll- to this effect.” ment in their current treatment program, and 8 Experts believed that since most Greeks of the percent had attempted suicide in the preceding time practiced suicide, most likely the Hippo- 12 months. Women also were significantly more cratic oath originated with the Pythagoreans, a likely than men to have attempted suicide prior school of ancient Greek philosophy that stood to the onset of heroin addiction. alone in its condemnation of suicide. While suicide attempts among men in the The Hippocratic oath has traditionally played study were likely to be related to the use of an important role for physicians who are heroin, with most first suicide attempts occur- addressing end-of-life issues. Even today, many ring after the onset of heroin use, suicidal behav- doctors struggle with the idea of assisted suicide ior among the women appeared to be related to because of the Hippocratic injunction that doc- problems of longer-standing than the use of tors should first do no harm. That a doctor heroin. should not be involved in suicide is very much a A deliberate heroin overdose as means of part of the ethics of medicine as many under- attempted suicide was reported by 10 percent of stand it. participants. Other methods used included hang- ing, poisoning, and gunshot. However, over- doses appeared overwhelmingly to be accidental Hispanics and suicide Among Hispanics, the —92 percent of those who had overdosed highest suicide rates occur among the elderly reported that their most recent overdose was (over age 65). Still, suicide is also a problem accidental. among Hispanic youth. In 1999, the Youth Risk 120 Hitler, Adolf

Behavior Surveillance System in a nationwide Although overall rates of mental illness survey of high school students found that in the among Hispanics roughly equal that of whites, 12 months preceding the survey, Hispanic stu- young Hispanics have higher rates of depression, dents (12.8 percent) were significantly more anxiety disorders, and suicide. The study also likely than white, non-Hispanic or black non- found that Hispanics born in the United States Hispanic students (6.7 percent and 7.3 percent, are more likely to suffer from mental illness than respectively) to have reported a suicide attempt. those born in Mexico or living in Puerto Rico. Among girls, Hispanic students (18.9 percent) Suicide risk has been found to be lower were also significantly more likely than white among recently immigrated Hispanics between non-Hispanic or black non-Hispanic students the ages of 15 to 34 when compared with their (9.0 percent and 7.5 percent, respectively) to Hispanic counterparts born in the United States. have reported a suicide attempt. Although rarely publicized, America’s His- Many Hispanic communities might well fall panic population suffers from firearms violence into high suicide risk categories because of such at rates far greater than the U.S. population factors as: being socially isolated; experiencing overall; about half of all suicides in the Hispanic interpersonal conflict or problems, including population are completed using guns. marital or family discord; lacking personal resources; high unemployment rate; mental dis- orders, especially depression, alcoholism, and Hitler, Adolf (1889–1945) German dictator, schizophrenia; and physical illness. founder-leader of the National Socialist German Hispanics are the fastest-growing racial/ Workers’ (Nazi) Party. Austrian-born son of a ethnic group in the United States; in 1999, customs official, he was orphaned at 15, refused there were more than 31 million Hispanics in admission to a Viennese art academy, lived in the United States with an average age of 28.8 abject poverty, and became a violent anti- years. The Hispanic population is growing sev- Semite. He served in the Bavarian army during eral times faster than the non-Hispanic popula- World War I, received the Iron Cross and tion—more than doubling between 1980 and attained the rank of corporal. Hitler wrote Mein 1999. The U.S. Census Bureau estimates that Kampf (My Struggle) while imprisoned in Lands- by the year 2005 Hispanics will surpass blacks berg Fortress for trying, with a group of embit- as the largest minority group in the United tered malcontents, to seize power in Bavaria in States. the beer hall putsch at Munich (November 8–9, Minorities are no more likely than whites to 1923). Preaching Aryan supremacy and fanatic suffer from mental illness, with the overall rate nationalism, he promised world conquest by the of mental disorders steady at one in five people, German “master race.” Appointed chancellor by but various factors often keep Hispanics from the aged President Hindenburg in 1933, and getting the help they need—and when they do, despite his own party being a minority in the the treatment may be substandard or too late. Of Reichstag, Hitler managed to establish a dictator- all the ethnic groups studied, Hispanics had the ship. When Hindenburg died in 1934, Hitler highest percentage—37 percent—without any combined the offices of president and chancellor health insurance. This group also faces major in the title of Der Führer. Thereafter, Hitler’s mil- language barriers in mental health care, in itaristic, aggressive foreign policy led inexorably which communication is especially vital to to World War II. proper treatment. Few mental health providers A carefully planned plot by leading army and identify themselves as Spanish-speaking, and civil officials to assassinate Hitler failed in July about four in 10 Hispanics say they do not have 1944, and Heinrich Himmler crushed the revolt. strong English skills. But when the victorious Allied armies converged Holland 121 on Berlin in April 1945, Hitler presumably killed experience disappointment when their loved himself along with his mistress-bride, Eva one is excluded from holiday conversations. Braun, in a bombed steel and concrete bunker on April 30. Several other high-ranking Nazi Holland (Netherlands) In Holland, where officials also committed suicide at the fall of EUTHANASIA and ASSISTED SUICIDE were legalized Berlin, including Himmler and propaganda min- in 2002, the suicide rate is 10.1 per 100,000. This ister Paul Joseph Goebbels. breaks down to 13.5 per 100,000 for men and 6.7 per 100,000 women. This represents an overall holidays and suicide Contrary to popular decrease from the 1984 high of 12.4 per 100,000. belief, suicides are not more common during the The suicide rate decreased from the 1984 rate of holidays. During the year, the suicide rate typi- 15.2 and 9.6 for women. For both sexes, the cally peaks in summer and again during April, highest age group at risk for suicide were those May, and October. For the most recent year for over age 75; at this age, the suicide rate for men which data were available (1996), November and was 34 per 100,000 and for women, 11.5. December ranked the lowest in daily rates of sui- Dutch physicians have practiced physician- cide, according to information from the National assisted suicide and euthanasia for more than Center for Health Statistics. Other studies have two decades by following specific guidelines. also found that the Thanksgiving and Christmas Among others, these parameters require that the holidays have unusually low suicide rates. patient be competent, voluntarily repeating the request for death, and experiencing unbearable suffering from an irreversible illness. holidays and survivors Holidays can be diffi- One of the main reasons why the Dutch allow cult for survivors of suicide. Survivors should voluntary euthanasia is they recognize that plan to eat well, exercise, and get plenty of sleep whatever the law says, people are helped to die. during these more stressful times. Holiday shop- Therefore, they reason, the best way to protect ping should be finished early to eliminate the vulnerable and make sure that assisted dying unnecessary stress. Communication is important happens only at the request of a competent and for survivors, who should decide what they can informed terminally ill person is to regulate handle comfortably and confide those needs to assisted dying. family and friends. In 2002, the Dutch Parliament approved a Survivors should plan the holiday ahead of new law on assisted suicide, the latest stage in a time, incorporating a schedule of activities to regulation process that has been going on relieve tension, and making changes in holiday for nearly 30 years. The new law enshrines traditions to make things less painful. Many peo- in Dutch statute the safeguards which successive ple find it helpful to start new traditions, such as court decisions have set down for regulating different holiday recipes, changing the time pre- assisted dying. Estimates suggest that 85 percent sents are opened, altering the time and place of of the Dutch public support legalized assisted the holiday meal, and so on. dying as a choice for terminally ill people. Survivors should plan to be with people they Under Dutch law, euthanasia and assisted sui- enjoy, and remember that tears are an honest cide are no longer criminal offenses. The follow- expression of love and . Some survivors ing criteria must be met by the doctor under the say they find it easier to spend holidays away law: from home. The person who has died should be included • The doctor must be satisfied that the patient in conversations with family and friends when has made a voluntary and carefully consid- discussing past holidays, since some survivors ered request. 122 homicide vs. suicide rate

• The patient’s suffering should be unbearable agree that gay and lesbian people are at far and without chance of improvement. higher risk of suicide than are heterosexuals. • The doctor must have informed the patient There are many reasons for this. One is that about his situation and prospects. homosexual activity is illegal or considered wrong in many countries, which can cause • The doctor must have come to the conclusion, homosexuals to feel isolated and depressed. (It is together with the patient, that there is no rea- important to remember, however, that there are sonable alternative in the light of the patient’s millions of homosexuals all over the world living situation. happy and fulfilled lives.) • The doctor must have consulted at least one Although most researchers agree that homo- other independent physician who must have sexuals are at high risk for suicide, the motives, seen the patient and given a written opinion causes, and predictability of future attempts re- on the due care criteria referred to above. main as enigmatic as with other identified • The doctor must have ended the patient’s life higher-risk populations. or provided assistance with suicide with due There are no accurate national statistics for medical care and attention. suicide rates among gays, lesbians, or bisexuals, since sexual orientation is not recorded on a Doctors who don’t make sure all the safeguards death certificate. Because sexual orientation is a are met may be prosecuted. In practice, Dutch personal characteristic that people can, and often doctors agree to only one in three requests for do choose to hide, in psychological autopsy stud- assisted suicide. ies of suicide victims where risk factors are exam- Regional review committees must examine all ined, it is difficult to know for certain the victim’s cases of assisted dying. These committees are sexual orientation. This is particularly a problem made up of a legal expert, a doctor, and an when considering homosexual youth who may expert on ethical or moral issues. Any doctor be less certain of their sexual orientation. who ends a patients’s life at the patient’s request, With regard to suicide attempts, several state or assists in a suicide, is under an obligation to and national studies have reported that high notify the municipal pathologist of the cause of school students who report being homosexually death. The municipal pathologist refers the mat- and bisexually active have higher rates of suicide ter to the regional review committee, which will thoughts and attempts compared to heterosexu- consider the case. If the doctor is found to have als. However, experts have not been in complete complied with the due care criteria, he or she agreement about the best way to measure will not be prosecuted. reports of adolescent suicide attempts, or sexual orientation, so the data are subject to question. homicide vs. suicide rate The suicide rate in Because school-based suicide awareness pro- the United States is higher than the homicide grams have not proven effective for teenagers in rate. For every two people killed by homicide, general—and in some cases have caused three people die of suicide. And for every person increased distress in vulnerable youth—they are who completes suicide, family and friends are not likely to be helpful for homosexual youths left behind to deal with the pain. either. Risk factors that increase likelihood for sui- homosexuality and suicide In recent years cide among gay and lesbian individuals include: there has been a great deal of research into the incidence of suicide among homosexuals. While • psychiatric disorders the findings are inconsistent, most researchers • substance abuses hopelessness 123

• family problems Lack of self-esteem without a traditional way • depression of regaining it became a major cause for a high suicide rate among the Cheyenne in modern • harassment, violence, and gender nonconfor- times. Isolated on the reservation, tribesmen suf- mity fered loss of pride, many of their traditions, and • celibacy or multiple partners means of supporting themselves. With tradi- • HIV and AIDS tional buffalo hunts, war parties, and other methods of handling feelings of unworthiness See PSYCHOLOGICAL AUTOPSY. and dishonor forbidden to them, many young men turned instead to open suicide. honor and suicide In many early societies, Among the Chinese, suicide was the accepted either actual suicide or suicidal attempts were way for a defeated general or deposed ruler to used to regain an individual’s lost honor. Among regain lost honor. The Japanese considered certain African tribes, for instance, men sought HARA-KIRI an accepted, honorable death for revenge against their enemies by killing them- samurai (members of the military class). Out- selves, a practice known as “killing oneself upon lawed in 1868, the ritualized hara-kiri form of the head of another.” When such a suicide oc- suicide continued to influence Japanese prac- curred, custom had it that the enemy responsi- tices. During World War II more than a thousand ble must, in turn, immediately kill himself in the young Japanese pilots died as KAMIKAZE flyers same way. This bizarre practice continued well who flew their planes at Allied warships. And in into modern times. 1970, famed Japanese author YUKIO MISHIMA committed hara-kiri as a plea to his countrymen ST. AUGUSTINE formulated his prohibitions against suicide in order not only to prevent early to revive old traditions and old values, including Christians from seeking martyrdom but also to the concept of dying with honor. forestall young Christian girls from killing them- The practice of dying with honor to preserve selves in order to preserve their chastity. beliefs has been prevalent throughout Jewish Lucrece, whose story is written so beautifully in history, as JEWS suffered persecutions and tor- a Shakespeare poem, killed herself before her tures in different countries in which they lived. family in order to affirm her honor after she was forcibly raped by Sextus Taquinius the night hopelessness There is almost always a com- before. plicated mix of feelings, attitudes, and motives Among the Romans, death to regain lost involved in any suicide attempt. Suicidologist- honor was chosen by such people as Ajax the psychologist Norman L. Farberow stresses that Greater, CHARONDAS, DEMOSTHENES, CATO THE the suicide decision is usually not impulsive; it is, YOUNGER, and many others. in fact, premeditated. Although it is sometimes In North America, Cheyenne Indian warriors carried out on impulse and may seem capricious, who had lost face would place themselves in life- suicide is usually a decision that is given long endangering situations. If the shamed warrior consideration. acted bravely in his risk-taking venture—per- Many suicidal people feel hopeless. Yet haps a buffalo hunt, a war party against another despite this oppressive feeling of hopelessness, tribe, or self-inflicted pain—he won honor the would-be suicide usually still wishes for a among his tribesmen, and thus regained lost last-minute solution to lifestyle problems. For self-esteem. If he failed and died from his many suicidal persons, there is an ambivalence, actions, the tribe considered his death an honor- a confused tugging between loving and hating, able, face-saving one. between hope and hopelessness, between want- 124 hospitalization, involuntary ing to break away from family and friends while a suicide attempt and to teach them how to pre- still wanting desperately to communicate with vent future crises. them. And all the while, there is present within Therapists show suicidal patients and parents the suicidal person that feeling of being without the importance of opening up channels of com- any real hope, of being entrapped in a life situa- munication within the family so they do not tion that cannot be controlled. have to use suicidal acts as their means of com- Hopelessness is the critical factor in suicidal munication. behavior—even more important than depression. hostile behavior Among the various behav- hospitalization, involuntary Like alcoholics, ioral hints or warning signs is aggressive, often drug abusers, or violent individuals, many suici- hostile behavior. dal individuals are caught in the web of denial In one study, 60 percent of those who had and will refuse to accept any help. Often, even attempted suicide had tried aggressive tech- close family members or trusted friends fail to niques as disobedience, sassiness, defiance, and convince them to meet with a professional ther- rebelliousness. Less than 18 percent of nonsui- apist or to enter a psychiatric hospital. In cases of cide attempters had tried such tactics. extreme denial, when critical suicidal danger Other aggressive patterns among suicidal exists the patients may have to be institutional- youngsters have included shoplifting, joyriding ized against their wishes. in another’s car, alcohol, and other drug abuse. Involuntary hospitalization is not the ideal Some run away from home, become sexually solution to the suicidal person’s problems. Most promiscuous, fight with friends and occasionally professionals in the mental health field maintain with members of their own families. that in certain instances suicidal patients must be Such hostile, aggressive behavior, including hospitalized for their own protection and the physical risk-taking, may indicate what psychia- protection of others. trists call “masked depression.” This is behavior that generates excitement and covers up or hospitals There are usually mixed reactions “masks” their real feelings, which are anxious, among suicide attempters after they awaken in a painful, and depressive. hospital. They often deny the attempt and refuse to discuss the realities of the event. Sometimes, Hume, David (1711–1776) Scottish philo- the patient is angry at having failed and vows sopher and historian whose Treatise of Human secretly to succeed at self-destruction the next Nature tackles major problems in human percep- time. Another group of attempters admit a great tion and existence. Hume wrote a short essay, feeling of relief at finding they are alive. For the “On Suicide,” published after his death, that was latter, the suicide attempt often represents a quickly suppressed. In this essay, he argues turning point. against considering suicide a crime. “The life of a Whatever the attempter’s attitude, however, man,” Hume wrote, “is of no greater importance the person must be evaluated and usually to the universe than that of an oyster.” The treated by a professional therapist. The success of implication was that a man who kills himself such therapy after a suicide attempt depends to does not disrupt the larger order of the universe. a large degree on the patient’s support from fam- Moreover, says Hume, he “does no harm to soci- ily, friends, and associates. Often, the parents of ety; he only ceases to do good which if it is an a suicidal child may undergo therapy at the same injury, is of the lowest kind.” time. Such therapy aims at helping parents Hume wrote that suicide cannot be a crime understand what problems and pressures led to against God or the natural law because God gave Hungary 125 humans the ability and sometimes the desire to nearly $1 million a year, mainly from dues and commit suicide. It is not wrong to go against book sales. nature by building dams, diverting rivers, and so In 1989, Ann Humphry also was diagnosed on, and it is not wrong to interfere in matters of with breast cancer. Three weeks after her surgery life and death—otherwise life-saving surgery and four days after Ann began a regimen of radi- would be wrong. Hume also believed that sui- ation and chemotherapy, Derek Humphry tele- cide could not be a crime against the community phoned home during a business trip to say he was because being a hermit is not wrong, and suicide leaving her. What followed was a vicious and very takes this withdrawal from society just one step public battle between the two, ending in divorce further. Finally, he believed that suicide cannot in 1990 after a highly publicized bitter separation. be a crime against the self because individuals The next year, Humphry married Gretchen know best what is good themselves. Crocker, youngest daughter of an Oregon farm- ing family; later that year Ann traveled into the humor, loss of Among the cluster of symp- Oregon wilderness and committed suicide. At toms noticeable in people who are clinically the time of her death, she was suing her former depressed is the loss of the sense of humor. They husband, charging libel and slander for com- withdraw from family and friends, keeping to ments he made about her mental state. Her sui- themselves; and they may cry for the most triv- cide made headlines worldwide, in part because ial reasons. They act sad and dejected and noth- of her allegation in her suicide note that she was ing appears humorous to them. driven to kill herself by Derek. Derek continued to serve as Hemlock’s national executive director until 1992, when he Humphry, Derek Co-founder of the HEMLOCK retired to concentrate on writing, lecturing, and SOCIETY with his second wife, Ann Wickett, in advising patients considering euthanasia. He is 1980 in Los Angeles, where the couple lived. currently president of the Euthanasia Research & Humphry had been a newspaper reporter for Guidance Organization (ERGO!), a nonprofit 35 years, working for a number of British news- group specializing in right-to-die guidelines, help- papers, including 14 years with the London Sun- ing dying patients and families with information day Times. In 1978, he moved to the United and advice, and briefing news media on end-of- States to work for the Los Angeles Times. life issues. He has continued to write books on the Humphry’s first wife, Jean, was diagnosed euthanasia theme, including Dying with Dignity: with breast cancer, and died in his arms in 1975 Understanding Euthanasia (1993) and Lawful Exit: after she drank a cup of coffee that she knew The Limits of Freedom for Help in Dying (1994). he had laced with secobarbital and codeine to end her suffering. Shortly thereafter, he wrote the story of his first wife death with Ann Wicett Hungary According to the World Health in a book called Jean’s Way. The international Organization (WHO), at least 1,000 people acceptance of the book as a classic account worldwide kill themselves each day. In recent of rational voluntary EUTHANASIA launched times, when countries are ranked according to Humphry on a career campaigning for the right their suicide rates, Hungary is at the top year in of what he terms “self deliverance”—the right and year out. This may say less about national to die. characteristics than about how facts are gath- Less than a year later, Humphry married Ann, ered, reported, or covered up. and in the next decade they built the Hemlock The reasons for the high rate of suicide in Society into a powerful national organization Hungary are obscure. The country enjoys one of with 30,000 members and gross revenues of the highest standards of living in Eastern 126 “hurried” children

Europe, and has one of the least repressive The age group most at risk for suicide in Hun- regimes. Dr. Ceza Varady, director of the Insti- gary are the elderly men and women; those over tute for Mental Health in Budapest, explains that age 75 kill themselves at a rate of 90.15 per “the phenomenon reflects the Hungarian tem- 100,000. This breaks down to 130.5 per 100,000 perament, which is volatile and likes dramatic men, and 49.8 per 100,000 women. The next- gestures.” highest risk group in men is between age 45 and Nearly 5,000 people complete suicide each 54 (92.7); the next-highest risk group in women year in Hungary, compared to a murder rate of is age 65 and 74 (24.1). only 300 per year. In comparisons of suicide rates in developed countries around the world, “hurried” children Term used to describe Hungary’s suicide rate shows up as the highest in children who are pushed by parents to grow up the world. Year after year, Hungary’s suicide rate too fast. SIGMUND FREUD was, perhaps, the first is nearly three to four times that in the United psychiatrist to show concern about this phe- States, whereas the U.S. murder rate is more nomenon. In 1910, discussing suicide in children than three times that of Hungary. before the VIENNA PSYCHOANALYTIC SOCIETY, Freud Over the last 30 years, the difference between noted that teachers, in their attempt to wean Hungary’s rates and those of other countries has children from early family life, often rushed the steadily increased. While other countries’ rates immature student too abruptly into the harsh have fluctuated or increased moderately, Hun- realities of adult life. gary’s suicide rates have skyrocketed to approxi- Psychology professor David Elkind wrote in mately twice the 1960 rates, which already were Growing Up Faster that hurried children today are leading the world. thrown into an adult world that overwhelms Many trace the origins of the internalized and terrifies them, sometimes causing self- aggression reflected in these high suicide rates to destructive behavior patterns. Elkind, a professor Hungary’s centuries-old history of being domi- of child study at , points out that nated—indeed, Hungarians have known only 50 hurried adolescents frequently suffer anxiety years of freedom in the last 500. about academic success. They then may solve In 1998, Hungary’s overall suicide rate was this anxiety by using alcohol and other drugs as 32.9, down from a high of 45.9 per 100,000 in these actions make things worse, suicide may 1984. Far more Hungarian men kill themselves become another “adult” option. (51.1) compared to Hungarian women (14.7). I

Iceland Iceland has one of the higher suicide cept, loss of purpose, and feelings of meaning- rates in the world. Numerous education and lessness that can lead to suicide. media-based programs have been employed to curb this epidemic, but none of these programs Ignatius of Antioch (A.D. 50–117) Christian have been successful. Therefore, many scientists bishop traditionally said to have been one of the have concluded that this high rate of suicide little children whom Jesus bade the Apostles must be influenced by a person’s genetics. Other imitate. There is little doubt that he was indeed experts believe the weather, and the long peri- a disciple of the Twelve: His name is linked espe- ods of darkness in winter, may influence the cially with those of John, Paul, and Peter. development of depression and suicide. During the period when the craving for mar- Iceland’s suicide rate is 10.1 per 100,000; tyrdom became almost epidemic among the this translates into 16.4 for men and 3.8 for early Christians, Ignatius of Antioch wrote let- women. Unlike many other countries, the male ters, particularly those to the Christian commu- age group most at risk for suicide is between age nity of Rome, that epitomized the state of zeal 25 and 34 (38.1); for women, it is over age 75 and mania. “I beseech you . . .,” he wrote, “suf- (13.3). fer me to be eaten by the beasts that I may be found pure bread of Christ. Rather entice the identity Loss of identity or self-image leads to wild beasts that they may become my tomb, and depression and if untreated, may push the per- leave no trace of my body, that when I fall asleep son further into suicide. I be not burdensome to any. Then shall I be truly It is during the teen years that so many a disciple of Jesus Christ, when the world shall changes produce extreme anxieties, tensions, not even see my body. Beseech Christ on my and mood alterations. Teenagers become fright- behalf, that I may be found a sacrifice through ened, dejected, and angry at both themselves these instruments.” and others. Christians generally despised the tendency Teenagers also develop a fascination with toward suicide among pagans, but premature, death and dying. Many who become suicidal voluntary death as a martyr characterized large usually lack a true or realistic concept of the segments in the Roman Empire between the finality of death. Those teenagers who receive reigns of NERO and Julian (A.D 54–363). too little love and understanding, who feel alien- ated and without support, and who suffer loss of imitation See CLUSTER SUICIDES. identity as a result, may become self-destructive. Loss of identity has also been identified as one of the causes of the high suicide rate among the immortality Younger children who attempt or elderly. Loss of job, family, lifelong friends, and successfully carry out suicide often do not have a physical health may bring about loss of self-con- true sense of mortality. To them, death represents

127 128 impulsiveness a rather vague, even romantic concept, with sui- Four out of five people who commit suicide cide an attractive fantasy that becomes a realistic have previously given clues—verbal, behavioral, method for testing feelings of immortality. or both—of their intent. Singly, these unex- Most young people’s experience with death is pected acts of impulsiveness may not be particu- restricted to books, films, or television. Tragically larly significant, but clustered with other CLUES, for many of these children, only the harsh real- they can predict potential suicide. ity of a suicide attempt makes them realize that they are, indeed, mortal. Suicidal young people index suicide The first suicide precipitating a often see death as a sort of magical, mystical suicide cluster. adventure. India The World Health Organization (WHO) impulsiveness A personality trait that may be has no reliable data on the rate of suicide in linked to suicide. Impulsiveness is the tendency India, although other reports from years ago to act without thinking through a plan or its suggest the rate fluctuates from 6.3 to 8.1 per consequences. It is a symptom of a number of 100,000. mental disorders, and therefore, it has been Nevertheless, India is notorious for a type of linked to suicidal behavior usually through its ritual suicide called SUTTEE, in which widows association with mental disorders and/or sub- threw themselves on their husbands’ funeral stance abuse. A recent government study found pyres, or drowned themselves in the Ganges that one in four nearly-lethal suicide attempts River. Suttee, which was related to most Indians’ occurred within five minutes of the decision to strong belief in life after death, was encouraged attempt. by Hindu priests and relatives of the widow. By The mental disorders with impulsiveness self-destruction, a faithful wife not only atoned most linked to suicide include borderline per- for her husband’s sins, but also opened the gates sonality disorder among young women, conduct of paradise to him. The general populace vener- disorder among young men and antisocial ated a widow who practiced suttee and con- behavior in adult men, and alcohol and sub- demned one who refused, sometimes actually stance abuse among young and middle-aged threatening her with physical punishment. The men. Impulsiveness appears to have a lesser role practice of suttee continued in India for hun- in older adult suicides. dreds of years. It was outlawed by the British Attention deficit hyperactivity disorder that rulers of India in 1829, yet slow-changing cus- has impulsiveness as a characteristic is not a toms saw it continue on occasion into the early strong risk factor for suicide by itself. Impulsive- 1900s. ness has been linked with aggressive and violent The custom of suttee, or in India, was not behaviors including homicide and suicide. How- indigenous to the country. It was practiced ear- ever, impulsiveness without aggression or vio- lier by the Scythians and Thracians. The Kathei, lence present has also been found to contribute and ancient Punjabi tribe, made sati a law to pre- to risk for suicide. vent the wife poisoning the husband. In addi- Most young people who kill themselves have tion, mass (known as jaubar) trouble controlling their impulses, reacting to was practiced by the women of the class situations before thinking things through and/or to avoid molestation by victors in battles with overreacting to stimuli. An adolescent may be other tribes. less depressed than an adult, but commits sui- , suicide by self-denial of food, is cide over a trivial event because of an inability to permissible only to ascetics, according to the Jain delay self-destructive behavior. religion. inpatient suicide 129

In India today, attempted suicide is socially inpatient suicide Completion of suicide by unacceptable. Survivors are considered to be patient at a hospital or institution. Most inpa- “tainted” and marriages in such families become tient suicides occur in psychiatric hospitals, fol- difficult. When suicides do occur, the most com- lowed by general hospitals and residential care mon method is ingestion of an insecticide, a facilities, according to the Joint Commission on wide variety of which are easily and commonly the Accreditation of Hospitals (JCAH). obtainable. In one study of inpatient suicides, of those cases in general hospitals most occur in psychi- indirect self-destructive behavior (ISDB) A atric units, followed by medical/surgical units group of behaviors that is distinguishable from and an occasional incident in an emergency overt self-destructive behavior by the criteria of room. In 75 percent of the cases, the method of time and awareness. The effect of the behaviors suicide is hanging in a bathroom, bedroom, or is long-term, and the person is usually unaware closet. Twenty percent of inpatient suicides of or does not care about the effects of the resulted from patients jumping from a roof or behavior. These behaviors have also been called window. unconscious suicide. Good patient care is the first step in prevent- Indirect self-destructive behaviors include ing inpatient suicides. The root causes of inpa- self-mutilation, disregard of physicians’ advice in tient suicides include having nonbreakaway long-term chronic illnesses, substance abuse, bars, rods, or safety rails; lack of testing of break- hyperobesity, smoking, violent crime, and com- away hardware; and inadequate security. Other pulsive gambling. Some experts also include risks include poor patient assessment methods, some high-risk sports, such as mountain climb- such as incomplete suicide risk assessment at ing, scuba diving, and hang gliding, when the intake, absent or incomplete reassessment, and participant exceeds the bounds of caution and incomplete examination of the individual. Staff- begins to take unreasonable chances. related factors, such as insufficient orientation or Personal characteristics of a person with ISDB training, incomplete competency review or cre- include strong tendencies toward denial, a focus dentialing, and inadequate staffing levels also on the present, and a need to obtain immediate contribute to the problem. gratification from his behaviors. There seems to There are a number of ways to reduce the risk be a strong flavor of excitement-seeking in the of inpatient suicides, such as improving suicide activities, as if it’s the stimulation of the process risk assessment procedures, training staff on sui- rather than the achievement of the goal that is cide risk factors, improving patient observation, most important. revising procedures for contraband detection, re- It is not known whether indirect or direct sui- placing nonbreakaway hardware, weight testing cidal behavior occurs more frequently in the all breakaway hardware, and redesigning, retro- same person or more generally substitute for fitting, or introducing security measures (such as each other. Some early research indicates it may patient monitors and alarms). The institutions be a factor of age, with the one substituting for should install appropriate shower heads, shower the other more often in young and middle years, bars, and closet bars that do not easily suggest and the two occurring more frequently together suicide methods. Staff should not leave doors in the older years. open that should be closed, and should not give patients access to sharp objects and other poten- indirect suicide Death as the unintended tially harmful items such as cleaning solvents. result of high-risk behavior. Particular attention should be paid to patients See also INDIRECT SELF-DESTRUCTIVE BEHAVIOR. who have multiple diagnoses that in combina- 130 inquest tion can increase the risk of suicide (for example, than usual or else has difficulty getting to sleep a combination of depression and substance at night. abuse). At the same time, the institution should For the person contemplating suicide, insom- review policies about passes and privileges for nia or excessive sleep patterns may be clues to patients who are considered a suicide risk. self-destruction. Organizations should assess a patient’s risk of suicide at admission, and constantly observe institutional suicide Instances of suicide out those at highest risk. Staff members who provide of loyalty are related to RITUAL SUICIDES and are any level of observation should ask at least once frequently described among different peoples in per shift about suicidal intent, and more often if various historical periods. suspicion is high. Staff should avoid relying on For instance, Nicholas of Damascus, an histo- pacts with patients that they will not act on sui- rian in the time of Augustus, was a chieftain of a cidal impulses. Celtic tribe, and employed a handpicked body- guard of 600 men who were bound by a vow to inquest A CORONER’s investigation to establish live and die with him, no matter whether the cause of death. An inquest is a public hearing in chief died in battle or of a fatal disease. which the coroner and six jurors sit in a quasi- Another instance of institutionalized suicide is judicial fashion to evaluate evidence presented the well-known practice whereby a widow or a (medical, investigative, and legal) to determine concubine gives her life when the husband or the manner, cause, and circumstances surround- master dies. HERODOTUS describes this custom ing a death. An inquest is conducted on all among the Thracians, who practiced polygamy. deaths where apparent suicide, homicide, or When a man died, the wives vied for the honor accidents were involved in the death. Witnesses of being judged favorite—and the woman and police are subpoenaed to testify under oath accorded this honor was then slain over the to the events leading to the death. It is the sole grave and buried with her beloved husband. responsibility of the jury to render a verdict Analogous to this case of institutional suicide is (accident, suicide, homicide, natural, undeter- the familiar Hindu custom of SUTTEE. Here the mined) and, if need be, to make recommenda- widow immolates herself with the husband’s tions or to place blame. corpse. assist public health agencies, public Yet another example is the altruistic suicides and private organizations, and law enforcement by the Japanese KAMIKAZE PILOTS of World War agencies in their attempts to detect foul play or II, who flew their planes at Allied warships, any existing hazardous conditions. Inquests assist destroying themselves in the process. insurance companies in making decisions on pol- See also HARA-KIRI; SEPPUKU. icy benefits for family members of the deceased and inquests help family members to learn all the insurance and suicide Generally speaking, facts concerning how their loved one came to state insurance laws explicitly prohibit life insur- die. This information helps them deal with their ance holders from collecting coverage in the grief and avoid needless confusion. event of suicide. Although insurers are not required to exempt suicides, it is nevertheless an insomnia One of the symptoms of DEPRESSION almost universal practice in the insurance busi- that increases the individual’s vulnerability to ness. suicidal thoughts. Family members notice im- While virtually all life insurance policies make mediately when someone is having sleep prob- some exclusion for death from suicide, the lems. The person affected awakens much earlier exclusion is often limited. After a period not to International Association for Suicide Prevention 131 exceed two years after the policy was purchased, • Intent, third degree: Voluntary self-injury was in most cases, death from suicide is covered on inflicted without seriously intending suicide the same basis as is death from any other cause. on the part of the attempter. The theory is that individuals contemplating suicide should not be able to purchase life insur- intentional underreporting The deliberate ance benefits for their survivors. Not only misrepresentation of a death by suicide as due to would that be bad business for insurers, but it another cause. could conceivably serve in some cases to remove some of a person’s hesitations about committing suicide. However, insurers assume International Association for Suicide Preven- that after an interval of a year or two, there is a tion Nonprofit international organization ded- vanishing likelihood that the person bought the icated to preventing suicidal behavior, to policy in contemplation of suicide. In most alleviate its effects, and to provide a forum for states, life insurance policies specify that the academicians, mental health professionals, crisis proceeds of the policy will not be paid if the workers, volunteers, and suicide survivors. The insured takes his or her own life within two IASP tries to increase contact and collaboration years after the policy’s date of issue. The suicide between professionals, the public and a growing exclusion is only six months in Arizona, Califor- membership. nia, Connecticut, Florida, Iowa, Kentucky, Founded by the late Professor Erwin Ringel in Ohio, Oregon, Rhode Island, Vermont, and Vir- Austria in 1960, the organization since that time ginia. There is no suicide exclusion in Maryland has grown to include professionals and volun- and Missouri. teers from more than 50 different countries. At one time, life insurance contracts excluded IASP is a nongovernmental organization in offi- the risk of suicide entirely. Today, the clause is cial relationship with the World Health Organi- intended to protect against adverse selection, not zation. The group encourages the work of to exclude the risk of suicide. voluntary organizations, such as the network of The question of whether a death was suicide crisis telephone services. may be decided in court. When this happens, Apart from such efforts for suicide preven- courts typically tend to hold for dependents. tion, the IASP provides information on various There is a legal presumption that a person will other forms of crisis intervention, such as psy- not take his or her own life, and this makes it dif- chotherapy and drug treatment; organizes bien- ficult to prove suicide even where the facts nial world congresses on suicide prevention; and clearly point to it. Indeed, the courts have gone provides regional seminars. Designed to monitor to extraordinary lengths at times in holding that the progress of suicide prevention activities on a suicide had not been proven and in deciding that global scale, the group also encourages the col- the insurance company was liable. lection of valid up-to-date national data on issues of suicidal behavior and provides expertise to develop guidelines for suicide prevention pro- intent A person’s aim, purpose, or goal to die, grams. The IASP also tries to raise the awareness and belief that death would follow the suicidal of governments, relevant international and action. There are different degrees of intent: national organizations and groups, and to the general public about issues of suicidal behavior. • Intent, first degree: Suicide was planned by Membership includes a subscription to a the victim. quarterly news bulletin, CRISIS: THE JOURNAL OF • Intent, second degree: Suicide was impulsive CRISIS INTERVENTION AND SUICIDE, and an informa- and unplanned by the victim. tion service on the Internet, including a calendar 132 International Handbook of Suicide and Attempted Suicide highlighting forthcoming events of relevance to 17-percent decrease in China, with the United the IASP community. States and the Russian Federation going in For contact information, see Appendix I. opposite directions by the same 5.3 percent. However, it is probably only the size of their International Handbook of Suicide and At- populations that puts these countries in the tempted Suicide The standard work on sui- same category, as they differ in almost every cide with a worldwide list of contributors, edited other aspect. Also, the magnitude of the change by Keith Hawton of the University of Oxford, does not reflect the actual magnitude of suicide England, and Kees van Heeringen, of the Uni- rates in those countries. For example, in the most recent year for versity Hospital in Ghent, Belgium. which data are available, suicide rates range International in scope, this authoritative text from 3.4 in Mexico to 14 in China and 34 in the includes information on understanding, treating, Russian Federation. It is very difficult to reach a and preventing suicidal behavior. It explores common explanation for this variation from one concepts and theories and covers key research country to the next. Although economic change that has supported conceptual development, is often suggested as a factor contributing to an preventive interventions, and clinical treatment. increase in suicide rates, increases in suicide rates have been observed during periods of international suicide rates Suicide is a major socioeconomic stability while stable suicide rates public health problem around the world, occur- have been seen during periods of major socioe- ring in all countries that report information. conomic changes. Taken as an average for 53 countries for which Nevertheless, these figures may hide impor- complete data is available, the age-standardized tant differences across some population seg- global suicide rate is 16 per 100,000—or one sui- ments. For instance, a stable suicide rate may cide every 43 seconds worldwide. In the year hide an increase in men’s rates that is statistically 2000, approximately 1 million people died from compensated for by a concomitant decrease in suicide. The rate of suicide is almost universally women’s rates (as occurred, for example, in Aus- higher among men compared to women by a tralia, Chile, Cuba, Japan, and Spain). The same ratio of 3.5 to 1: The rate for men was 24 per would apply to extreme age groups, such as ado- 100,000 and is 6.8 per 100,000 for women. lescents and the elderly. In the last 45 years, suicide rates have While a rising unemployment rate is usually increased by 60 percent worldwide. Suicide is accompanied by a drop in suicide rates of the now among the three leading causes of death general population (for example, in Finland), it among those age 15 to 44 years (both sexes); often leads to an increase in suicide rates among these figures do not include suicide attempts, elderly and retired people (for example, in which are up to 20 times more frequent than Switzerland). completed suicide. It is well known that availability of means Rates within a country can vary quite a bit to complete suicide has a major impact on from year to year. Trends in the very largest actual suicides in any region, such as easy countries of the world (those with a population access to toxic substances in China, India, and of more than 100 million) are likely to provide Sri Lanka, or firearms in El Salvador and the reliable information on suicide mortality. Infor- United States. This is particularly the case for mation is available for seven of 11 of these firearm availability. Of all the people who died countries over the past 15 years. In these coun- from firearm injuries in the United States in tries, the trends range from an almost 62 per- 1997, for example, more than half died by cent increase in Mexico’s suicide rate to a suicide. intervention 133

Although traditionally suicide rates have been 1. Take threats seriously. Four out of five peo- highest among old men, rates among young ple who complete suicide have tried it or people age 15 to 34 have been increasing to such have threatened it previously. The old myth, an extent that they are now the group at highest “those who talk about it won’t do it,” is dan- risk in a third of countries, both developed and gerously false. More than likely, by threat- developing. Although data on suicide attempts ening suicide, the person is calling for are available only from a few countries, figures help—trying to say how bad things really indicate that the number of suicide attempts are. may be up to 20 times higher than the number 2. Watch for clues. Most people considering sui- of completed suicides. cide give clues of their intent. Look for Mental disorders (particularly DEPRESSION and marked changes in personality, behavior, and substance abuse) are associated with more than appearance. Watch for signs of depression, 90 percent of all cases of suicide; in particular, such as insomnia, loss of appetite, or contin- high levels of alcohol consumption (such as in ual exhaustion. Be alert when a person turns the Baltic States and the Russian Federation) has to destructive behavior patterns such as drug been linked to higher suicide rates. Most of the and alcohol abuse, especially when this suicides in some countries of central and eastern behavior is unusual. A person feeling suicidal Europe have recently been attributed to this may start preparing for death. Making out a problem. will, giving away beloved pets and valuable However, suicide results from many complex possessions, saving pills, or buying a gun sociocultural factors and is more likely to occur could indicate that a person is contemplating particularly during periods of socioeconomic, suicide. family, and individual crisis situations such as 3. Answer cries for help. Once alerted to these loss of a loved one or a job. clues that may constitute a “cry for help” According to the WORLD HEALTH ORGANIZATION, from a loved one or friend, you can help in which gathers global suicide statistics, the pre- several ways. The most important of these is vention of suicide has not been adequately not to ignore the issue. It is better to offer addressed due to a lack of awareness that suicide help early than to regret not doing so later. is a major problem, and the taboo in many soci- The first step is to offer support, understand- eties to discuss it openly. In fact, only a few ing, and compassion, no matter what the countries have included “prevention of suicide” problems may be. The suicidal person is truly among their priorities. Reliability of suicide cer- hurting. tification and reporting is also in great need of 4. Confront the problem. If you suspect that a improvement. person is suicidal, begin by asking questions See also ABUSE, SUBSTANCE; INTERNATIONAL AS- such as, “Are you feeling depressed?” “Have SOCIATION FOR SUICIDE PREVENTION. you been thinking of hurting yourself?”— leading up to the question, “Are you thinking of killing yourself?” Be direct. Don’t be afraid A suicide associated interpersonal suicide to discuss suicide with the person. Getting with the loss of an interpersonal relationship. him to talk about it is a positive step. Be a good listener and a good friend. Don’t make intervention The cardinal rule of suicide moral judgments, act shocked, or make light intervention is the same as that for prevention: of the situation. Offering advice such as, “Be Do something. grateful for what you have . . . you’re so The following guidelines are offered by the much better off than most,” may only deepen AMERICAN ASSOCIATION OF SUICIDOLOGY (AAS). the sense of guilt the person probably already 134 involuntary commitment

feels. Discussing it may help lead the person involuntary commitment The short-term away from actually doing it by giving him the emergency hospitalization of a person deemed to feeling that someone cares. be a danger to self or others, such as someone 5. Tell them you care. Persons who attempt sui- who attempts suicide. The purpose of involun- cide most often feel alone, worthless, and tary commitment is to help a person receive nec- unloved. You can help by letting them know essary and appropriate mental health and/or that they are not alone, that you are always substance abuse treatment. there for them to talk to. Tell loved ones how “Involuntary commitment” is a legal action much you care about them, and offer your that begins with an appearance before a magis- support and compassion. By assuring the per- trate. Any person who believes an individual son that some help is available, you are liter- meets any of the criteria listed above and wishes ally throwing him a lifeline. Remember, to pursue an involuntary commitment must first although a person may think he wants to die, appear before a magistrate to petition for an he has an innate will to live, and is more than evaluation for commitment. The person who likely hoping to be rescued. petitions does not have to be a family member, 6. Get professional help. The most useful thing but firsthand knowledge is usually required. A you can do is to encourage the person who is petition may be filed in the county in which the considering suicide to get professional help. person is found or in the county of residence. A There are mental health clinics, psychiatrists, petition must be based on facts to show mental psychologists, social workers, family doctors, illness or substance abuse and dangerousness. and members of the clergy who can help in If there are reasonable grounds for commit- every community. And in your community ment, a custody order will be issued to have the there are groups of people dedicated specifi- individual placed in custody by a law enforce- cally to preventing suicide. Your ability to get ment officer and taken to a physician or psy- professional guidance for the suicidal person chologist for an examination. may save his life. When a delay would endanger life or prop- 7. Offer alternatives. Don’t leave the initiative erty, a law enforcement officer may restrain a up to a suicidal person. Instead, provide him person and then take that person to an approved with a list of agencies in your area where he 24-hour facility for examination. As soon as the can go for help. These centers provide profes- person is in custody, law enforcement will trans- sional counseling to individuals and offer port the client to a physician or psychologist alternative ways to solve problems. A list of who performs an examination to determine the over 250 centers throughout the United necessity for involuntary commitment. The States is in Appendix 1 of this work. physician or psychologist can recommend inpa- tient treatment, outpatient treatment, or release. Once every minute of every day, someone Within 24 hours of the person’s arrival at a in America attempts suicide. Official statistics hospital or treatment facility, a second examina- show nearly 30,000 people take their own lives tion to determine the necessity for involuntary each year. Suicide victims come from all walks commitment is completed. The examiner may of life, from all kinds of economic and educa- again recommend inpatient treatment, outpa- tional backgrounds. The presence of a good tient treatment, or release. friend, a caring and loving family member, or If a person is held for inpatient treatment, he involvement with helping professionals, can all or she has the opportunity to appear before a lower suicide risk and can reduce the shocking District Court Judge within 10 days. The judge statistics. determines if continued involuntary commit- “Is Life Worth Living?” 135 ment is appropriate. The hospital and court will Islam MUSLIMS have always strongly con- notify the family and petitioner of the hearing demned suicide. The QUR’AN, holy scriptures of and request their presence for input to help the Islam, expressly forbids suicide as the gravest sin, judge decide whether to further hold the patient a more serious crime, in fact, than homicide. or order a release. The judge may commit the Muslims believe that each individual has his or patient for inpatient treatment, outpatient treat- her Kismet, or destiny, which is preordained by ment, a combination of inpatient and outpatient God and must not be defied. treatment, treatment at another facility, or may The phenomenon of suicide missions involv- release the person back into the community. ing Islamic terrorists would seem to contradict See also ABUSE, SUBSTANCE. the historic attitude. But these are not viewed as suicide, but as jihad—a holy mission in which Iran There are no suicide rate statistics for Iran death is guaranteed to lead to paradise in the from the WORLD HEALTH ORGANIZATION. This may next life. be related to the fact that Iran is 98 percent Mus- It is also true that while strong religious pro- lim, with most citizens belonging to the Shia hibitions have kept the reported suicide rates sect, a minority branch that is more conservative low, they have also suppressed the reporting of than the majority Sunnis. any such events by the family to avoid the The QUR’AN strictly prohibits suicide, promis- shame and embarrassment that could follow. ing punishment in Hell. Therefore, suicide is The fundamentalist Islamic movement has embarrassing and brings shame onto the family. strongly encouraged many Muslims to accept a See also ISLAM; TERRORISM AND SUICIDE. theology in which under certain circumstances becoming a suicide-bomber is not considered Ireland Ireland ranks low among countries in suicide but is rather considered a form of reli- its suicide rate, perhaps due to the predominant gious “struggle” of an aspect of jihad. Therefore Catholic religion, which frowns on suicide. (in the Islamist view), a Muslim can effectively Catholics believe that suicide (under most cir- complete suicide without violating fundamental cumstances) is a mortal sin that is punishable in Islamic law. the hereafter. Dozens of Muslims have died in this fashion Death from suicide kills 11.3 Irish out of every over the last 20 years, mostly in Israel, although 100,000, according to 1996 statistics from the as of September 11, 2001, some have also died World Health Organization. This breaks down to in the United States. a much higher rate among Irish men (19.2 per 100,000) compared to Irish women (3.5). “Is Life Worth Living?” A now-famous Unlike many modern industrialized countries, speech delivered by the American philosopher- suicide among the Irish occurs most often in the psychologist WILLIAM JAMES, in 1895, to the Har- younger age groups; highest risk is between age vard Young Men’s Christian Association. James 25 to 34 (34.6 per 100,000) followed by 35 to 44 had suffered severe clinical DEPRESSION as a age group (29.2). young man, so was well qualified to discuss from firsthand knowledge the suicidal impulses that irrationality A warning sign or distress signal can overtake a person. In addressing the title that could indicate a suicidal person is in danger. question in his lecture, James’s answer to the When a person begins to act irrationally, this question was a resounding “yes.” While it’s true may imply severe stress or mental illness, espe- that none of us can prove God exists or that rea- cially when the individual’s behavior represents son guides the course of the universe, anyone a marked and sudden change in manner. can make a positive decision to believe those 136 isolation things, said James. “Believe that your life is there are extenuating circumstances, such as the worth living,” he advised, “and your belief will fear of being taken captive or the possibility of help to create the fact.” The philosopher consid- suffering humiliation or unbearable pain. ered suicide a “religious disease,” the cure for See also BIBLICAL SUICIDES. which is “religious faith.” Italy Latest WORLD HEALTH ORGANIZATION statis- isolation A person contemplating suicide will tics show this country has a suicide rate of 8.1 sometimes retreat from life, withdrawing from per 100,000; Italian men commit suicide at a family members and friends. In severe cases, rate of 12.3 per 100,000 compared to 3.9 of Ital- such a person becomes suffocatingly depressed ian women. The risk of suicide in Italy is very and suicidal, refusing to allow even parents or a low for young children and teenagers, and spouse to intrude. increases with age for every group. Those at Whatever the reason (growing up feeling highest risk among Italians are the aged (over unloved, loss of a loved one, or illness) isolation 75); 43.4 of this age group per 100,000 commit is a crucial indicator of suicidal behavior. suicide. As a predominantly Catholic country, Italy Israel The suicide statistics for Israel are fairly has always had relatively low rates of suicide, low among industrialized nations, at just 5.4 per together with IRELAND and SPAIN. 100,000 as of 1996 figures compiled by the WORLD HEALTH ORGANIZATION. As in most coun- Ixtab Mayan goddess of the noose and the tries, more Israeli men commit suicide (8.2 per gallows, and the protector of those who commit- 100,000) compared to Israeli women (2.6). ted suicide. In the Mayan culture, hanging was To a startling degree, the population most at the only method of suicide deemed appropriate; risk among Israelis are the aged (those over 75); anyone completing suicide this way was guaran- they experience a risk of 40.5 per 100,000. teed a place in the afterlife. The Mayans believed Although JEWS worldwide have historically that those who completed suicide or died by had low suicide rates, the suicide rates among hanging (along with slain warriors, sacrificial Jews in Israel appear to be slowly increasing. victims, priests, and women who died in child- Of the three major religions in the United birth) were taken straight to paradise by Ixtab. States, Jews have the lowest suicide rates. How- Ixtab, “She of the Rope,” was typically de- ever, religious statistics are difficult to compile picted as hanging from a tree with a noose because religion is not shown on death certifi- around her neck, her eyes closed in death, and cates. her body partly decomposed. Due to her malev- The HEBREW BIBLE contains only six brief ref- olent customs, she is also considered to be a erences to self-destruction, and in each case, manifestation of Cizin (the Devil). J jail suicide Suicide that takes place in a local drew lots to determine who among them would holding cell or detention facility. Jail suicide is kill their companions and then take their own the leading cause of death in such sites (usually lives. At slaughter’s end, about 960 persons had by HANGING). Some studies have suggested that either been killed or taken their own lives. Only inmates at greatest risk for suicide are those two women and five children had escaped the housed in short-term centers (57.5 per 100,000) massacre, and remained alive to tell the story as versus 16 to 17 per 100,000 for longer-term jails. recorded in The Jewish War, a contemporary The greatest period of risk appears to be within account of the war with Rome. the first 10 days of incarceration. High-risk inmates are young white men in James, William (1842–1910) American phi- their 20s who have a history of alcohol and drug losopher and psychologist who admitted to sui- abuse, a history of prior suicide attempts, but no cidal impulses as a young man while suffering previous mental illness. The nature of the severe clinical DEPRESSION. In 1895, he delivered charges is not a good indicator of suicide risk. a now-famous address to the Harvard YMCA The risk of suicide is also related to the degree of and spoke of those feelings and what he called supervision provided by the correctional staff. “the nightmare view of life.” Entitled “IS LIFE Incarceration seems to provide significant WORTH LIVING?” James’s lecture was a classic stress on vulnerable victims, which is aggravated example of positive thinking. He answered the by inadequate psychological care. title question with a resounding “Yes,” and told his audience: “Believe that life is worth living Jair, Eleazar ben Zealot leader of ancient and your belief will help to create the fact.” Hebrews at MASADA who became known for the The brother of novelist Henry James, William most famous mass suicide in the Old World. It taught at Harvard. Perhaps his most influential took place in A.D. 73 at the Fortress of Masada at thesis was that faith, which had been eroded by the edge of the Judean Desert overlooking the the isolation accompanying advancing urbaniza- Dead Sea. The Romans had overrun Judea and tion and by the individualism fostered by the destroyed the Second Temple in A.D. 70, but a teachings of Protestantism, had diminished to a garrison of 1,000 men, women, and children of dangerous degree. Among his books are The Eleazar ben Jair’s Zealot sect held the fortress Varieties of Religious Experience (1902) and Prag- and continued to resist the Roman forces, using matism (1907). modern-day guerrilla war tactics. When defeat appeared certain, the Hebrew leader urged his Japan The Japanese at one time ritualized sui- followers to kill themselves rather than become cide in what they called HARA-KIRI or SEPPUKU. Roman slaves. Outlawed in 1868, this form of ceremonial death The Jewish historian JOSEPHUS writes that the had been an integral part of the old moral code, soldiers killed their wives and children, then going back to the days of the Samurai warrior.

137 138 Japanese suicide

The only honorable means for a disgraced war- losophy that says the human body is merely a rior to redeem himself was to commit seppuku, temporary home for the soul. Thus, biological in which he disemboweled himself with his own existence may not have much meaning. sword. A samurai warrior would sometimes kill WORLD HEALTH ORGANIZATION statistics for 1997 himself to show allegiance to a fallen leader. indicate that the Japanese suicide rate per Also, an emperor might order a member of the 100,000 population was 18.9 (26.0 for men and military class to commit hara-kiri to avoid the 11.9 for women). disgrace of a public execution. The ritual of sep- puku sometimes took hours to complete (it was Japanese suicide See SEPPUKU. an elaborate process). Then a second person, usually the closest friend of the suicide who con- sidered himself honored to terminate the pain Jews BIBLICAL SUICIDES among the Jews are and suffering, ended the ritual by beheading the rare; only seven instances are reported in the suicide with a sword. HEBREW BIBLE and one in the New Testament. The ritual of seppuku was institutionalized Neither the Hebrew Bible nor the New Testa- during the feudal ages, from 1190 through 1867, ment prohibits suicide, nor is suicidal behavior and characterized Bushido, the moral code of condemned. Even of JUDAS ISCARIOT we are told the warrior class. only that “he went and hanged himself” Even though the practice has been outlawed, (Matthew 27:5). the tradition of suicide with honor is still in evi- The Judeo-Christian tradition (as well as dence from time to time in Japan. During World ISLAM) has always held that suicide in the form War II, for example, more than 1,000 young of martyrdom was permissible. In fact, the most Japanese soldiers died as KAMIKAZE PILOTS while significant sanction of suicide among Jews was flying their planes at Allied warships. When to avoid apostasy, the forced rejection of the defeat was inevitable in that conflict, a number Jewish faith and adoption of another religion or of prominent, high-ranking army and navy offi- God. Suicide, however, was in violation of the cers committed ritual hara-kiri rather than suffer Fifth Commandment, delivered to Moses on the humiliation of surrender. Sinai: Thou shalt not kill. But Jews did look at More recently, in 1970, the famous novelist, suicide as a positive act if employed to prevent playwright and actor, YUKIO MISHIMA, committed torture, rape, or slavery. King Saul fell on his ritual suicide at the age of 45. He urged his coun- sword after defeat in battle, and the defenders’ trymen to return to old values and traditions, mass suicide at MASADA to prevent capture by one of which was the ancient concept of dying the Romans was considered heroic. with honor. In Talmudic times (A.D. 200–500) the number Some suicidologists speculate that the old of recorded suicides rose. As the act became Japanese notion of death with honor may be more frequent, a condemnatory tone was intro- responsible, at least in part, for the high rate of duced for the first time. The Talmud decrees that suicide among today’s young Japanese. More a suicide is to receive no eulogy or public than twice as many Japanese young people as mourning; he is to be buried apart, in commu- Americans between the ages of 15 and 24 kill nity cemeteries. themselves. This may be due in part to deep feel- There was never universal agreement on the ings of insecurity that develop in many Japanese matter of suicide among Jews. Some authorities homes, along with fierce competition in school said relatives had a duty to the deceased regard- and in the job market. less of the circumstances of death. Another basic belief typical of the Japanese is Today, although considered as a crime against the ancient Buddhist concept of muso-kan, a phi- God, suicide may sometimes be explained away, Josephus, Flavius 139 understood, and forgiven among Jews. This more like a prison. Dissent was not possible, and enlightened point of view has been incorporated offenders were put into “The Box,” a 6-by-4-foot into the approach of the three denominations of underground enclosure. Misbehaving children modern Judaism. A study of suicide among were dangled into a well late at night. Loud- white adults of New York City’s three major reli- speakers broadcast Jones’s voice at all hours. gions showed the rate for Jews higher than that Still, the U.S. government did not intervene for Catholics, but lower than for Protestants. until November 1978, when U.S. Representative decided to lead a delegation of reporters and relatives to Jonestown after being johar A RITUAL SUICIDE by self-immolation of the widow of a man killed in battle in India. notified by people worried about their relatives in the People’s Temple. Ryan’s group arrived on See also SUTTEE. November 17, but the mood at the compound soured after some Jonestown residents confided Joluo (of Kenya) Members of this African that they wanted to defect. tribe manage to keep knowledge of cases of sui- The group was ambushed the next day as cide within the clan, lest the clan’s prestige in the they tried to leave at a nearby airstrip, and Ryan community suffer. Other clans, such as, the GISU and four others were killed. Later that night, OF UGANDA, believe that to conceal a suicide is Jones told his followers that it was time to com- not only dangerous, but also culpable. mit suicide. He was later found shot through the head. See also CULT SUICIDE. Jones, Reverend Jim See JONESTOWN MASSACRE.

Jonestown Massacre The mass suicide-exe- Joplin, Janis (1943–1970) American singer- cution of followers of the Reverend Jim Jones’s entertainer who died, some say deliberately, People’s Temple cult on November 18, 1978. On from an overdose of heroin in the Landmark that date, the Rev. Jim Jones led a mass suicide- Hotel, Los Angeles. Her road manager discov- execution of 911 of his followers of the People’s ered the body the next day. Remnants of the Temple in the jungle of the Cooperative Repub- heroin were found in a wastebasket by her bed. lic of Guyana. On the night of the suicide, Jones Joplin became known as the Queen of the Hip- ordered more than 900 of his followers to drink pies. cyanide-poisoned punch. He told guards to shoot anyone who refused or tried to escape. Josephus, Flavius (A.D. 37–?95) Jewish his- Among the dead were more than 270 children. torian and soldier who commanded a Jewish Only two years before, Jones (the charismatic force in Palestine in the uprising against Rome in leader of the People’s Temple, an interracial A.D. 66. He was forced to surrender and was helping organization) was popular among San imprisoned in Rome by Vespasian. During the Francisco’s political circles. But after an August final moments of his battle with Vespasian, Jose- 1977 magazine article detailed ex-members’ sto- phus debated with his soldiers and offered vari- ries of beatings and forced donations, Jones ous reasons why suicide was undesirable. He abruptly moved his group to Jonestown, a set- reluctantly agreed to the insistence of his sol- tlement in the jungle of Guyana on South Amer- diers that suicide was preferable to capture. ica’s northern coast. Interestingly, following the Jewish custom of The plan was to establish an egalitarian agri- that time, each soldier slew one other soldier cultural community, but members who worked who was in turn killed by the next man. It ended the fields and lived mostly on rice felt it was with just Josephus and a fellow soldier remain- 140 Joyce, James ing, and Josephus was easily able to convince ham drew out his watch briskly, coughed and the soldier to surrender along with him. put it back. “The greatest disgrace to have in the Later, he became a follower of Titus and family,” Mr. Power added. “Temporary insanity, adopted Roman citizenship. He wrote The Jew- of course,” Martin Cunningham said decisively. ish War, an account of the war with Rome “We must take a charitable view of it.” “They (A.D. 67–73); The Jewish Antiquities, a history of say a man who does it is a coward,” Mr. Dedalus the Jews from the beginning to the outbreak said. “It is not for us to judge,” Martin Cun- of the war; and an account of his own life, ningham said. defending his conduct and emphasizing his pro-Roman sentiments. He wrote sensitively By the 20th century, suicide in ENGLAND was about the defenders of MASADA, who ultimately more a social disgrace than it was a sin—at least killed themselves rather than surrender to the among the middle class. Romans. Josephus agreed on the obligation to uphold Judaism and suicide See JEWS. and defend the Torah, “to sanctify the Holy Name,” under all circumstances. In this cause even suicide was justified. Judas Iscariot The disciple who betrayed Jesus for 30 pieces of silver. Motives given for the betrayal are greed (according to Matthew) Joyce, James (1882–1941) Irish novelist and the power of the devil (according to John). who left IRELAND in 1902 and spent the remain- At the Last Supper (a Passover feast), Jesus der of his life on the Continent. At the beginning predicted the betrayal, which Judas accom- of the 20th century, popular opinion generally plished by leading soldiers to Jesus and identify- viewed suicide as a deviation from normality. ing him with a kiss. Judas, in remorse, killed Joyce presents this attitude in an episode in his himself by hanging (Matthew 27:3–7). Acel- famous novel Ulysses. On the way to a funeral, dama, where Judas killed himself near four men discuss attempted suicide and death. Jerusalem, became a pauper’s burial ground after it was bought by the priests with the 30 “But the worst of all,” Mr. Power said, “is the pieces of silver flung at their feet by Judas. man who takes his own life.” Martin Cunning- K kamikaze pilots An example of ALTRUISTIC he was found dead with a gas conduit in his SUICIDE that occurs among people so dedicated to mouth in the room, which commanded magnif- a cause or to certain values of their society that icent views of both oceans and mountains.” they place duty before personal needs, even Kawabata was 72 years old. before their lives. The Japanese kamikaze pilots of World War II flew their planes at Allied war- Keats, John (1795–1821) British romantic ships, destroying themselves in the process. poet who had studied to be a surgeon. Lamia and More than 1,000 young Japanese died in this Other Poems (1820), including his great odes and manner. narrative poems (“The Eve of St. Agnes”), See also JAPAN; TERRORISM AND SUICIDE. secured his reputation. Keats was seriously ill with tuberculosis, a condition exacerbated by his Kant, Immanuel (1724–1804) German tran- tormented love for Fanny Brawne and which scendentalist philosopher whose most famous caused him to suffer deep depression and suici- work is the Critique of Pure Reason (1781). Con- dal feelings. He died in Rome at age 25, con- cerning suicide, Kant sided with the major reli- vinced that true feelings cannot survive into gions, that it was morally wrong. But he took a middle age. He was idolized by the ROMANTICS of different line of reasoning to reach that conclu- the era. sion. Life, to Kant, was sacred because it was part of nature. As such, he said, each life has a place Kentucky Although suicide has never been a within the laws of nature, and each person must crime in the United States, and the property of preserve his or her own life. To ignore this duty suicides has never been confiscated, attempted and end one’s life is immoral. To Kant, true suicide was at one time regarded as a felony in a morality is rising above individual and personal few states, among them the state of Kentucky. feelings of despair, carrying out one’s duties, and But even in that state, attempters were almost living one’s life in the face of adversity. However, never prosecuted. The state now rarely prose- he did write, “It is not suicide to risk one’s life cutes persons who help others attempt or com- against one’s enemies, and even to sacrifice it, in mit suicide, although this is still regarded as a order to preserve one’s duties towards oneself.” criminal offense. Still, the stigma against suicide remains in the general population. Kentucky is Kawabata, Yasunari (1900–1972) Japanese in the South, the region with the lowest rate for novelist and winner of the Nobel Prize in litera- suicide in the United States (with the exception ture in 1968. According to reports, he “left his of Florida). home in Kamakura in the afternoon of April 16, 1972, for his workroom in nearby Zushi. There Kevorkian, Jack (1928– ) American physi- was no sign of suicidal thoughts. That evening, cian known also as Doctor Death, who has

141 142 Kevorkian, Jack campaigned for the legalization of PHYSICIAN- Next, Kevorkian attended the deaths of Mar- ASSISTED SUICIDE. Taken to court many times for jorie Wantz, a 58-year-old Sodus, Michigan, helping patients die, he was finally convicted in woman with pelvic pain, and Sherry Miller, a Michigan of second-degree murder and delivery 43-year-old Roseville, Michigan, woman with of a controlled substance in the death of a multiple sclerosis. The deaths occurred at a patient. He was sentenced to 10 to 25 years in rented state park cabin near Lake Orion, Michi- prison, and will be eligible for parole in 2005. gan. Wantz died from the suicide machine’s Kevorkian was born in Pontiac, Michigan, the drugs; Miller died from carbon monoxide poi- son of Armenian immigrants, and graduated soning inhaled through a face mask. Shortly from the University of Michigan medical school thereafter, the state board of medicine summar- with a specialty in pathology in 1952. Four years ily revoked Kevorkian’s license to practice med- later, he published a journal article, “The Fundus icine in Michigan. Oculi and the Determination of Death,” which Kevorkian next assisted in the suicide of discussed his efforts to photograph the eyes of Susan Williams, a 52-year-old woman with mul- dying patients, a practice that earned him the tiple sclerosis, by carbon monoxide poisoning in nickname Doctor Death. In December 1958, he her home in Clawson, Michigan, in May 1992. presented a paper at a meeting in Washington, Three months later, charges against Kevorkian D.C., advocating medical experimentation on in the deaths of Miller and Wantz were dis- consenting convicts during executions, which missed in Oakland County Circuit Court, but the prompted the University of Michigan to ask dismissal was appealed. Kevorkian to leave his residency there in 1961. Two months later, in September 1992, Lois He became chief pathologist at Saratoga Gen- Hawes, 52, a Michigan woman with lung and eral Hospital in Detroit in 1970, quitting his brain cancer, died from carbon monoxide poison- pathology career in the late 1970s to move to ing at the home of Kevorkian’s assistant Neal California. By the 1980s, he was again working Nicol in Michigan. This was followed two months in medicine, and published many articles in the later by the suicide of Catherine Andreyev of German journal Medicine and Law outlining his Moon Township, Pennsylvania, who also com- ideas on EUTHANASIA and ETHICS. In 1987, he mitted suicide in Nicol’s home. She was 45 and began to advertise in Detroit papers as a physi- had cancer. Hers was the first of 10 deaths cian consultant for death counseling. By the Kevorkian attended over the next three months; next year, he published “The Last Fearsome all died from inhaling carbon monoxide. Taboo: Medical Aspects of Planned Death,” in On December 3, 1992, the Michigan legisla- Medicine and Law, which outlined his proposed ture passed a ban on assisted suicide to take system of planned deaths in suicide clinics, effect on March 30, 1993. Shortly before the including medical experimentation on patients. ban went into effect, Hugh Gale, a 70-year- The next year he built his thanatron (“suicide old man with emphysema and congestive heart machine”) and in June 1990, he was present at disease, committed suicide in his Roseville the death of Janet Adkins, a 54-year-old Port- home. Prosecutors investigated after Right-to- land, Oregon, woman with Alzheimer’s disease. Life advocates found papers that show She died using the suicide machine in Kevorkian altered his account of Gale’s death, Kevorkian’s 1968 Volkswagen van. deleting a reference to a request by Gale to halt On December 12, 1990, an Oakland County the procedure. Circuit Court judge forbid Kevorkian from help- On February 25, 1993, Michigan governor ing with any other suicides, and a year later John Engler signed the legislation banning murder charges against Kevorkian in the death assisted suicide, making it a felony to aid in a of Adkins were dismissed in U.S. District Court. suicide, but allowing the law to expire after a Kevorkian, Jack 143 blue-ribbon commission studied permanent leg- A month later, the Michigan Supreme Court islation. upheld the constitutionality of Michigan’s 1993 A California judge next suspended Kevork- ban on assisted suicide, and also ruled that ian’s medical license after a request from that assisted suicide is illegal in Michigan under com- state’s medical board on April 27, 1993. Four mon law. The ruling reinstated cases against months later, Thomas Hyde, a 30-year-old Novi, Kevorkian in four deaths. Michigan, man with ALS, was found dead in On June 26, 1995, Kevorkian opened a “sui- Kevorkian’s van on Belle Isle, a Detroit park. On cide clinic” in an office in Springfield Township, September 9, 1993, hours after a judge ordered Michigan. Erika Garcellano, a 60-year-old him to stand trial in Hyde’s death, Kevorkian Kansas City woman with ALS, was the first was present at the death of cancer patient Don- client. A few days later, the building’s owner ald O’Keefe, 73, in Michigan. asked Kevorkian to leave. Kevorkian was then After refusing to post $20,000 bond in the ordered to stand trial for assisting in the 1991 case involving Hyde, Kevorkian began to fast in suicides of Sherry Miller and Marjorie Wantz. a Detroit jail from November 5 to 8, 1993. On Shortly thereafter, a group of doctors and November 29, 1993, he began to fast in Oak- other medical experts in Michigan announced land County jail for refusing to post $50,000 their support of Kevorkian, saying they would bond after being charged in the October death of draw up a set of guiding principles for the “mer- Merian Frederick, 72. On December 17, 1993, ciful, dignified, medically-assisted termination he ended his fast and left jail after an Oakland of life.” County Circuit Court judge reduced his bond to Further supporting Kevorkian’s position, the $100 in exchange for his vow not to help with Ninth U.S. Circuit Court of Appeals in San Fran- any more suicides until state courts resolve the cisco ruled that mentally competent, terminally legality of his practice. ill adults have a constitutional right to help in The U.S. Circuit Court dismissed charges dying from doctors, health care workers, and against Kevorkian on January 27, 1994, in two family members. It was the first time a federal deaths—becoming the fifth lower court judge in appeals court endorsed assisted suicide. Shortly Michigan to rule that assisted suicide is a consti- thereafter, on March 8, 1996, a jury acquitted tutional right. Four months later, a Detroit jury Kevorkian in helping with two deaths. acquitted Kevorkian of charges he violated the The next month, a trial began in Kevorkian’s state’s assisted suicide ban in the death of Thomas home town of Pontiac in the deaths of Miller Hyde. In further support of his position, on May and Wantz. For the start of his third criminal 10, 1994, the Michigan Court of Appeals struck trial, he wore colonial costume—tights, a white down the state’s ban on assisted suicide on the powdered wig, and big buckle —to protest grounds it was enacted unlawfully. the fact that he was being tried under a cen- Oregon became the first state to legalize turies-old common law. He would face a maxi- assisted suicide when voters passed a tightly mum of five years in prison and a $10,000 fine restricted Death with Dignity Act on November if convicted in the deaths, but on May 14, 1996, 8, 1994, but legal appeals kept the law from tak- the jury acquitted him. ing effect. Six months later, his lawyer announced a pre- Hours after Michigan’s ban on assisted suicide viously unreported assisted suicide of a 54-year- expired on November 26, 1994, 72-year-old old woman, bringing the total number of his Margaret Garrish died of carbon monoxide poi- assisted suicides to 46 since 1990. A mistrial was soning in her home in Royal Oak. She had declared on June 12, 1997, in what was arthritis and osteoporosis. Kevorkian was not Kevorkian’s fourth trial; the case was later present when police arrived. dropped. 144 kindling

Then on June 26, 1997, the U.S. Supreme kindling The increasing susceptibility to sui- Court ruled unanimously that state govern- cide with recurrent stress. ments have the right to outlaw—or to approve— doctor-assisted suicide. The high court had been asked to decide whether state laws banning the Klagsbrun, Francine Author-researcher who practice in New York and Washington were wrote the bestseller, Too Young to Die: Youth and unconstitutional. Suicide. With an introduction by Harold S. Kush- Five months later, Oregon residents voted to ner, author of When Bad Things Happen to Good uphold the state’s assisted suicide law, the first of People, Klagsbrun’s book has been highly its kind in the nation. The law allows doctors to acclaimed as an important work on the subject prescribe lethal doses of drugs to terminally ill of youth and suicide. patients. On March 14, 1998, Kevorkian’s 100th Koestler, Arthur (1905–1983) British writer assisted suicide took place, involving a 66-year- born in Vienna who in 1940 settled in Britain, old Detroit man. Six months later, Michigan’s where his anti-Stalinist novel Darkness at Noon second law outlawing physician-assisted suicide (1940) was first published. In addition to several went into effect. The next month, Michigan vot- novels, he wrote a number of books on political ers rejected a proposal that would have legalized and philosophical topics. physician-assisted suicide for the terminally ill. Koestler suffered in later life from Parkinson’s That same month, 60 Minutes aired a video- disease, and in 1983, he and his wife Cynthia, tape showing Kevorkian giving a lethal injection committed suicide together. He was 78 and to Thomas Youk, 52, who suffered from Lou already dying (he had written a suicide note in Gehrig’s disease. The broadcast triggered an June 1982), but Cynthia Koestler was only 55 intense debate within medical, legal, and media and in good health. circles, and prompted Michigan to charge Koestler was a vice president of the VOLUN- Kevorkian with first-degree murder for violating TARY EUTHANASIA SOCIETY in London and had the assisted suicide law and delivering a con- written an essay for the society’s booklet “A trolled substance without a license in the death Guide to Self-Deliverance.” of Youk. Prosecutors later dropped the suicide The Koestlers’ maid found a note on March charge. Kevorkian insisted on defending himself 3, 1983, instructing her to ring the police and to during the trial and threatened to starve himself tell them to come to the house. Police found the if sent to jail. He was convicted on April 13, Koestlers sitting in their usual places, he in the 1999, and sent to prison for from 10 to 25 years. armchair with an empty brandy glass in his On April 22, 2002, the state Supreme Court hand; Cynthia to his left, on the sofa. They had refused to hear Kevorkian’s request for a new been dead about 36 hours from an overdose of trial. In its 6–1 decision, the high court declined BARBITURATES. Cynthia Koestler had typed a brief to review a November ruling by the Michigan footnote to her husband’s suicide note: “I should Court of Appeals, which rejected Kevorkian’s bid have liked to finish my account of working for for a new trial. The state Supreme Court said it Arthur—a story which began when our paths was not persuaded that the questions presented happened to cross in 1949. However, I cannot should be reviewed by the court. Kevorkian had live without Arthur, despite certain inner argued that euthanasia is legal and that his con- resources.” viction was unconstitutional. Kevorkian lawyer Mayer Morganroth said he planned to appeal to the federal courts and to ask the U.S. Supreme Kraepelin, Emil (1856–1926) German psy- Court to consider the case. chiatrist and author of Lectures on Clinical Psychia- Kübler-Ross, Elisabeth 145 try, who expressed the belief that mental distur- and the author of the ground-breaking 1969 bances were a direct factor in at least one-third book On Death and Dying. of all suicides. Many authorities disagree, stress- Now in her 70s, she has spent most of her life ing that such a relationship should be considered working with the dying. She was born one of with great care because of the problems in defin- triplets in Zurich, SWITZERLAND, and graduated ing mental health and mental illness. His rela- from medical school at the University of Zurich tively large rate figure is based on fact that the in 1957. She came to the United States a year high incidence of mental illness among suicides later, where she was appalled by the standard had been previously pointed out by a number of treatment of dying patients in New York hospi- investigators. tals. She completed her degree in psychiatry at the University of Colorado in 1963. Unlike her colleagues, she made it a point to Kristin Brooks Hope Center A nonprofit sit with terminal patients, listening as they organization founded by H. Reese Butler II, hus- poured out their hearts to her. She began giving band of the late Kristin Brooks Rossell-Butler, lectures featuring dying patients who talked 28, who hanged herself April 7, 1998, after a about what they were going through, and began battle with manic DEPRESSION and postpartum to write the first of a series of books on the topic. depression. After losing his wife, Reese founded Dr. Kübler-Ross has been awarded more than the center to help find solutions for women who 25 honorary doctorates from major universities suffer from postnatal/postpartum depression and received the Modern Samaritan Award and and manic depression. The center also operates the Ideal Citizen Award. Dr. Kübler-Ross the first national toll-free crisis phone line, the founded a growth and healing center called NATIONAL HOPELINE NETWORK. Shanti Nilaya in Escondido, California. For contact information, see Appendix I. In 1995, she suffered a series of major strokes, which left her paralyzed and facing her own Kübler-Ross, Elisabeth Psychiatrist and death. While her health has stabilized, she has world-renowned authority on death and dying, not completely recovered from her strokes.

L

“Lady Lazarus” Poem written by SYLVIA PLATH tional days, if the person gives overt indication in which she all but boasted of a recent suicide of continued danger to self or by an attempt or attempt. She concluded the poem with: threat to suicide in the first 14-day period, or if he was originally detained for an attempt or Dying threat and, in the judgment of the psychiatrist, Is an art, like everything else. continued to present that threat. (In other I do it exceptionally well. words, he need not have made an additional I do it so it feels like hell. attempt or threat during the first 14 days of hos- I do it so it feels real. pitalization.) I guess you could say I’ve a call. Unfortunately, while LPS solved one problem, it created a new one. Because inadequate provi- On February 11, 1963, Sylvia Plath com- sions were made to help the suicidal person, mitted suicide. Her suicide attempt 10 years many patients discharged after the short time before had been, from all appearances, deadly span have turned up quickly in municipal hospi- serious. tals or alone on the streets of cities and towns throughout the state. Lanterman-Petrie-Short Act (LPS) Adopted in California in 1967, the act is considered a Latin America Generally speaking, suicide landmark in the reform of INVOLUNTARY COMMIT- rates per 100,000 population show that Latin MENT, for suicidal persons in particular and for American countries rank lower than most psychiatric patients in general. In that state, reporting nations. Authorities believe that the prior to LPS, a person could be committed indef- relative low rates in most Latin American coun- initely if found to be “of such mental condition tries may be due to the prevalence of Catholi- that he is in need of supervision, treatment, care cism with its authoritarian body of common or restraint,” or “dangerous to himself, or to the beliefs concerning suicide. It should be noted person or property of others . . .” that data regarding different countries are often Under the old system, California courts com- of questionable reliability because of varying mitted more than 1,000 persons a month to state reporting methods and criteria used by the institutions, often after only cursory psychiatric United Nations. examination and court hearing. LPS, on the other hand, prohibits involuntary detention for longer than 72 hours. If these conditions as Law, Liberty and Psychiatry Book by right- described by law prevails, the person can be cer- to-suicide advocate psychiatrist Thomas Szasz. tified for 14 days of “intensive treatment.” After Szasz writes: “In a free society, a person must expiration of the 14-day certification period, sui- have the right to injure or kill himself . . . there cidal persons can be confined for up to 14 addi- is no moral justification for depriving a person of

147 148 law and suicide his liberty in order to treat him.” Dr. Szasz While a number of countries still retain laws opposes involuntary hospitalization or forced making attempted suicide a crime, in most the treatment for suicidal persons under any cir- law is used to register the attempts and to pro- cumstances. INTERVENTION, he believes, should vide for treatment. In the United States, laws come only when a person asks for help. against completing, or attempting suicide have been repealed in each of the states. Aiding and law and suicide In western European tradi- abetting suicide remains against the law in 21 of tions, the law has traditionally not approved of the states. suicide and, because of that, of those who expe- In the courts, the attitude of the law on the dite it. Suicide was considered to be a type of case for and treatment of suicide has moved murder, and therefore a felony, according to from rigid accountability for all such deaths to Anglo-American law in the 17th and 18th cen- the principles of foreseeability and the need to turies. But because the successful suicidal person take reasonable risks (within the standard of escaped traditional forms of punishment by care in the community) in the treatment pro- dying, the law looked elsewhere for an appro- gram in order to allow improvement. priate response. The solution, developed by both ecclesiastical and civil law, imposed burial Let Me Die Before I Wake Book written by restrictions on those who killed themselves. DEREK HUMPHRY, founder of the HEMLOCK SOCI- These laws also punished the victim’s family by ETY, and most recently published in 1984 by requiring that all the victim’s assets be forfeited Hemlock/Grove. This controversial guide to to the Crown, sometimes leaving the survivors “self-deliverance” for the dying person has been destitute. By the mid-19th century these types of and still is widely debated in many professional punishment had disappeared both in England circles and in the media. First editions of this and the United States, but suicide was still con- 1981 book were sold only to members of the sidered to be a crime. Hemlock Society. Public desire for more infor- Today, neither suicide nor attempted suicide is mation about voluntary EUTHANASIA resulted in a crime in any state, although many jurisdictions later extended editions. still consider it illegal to help someone else Derek Humphry and the late Ann Wickett, his attempt or commit suicide. PHYSICIAN-ASSISTED ex-wife, also wrote The Right to Die: Understanding SUICIDE is legal in Oregon. Euthanasia. law enforcement officers See POLICE SUICIDE. Lettres Persanes In one of his Lettres Persanes, written in 1721 by “Usbeck” from Paris to his legal aspects of suicide Early legal aspects of friend “Ibben” in Smyrna, French writer Charles suicide found civil and church law almost insep- de Secondat, Baron de MONTESQUIEU, ridicules arably mixed. English law incorporated ecclesi- the European laws on suicide and defends its astic canons when King Edgar adopted into civil practice. The French political philosopher’s The law the punishments against the corpse (degra- Persian Letters, published anonymously at Am- dation) and estate (confiscation) of the suicide. sterdam in 1721, is a bitter satire on the church These customs were discontinued only in and the . Defending suicide, he 1823 when the law burying the corpse at a cross- wrote: “Life has been given to me as a gift. I can roads was repealed, and in 1870 when the law therefore return it when this is no longer the forfeiting goods was erased. case . . .” He added, “when I am overwhelmed by Attempted suicide became a crime in ENGLAND pain, poverty and scorn, why does one want to in 1854 and continued until its repeal in 1961. prevent me from putting an end to my troubles, Lindsay, Vachel 149 and to deprive me cruelly of a remedy which is behavior. Thus, he said, not all suicides were in in my hands?” a state of damnation. He did, however, divided suicide into direct Levy, Jerrold E. Author of Navajo Suicide who and indirect forms and condemned those types considered that traditional modes are inade- involving intemperance, gluttony, dueling, and quate to maintain the relationships that are foolhardiness. Sym’s main interest, though, was important in modern Navajo society. Navajo in the prevention of suicide, as the book’s title men, for example, are more affected than expresses. He describes certain premonitory and women, since they must always undertake new diagnostic signs, such as “unusual solitariness, roles. In the matter of suicide, Levy wrote, role neglect of one’s duties, change in behavior, talk- situations offer a better framework than rela- ing to oneself, a distracted countenance and car- tionships. riage, and threatening speech and action.” See also NATIVE AMERICANS. Lincoln, Mary Todd (1818–1882) The wife of President Abraham Lincoln who was assessed See INSURANCE AND SUICIDE. life insurance by the court for insanity after his assassination. Son Robert Lincoln tried to have his mother Lifekeeper Foundation A group formed in declared legally incompetent after she began to 1995 to promote suicide awareness, education, suffer hallucinations and phobias, but the law and prevention through art forms such as Life- required a trial before a person could be institu- keeper Jewelry, Poetry, and the Lifekeeper tionalized. National Memory Quilt project. The Lifekeeper Mrs. Lincoln attempted suicide after being Foundation works with national suicide and judged insane by the court, and she was placed mental health organizations to continue and in a sanitarium, where she received treatment. develop other projects and carry the message She improved sufficiently for yet another court that suicide happens in good families and that it to reverse the insanity verdict in 1876. She died can happen to anyone. six years later. The foundation was formed in 1995 by Sandy Martin, in memory of her only child, Tony, who Lindsay, Vachel (1879–1931) One of Amer- killed himself at age 17, on December 16, 1988. ica’s best-known poets during the early decades She is the vice president of SUICIDE PREVENTION of the 20th century whose international fame ADVOCACY NETWORK (SPAN), a board member of began with the publishing of his poem, “General the AMERICAN SUICIDE FOUNDATION (ASF), and a William Booth Enters Into Heaven,” a tribute to member of AMERICAN ASSOCIATION OF SUICIDOL- the founder of the Salvation Army, in Poetry OGY (AAS). magazine in 1913. For contact information, see Appendix I. Born Nicholas Vachel Lindsay on November 10, 1879, in Springfield, , he was the sec- Life’s Preservative against Self-Killing Trea- ond of six children and the only son of physician tise written by John Sym, an English country Vachel Thomas Lindsay and Esther Catharine clergyman (1581?–1637), who worried about an Frazee Lindsay. Vachel was taught at home by increase in suicide in his country. The work his mother until he was eight years old. After made available to readers his personal experi- skipping seventh grade and winning writing ences in counseling potential suicides. Sym prizes, he graduated from Stuart School in 1893. believed that many suicides were sick in mind Throughout his lifetime, Vachel detested al- and could not be held responsible for their cohol, didn’t smoke, and believed in a chaste 150 Litman, Robert E., M.D. lifestyle. Expected to become a doctor like his Dr. Litman traced the development of SIG- father, he enrolled at Hiram College as a premed MUND FREUD’s thoughts on suicide from 1881 to student in 1897, but three years later he trans- 1939, pointing out that, among other things, ferred to the Art Institute of Chicago. While he there is more to the psychodynamics of suicide enjoyed drawing, he was unhappy at Chicago than hostility, including rage, guilt, anxiety, and and moved to the New York School of Art, dependency, together with feelings of abandon- where he began to combine poetry and art. ment and of helplessness and hopelessness. Between 1906 and 1912, Lindsay took to Dr. Litman has conducted many studies relat- wandering on foot across the country, walking ing to suicide, suicidal behavior and the PREVEN- penniless and stopping at farms and villages TION and INTERVENTION aspects of suicide. along the way to trade poetry for food and shel- ter. In 1920, Lindsay became the first American Little Prince, The Popular children’s book poet invited to recite at Oxford University and published in 1943 by ANTOINE-MARIE-ROGER DE undertook his first national lecturing tour. SAINT-EXUPÉRY, which describes a fantasy roman- However, his popularity began to fade during ticizing suicide as a form of “going home.” Saint World War I, and he began working as an En- Exupéry was an expert pilot and author of many glish instructor at Gulf Park College in Gulf Park, popular books when he wrote The Little Prince, Mississippi. In 1924, Lindsay was invited to his most famous work. Spokane, Washington, as a poet-in-residence, He was 44 years old when he disappeared in where the 45-year-old poet married Elizabeth his plane on July 31, 1944, after leaving Bastia Connor, a 23-year-old high school English in Corsica on an Allied reconnaissance mission teacher, in 1925. over France. He never returned, and no trace of By the next year, his behavior was becoming him or his plane was ever found. Some people increasingly erratic, dogged by unreasonable are convinced the pilot-author’s death was a sui- rage and paranoia, exacerbated by diabetes and cide, stressing that the evening before his final epilepsy. Lindsay began to display signs of a seri- flight he had prepared a letter in the form of a ous personality disorder, and recurring bouts of will. Others who saw him before he left noted depression confined him to bed and blocked his that he had complained of a sleepless night and writing. For most of his working life, Lindsay appeared restless and depressed. was tortured by doubts and fears that shattered his self-esteem, and he suffered with bouts of British philoso- manic-depressive illness. In 1931, despondent, Locke, John (1632–1704) pher regarded as the father of empiricism, who exhausted, and in substantial debt, Lindsay com- denied the existence of any inborn knowledge mitted suicide by drinking Lysol. His suicide note or innate ideas. Lock’s theological argument read: “They tried to get me—I got them first!” against suicide had wide support in Great See MANIC DEPRESSION. Britain at the time. In his Two Treaties of Govern- ment Locke wrote: “. . . Man being all the work- Litman, Robert E., M.D. Founder of the Los manship of one omnipotent and infinitely wise Angeles Suicide Prevention Center and former Maker; all the servants of one sovereign Master, president of the AMERICAN ASSOCIATION OF SUICI- sent into the world by His order and about His DOLOGY. business; they are His property, whose work- Dr. Litman is a pioneer in the area of PSYCHO- manship they are made to last during His, not LOGICAL AUTOPSIES—along with Edwin Shneid- another’s pleasure . . . Everyone . . . is bound to man and Norman L. Farberow—and is one of preserve himself, and not to quit his station the foremost experts in suicide and the law. wilfully . . .” loss 151

London City that had high suicide rates in Los Angeles Suicide Prevention Center The areas with rooming houses and single-person first agency in the United States to establish a 24- dwelling units, and in areas with high rates of hour suicide prevention hotline. The center was mobility and other signs of social disorganiza- founded in 1958 by psychologists Norman L. tion, according to a study done by Peter Sains- Farberow and EDWIN S. SHNEIDMAN. They began bury in the 1980s. the center with an all-professional staff but in Such analyses of suicide rates within small, time welcomed volunteers to the program, specific geographic areas have led experts to which includes research, prevention, and inter- valuable clues in the etiology of the phenome- vention aspects. Today the center is part of the non. Didi Hirsch Community Mental Health Center. As a whole, in 1997 ENGLAND and WALES had a Shneidman and Farberow, both pioneers in suicide rate of 6.6 per 100,000, considerably less the field of SUICIDOLOGY, made the Los Angeles than the 8.9 in 1981 and 8.6 in 1982. The suicide center the prototype for prevention and crisis rate for men was also lower than in the 1980s centers, not only in the United States, but (10.3 per 100,000) and for women it was much throughout the world. Much of the research that lower (2.9 compared to 5.9 in 1982). As in many has been done about destructive behavior, sui- industrialized countries, the highest suicide rate cide, and suicide prevention has been by these among men occurred in those over age 75. In two authorities at the center. women, the highest suicide rate was during mid- Among other things, they developed the vital dle age (45 to 54)—a rate of 4.4 per 100,000. research method called the PSYCHOLOGICAL AUTOPSY, a means to help medical examiners and loneliness Loneliness is a state that exacer- coroners determine the cause of a death when it bates any other problem, disappointment, loss of is not clearly indicated. job, or death in the family, and that has been The Suicide Prevention Center operates with closely related to hopelessness-helplessness. more than 100 volunteers who have been People thinking of suicide often feel lonely and trained by professionals specializing in suicide hopeless. Life loses its value and death seems the prevention. Volunteers perform telephone crisis perfect release from troubles. intervention, bereavement support, and com- Philosopher Bertrand Russell wrote of loneli- munity education and outreach. ness in his Autobiography (1967), stating: “I have For contact information, see Appendix I. sought love . . . because it relieves loneliness— that terrible loneliness in which one shivering loss DEPRESSION is often caused by a person’s consciousness looks over the rim of the world feeling a deep sense of loss for someone or some- into the cold, unfathomable lifeless abyss . . .” thing. It may be triggered by the loss of a loved one, a job, or even the loss of a particular feeling The Loneliness of Children Book by Vander- or sense of being (such as, loss of feeling wanted bilt University professor John Killinger, who the- or needed). This loss is so significant that it leads orized that women seeking child care must to overwhelming sorrow, feelings of weakness choose between their children’s needs and their and unworthiness. own. He argues that America’s children must not Any loss of a child, a spouse, or health can be deprived of the parental attention that creates lead to severe, unrelenting depression and, sub- security and sound character. Lack of proper sequently, to suicidal thoughts. Young people are parental care and attention can create insecurity, especially vulnerable to crippling losses. anxiety, even fear—and sometimes leads to a It is no accident that the suicide rate is higher despair that establishes a suicidal mind-set. among the unmarried, the divorced, and the 152 LOSS widowed than among the married. Similarly, and ineptness, and they too can and do turn those who live in anonymous urban settings are against themselves and others. more likely candidates for suicide than those liv- Young people who feel unloved by parents ing in rural areas, where the sense of commu- consider themselves “expendable.” The expend- nity and extended family is stronger. The able child feels his parents don’t love him, feels individual cannot adjust to a sudden, shocking anger but can’t express it, and feels that his par- loss—of a job, a marriage, a wife, a close friend, ents never wanted children and, thus, would be or money. All these losses, unless help is forth- better off without him. In an effort to gain this coming, may result in an ANOMIC SUICIDE. In this longed-for parental love, the child turns his type of suicide, the individual’s society seems to anger inward becoming suicidal. have lost its familiar structure and customary Another idea that may trigger youth suicides guiding organization. is what some experts term the “Romeo and Juliet Factor.” Even before Shakespeare wrote about these two star-crossed teenage lovers, LOSS (Loving Outreach to Survivors of a romantic love in literature and drama had often Suicide) National nondenominational self- been associated with death. Often, lovers help support group for those who have experi- planned to be “reunited in death.” The linking of enced a death by suicide of a family member or love and death can produce lethal results for close friend. LOSS, which is sponsored by romantically inclined teenagers. However, inves- Catholic Charities, has chapters throughout the tigators have pointed out that this usually occurs country. only in the young person already emotionally LOSS offers a safe, nonjudgmental place distressed and at risk for potential suicide. where group members are assisted throughout the grieving process. The support and under- standing of the trained social workers coupled love pact suicide See SUICIDE PACT. with the knowledge and firsthand experience of the LOSS members help survivors real- Lowell, Robert (1917–1977) American poet ize they are not alone and that they will not feel noted for his complex poetry and turbulent life, the intense sadness for the rest of their lives. which was entangled with the social, political, Founding director of the program is the Rev. and ideological movements in the United States Charles T. Rubey, director of programs for during the post–World War II years. Lowell was Catholic Charities in Chicago. called the father of the “confessional poets,” a For contact information, see Appendix I. term used to describe JOHN BERRYMAN, SYLVIA PLATH, and ANNE HARVEY SEXTON, among others. love During adolescence, young people expe- From 1949, Lowell, diagnosed with BIPOLAR rience many emotional as well as physical DISORDER (manic DEPRESSION), spent periods of changes. Often intense emotions experienced in time in mental hospitals, drank heavily, and was early childhood are restimulated by adolescent married three times. During this period, he later changes, adding to the stresses, pressures, and admitted to having suicidal thoughts, and wrote problems ordinarily accompanying these years. about his ambivalence: “Do I deserve credit for For example, just as crippling as the actual phys- not having tried suicide—or am I afraid the ical loss of a parent is the sense of love lost, a exotic act will make me blunder, not knowing feeling of not being loved or cared for. Young error is remedied by practice . . .” people who grow up feeling unloved come to He was on his way to see his second (former) think of themselves as unworthy of love. Even wife in New York when he died of a heart attack adults may develop a self-image of uselessness on September 12, 1977. Lucian 153

Lowry, Malcolm (1909–1957) English nov- person is “overidentified” with his society and elist famous primarily for his novel Under the Vol- kills him or herself out of loyalty to its expecta- cano, now recognized as a masterpiece. Born in tions or demands. England and educated at Cambridge, he was a profoundly unhappy man. An alcoholic, Lowry LSD Lysergic acid diethylamide (LSD) is one of confessed to thoughts of suicide to escape his a group of hallucinogenic drugs that produce isolated alcoholic hell, much like the hero of his psychotic symptoms and behavior. Symptoms great novel. He died in Sussex, ENGLAND, some- may include hallucinations, illusions, body and what mysteriously by “misadventure.” Alcohol time-space distortions, and, less commonly, and sodium amytal tablets were involved, lead- intense panic or mystical experience. Some users ing some to suspect suicide and others to suggest attempt suicide while in an LSD-induced state. murder, by his wife. Lucan (Marcus Annaeus Lucanus) (A.D. loyalty suicides A term sometimes used to 39–65) Roman poet at first a favorite of NERO describe suicides committed out of loyalty, such who later became involved in a conspiracy as soldiers who slay themselves out of a desire to against him. Upon its discovery, Lucan commit- either imitate their leader’s example, or simply ted suicide. As Lucan himself said, “how simple to join their leader in the afterlife they envision. a feat it is to escape slavery by suicide.” In his account of Otho’s death, the Roman writer Tacitus mentions that some of the Lucian (ca. A.D. 125–ca. 190) Greek satirist emperor’s soldiers “slew themselves near his and teacher of rhetoric and philosophy who pyre . . .” Such suicides closely parallel INSTITU- became prefect at Alexandria in later life. After TIONAL SUICIDE and RITUAL SUICIDES, such as the witnessing the fiery suicide by immolation of Hindu custom of SUTTEE, in which the widow Peregrinus, he wrote an essay, “The Death of immolates herself with the corpse of her hus- Peregrinus,” depicting the Cynic philosopher as band. These “loyalty suicides” are also related to an exhibitionist, a man with an insatiable crav- the concept of ALTRUISTIC SUICIDE, in which the ing for notoriety.

M magical thinking and suicide A fantasy that, 1980 to 1998, the largest relative increases in in relation to suicide, is associated with a feeling suicide rates occurred among those 80 to 84 of power and complete control—a “You’ll be years of age. The rate for men in this age group sorry when I’m dead” fantasy. increased 17 percent (from 43.5 per 100,000 to An illustration of magical thinking and suicide 52). Firearms were the most common method of is the old Japanese custom of killing oneself on suicide by men over 65 in 1998, accounting for the doorstep of someone who has caused insult 78 percent. or humiliation. Similar to MANIPULATIVE SUICIDE, Suicide rates among the elderly are highest in this case a fatal result is intended. Sometimes for those men who are divorced or widowed. In also called “aggressive suicide,” magical thinking 1992, the rate for divorced or widowed men in a power struggle often means that if one per- over age 65 was 2.7 times that for married men, son can’t win, he or she can at least get in the 1.4 times that for never-married men, and more last word by committing suicide. than 17 times that for married women. Young men are also at higher risk for suicide. males and suicide Generally speaking, The risk for suicide among young people is although women attempt suicide about three greatest among young white men, although times as often as men, men complete suicide from 1980 through 1995, suicide rates increased about three times as often as women. most rapidly among young black males. Men are at particular risk of completing sui- White men have, for the past years (1950 to cide suddenly without warning, without being 1998), consistently had the highest suicide rates aware of the warning signs of DEPRESSION. of any race and sex category. During this same According to the National Center for Health Sta- period, men of other races had the second high- tistics, white men have the highest suicide rate. est rates; white women had the third highest In 1998, white men accounted for 73 percent of rates, while women of other races have consis- all suicides. Indeed, suicide claims more than tently had the lowest rates. 24,000 men’s lives every year. Most younger and middle-aged men who attempt suicide share evi- Malinowski, Bronislaw (1884–1942) Polish dence of impulsivity. They are aggressive sexu- anthropologist and author of Crime and Custom in ally, financially, and interpersonally, with a Savage Society, a book presenting what has often tendency to act on their feelings. been called “the best-known case in the history Suicide is an option that for men, climbs only of anthropological theory,” dealing with the case more steeply with age. By age 25, men are six of suicide among the Trobriand (in the south- times as liable to take their own lives as are west Pacific). Malinowski uses his collected women; by age 85, they are 13 times more likely material to show how public disapproval of a to kill themselves. Men accounted for 83 percent man who had committed a major sin (in this of suicides among those over age 65, and from instance, incest) acted as a legal device by

155 156 Man Against Himself prompting the offender to complete suicide. Patients often fall into a deep, dark despondency, Although Malinowski’s argument was con- and are inundated by oppressive thoughts of sui- cerned with the field of law, the case led anthro- cide. Family members, friends, and associates pologists to reconsider the nature of suicide in should be alert to the victim’s symptoms, suici- primitive societies. dal conversation, and overt hints of death wishes. Man Against Himself Definitive work by psy- chiatrist KARL MENNINGER, who agrees with manipulative suicide An attempt to manipu- Freud in the existence of simultaneous contra- late others by attempting suicide, usually with a dictory drives: the life instinct (Eros) and the nonfatal intent. Basically, the person trying to death instinct (Thanatos). In Man Against Himself, commit suicide is saying: “If you don’t do what I Menninger describes, analyzes, and interprets want, I’ll kill myself.” the many self-destructive acts in which people However, the word manipulative does not engage. He writes about different kinds of deaths imply that a suicide attempt is not serious. Fatal that result from the interplay of the life and attempts are often made by people who are death instincts, which take different forms and hoping to influence the feelings of others, which he calls chronic, focal, and organic sui- despite the fact that they will not be around to cides. Menninger believed that within the act of witness the success or failure of their efforts. suicide, three elements occur in varying propor- Nevertheless, while people sometimes die or are tions in each suicide: (1) the wish to kill; (2) the injured as a result of their attempts, the inten- wish to be killed; (3) the wish to die. tion in a manipulative suicide attempt is to cause guilt in another person. The person who manic depression The informal term for attempts suicide usually does not really intend to die. BIPOLAR DISORDER characterized by swings between episodes of both mania and DEPRESSION. The illness may be subdivided into manic, Many Faces of Suicide, The Book edited by depressed, or mixed types on the basis of the suicide expert Norman J. Farberow, outlining presenting symptoms. the area of INDIRECT SUICIDE (“focal” or “organic” In the mixed or circular type, extreme mood suicide), noting its characteristics and its differ- swings alternate from the depths of despair entiation from direct or overt suicide, especially (lowered mood, sleep disturbance, decreased in terms of time and the role of intention. appetite, intense feelings of worthlessness) to A number of experts contributed chapters to soaring heights of euphoria (excitement, expan- the book on such subjects as hyperobesity, auto sive or irritable mood, flights of ideas, dis- accidents, heart disease, psychosomatic illnesses, tractibility, impaired judgment, and sometimes malingering, gambling, and high-risk activities. grandiosity). This disease often begins during adolescence or in the early 20s and may con- MAO inhibitors A group of antidepressant tinue throughout the patient’s life. drugs that inhibit the enzyme monoamine oxi- Manic depression is caused by biochemical dase responsible for breaking down serotonin disorders within the brain. Physicians usually and norepinephrine in the brain. treat the illness with lithium carbonate, an alkali The main types of MAO inhibitors are isocar- metal to reduce the duration, intensity, and fre- boxazid (Marplan), phenelaine (Nardil), and quency of the mood swings. tranylepromine (Parnate). These extremely As the depression phase becomes more potent drugs cause frequent side effects that may severe, the danger of suicide becomes greater. be severe. Used in combination with other martyrdom 157 drugs—narcotics, stimulants, depressants—in an A lethal dose has never been established since uncontrolled manner, the effect can be fatal. The no deaths directly related to the action of mari- same is true when MAO inhibitors are taken juana have been reported. with foods that contain tyramine, such as Although no reliable data exists to prove or cheese, herring, salami, and chocolate. MAO disprove effects of marijuana use on suicide inhibitors are considered extremely dangerous rates, neither marijuana nor alcohol relieves drugs and are usually only administered under depression. close medical supervision. See also DRUG ABUSE.

Marcus Aurelius (A.D. 121–180) Roman marital status and suicide Suicide rates are emperor and Stoic who approved of suicide only lowest among married persons. It should be when committed on a rational basis, but not to noted, however, that most people who kill simply express irrational ideas. As Marcus Aure- themselves are married simply because the lius wrote: “how admirable is the soul which is majority of adults are married (though this has ready and resolved, if it must this moment be been changing in recent years). In other words, released from the body, to be either extinguished even though the suicide rates are low for married or scattered or to persist. This resolve too must adults, the actual number of suicide victims arise from a specific decision, not out of sheer among marrieds is relatively high. opposition like the Christians, but after reflec- According to data from the National Center tion and with dignity, and so as to convince oth- for Health Statistics, age-adjusted suicide rates ers, without histrionic display.” by marital status for white men, black men, white women, and black women show that mar- marijuana The dried tops, leaves and stems of ried persons in all four race and sex groups have the Indian hemp plant Cannabis sativa, which the lowest suicide rates. Single persons who had contain the psychoactive substance tetrahydro- never married have rates twice as high as for cannabinol (THC) and that is usually smoked in those who are married with children. Rates are cigarettes or pipes. high among widowed and divorced people in Marijuana is a popular abused substance, and almost all age groups. (Among the widowed, a despite its illegal status in the United States, spouse’s death often acts as a strong precipitating there are an estimated 16 million regular Amer- factor to take their own lives.) The most aston- ican users. The number of users increased each ishing feature of suicide rates by marital status is year until 1978; since that time, surveys have the very high rates for widowed men of both shown significant decline. This decrease in use is white and black races. Only among white attributed to a change in attitude among young women did divorced persons have a rate that people. In 1978, 35 percent felt that regular mar- exceeded the rate for widowed persons. ijuana was associated with great risk; by 1982, this figure had risen to 60 percent. martyrdom There have been many instances People who use marijuana are also apt to in history of the phenomenon linking suicide drink alcohol. When alcohol is taken with mari- with a desire for martyrdom. Voluntary martyr- juana there is a greater impairment of motor and dom was common among the early Christians. mental skills than with either drug alone. While As a youth, ORIGEN of ALEXANDRIA (c. A.D. 185– the use of marijuana does not produce physical 253/54) experienced the martyrdom of his dependence, after long-term chronic use it does father in 202 and wanted to suffer the same fate. often produce psychological dependence on the However, Origen’s mother prevented him from euphoric and sedative effects. committing suicide. 158 Masada

Other early examples include Vibia Perpetua, as a place of refuge for anyone in danger of a young married mother, age 22, who chose to capture. After the fall of Jerusalem in A.D. 72, die in the arena in the reign of Septimius Masada remained the only point of Jewish resis- Severus. EUSEBIUS, bishop of Caesarea, tells of tance. A few surviving Jewish fighters who Christians about to be tortured who chose in- crossed the Judean mountains joined the de- stead suicide, regarding death as a prize snatched fenders of Masada, and it became the rebels’ from the wickedness of evil men. base for raiding operations. This type of pathological craving for martyr- In A.D. 72, the Roman governor Flavius dom and its emotional climate characterized Silva decided to uproot this outpost of resis- large groups in the Roman Empire between the tance and marched against Masada at the reigns of Nero and Julian (A.D. 54 to 363). head of almost 15,000 troops and Jewish war Ultimately, strengthened by the increasingly prisoners. The troops prepared for a long important status of Christianity, both as a toler- siege, building eight camps at the base of the ated faith and as the state religion, voluntary Masada rock and surrounded it with a high martyrdom was discouraged by church leaders, wall, leaving no escape for rebels. As the and opposition to all suicide was stiffened. It was Romans closed in, Eleazar gathered all the not until 563, however, at the Council of Braga, Masada defenders and persuaded them to kill that suicide as an act was condemned by the themselves rather than fall into the hands of church. This position remained canon law until the Romans. 1284 when the Synod of Nimes refused burial in The people set fire to their personal belong- consecrated ground to suicides. Recent examples ings, and then 10 people chosen by a lot killed of voluntary martyrdom include the KAMIKAZE everyone else, and then completed suicide. In PILOTS of Japan in World War II and the Middle the morning, Romans entered a silent fortress Eastern terrorists who willingly die during or as and found some 960 dead Jews. Two women a result of their actions in behalf of jihad (or holy and five children survived the MASS SUICIDE by war). hiding in a cave, and told the story to Jewish his- torian and soldier Flavius Josephus (see JOSE- PHUS, FLAVIUS). A Jewish fortress besieged by the Masada See also MASS SUICIDE. Romans in A.D. 72 to 73. The citadel was a site of the most dramatic and symbolic act in Jewish history, where rebels chose mass suicide rather mass suicide Suicide among a large number than submit to Roman capture. of people all at the same time. In the past 20 The Masada originally was the royal citadel of years there have been a number of notable mass King Herod, located at the top of an isolated rock suicides in the United States and other parts of on the edge of the Judean desert and the Dead the world. Sea valley. In 40 B.C., Herod fled from Jerusalem In March 1997, the bodies of 39 young people to Masada with his family in a moment of dan- who were part of the HEAVEN’SGATEreligious cult ger. Later, he fortified the citadel as a refuge died in a mansion near San Diego. The victims, from his enemies. who were all between 18 and 24 years old, At the outbreak of the Jewish war, Mena- drank a lethal mixture of phenobarbital and hem, son of Judah the Galilean, captured vodka and then settled to die over a three-day Masada at the head of a band of Zealots. After period. The victims (21 women and 18 men) Menahem was murdered in Jerusalem by Jew- apparently believed their deaths would lead to a ish rivals, his nephew Eleazar ben Yair escaped rendezvous with a UFO hiding behind Comet to Masada. During these years, Masada served Hale-Bopp. McIntosh, John L. 159

A number of mass suicides have been linked MASADA is perhaps the best known site of to the SOLAR TEMPLE, an international sect that mass suicides in the ancient world. An eerie par- believes ritualized suicide leads to rebirth on a allel to Masada occurred during World War II at planet called Sirius. Mass suicides occurred on TREBLINKA, one of the most terrifying Nazi con- March 23, 1997, when the burned bodies of five centration camps. Untold thousands of Jews, Temple members (three women and two men) mostly from Eastern Europe, were sent for were found inside a house in Quebec. In Decem- extermination to Treblinka in eastern Poland. ber 1995, 16 Solar Temple members were found Over time, these people started to commit sui- dead in a burned house outside Grenoble in the cide one by one rather than submit to the hor- French Alps, and in October 1994, the burned rors they were experiencing and the ultimate bodies of 48 Solar Temple members were discov- persecution that would end in extermination at ered in a farmhouse and three chalets in the hands of their Nazi tormentors. Their deaths Switzerland. At the same time, five bodies by suicide affirmed the freedom to control their (including an infant) were found in a chalet own lives and deaths. These acts of suicide also north of Montreal. led to solidarity among them, with those who Members of another cult, known as the remained alive helping those who wanted to kill , died on April 19, 1993, when themselves so they would die quickly. at least 70 cult members ended their lives after In 17th-century Russia, the Great Schism fire and a shootout with police and federal (The Raskol) left the dissenting religious group agents after a 51-day siege of the compound called the Raskolniki in such despair that many near Waco, Texas. The sect’s leader, David followers sought death rather than wait for the Koresh, who had preached a messianic gospel of end of the world (which they had predicted sex, freedom, and revolution and told followers would occur before the end of the century). he was Jesus Christ, died of a gunshot wound to Between 1672 and 1691, more than 37 mass the head sometime during the blaze. immolations took place in which more than In October 1993, 53 Vietnamese hill tribe vil- 20,000 Raskolniki voluntarily burned to death. lagers committed mass suicide with flintlock They had thought it senseless to live and risk guns and other primitive weapons in the belief being contaminated by heresy. they would go straight to heaven. Officials said See also CULT SUICIDE. they were the victims of a scam by a man who received cash donations for promising a speedy Histo- road to paradise. Maximus Valerius (42 B.C.–A.D. 37) rian and contemporary of the Roman emperor, Mexican minister Ramon Morales Almazan Tiberius who wrote that Roman suicides were and 29 followers suffocated in December 1991 not uncommon during the rule of Caesar Augus- after he told them to keep praying and ignore tus. He recorded that in the important port city toxic fumes filling their church. The year before, of Marseilles, the municipal senate actually sup- 12 people died in a religious ritual in Tijuana, plied free HEMLOCK-laced poison to anyone who apparently after drinking fruit punch tainted by industrial alcohol. could give valid reasons for wanting to commit suicide. The Jonestown mass suicide (see JONESTOWN MASSACRE) occurred on November 18, 1978, when the Rev. Jim Jones led more than 900 fol- McIntosh, John L. Suicidologist and professor lowers to their deaths at the compound in of psychology at Indiana University at South Guyana, by drinking a cyanide-laced grape Bend who wrote Suicide Among U.S. Racial Minori- punch. Cult members who refused to swallow ties, Suicide Among Children, Adolescents, and Stu- the liquid were shot. dents, and Suicide Among the Elderly. He is 160 media, effects of suicide coverage co-editor (with Edward J. Dunne and Kaven medical personnel Physicians, nurses, and Dunne-Maxim) of Suicide and Its Aftermath: ancillary medical therapists and technicians Understanding and Counseling the Survivors. He also serve as a first line of defense against suicide. compiled Research on Suicide: A Bibliography, pub- They are frequently called “gatekeepers” because lished in 1985, an important addition to the bib- they are often the first persons to learn of liographies on suicide. Professor McIntosh is a DEPRESSION or suicidal feelings, many of which past president of the AMERICAN ASSOCIATION OF are masked or disguised in physical symptoms. SUICIDOLOGY. Medical personnel trained in interpretation of the common physical and emotional signs of media, effects of suicide coverage A num- depression provide the opportunity for early ber of suicidologists and other authorities have identification and intervention. criticized news coverage by newspapers, maga- Medical personnel in hospital emergency zines, television, and radio, contending that read- rooms or serving in emergency medical services ing or hearing about a suicide victim in the news are often called on to save the life of a person who made a suicide attempt. Often the first to be is often enough to trigger COPYCAT SUICIDES. In 1979, sociologist David Phillips found that greeted by an attempter on recovery, the atti- news stories of suicides did stimulate a wave of tude and understanding is crucial for averting imitative acts. He checked Los Angeles traffic further suicide attempts or subsequent suicidal records for periods immediately following behavior. Medical personnel are also important locally publicized suicides and discovered that in their interaction with the families of the for three days after a suicide report in the Los attempters who may be puzzled, confused, or Angeles area, auto fatalities rose by 31 percent. angry. He later found a similar jump in fatalities in There is an ongoing need for medical person- Detroit, following front-page coverage of a sui- nel to be trained in INTERVENTION, prevention, cide. (It would be impossible, of course, to prove and POSTVENTION. that the auto deaths were suicides rather than In addition to medical emergency services accidents.) that offer help immediately in suicide crises, On the other hand, studies have revealed that many communities now have mental health a drop in suicides in cities has taken place during centers, crisis centers, suicide prevention cen- extended newspaper blackouts, such as, when a ters, “hot lines,” and walk-in services. strike has shut down the paper. On the other hand, there have been many reports of rises in Menninger, Karl (1893–1990) Psychiatrist the number of suicides following media coverage and founder of the famed Menninger Institute in of a celebrity’s suicide. Topeka, Kansas, considered by many to be one Most experts appear to agree that the far of the foremost figures in American psychiatry. greater danger lies in preventing discussion and He is author of many books, including MAN exposure of the subject of suicide. Not to report AGAINST HIMSELF, in which he describes and inter- and discuss suicide simply places it back in the prets the many self-destructive acts in which taboo category and promotes more myth and people engage. misinformation, which, ultimately, may cause He summed up suicide in this way: the wish more suicides. to kill, the wish to be killed, the wish to die. He Although exposure to suicides is a possible said there is extreme anger against others, as risk factor, research has not yet determined the well as oneself in the suicidal person. Menninger effects of exposure to previous suicides on sub- extended Sigmund Freud’s concept of the death sequent suicides. instinct (self-destruction) and its role in man’s mercy killing 161 functioning, especially as it interacts with the life Researchers suggest that about a third of all peo- instinct (self-preservation) in times of stress and ple who kill themselves are found to have been crisis. His book The Vital Balance describes five suffering from mental illness requiring treat- levels of personality organization from high to ment. poor at which a person can function. Suicide, DEPRESSION is one of the highest risks for sui- because it is self-destructive and often lethal, is cide, often featuring feelings of worthlessness listed in level 5, the lowest level. and despair and a wish to die, and people who Together with his father, Charles Frederick, die by suicide are frequently suffering from Karl Menninger opened the Menninger Clinic in undiagnosed, undertreated, or untreated depres- Topeka, Kansas, aimed at collecting many spe- sion. An estimated 2 to 14 percent of people who cialists in one center. In 1926, they were joined have been diagnosed with major depression die by Karl’s brother William, also a psychiatrist. The by suicide. Suicide risk is highest in depressed Menninger Foundation, established for research, individuals who feel hopeless about the future, training, and public education in psychiatry, was those who have just been discharged from the founded in 1941 and soon became a U.S. psy- hospital, those who have a family history of sui- chiatric center. cide, and those who have made a suicide attempt in the past. menstruation and suicide Some experts Also at high risk are individuals who suffer believe that menstruation is linked to suicide from depression at the same time as another attempts in some girls. Since every type of per- mental illness. Specifically, the presence of sub- son under almost every conceivable circum- stance abuse, anxiety disorders, SCHIZOPHRENIA, stance commits suicide, it might be possible to and BIPOLAR DISORDER put those with depression say the menstrual cycle sometimes brings on at greater risk for suicide. DEPRESSION which, in turn, makes the poten- Between 3 and 20 percent of those diagnosed tially suicidal person more vulnerable. How- with bipolar disorder (manic depression) die by ever, all victims of suicide usually show signs of suicide. Hopelessness, recent hospital discharge, intense emotional stress or mental disturbance, family history, and prior suicide attempts all severe depression being only one symptom. raise the risk of suicide in these patients. Therefore, menstruation is more likely to be a Among those people who are psychotic, the contributing or precipitating factor than a pri- rate among schizophrenics and manic depres- mary cause. sives is disproportionately high. An estimated 6 to 15 percent of those diagnosed with schizo- phrenia die by suicide. In fact, suicide is the lead- mental illness Although most people who ing cause of premature death in those diagnosed suffer from a mental illness do not die by suicide, with schizophrenia. Between 75 and 95 percent having a mental illness does increase the likeli- of these individuals are men. hood of suicide. This does not mean that every People with personality disorders are approx- person who is mentally ill is suicidal, or that imately three times as likely to die by suicide everyone who commits suicide is mentally ill. than those without. Between 25 and 50 percent Still, research suggests that 90 percent of suicides of these individuals also have a substance abuse had a diagnosable mental disorder. disorder or major depressive disorder. Even among mentally healthy people, a suici- See ABUSE, SUBSTANCE. dal act is an abnormal reaction to stress. This is why individuals who are mentally ill—especially those suffering from a depressive illness—are mercy killing See ASSISTED SUICIDE and usually considered to be at high risk for suicide. EUTHANASIA. 162 methods of suicide methods of suicide Firearms are the most people think of acetaminophen as a safe commonly used method of suicide in the United painkiller, an overdose can be very dangerous. States. The ICD (International Classification of Two or more methods, or a combination of Diseases) includes firearms and explosives in the drugs, is used in about 20 percent of attempted same category, although only 1 percent of sui- suicides, increasing the risk of death, particularly cide deaths classified thus are due to “explo- when drugs with serious interactions are com- sives.” In 1970, 50.1 percent of the suicides in bined. America were committed with firearms and Violent methods such as shooting and hang- explosives. By 1998, 60 percent of all suicides ing are uncommon among unsuccessful suicides. were committed with firearms and explosives. The pattern of suicide by method doesn’t vary Middle Ages There were varying social atti- a great deal by race, but does vary considerably tudes and practices with respect to suicide dur- by sex. Male patterns of suicide method didn’t ing the Middle Ages. Folk beliefs, ecclesiastical change much between 1970 and 1998. In 1970 views, and medical theories considered suicide as in 1980, firearms and explosives were the as a crime. number one method of suicide for males, fol- Antagonism to suicide and its eventual con- lowed by HANGING, strangulation, suffocation, demnation in the Holy Roman Empire were and poisoning. related to economics, religion, philosophy, and There was a noticeable shift, however, ultimately the law. between 1970 and 1980 in the most frequent On the Continent, various municipal law suicide method employed by women. In 1970, codes did not punish suicide. The Carolina, the poisoning by solids or liquids was the most fre- Criminal Constitution of Charles V, in 1551 con- quently used method, followed by firearms (and fiscated the property of a suicide while the dead explosives), in 1998, firearms and explosives victim was under accusation of a felony. were the methods used most frequently by In those times, the corpse of the suicide was women, followed by poisoning by solids and often subjected to bizarre indignities and degra- liquids. There was also an increase in the percent dations. Most of these practices stemmed from of suicides in which firearms and explosives long-standing religious and magical roots. For were used by males and by females in both racial example, the practice of pinning down the groups. body of a person who committed suicide pre- The choice of methods is determined by cul- dates Christianity among Europe’s Germanic tural factors and availability and may reflect the peoples. seriousness of intent, since some methods (such In fact, legal and ecclesiastical attitudes as jumping from heights) make survival virtually toward suicide remained conservative until well impossible, whereas others (such as drug over- into the 18th century; suicide was equated with doses) make rescue possible. However, using a murder in various parts of Europe, and the method that proves not to be fatal does not nec- corpse was treated accordingly. essarily imply that the intent was less serious. In France and England, the body was dragged Drug ingestion is the most common method through the streets, head downward on a hur- used in suicide attempts. Use of BARBITURATES has dle, and then hanged on a gallows. decreased (to less than 5 percent of cases), but The three common penalties—confiscation of use of other psychoactive drugs is increasing. property, degradation of the corpse, and refusal Use of salicylates has decreased from more than of burial in consecrated ground—reflect atti- 20 percent of cases to about 10 percent, but use tudes toward suicide during the Middle Ages of acetaminophen is increasing. Although most that were prevalent throughout the 18th cen- Mithradates 163 tury. It was not until the Renaissance that new military defeat History is filled with examples attitudes toward suicide began to emerge. of self-destruction to escape the consequences of military defeat. Such examples go back to bibli- Mihara-Yama volcano Japanese volcano that cal times as exemplified by AHITOPHEL, a sup- in the past was a magnet for people who wanted porter of Absalom in his revolt against his father, to commit suicide. The problem began on Janu- King David. When Ahitopel saw that Absalom ary 7, 1933, when two young women bought would be defeated, “he saddled his ass, and went steamship tickets to the Japanese island of home to his own city. And he set his house in Oshima, site of the Mihara-Yama volcano. order and hanged himself.” The women climbed to the top and stood Vulteius, a tribune supporting Caesar in the on the lip of the boiling crater as clouds of sul- civil war against Pompey, saw that escape was fur puffed into the air. The older of the two, impossible and called upon his troops to die by Mieko Ueki, 24, explained that to jump into their own hands rather than fall alive into the Mihara-Yama would be a beautiful way to die, enemy’s hands. Not one soldier survived. because one would instantly rise to heaven in a The defeat of the Jewish Zealots on MASADA swirl of smoke. Then she announced her inten- and their subsequent slaughter is another exam- tion to do exactly that. After a mild protest ple, as is the defeat of Flavius Josephus that from her companion, the women bowed to resulted in the suicide of all but one of his men each other, and Mieko hurled herself into the and himself—and his subsequent conversion to stinking lava. a Roman citizen. This “poetic suicide” so entranced the Japan- As recently as World War II, a number of Ger- ese that 143 people later plunged to their deaths man and Japanese military leaders chose suicide into the crater that year, including six on a sin- rather than surrender to Allied authorities. gle day in April. Eventually, the volcano became See JOSEPHUS, FLAVIUS. such a suicide magnet that the Japanese govern- ment finally closed passage to Mihara-Yama in Mishima, Yukio (1925–1970) Noted Japan- 1935—after 804 men and 140 women had fol- ese novelist and a candidate for the Nobel Prize lowed Mieko’s volcanic leap. in literature who committed HARA-KIRI on November 25, 1970, with one of his admirers, Miletus, maidens of Young Greek women in following the traditional SAMURAI ritual. ancient times living in the now-ruined city of Mishima had been hailed as a writer of genius Miletus in western Asia Minor who were seized upon the publication of his first major work, the with the desire to die. So many young women of autobiographical Confessions of a Mask in 1949. He the city became intent on hanging themselves— was also a playwright, a master of the ancient for no apparent reason whatsoever—that the martial arts of karate and swordsmanship, and city fathers decided to seek legal means to stop an actor in both his own stage plays and on the the deaths. screen. The Milesians decided to pass a law requiring Mishima’s dramatic suicide was considered all maidens who hanged themselves to be car- not as a rash act, but as a bold gesture planned ried to their graves naked except for the rope in great detail months before by a man who with which they had committed suicide. The envisioned violent death as the ultimate asser- vision of such a shameful, disgraceful burial tion of self. was so distasteful to the young women of Mile- tus that the epidemic of hangings immediately Mithradates (ca. 131–63 B.C.) King of Pon- ceased. tus who overran Roman territories throughout 164 Monroe, Marilyn

Asia Minor, and sent large armies into Greece. While he considered suicide to be a foolish act, Sulla in Greece and Timbria in Asia defeated he did not believe it was immoral. Instead, he Mithradates, and he concluded peace, ca. 84 tried to understand and explain in his essays the B.C., giving up his conquests and paying tributes. various situations that might lead people to com- War broke out again in 74 B.C., ending in his mit suicide. defeat by Pompey in 66 B.C. When his plans for a new war failed, he ordered a mercenary to kill Montesquieu, Charles-Louis de Secondat, him. Mithradates had immunized himself baron de la Brède et de (1689–1755) against poisons by years of swallowing small French political philosopher whose first impor- doses. When he finally tried to commit suicide tant work, The Persian Letters, published anony- by taking poison, he failed—and then had to mously at Amsterdam in 1721, was a bitter satire order a slave to kill him. on the church and the politics of France. His work ridiculed the barbarous and unjust Euro- Monroe, Marilyn (1926–1962) American pean laws on suicide, a practice he defended. In movie actress who died at age 36 from an appar- one of his Lettres Persanes, written by “Usbek” ent overdose of drugs and alcohol. Her death is from Paris to his friend “Ibben” in Smyrna, Mon- still controversial, but is generally presumed to tesquieu wrote: “Life has been given to me as a have been a suicide. Just after the movie star’s gift. I can therefore, return it when this is no death, the notes of a number of suicides linked longer the case . . .” their own deaths to Monroe’s. Subsequent study noted a 12 percent rise in the number of suicides mood swings Four out of five people who in both the United States and England following complete suicide have previously given verbal or her death. behavioral “clues” of their intention to do so. Among specific behavior changes are sudden Montaigne, Michel de (1533–1592) French mood swings that seem unpredictable. These writer and mayor of Bordeaux, who was the first persistent highs and lows are a warning that the major dissenter about the sin of suicide among person is unhappy, unstable, and increasingly European writers. In a series of five essays that sapped of both energy and emotional stability. explored the subject of suicide, he argued that suicide should be considered a matter of per- sonal choice, a human right that should be a More, Sir Thomas (1478–1535) English rational option under some circumstances. author and statesman who became Lord Chancel- In his “A defense of legal suicide” (1580), he lor in 1532. On his refusal to take the oath im- wrote: “Death is a remedy against all evils: It is a pugning the authority of the Pope, as demanded most assured haven, never to be feared, and by King Henry VIII, he was beheaded in 1535. For often to be sought: All comes to one period, this martyrdom, he was canonized in 1935. whether man makes an end of himself, or Sir Thomas More justified suicide as a form of whether he endure it; whether he run before his EUTHANASIA in his Utopia (written in Latin, 1515 day, or whether he expect it: whence soever it to 1516). come, it is ever his own, where ever the thread be broken, it is all there, it’s the end of the web. mortality statistics Statistics for a city, state, The voluntariest death is the fairest. Life depen- region, or country that are used to establish var- deth on the will of others, death on ours.” ious general associations between suicide and In his writing, Montaigne broke with the the personal characteristics of individuals who Christian church in its attitude toward suicide. kill themselves (age, sex, religious, or marital murder-suicide 165 status), between suicide and temporal or sea- multiple suicides See CLUSTER SUICIDE; MASS sonal events, and between suicide and geo- SUICIDE. graphic locations. It is from these general associations that experts gain clues that allow murder-suicide Also called homicide-suicide, them to test specific hypotheses concerning or dyadic death, this is a lethal event in which a causes. perpetrator kills one or more people and then Rates of suicide are calculated by dividing the commits suicide, usually within a very short number of persons in a group committing sui- period of time. Studies have shown the perpe- cide by the total number of persons in that trators of murder-suicide have profiles that group. One major problem in this regard is that resemble individuals who commit suicide rather of obtaining valid data on completed suicides. than those who commit homicide. Rankings, such as those used by the U.S.’s Experts aren’t sure exactly how many mur- Centers for Disease Control (CDC), are based on der-suicides occur in the United States because death certificate data and may represent a signif- there is no national surveillance system to track icant degree of misclassification and subsequent these deaths. However, estimates suggest that under reporting of suicide as a cause of death. murder-suicides account for up to 1,000 to 1,500 According to officials at the CDC, one survey of deaths each year—a mortality rate similar to 200 medical examiners found that more than meningitis or tuberculosis. half believed that the reported number of sui- Murder-suicides are emerging as a public cides is probably less than half the true number. health problem particularly in the elderly popu- The limited accuracy and reliability of suicide lation. One recent Florida study has shown that statistics are, in part, attributable to the lack of a murder-suicide rates among people over age 55 commonly accepted and applied definition of are higher than rates in younger age groups, and suicide, according to the CDC. Judgments by that murder-suicides account for about 3 percent physicians, coroners, and medical examiners of all suicides and about 12 percent of all mur- play a part in the process by which suicides are ders among the elderly. Applying these Florida classified, but there are no uniform criteria for figures to the country as a whole, experts esti- the classification of suicide to guide these judg- mate that about 200 murder-suicides occur ments. every year among people 55 and older. Most of these acts involve older men killing their spouses Mourning and Melancholia Paper written by or lovers. The Florida study also suggested that SIGMUND FREUD in 1917 that explored the indi- for each unsuccessful murder-suicide—that is, if vidual mind for the cause of suicide, postulating one person (usually the perpetrator) survives— that people who kill themselves are actually there are five that are successful. killing the image of the love object within Although many studies have investigated them—a love object they both hate and love and murder-suicides since 1900, it was not until with which they identify with strongly. 1995 that rates and clinical patterns were stud- Freud later commented that he doubted that ied in older people. In the past, murder-suicides suicide could occur without the repressed desire among the elderly were presumed to be suicide for either matricide (murder of the mother) or pacts, mercy killings, or altruistic actions. patricide (murder of the father). Murder, he Although more recent research has found that said, is aggression turned upon another; suicide men are most often the perpetrators, these mur- is aggression turned upon the self. This is why der-suicides are not mercy killings, altruistic Freud called suicide “murder in the 180th events, or suicide pacts, and are neither acts of degree.” love nor compassionate murders. Instead, 166 Muslims research indicates these murder-suicides are acts untreated depression in older perpetrators and of desperation and DEPRESSION, other forms of the existence of domestic violence in about one- psychopathology, or domestic violence. third of older homicide-suicides underscores the While suicide pacts do occur among older importance of careful interviews when one or couples, they are very rare, and make up less both members of an older couple present for than one-tenth of 1 percent of all suicides in the medical appointments. older population. About 85 percent of murder- suicides involve spouses or partners, and the Treatment remaining victims are siblings or other family Intensive treatment of depression and other psy- members. chiatric problems is required, together with Although murder-suicides are relatively rare removing guns or other lethal weapons, social compared to homicides and suicides, they have a support for spouses and families, and appropri- dramatic, enduring impact on surviving family ate interventions to deal with marital conflict— members and the communities in which they especially where the older woman is a potential occur. Reports of the annual rates for homicide- victim of aggressive, lethal behavior. suicide have been remarkably constant in the United States and other countries, ranging from Muslims The followers of ISLAM who have 0.2 per 100,000 to 0.3 per 100,000. Murder-sui- always strongly condemned suicide. The QUR’AN, cides, reported in terms of the percentage of total the holy scriptures of Islam, specifically declares homicides, vary regionally in the United States that suicide is a more serious crime than homi- from 1 percent to 20 percent, but average 5 per- cide. Muslims believe that God is the creator, the cent. giver of life, and He alone has the right to end it. The percentages have been reported to vary However, some radical Muslim groups interpret from 3 percent to 60 percent in other countries. their beliefs to justify TERRORISM AND SUICIDE.In In Canada, the only country with a national sur- committing suicide, a person violates his kismet, veillance system for murder-suicide, experts or destiny, which is preordained by God. The report that about 10 percent of homicide offend- faithful Muslim awaits his destiny; he does not ers committed suicide. snatch it from the hands of God. While there are The variation in homicide-suicide rates is some suicides in Muslim countries, strong reli- related to homicide rates, i.e., the higher the gious prohibitions have historically kept rates homicide rate in a region, the lower the percent- relatively low, or at least kept suicides from age of homicide-suicides. There are no national being acknowledged and recorded when they or international data for murder-suicide rates by did occur. age. This is likely due to the low base rates for all ages as well as the lack of operational definitions and surveillance systems. Musset, Alfred de (1810–1857) French Mental health experts should assess the risk poet, dramatist, novelist whose only novel was for murder-suicide in all older patients in the Confessions of a Child of His Age (1835). Autobio- presence of a history of thoughts about suicide graphical in structure and content, it mirrors the or violence, or if long-married older couples disenchantment and pessimism of the young both have health problems. Assessment can be writers of the age, the mal du siècle (“sickness of complicated for many reasons, especially since the century”). Typical of the idealization of sui- the victim, rather than the perpetrator, may be cide at the time was de Musset’s comment after the patient. The perpetrator may also resist eval- seeing a lovely view in nature: “Ah! It would be uation. The strong evidence of undetected and a beautiful place in which to kill oneself.” He myths concerning suicide 167 was content, however, merely to posture—and • The person who talks a great deal about sui- write about it. cide won’t actually attempt it. • A person who tries and fails to commit suicide Myth of Sisyphus, The Famous essay by probably will not attempt suicide again. French existentialist Albert Camus, which ana- • If a person has been very depressed for a time, lyzed the problems of life, such as whether or says there’s nothing to live for, and wants to not life is worth living. Camus wrote: “There is die, then abruptly begins to act relaxed and but one truly serious philosophical problem and cheerful, the suicidal thoughts have passed. that is suicide.” • The individual who attempts suicide has got to When he wrote The Myth of Sisyphus in 1940, be crazy. France had just fallen to the Germans, and Camus had suffered a serious personal illness • Once someone decides to kill himself, nothing and depressive crisis—but he began his essay can stop him. with suicide and ended it with an affirmation of • Statistics indicate that suicide occurs mostly individual life, in and for itself, as desirable be- among the very wealthy because they are so cause it is “absurd,” with no final meaning or jaded and bored with life. metaphysical justification. • It cannot be suicide if the person didn’t leave a note. myths concerning suicide Over the years, • They loved each other so much, they wanted many myths have been developed regarding sui- to die together. cide. In fact, like other once-taboo subjects, fal- lacies, myths, and misconceptions seem intrinsic None of these popular myths about suicide is to suicide. Unfortunately, they often do great true, but each one is still widely believed by most damage. Several of the more prevalent and inac- people. curate myths surrounding the topic of suicide include:

N

National Association of Social Workers National Hopeline Network A national toll- Professional association that is a good source of free suicide (1-800-SUICIDE; 1- recommendations for suicide information. The 800-784-2433) that links local centers around group encourages the public to call for referrals, the country to serve the needs of the depressed offers aid in social work, social welfare, and and suicidal public. A call to 1-800-SUICIDE will , arranges interviews, and supplies automatically route the caller to the nearest local statistics, newsletter, and monthly newspaper crisis line or mental health center. The network HASW News. is managed by the KRISTIN BROOKS HOPE CENTER. For contact information see Appendix I. National Institute of Mental Health (NIMH) National Center for Health Statistics Federal institute that has been active over many (NCHS) Federal agency responsible for gath- years in studying the multifaceted problems ering and maintaining statistics about suicide. relating to suicide and suicide prevention; as a The NCHS is part of the Centers for Disease division it has always been the main source of Control and Prevention, U.S. Department of funding in research into the etiology and treat- Health and Human Services—the federal gov- ment of suicide and the dissemination of infor- ernment’s principal vital and health statistics mation to those involved in working with agency. suicidal persons. Since 1960, when the National Office of Vital Statistics and the National Health Survey merged National Mental Health Association The to form NCHS, the agency has provided a wide oldest, largest nonprofit agency addressing all variety of data with which to monitor the aspects of mental illness, including suicide. nation’s health. Its data systems include infor- There are more than 340 affiliate groups nation- mation on vital events as well as information on wide. suicide, means of death, health status, lifestyle For contact information see Appendix I. and exposure to unhealthy influences, the onset and diagnosis of illness and disability, and the National Organization of People of Color use of health care. Against Suicide A nonprofit organization These data are used by policymakers in gov- founded by three African-American suicide sur- ernment, by medical researchers, and by others vivors designed to bring suicide and DEPRESSION in the health community. NCHS is located in awareness to minority communities that have Hyattsville, Maryland, with offices in Research historically been discounted from traditional Triangle Park, North Carolina, and with a CDC- awareness programs. liaison office in Atlanta, Georgia. According to the Surgeon General’s 1999 For contact information, see Appendix I. report on suicide, the rate of suicide among

169 170 National Self-Help Clearinghouse

African-American men increased 105 percent 2001, Satcher unveiled a national blueprint of between 1980 and 1996. In accordance with the goals and objectives to prevent suicide, the Surgeon General’s Call to Action to Prevent Sui- eighth leading cause of death in the United cide, the group’s objectives will be to: States. The document established 11 goals and 68 measurable objectives for public and private • Educate those who work in the field of coun- sector involvement to prevent suicides and seling and education attempts, as well as reduce the harmful afteref- • Provide insight on depression and other brain fects on families and communities. disorders “Suicide has stolen lives and contributed to • Share feelings and methods of coping with the disability and suffering of hundreds of thou- survivors sands of Americans each year,” Satcher explained. “Only recently have the knowledge • Educate bereaved family members and friends and tools become available to approach suicide • Educate those who work with young adults as a preventable problem with realistic opportu- on a daily basis nities to save many live.” • Share information on suicide prevention and The public health approach laid out in his intervention national strategy represents a rational and orga- • Convey a message of hope nized way to marshal prevention efforts and ensure that they are effective. The HHS collabo- For contact information, see Appendix I. rated with key advocacy groups representing clinicians, researchers, and survivors to develop National Self-Help Clearinghouse Co- the goals and objectives. The goals and objec- founded in the mid-1970s by Dr. Alan Gartner tives lay out a framework for action and guide and Dr. Frank Riessman, both pioneers in the development of an array of services and pro- self-help field, this organization provides a com- grams. It strives to provide direction to efforts to plete list of self-help groups nationwide. modify the social infrastructure in ways that will affect the most basic attitudes about suicide and that will also change judicial, educational, A National Strategy for Suicide Prevention social service, and health care systems. The 68 program that represents the combined work of specific objectives contained in the report advocates, clinicians, researchers, and survivors include: around the nation designed to prevent suicide and guide development of an array of preventive • Implementing integrated community-based services and programs. It is designed to be a cat- suicide prevention programs that build life alyst for social change with the power to trans- skills, beliefs, and values, and connections to form attitudes, policies, and services. family and community support known to In 1999, Surgeon General David Satcher reduce the risk of suicide released A Call to Action to Prevent Suicide, a mes- • Incorporating suicide-risk screening at the pri- sage to the nation that included a set of recom- mary health care level mendations derived from a national conference held in Reno, Nevada, in 1998. At that time, the • Increasing the number of states that require Call to Action included 15 recommendations that health insurance plans to cover mental health provided the context for the development of the and substance abuse care on a par with cover- National Strategy to Prevent Suicide. age for physical health care As part of his ongoing effort on the National • Providing treatment for more suicidal persons Strategy for Suicide Prevention, on May 2, with mental health problems Nazi concentration camps 171

• Developing technical support centers to the National Center for Health Statistics reported increase the capacity of states to implement that the three fastest-rising causes of death and evaluate prevention programs among Native Americans, in order of frequency, • Increasing availability of comprehensive sup- were cirrhosis of the liver, suicide, and homicide, port programs for survivors of suicide all of which could be traced to alcoholism. The same report estimated that the incidence of • Increasing the number of professional and drinking among Indians was double that among volunteer groups as well as faith-based com- the general population. munities that integrate suicide prevention into There have been numerous attempts to their ongoing activities explain why the problem of alcoholism is so • Improving suicide prevention education and great among Native Americans, and in these training for health care professionals, coun- attempts, there has been a tendency to ignore selors, clergy, teachers, and other key “com- the diversity of the population. Native Ameri- munity gatekeepers” cans in North America comprise a large number • Increasing the number of television programs of distinct peoples with unique cultures and and movies that accurately and safely depict world views. suicide and mental illness The major cause of drinking problems and • Implementing a national violent death report- high rates of both homicide and suicide among ing system that includes suicide Native Americans in the United States and Canada is probably sociocultural stress, with a Future installments of the national strategy will lack of identification with white society and a be released as work is completed. Currently, rejection of its goals. As Indian traditions have about 25 states have begun efforts to enact their been weakened and family relations disturbed, own suicide prevention strategies. Native Americans experience powerlessness and Collaborators who developed the goals and anxiety. objectives included the SUICIDE PREVENTION AND The most promising methods of handling ADVOCACY NETWORK (SPAN), the AMERICAN FOUN- problems concerning alcoholism, suicide, and DATION FOR SUICIDE PREVENTION, the AMERICAN homicide should include Native Americans in the ASSOCIATION OF SUICIDOLOGY, and hundreds of planning and implementation of their own pro- individuals working at state, tribal, and local lev- grams on a community (tribal) basis. It is im- els to prevent suicide. The U.S. Air Force con- portant, for therapists, social workers, and tributed significantly to the effort by providing a counselors to be sensitive to tribal cultures and model for comprehensive community-based sui- variations from tribe to tribe. Interestingly, some cide prevention programs and its direct support specifically Indian Alcoholics Anonymous groups of the strategy development process. have integrated elements of their traditional cul- tures into the AA format and setting, and they have achieved more success than standard AA Native Americans According to the U.S. Cen- programs. ters for Disease Control, suicide rates for Native Americans from 1979 to 1992 were 1.5 times higher than the national average. However, Nazi concentration camps Despite the some experts question this because of the diffi- heroic defense mechanisms by those imprisoned culty in discerning any one common Native in the infamous Nazi concentration camps many American suicide pattern and the absence of any prisoners committed suicide. Thousands of JEWS report of suicide incidence in many studies of from Eastern Europe, for example, were sent to Native American groups. Nevertheless, in 1972 TREBLINKA to be exterminated. Most realized 172 Nero they had no hope and were destined never to Research has shown that more than 95 per- leave the camp alive. Numb to everyone and cent of people who committed suicide have low everything around them, one by one they began levels of serotonin in certain brain regions, and completing suicide. Their deaths served as an serotonin deficiency is characteristic of those affirmation of their freedom to control their own who make the most dangerous suicide attempts. lives and deaths. These suicidal acts led to a sol- People who succeed at suicide are the ones who idarity of sorts, and those who chose to remain plan the most carefully, rather than acting alive helped those who wanted to die quickly. impulsively—and low serotonin occurs three There are no reliable statistics available on times more often in those who plan the most how many people opted for suicide while sub- carefully. jected to the brutalities of life in the Nazi camps. However, simply having low levels of sero- tonin alone does not guarantee a person is going to attempt suicide. Instead, low levels are linked Nero (A.D. 37–68) Roman emperor who fled Rome with enemies hard on his heels. He took to a person’s predisposition to commit suicide refuge in a villa several miles outside the city, rather than definite cause that triggers suicidal where four faithful servants insisted that he behavior in every case. commit suicide honorably, rather than fall into Researchers aren’t sure what causes serotonin the hands of those who had seized power in levels to drop, although the condition is probably Rome. affected by a number of factors, including genet- As he watched the men prepare his funeral ics, diet, drugs and alcohol, gender, and age. pyre, he muttered through tears, “Qualis artifex Unfortunately, it’s not possible for patients to pereo!” (“How great an artist dies here!”) Nero simply go to their family doctor for a serotonin actually had himself killed by an attendant. test. Further research is needed to find more During his lifetime, he had caused several sui- direct tests of serotonin levels. cides, including those of his teacher SENECA, the poet LUCAN, and Petronius, thought to be the New Jersey Among those states ranked by author of the Satyricon. These were all compul- suicide rates per 100,000 population (1999), sory suicides in lieu of execution. New Jersey, despite its dense population, was far below the national average that year, with a rate of 6.9 suicides per 100,000. The U.S. suicide rate Netherlands See HOLLAND. in 1999 was 10.7 per 100,000. neurobiology of suicide The link between certain brain chemicals and suicide has been sus- New Testament Biblical suicides are rare; pected for some time. In particular, the levels of there is only one instance reported in the New serotonin—a brain neurotransmitter important Testament, that being the death of JUDAS ISCAR- in a wide range of body processes and emotions, IOT, reported simply and briefly in the Book of including DEPRESSION—is considered a possible Matthew, 27:5—“he went and hanged himself.” predictor of suicide. Indeed, some research has found that people with low levels of serotonin Nietzsche, Friedrich Wilhelm (1844–1900) are six to 10 times more likely to commit suicide German philosopher who was profoundly moral than are people with normal levels. Three differ- and religious. Nietzsche was regarded in his own ent measures of serotonin function that are time as an Antichrist because of his rejection of completely unrelated all show the same thing— time-honored values. a deficiency in patients with a history for more He often contemplated suicide and wrote, lethal suicide attempts. “The thought of suicide is a strong consolation: it Norway 173 helps to get over many a bad night.” He did not, After reportedly canceling their home nursing however, advocate suicide as a solution to all care, Chester and Joan overdosed on sleeping life’s problems, noting, “Suffering is no argu- pills. The contents of the suicide note, which ment against life.” asked that they not be resuscitated, indicated that the Nimitzes had given considerable thought to ’night, Mother Marsha Norman’s Pulitzer their decision and that they were not suffering Prize–winning drama about a young woman from DEPRESSION or another type of MENTAL ILL- with epilepsy who threatens suicide to her NESS, but that they made the rational decision to mother at the beginning of the play. She then take their lives because their health problems proceeds to get her mother’s life in order before severely limited the quality of their lives. she commits the act. During the tense, contro- versial 90-minute work, the mother, Thelma, No One Saw My Pain: Why Teens Kill Them- strongly but ineffectually tries to dissuade her selves Book about how eight families survived daughter Tessie from using the gun. The daugh- teenage suicide by Andrew E. Slaby, M.D., and ter is a person who has never realized any of her Lili Frank Garfinkel, published by W. W. Norton dreams and finds herself in a vacuum. It is a & Co. (1996). In this book, Slaby, a psychiatrist two-character close-up of suicide—not the specializing in DEPRESSION and crisis INTERVEN- actual act, but the motivations behind Tessie’s TION, profiles seven families responding to the carefully planned self-destruction. loss of a teenager and one case of failed suicide. He notes that few cries for help are followed up night time and suicide Studies have linked by doctors, teachers, suicide hotlines, or even evening hours with higher rates of suicide. Sig- the police, and charges that today’s generation nificantly more suicides do occur between noon faces serious stresses in divorce, drugs, violence, and 6 P.M., and significantly fewer between mid- and economic instability. night and 6 A.M. However, it is often difficult to determine precisely when a suicide actually took North Carolina In 1999, the state recorded a place. Researchers admit they must sometimes suicide rate per 100,000 population of 11.6. discard cases from their samples because they cannot pinpoint when a suicide occurred. For instance, if a person ingests a lethal dose of drugs North Dakota The state in 1999 had a 11.5 at 10 A.M., but doesn’t “die” until 3 P.M., when suicide rate per 100,000 population. did the person commit suicide? Norway The suicide rate in Norway is approx- Nimitz, Admiral Chester W., Jr. Naval imately one-third that of neighboring Scandina- admiral who, together with his dentist wife, vian countries DENMARK and SWEDEN, even Joan, committed a DUAL SUICIDE on January 2, though all three countries are very similar ethni- 2002. At age 86, Nimitz was described as an cally, culturally, and geographically. In Suicide intelligent, decisive, confident man whose in Different Cultures, Norman Farberow argues exceptional organizational and planning skills the lower Norwegian rate is due to its more sup- helped him to advance through naval ranks portive family environments and childrearing to become an admiral, as had his father be- practices. fore him. A submarine commander during According to the WORLD HEALTH ORGANIZATION World War II, he became chief executive for (WHO) 1995 statistics, Norway has a suicide rate a technology company after leaving the per 100,000 population of 12.6 (males 19.1 and service. females 6.2). The age group with the highest sui- 174 Notebooks cide rate per 100,000 population is 65–74; with their lives—as long as they cause no harm to a 20.6 rate. others by doing so. He did establish one condi- tion: People who have responsibilities to others Notebooks The French journalist, dramatist should not commit suicide. La Nouvelle Heloise, and novelist ALBERT CAMUs wrote in his Note- published in 1761, was highly successful. books: “There is only one liberty, to come to terms with death. After which, everything is nurses Data on the relation between occupa- possible.” Camus was awarded the Nobel Prize tion and suicide are very sparse and tend to be in literature in 1957. He died at age 47 in 1960, mixed. In general it seems that those engaged in the result of an automobile accident near Sens, work giving nurturance and help to others (in- France. cluding nurses, social workers, physicians, police officers) tend to have higher suicide rates than most other professions or occupations. notes, suicide See SUICIDE NOTES. As for their role as a key segment of the “gate- keeping” process, nurses, along with doctors, No Time to Say Goodbye: Surviving the Sui- social workers, clergy, and others, have the cide of a Loved One Nonfiction book about unique opportunity of being in a position to surviving the suicide of a spouse by Carla Fine, identify and improve the potential suicide’s dan- whose husband killed himself in 1992. Combin- gerous behavior situation. The nurse, for ing her experiences, those of other survivors, instance, who works with a family physician is and advice from mental health professionals, of central importance in both suicide treatment Fine provides a compassionate guide for dealing and reduction. Nurses are often in a position to with the guilt, anger, and confusion after the establish a meaningful relationship with the dis- suicide of a loved one. traught person. Yet, too often many nurses, not unlike doctors, are restricted by insufficient time Nouvelle Heloise, La Novel by the French and/or lack of suicide prevention-intervention philosopher JEAN-JACQUES ROUSSEAU in which he knowledge. emphasizes the natural right people have to end O obligatory suicide Ethical concept of suicide at-risk populations include psychiatrists, psy- as a personal duty. chologists, ophthalmologists, anesthesiologists, physicians, musicians, dentists, law enforcement obsession with death A clue that a person officers, lawyers, and life insurance agents. may be at risk for suicide. Poets SYLVIA PLATH and Suicide rates are higher among the employed ANNE HARVEY SEXTON, both of whom killed them- than the unemployed, and tends to increase dur- selves, appeared to have a romance with death. ing economic recessions and times of rising Sexton, who committed suicide in 1974, wrote unemployment, and decrease in times of high “Wanting to Die” (a poem published in 1966) in employment and during wars. which she describes her desire to die as “the See also POLICE SUICIDE. almost unnameable lust.” Newspaper columnist and author James Oklahoma Oklahoma ranks seventh among Wechsler recalled that his son displayed suicidal all U.S. states by suicide rates per 100,000 popu- gestures, such as almost walking into a moving lation (14.7) for the year 1999. car, driving his motor bike into a bus, and almost strangling himself on the strings of his guitar. In his book, In a Darkness, Wechsler says his son’s old age and suicide See ELDER SUICIDE. death wish remained strong—until Michael did kill himself. Wechsler wrote “. . . how often we Omega: Journal of Death and Dying Quar- failed to say or do some things that might (or terly publication, published by Baywood Pub- might not) have mattered.” lishing Company, Inc., 26 Austin Ave., Box 337, Amityville, N.Y. 11701. occupation and suicide risk The link This journal discusses suicide, , between a person’s job and risk of suicide has the process of dying, bereavement, mourning, been controversial. Some researchers have and funeral customs by contributions from pro- found that the greater the responsibility, the fessionals in universities, hospitals, clinics, old greater the risk of suicide, but a fall in status also age homes, suicide prevention centers, funeral increases the risk. Other scientists report that directors, and others concerned with THANATOL- professionals have the lowest suicide rate, while OGY and the impact of death. business and repair services, construction, agri- Omega, a rigorously peer-reviewed journal, culture, forestry and fisheries, mining, and draws contributions from the fields of psychol- entertainment and recreation had the highest ogy, sociology, medicine, anthropology, law, rates. education, history, and literature. The journal What scientists do agree on is that work in serves as a reliable guide for clinicians, social general tends to protect against suicide, and workers, and health professionals who must deal some groups are at special risk. These special with problems in suicide and bereavement.

175 176 On Suicide

On Suicide Essay by Scottish philosopher Conrad attempts suicide with a razor blade. The David Hume discussing the difficulties and con- turning point comes only when Conrad realizes tradictions in moral arguments for and against he wasn’t guilty of causing his brother’s death, the act of suicide. The famed philosopher’s essay that nobody was guilty, and that he didn’t have was published following his death in 1776, but to be the perfect son. The novel gives readers then was quickly suppressed. realistic insights into the problems of the suicidal The short essay argues against the position of mind. suicide as a crime. “The life of a man,” wrote Hume, “is of no greater importance to the uni- Oregon law The state of Oregon is the only verse than that of an oyster.” The man who com- place in the United States that specifically allows mits suicide, according to Hume, does not PHYSICIAN-ASSISTED SUICIDE if certain stringent disrupt the larger order of the universe. Hume guidelines are met. Oregon citizens approved a adds, that person “does no harm to society; he law in November 1994 that would allow legal- only ceases to do good; which if it is an injury is ized physician-assisted suicide under limited of the lowest kind.” Other 18th-century philoso- conditions. Under the Death With Dignity law, a phers agreed with David Hume’s stance that sui- person who sought physician-assisted suicide cide is the individual’s moral right. would have to meet certain criteria, including:

Oppenheim, David E. In 1910 this promi- • must have six months or less to live nent Viennese educator met in Vienna with • must make two oral requests for assistance in members of the Vienna Psychoanalytical Society dying to try to discover the mysterious causes of sui- • must make one written request for assistance cide among that city’s high school students. Luminaries in attendance included Alfred Adler, • must convince two physicians that he is sin- Wilhelm Stekel, and SIGMUND FREUD the founder cere, is not acting on a whim, and that the of psychoanalysis. Freud later said of the April decision is voluntary 27th meeting (formally called to discuss “Suicide • must not have been influenced by depression in Children”) that little was accomplished and • must be informed of “the feasible alternatives, indicated that much more work in this area including, but not limited to, comfort care, needed to be done. hospice care and pain control” • must wait for 15 days between the request Ordinary People Novel by Judith Guest later and the act made into a movie, that deals with the aftermath of a teenage suicide attempt after a 17-year-old Patients who meet all these requirements had failed in trying to save his older brother in a could receive a prescription of a BARBITURATE boating accident. No one in the upper-middle- that would be enough to cause death. Mercy class family talks about the accident, but young killings by a family member or friend would not Conrad is filled with SURVIVOR GUILT. He believes be allowed, and assisted suicides like those per- that his parents, particularly his mother, blame formed by Dr. JACK KEVORKIAN would not be him for not being able to save his brother. He allowed. Physicians would be prohibited from feels his parents wish that he’d been the son to inducing death by injection or carbon monoxide. die, since his brother seemed to be the favored The National Right to Life Committee, sup- child. ported by the ROMAN CATHOLIC CHURCH, obtained The parents of this seemingly all-American a court injunction to delay implementation of family miss all the suicidal clues and signals. the measure, and the law became stalled in the Oregon law 177 appeals process. In the meantime, the measure nally ill patients kill themselves would be a vio- was not enacted. The Oregon Medical Associa- lation of the Controlled Substances Act, and was tion originally took no stand on the matter, but not a legitimate medical use under the federal later objected to it because of what it considers drug laws. He warned that the government legal flaws. would impose severe sanctions on any doctor In the first full year after assisted suicide who wrote a prescription for lethal doses of became legal in Oregon, relatively few people medicine for a patient. requested help in dying. Only 23 actually ob- On March 26, 1998, a woman in her mid-80s tained medication to induce their death, and at died from a lethal dose of barbiturates which had least six of these patients never used the pills, been prescribed by her doctor under this law. but died a natural death. She was the first person to publicly make use of In 1997, conservatives within the Oregon physician-assisted suicide in Oregon. She had government forced approval in early June 1997 been fighting breast cancer for 20 years and of a second public referendum. This mail-in recently had been told by her doctor that she ballot procedure was held from October 15 had less than two months to live. She had been through November 4, 1997. But in a surprising experiencing increased difficulty breathing. She development, an employee of the state attorney made a tape recording in which she said that she general’s office said on November 4, 1997, that was “looking forward to” death because she the law had cleared all of the court appeals on would “be relieved of all the stress I have.” Her October 27, and was actually in force. Within 24 personal doctor would not help her end her life, hours of the announcement of the results, state so she turned to an advocacy group called Com- officials started to prepare forms for physicians passion in Dying, who found a doctor to help to record instances of assisted suicide, which her. She fell into a deep sleep about five minutes were later distributed to physicians in the state. after taking the lethal dose of pills, and died The “Request for Medication to End my Life peacefully about 25 minutes later. in a Humane and Dignified Manner” form By mid-1988, Attorney General Janet Reno required two doctors to record: reversed Constantine’s earlier ruling and stated that doctors who use the law to prescribe lethal • the patient’s medical diagnosis drugs to terminally ill patients will not be pro- • the prognosis secuted. She further noted that “there was no • the date of the first request for suicide assis- evidence that Congress meant for the DEA to tance have the novel role of resolving the profound moral and ethical questions involved in the • an assessment that the patient is capable, fully [physician-assisted suicide] issue . . . the drug informed, and acting voluntarily laws were intended to block illegal trafficking in • that the patient is aware of risks associated drugs and did not cover situations like the Ore- with the medication gon suicide law.” • that the patient has been informed of alterna- By the end of 1998, only about one Oregon- tives, such as hospice and pain management, ian per month had chosen to commit physician- and that the patient can withdraw the request assisted suicide. Although many people thought at any time large numbers of terminally ill patients would take advantage of the law, the U.S. Centers for Immediately after the law was affirmed, Thomas Disease Control found that during the calendar Constantine, the administrator of the federal year 1998, only 23 patients sought help to die Drug Enforcement Administration (DEA) during 1998. Of the 23, 15 committed suicide, announced that prescribing drugs to help termi- usually within a day of receiving the prescrip- 178 Oregon law tion. Six died from their illnesses without using The attorney general of Oregon, Hardy Myers, the medication, and two remained alive at the quickly initiated a lawsuit to have Ashcroft’s end of 1998. Further, the CDC found that gen- directive declared unconstitutional. A doctor, der, education, and health insurance status, or pharmacist, and three people who may want to fear of pain did not play an influential role in kill themselves with a doctor’s help were plain- prompting a person to seek help in dying. The tiffs. The federal district court in Oregon issued a CDC compared these 15 patients with 43 others temporary injunction to prevent the federal gov- with similar fatal diseases but who elected to ernment from enforcing Ashcroft’s interpreta- not seek help, and found a number of deter- tion of the Controlled Substances Act (CSA). mining factors that led people to seek help in In April 2002, a federal judge upheld Oregon’s dying. law allowing physician-assisted suicide, ruling These factors included concern about loss of that the Justice Department does not have the autonomy or control of bodily functions, never authority to overturn it. having married, being divorced and having led The U.S. Supreme Court unanimously ruled an independent life. Six of the 15 had to change (on June 26, 1997) that the average American doctors at least once to find one willing to write has no constitutional right to a physician- a prescription. Of the 15 who committed suicide, assisted suicide, which means that New York and all were white; eight were male, with a median Washington laws banning such suicides are con- age of 68 years. stitutional. On the other hand, the court implied Doctors usually prescribed a fatal dose of Sec- that there is no constitutional bar that would obarbital, along with an antivomiting medicine prevent a state from passing a law permitting so that the barbiturate would be properly physician-assisted suicide, which is what Oregon adsorbed. Everyone who committed suicide did. This means that the legality of physician- became unconscious within five minutes, and assisted suicide must be fought on a state- most were dead within an hour. by-state basis. Chief Justice Rehnquist wrote: During the year 2001, 21 Oregonians ended “Throughout the nation, Americans are engaged their lives with the help of the assisted suicide in an earnest and profound debate about the law (six fewer than in the previous years). Over morality, legality and practicality of physician- the first three years that the law has been in assisted suicide. Our holding permits this debate place the number of patients choosing legal PAS to continue, as it should in a democratic society.” has remained stable, at about six per 10,000 The Supreme Court decision was very nar- deaths. College-educated patients were much row, ruling only on whether the public had a more likely to choose physician-assisted suicide general right to assisted suicide. The case was than were those with less than a high school originally brought by six terminally ill individu- diploma, by a factor of 12 or more. als in intractable pain who wanted access to On November 5, 2001, Attorney General assisted suicide, but by the time the court heard John Ashcroft wrote a letter to Asa Hutchinson, legal arguments, all six had died. Because the chief of the Drug Enforcement Administration, court was unable to rule on whether terminally declaring that assisting a terminally ill patient to ill individuals should have a right to assisted sui- commit suicide is not a “legitimate medical pur- cide, they made a decision on whether citizens pose” for federally controlled drugs. He said that generally had that right. any physicians who use drugs to help patients Many of the justices indicated that certain die face suspension or revocation of their groups within society might have a constitu- licenses to prescribe federally controlled drugs. tional right to access to suicide (such as people This reversed an earlier order in June 1998 by who are terminally ill and in intractable pain). If his predecessor, Janet Reno. a case were brought by such a person, the court Otto, Emperor 179 might find in that person’s favor. The problem and CBS Records were sued in Los Angeles will be to find a person who can survive a ter- Superior Court by the boy’s parents. minal illness long enough for the case to make it Osbourne, 37, said his lyrics were misinter- to the Supreme Court. preted, that “They’re really anti-suicide, anti- drink and drugs.” McCollum’s father, Jack, charged that the music was an “invocation to the organic suicide A suicide attempt at a devil.” On August 7, 1986, Judge John Cole dis- response to serious physical illness or pain. missed the lawsuit, saying that the McCollum attorney failed to show why Osbourne’s songs Origen of Alexandria (ca. A.D. 185–ca. 254) should not be provided First Amendment protec- As a youth, Origen experienced the martyrdom tion. Judge Cole was quoted by the wire services of his father in A.D. 202 and was possessed by a as saying: “Trash can be given First Amendment desire to suffer the same fate. His mother pre- protection, too.” vented him from self-destruction, but he still victimized himself through self-castration—to other-driven suicide Completion of suicide become a eunuch for the kingdom of heaven. As that is impelled by another person. historian George Rosen notes: “Perhaps his self- castration . . . may be interpreted as a symbolic Otto, Emperor German emperor referred to surrogate for voluntary death.” After years of by JOHANN WOLFGANG VON GOETHE as the one teaching in Caesarea in Palestine, he died as a person who, in the writer’s youth, he had so result of tortures inflicted during the Decian per- admired. Since the Emperor Otto had stabbed secution. himself, Goethe decided that if he were not brave enough to die in such a manner, he was- Osbourne, Ozzy (1948– ) Former leader n’t brave enough to die at all. Goethe wrote: “By of the rock group Black Sabbath who produced this conviction, I saved myself from the purpose, the album “Speak to the Devil” and a macabre or indeed, more properly speaking, from the song called “Suicide Solution,” which contains whim of suicide.” Goethe, who wrote the auto- such lines as, “Suicide is the only way out; don’t biographical novel The Sorrows of Young Werther you know what it’s really about?” —acclaimed all over Europe, with its themes of In October 1984, John McCollum, 19, a fan of martyrdom, unrequited love, and excessive Osbourne’s, put on the album and shot himself sensibility—died at the age of 83, asking for in the head with his father’s pistol. Osbourne more light.

P paraquat A deadly poisonous insecticide first SURVIVOR GUILT is also usually strong in the synthesized in 1882, but only recognized as an case of surviving parents. While nobody can herbicide in 1955 by ICI (now Zeneca). Its minimize the impact of a suicide and nobody can extreme toxicity and its involvement in suicide wholly free survivor parents of the anger, guilt, around the world (700 cases in 10 years in remorse, and pain they feel, there are today a Malaysia alone, for example) has led to bans and number of self-help groups nationwide that are strict controls. Poisoning by paraquat causes set up to help parents (as well as other survivors) death within several hours to a few days as a mourn and heal. Edwin S. Shneidman coined result of multiple organ failure. There is no anti- the term POSTVENTION to describe this help, dote. which means giving survivors the kind of sup- port they need immediately after a suicide and, in time, assisting them in coming to terms with parasuicide A nonfatal act in which a person the tragedy. deliberately causes self-injury or ingests a sub- Aside from professional help provided by doc- stance in excess of any prescribed dosage. The tors, psychiatrists, and psychologists, surviving term was suggested as a replacement for the parents need the sharing, caring, and under- phrase ATTEMPTED SUICIDE, which was often hard standing of others in a similar situation. They to decide in terms of intention, consciousness, need to be able to talk with other people who extent of injury, extent of effort to injure, differ- will not judge them, not patronize them, but entiation from substance abuse, and other fac- through their own experiences know how to lis- tors, but is now out of vogue. ten intelligently. The term was introduced in 1969 by psychia- trist Norman Kreitman of the Royal Edinburgh Hospital as a word that described the action partial suicide Nonfatal self-destructive act without having to decide a person’s intent. Para- sometimes called self-mutilation. This is, prop- suicide may be a genuine attempt by persons to erly speaking, a “quasi-suicidal attempt.” kill themselves, or it has been suggested that it can be a cry for help, as the only way that dis- passive euthanasia Intentionally not prevent- tress is recognized. ing death in those who suffer from a terminal See ABUSE, SUBSTANCE. condition. Passive EUTHANASIA involves letting someone die from a disease or injury, whereas parents of suicides While a suicide almost active euthanasia involves taking active steps to always concerns several other people, parents kill a person. For example, passive euthanasia usually feel most responsible. This is especially includes removing life support equipment (such true when a teenager or young adult commits as turning off a respirator), stopping medical pro- suicide; parents blame themselves regardless of cedures or medications, stopping food and water what may have caused the tragic action. and allowing the person to dehydrate or starve to

181 182 Peau de Chagrin, La death, or not performing cardio-pulmonary on mental symptoms, including suicidal tenden- resuscitation (CPR) and allowing a person whose cies, to which young girls are prone if they suf- heart has stopped to die. fer menstrual problems. These symptoms, Perhaps the most common form of passive particularly as related to suicidal behavior, have euthanasia is to give a patient large doses of been interpreted as an example of psychopathic morphine to control pain, in spite of the likeli- collective behavior. hood that the painkiller will suppress respiration See also MILETUS, THE MAIDENS OF. and cause death earlier than it would otherwise have happened. Such doses of painkillers have a Perlin, Seymour, M.D. Editor of the defini- dual effect of relieving pain and hastening death. tive collection, A Handbook for the Study of Suicide. Administering such medication is regarded as Dr. Perlin is emeritus professor of psychiatry and ethical in most political jurisdictions and by most behavioral science, Department of Psychiatry, medical societies. George Washington University Medical Center These procedures are performed (or not per- in Washington, D.C. He is also founder and past formed) on terminally ill, suffering persons and president of the AMERICAN ASSOCIATION OF SUICI- on individuals with massive brain damage who DOLOGY. are in a coma from which they cannot possibly regain consciousness. personality A number of studies have shown that a large percentage of young suicidal peo- Peau de Chagrin, La Essay written by French ple—both attempters and completers—have author HONORÉ DE BALZAC in 1831 to support the come from disrupted or disturbed home envi- romantic dogma that the intense, true feeling ronments, lacking in stability and support. For of life does not survive into one’s middle years. instance, parents may be divorced, constantly Balzac said the alternatives were “To kill the quarreling, or one or both parents absent emotions and so live on to old age, or to accept because of death or desertion. Sometimes a par- the martyrdom of our passions and die ent is alcoholic, or a child abuser. Children who young . . .” Interestingly, Balzac died in 1850 at grow up in these kinds of unstable or broken age 51. homes can feel abandoned and lonely, filled with resentment and anger at both the parent(s) who have hurt them and at themselves. penacide Completion of suicide to end In addition, some PERSONALITY DISORDERS, intense pain. resulting in serious mental illnesses, are trace- able to chemical changes in the brain. One major Penitentials A code of penalties for moral danger signal of possible suicide is a change in offenses written by Egbert, archbishop of York. personality or behavior, such as a tendency for a The Penitentials appeared in the mid-eighth cen- person to become uncommunicative and to iso- tury, and made an exception to the church posi- late him- or herself. There is a noticeable loss of tion refusing burial in consecrated ground to interest in friends, family, and activities and suicides if the person was insane. There was, decreased sexual desire. throughout the medieval period, a growing Studies show an affective disorder is one of recognition that mental and emotional disorder the most important factors that promoted risk may lead to suicide. for suicidal behavior in adults and children.

Peri parthenion Fragmentary Hippocratic personality disorders Persons with personal- work (On the Diseases of Maidens) that comments ity disorders are prone to ATTEMPTED SUICIDE— physician-assisted suicide 183 especially emotionally immature people with In more recent times, Immanuel Kant called borderline personality disorder or antisocial per- suicide “an insult to humanity.” Dietrich Bon- sonality disorder, who tolerate frustration poorly hoeffer viewed suicide as a sin in that it repre- and react to stress impetuously with violence sented a denial of God. and aggression. Modern-day attitudes toward suicide are no Psychological autopsies found that between less complex and controversial than those of ear- 31 and 57 percent of completed suicides were lier times. diagnosed as having a personality disorder. Moreover, 71 percent of personality-disordered physical health, loss of It is not uncommon inpatients had a history of suicidal behavior. for someone who gets sick to view him- or her- Some people with personality disorders have self as being less than a complete person. This a history of excessive alcohol consumption, drug can often lead to serious DEPRESSION and, ulti- abuse, or criminal behavior. An inability to form mately, suicidal thoughts. Loss of physical health mature, lasting relationships typical of these dis- can be as psychologically damaging or devastat- order may lead to reduced social opportunity, ing as a loss of identity. However, no studies are loneliness, and depression. This may account for available to indicate what percent of suicides the large number of attempted suicides among result from loss of physical health. So many separated or divorced people. other psychological and social factors affect such suicides that no single causal force can be pin- philosophers and suicide Throughout his- pointed. tory the concept of suicide has fascinated philosophers, who influenced peoples and physician-assisted suicide Suicide in which a societies. doctor helps a person to kill himself. Some peo- For example, Greek and Roman philosophers ple who decide that they wish to complete sui- discussed suicide and usually endorsed it within cide are physically unable to accomplish the act, specific limitations. The STOICS were perhaps and would need assistance from their physician. staunchest of the pro-suicide group, led by their In a physician-assisted suicide, a doctor sup- founder ZENO. The EPICUREANS considered that plies information or the means of complete sui- one’s destiny was a personal choice. CATO, Pliny cide (such as a prescription for a lethal dose of and SENECA all thought the choice of suicide was sleeping pills, or a supply of carbon monoxide acceptable. However, there have been many dis- gas) to a patient so that they can commit suicide. senters among philosophers. PLATO, for one, Throughout North America, completing sui- strongly opposed suicide, as did Virgil, Ovid and cide or attempting to commit suicide is not a Cicero. legal offense. However, helping another person As time went on, new views of suicide commit suicide is a criminal act. The only excep- became popular. JOHN DONNE reacted against the tion is Oregon which—under severe restric- existing attitudes of the church toward suicide tions—allows people who are terminally ill and and viewed the act as neither a violation of the in intractable pain to get a lethal prescription law nor against reason (though he considered it from their physician. Physician-assisted suicide contrary to the law of self-preservation). Other is not specifically mentioned in the laws of North 17th-century philosophers and secular writers Carolina, Utah, and Wyoming. In Canada, phy- echoed Donne’s position, including DAVID HUME, sician-assisted suicide is illegal throughout Baron de Montesquieu, Voltaire, and JEAN- the country. JACQUES ROUSSEAU defended suicide under cer- Oregon citizens approved a law in November tain conditions. 1994 that would allow legalized physician- 184 physicians assisted suicide under limited conditions. Under ian, who has promoted this type of intervention, the Death with Dignity law, a person who and assisted at the deaths of hundreds of sought physician-assisted suicide would have to patients. Originally, he hooked his patients up to meet certain criteria, including: a machine that delivered measured overdoses of medications after the patient pushed a button to • must have six months or less to live initiate the sequence. More recently, he pro- • must make two oral requests for assistance in vided carbon monoxide and a face mask so that dying his patient could trigger the flow of gas. • must make one written request for assistance According to a recent decision by the U.S. Supreme Court, which reversed the decisions • must convince two physicians that he is sin- rendered in two lower courts, the justices found cere, is not acting on a whim, and that the no constitutionally protected right to physician- decision is voluntary assisted suicide. More than 50 health care groups • must not have been influenced by depression had signed an amicus (“friend of the court”) • must be informed of “the feasible alternatives, brief opposing physician-assisted suicide. The including, but not limited to, comfort care, high court had accepted two cases from the hospice care, and pain control” Ninth and Second U.S. Circuit Courts of Appeals, • must wait for 15 days between the request both of which raised the question of whether a and the act constitutional right exists to physician-assisted suicide. The two circuit courts had found that Patients who meet all these requirements the state laws banning physician-assisted suicide could receive a prescription of a BARBITURATE in Washington and in New York violated the that would be enough to cause death. Mercy protections of the 14th Amendment of the killings by a family member or friend would not Constitution. The Supreme Court’s decision be allowed, and assisted suicides like those per- acknowledges that a constitutional right to formed by Dr. JACK KEVORKIAN would not be physician-assisted suicide does not exist. allowed. Physicians would be prohibited from The issue of assisted suicide has highlighted inducing death by injection or carbon monoxide. the deficits in care of the dying and focused The National Right to Life Committee, sup- attention on the preeminent obligation of health ported by the ROMAN CATHOLIC CHURCH, obtained care professionals to provide responsible, a court injunction to delay implementation of respectful, appropriate, and ethically sound care. the measure, and the law became stalled in the The AMERICAN MEDICAL ASSOCIATION and the appeals process. In the meantime, the measure American Nurses Association believes that doc- was not enacted. The Oregon Medical Associa- tors and nurses (respectively) should not partic- tion originally took no stand on the matter but ipate in assisted suicide, since this violates ethical later objected to it because of what it considers traditions of these professions. legal flaws. See OREGON LAW. In the first full year after assisted suicide became legal in Oregon, relatively few people physicians Medical doctors have one of the requested help in dying. Only 23 actually highest suicide rates of any professional group. obtained medication to induce their death, and The number of doctors who commit suicide in at least six of these patients never used the pills, the United States each year—between 100 and but died a natural death. 150—is more than the size of an entire graduat- The most famous example of a physician- ing class from an average-size medical school. assisted suicide is that advocated by Dr. Kevork- More doctors die by suicide each year than from Plath, Sylvia 185 drownings, plane crashes, accidents, and homi- men was HANGING/strangling/suffocation (19.1 cides combined. percent). Solid and liquid poisons was the third Unlike the general population, medical doc- most common method for men (7 percent). tors are much more likely to use drugs, not guns, to kill themselves, and they tend to do so during Plath, Sylvia (1932–1963) American poet the most productive years (the mean age is 48). and novelist whose best-known work is the The suicide rate for male physicians is estimated novel The Bell Jar, first published pseudony- at 1.15 times greater than the expected rate of mously in England in 1962. A semi-autobio- the general male population (some studies indi- graphical work, the novel is about a woman cate the rate is double.) For women physicians, caught up in a crisis so severe that she attempts the rate is three times higher than the expected suicide. It recounts the heroine’s rebellion rate of the female population. In the 25 to 39 age against the constricting forces of society and her group, 26 percent of all physicians’ deaths are emotional and psychological conflicts resulting attributed to suicide. from family tensions. Similar themes may be found in Sylvia Plath’s poetry. pills, as suicide method In the past, the most Sylvia’s surface perfection masked grave per- common method of suicide for women was poi- sonal problems, some of which may have begun soning by solids or liquids (36.7 percent), fol- with the death of her college professor father lowed by firearms (and explosives) (30.2 when she was eight. During the summer follow- percent). By 1980, firearms and explosives were ing her junior year at Smith, after returning the methods most often used by women (38.6 from a stay in New York City, where she had percent), followed by poisoning by solids, been a student “guest editor” at Mademoiselle including pills, and liquids (26.9 percent). magazine, Sylvia nearly succeeded in killing her- Historically, suicidal women seemed to prefer self by swallowing sleeping pills. She later ingesting a lethal dose of drugs, swallowing pills described this experience in The Bell Jar. or poison, or inhaling gas. The speculation was After a period of recovery involving elec- that women didn’t want to shed their blood or troshock and counseling, Plath resumed her aca- disfigure themselves, thus they would choose a demic and literary efforts, graduating from more passive means of self-destruction. Others Smith summa cum laude in 1955 and awarded a theorized that women opted for using a passive Fulbright scholarship to study at Cambridge, method, such as pills, because they really didn’t England. It was in England where she met and want death by suicide, rather they were “crying married Ted Hughes. out for help,” calling attention to an intolerable In 1959, after suffering one nervous break- situation. This increase in firearms as a method down and suicide attempt, from which Plath among female suicides indicates a move toward recovered, and after a brief teaching stint at more lethal methods, say authorities—that is, Smith, she and her husband and two children methods with less chance for intervention or moved to England. Her marriage to English poet rescue. Ted Hughes subsequently ended. As of 1999, both men and women still killed On February 11, 1963, on her third attempt, themselves with firearms more often than any Sylvia Plath killed herself with cooking gas at the other method; 61.7 percent of men used this age of 30. Poems that were collected after her method, as did 36.9 percent of women. For suicide ensured her posthumous reputation as a women, the next most common method was by major poet. These poems, a haunting record of ingesting solid and liquid poisons and pills (30 her encroaching mental illness, include the vol- percent); the next most common method for umes Ariel, Crossing the Water, and Winter Trees. 186 Plato

Plato (ca. 428–ca. 348 B.C.) Greek philoso- later, she was given another five years’ probation pher who founded the famous Academy at for forging prescriptions for Valium. The day Athens, whose writings include The Apology, before her death, Plato went on the Howard Stern Phaedo and The Republic. His great teacher, radio show in New York to deny a former room- SOCRATES, was one of the most notable suicides mate’s claims that she was taking drugs. Plato of ancient times. Plato quoted Socrates as saying insisted she had been sober for about 10 years, before his death (which was really a form of exe- but said she had taken painkillers when her wis- cution ordered by the rulers of Athens), “No dom teeth were removed four months earlier. man has the right to take his own life, but he must wait until God sends some necessity upon poets Throughout the years, there has been a him, as he has now sent me.” seemingly endless number of poet-suicides. Plato, and his own student, ARISTOTLE, both Toward the end of the 18th century, the roman- disapproved of suicide. Plato looked upon peo- tics made suicide a major theme and preoccupa- ple as the “chattels” of God, and, as such, they tion, if not obsession. In the Middle Ages, the had no right to destroy themselves. ALFRED AL- church’s influence was so powerful and per- VAREZ, in The Savage God, tells us that Plato used vasive that suicide was simply not a possible the simile of the soldier on guard duty who subject. It was during the Renaissance and must not desert his post, and also that of man as Reformation that the religious taboos begin to the property of the gods, who are as angry at lose their power so that poets could again discuss our suicide as we would be if our chattels de- suicide. JOHN DONNE wrote the first book in En- stroyed themselves. Life itself was the discipline glish on the subject, BIATHANATOS (not published, of the gods. however, in his lifetime). It was after the rationalists, such as VOLTAIRE Plato, Dana Former child star whose drug- and DAVID HUME, attacked the suicide taboos, overdose death was ruled a suicide. The 34-year- superstitions, and primitive punishments, that old former star of the NBC sitcom Diff’rent Strokes the laws were slowly changed; along with shift- died May 8, 1999, while visiting her fiancé’s ing emotional attitudes, the stage was set for the parents in Oklahoma. romantic era with its sublime agony. Police initially said she died of an accidental Since then the world has witnessed poet-sui- THOMAS CHATTERTON overdose of a painkiller and VALIUM, but the state cides who include: , Gerard later found that she had fatal concentrations de Nerval, VIRGINIA WOOLF, HART CRANE, DYLAN of the muscle relaxant Soma and a generic form THOMAS, Delmore Schwartz, MALCOLM LOWRY, of the painkiller Lortab in her body, together JOHN BERRYMAN, Cesare Pavese, Randall Jarrell, with the equivalent of seven tablets of the mus- SYLVIA PLATH, ANNE HARVEY SEXTON, and the Russ- cle relaxant in her stomach. The death was ruled ian poets Mayakovsky, Yesenin, and Tsvetayeva. a suicide because of the high level of drugs and There have been countless others. her history of suicidal tendencies, although she did not leave a suicide note. poison, as suicide method Among the five Plato had been prescribed both drugs, accord- most popular or preferred methods used to com- ing to her fiancé, for back injuries she suffered in mit suicide, poison ranks second among women a car accident. and third among men. Her life became less successful after her TV The U.S. Centers for Disease Control uses the show was canceled in 1984. She was arrested classifications “poisoning by solids or liquids,” seven years later for robbing a Las Vegas video which includes poisoning by drugs or pills. store and placed on five years’ probation. A year See also PILLS, AS SUICIDE METHOD. pontifex maximus 187

Pokorny, Alex D. Author-psychiatrist, whose police officers say they are reluctant to tell supe- contributions to the literature of suicide includes riors they are having problems for fear it may “Suicide Rates in Various Psychiatric Disorders,” destroy their careers. Instead, they try to solve Journal of Nervous Mental Disorders (1964) their problems by themselves, which often leads 139:499–506. He investigated the suicide rate to alcohol or substance abuse and suicide. among former patients of a psychiatric service of Experts suspect that many suicides by police a Veteran’s Hospital (in Texas) over a 15-year go unreported to avoid stigmatizing families and period and calculated the suicide rates on the to allow them to collect insurance claims and basis of 100,000 such patients per year as fol- other compensation. lows: DEPRESSION, 566; SCHIZOPHRENIA, 167; Typically, the officer who commits suicide is a neurosis, 119; PERSONALITY DISORDER, 130; ALCO- young white man working patrol, abusing alco- HOLISM, 133; and organic brain syndrome, 78. He hol, separated or seeking a divorce, and experi- noted that, as a subgroup, manic-depressive encing a recent loss or disappointment. Often he patients had the highest rate. is coping with a domestic dispute, and 90 per- cent of the time the officer is drinking heavily when he shoots himself. police suicide Law enforcement officers rep- See ABUSE, SUBSTANCE. resent a career that carries one of the highest risks for suicide of all. Every 24 hours, one police officer commits suicide, and a third of all active politics There have been a number of studies duty and retired officers suffer from post-trau- on the link between presidential elections and matic stress syndrome (PTSD). In fact, twice as suicide. The various studies, while generally many police officers (about 300 each year) com- inconclusive in their results, indicate that there mit suicide as are killed in the line of duty, is usually a slight drop in deaths by suicide prior according to a study by the National Association to U.S. presidential elections—and a slight of Police Chiefs. increase in the number of deaths by suicide fol- Undiagnosed PTSD leads to feelings of hope- lowing such elections. There was a noticeable lessness, despair, and after many years, suicide. increase in suicides in the United States follow- One recent study revealed that New York City ing the assassination of President John F. officers kill themselves at a rate of 29 per Kennedy in 1963. 100,000 a year—more than double the national suicide rate of the general U.S. population (12 Pollock, Jackson (1912–1956) American per 100,000). Most of the victims of police sui- painter who died on August 11, 1956, in East cide are young men with no record of miscon- Hampton, New York, in an auto accident be- duct, who shoot themselves while off duty. lieved to have been deliberate. Many authorities While there are no government statistics on called the accident “autocide.” Pollock, an alco- the suicide rate of police officers, the Occupa- holic, was filled with self-doubt and anxiety. tional Safety and Health Administration reports that the police have a life span eight to 11 years shorter than other Americans. The high-stress pontifex maximus The highest priest of dynamics of the job sometimes lead officers to Roman religion and official head of the college take their own lives, and the fact that officers of pontifices. As the chief administrator of reli- walk around each day with a weapon handy at gious affairs, he regulated the conduct of reli- all times also plays a role. Alcohol is also often a gious ceremonies, consecrated temples and factor, along with troubled marriages or rela- other holy places, and controlled the calendar. tionships. As problems and stress mount, many During the time of the Roman empire and until 188 Portwood, Doris

Christianity became firmly established, the potential suicides Almost every type of per- emperor was designated pontifex maximus. son, young or old, poor or rich, white or black, After the supremacy of Christianity, the popes educated or illiterate, Christian or Jew, com- assumed the title. pletes suicide. But the person most likely to In Rome, a was refused an attempt or commit suicide is one who has previ- honorable burial according to that part of the ously tried or threatened suicide; experienced civil law administered by the pontifex maximus. chronic illness and/or isolation; suffered extreme This practice was continued into the Imperial financial stress resulting from joblessness or period, and was a vestige of earlier religious bankruptcy (or both); suffered a recent death in views. However, suicide was never a penal the family; experienced acute domestic troubles offense in Rome and in time there were, for all (such as, divorce, separation, or a broken home); practical purposes, no penalties. experienced severe DEPRESSION; been psychotic and exhibited withdrawal and confusion; been Portwood, Doris A EUTHANASIA pioneer and an active alcoholic for a number of years; chron- author of the 1978 groundbreaking book, COM- ically abused or misused addictive drugs; or has MON SENSE SUICIDE: THE FINAL RIGHT, a thoughtful had a history of suicide in the family. and honest examination of suicide. In this work, Most potential suicides leave clues to their she addressed the audience of which she was a imminent action. Sometimes these warning member—the aging—urging a reappraisal of signs are broad hints, sometimes only subtle current attitudes toward suicide in the context changes in behavior. of the elderly. She wrote: “Today, the needs of However, suicide is usually premeditated—a the individual and those of the social commu- decision that has come only after long consider- nity appear to merge, in an economic sense, on ation. While it might seem impulsive or capri- the question of old-age suicide. A planned cious, the decision is not impulsive. It is possible, departure that serves oneself, one’s family, and therefore, to spot a potential suicide if others also the state surely is worthy of decent consid- know what to look for. eration.” See also CLUES OF SUICIDE. Portwood was the author of two books for children on Chinese subjects, and had worked as poverty In Europe during the mid-19th cen- an editor in the U.S. Office of War Information tury, numerous authors who wrote about sui- in India during World War II. cide related the action to poverty, and believed At age 82 and suffering from Parkinson’s dis- that for this reason, suicide occurred more often ease, she took BARBITURATES in the presence of among the laboring poor in urban settings. two close friends and died quietly in her home Today, while poverty is certainly a public outside Portland, Oregon. problem, it is only one of the many more serious risk factors behind the overall rate of suicide postvention Term coined by suicide expert increases in the United States. EDWIN S. SHNEIDMAN, to describe the intervention Poverty would not explain the marked of others needed by all survivors of suicide increase in the contribution of young men and (attempters, families of suicides, friends, associ- women suicides since the 1950s. ates, and so on). Although the potential for the act of suicide is Postvention means extending to suicide sur- universal, there are many complex cultural, eco- vivors the caring support they need immediately nomic, and social experiences that affect and after a suicide and, in time, assisting them to shape the overall dynamics of the suicide phe- come to terms with the tragedy. nomenon. Poverty alone cannot adequately prevention 189 explain how suicide has grown to its present tress, the tension, and anguish—and then work proportions in our modern society. to treat these emotions within the suicidal per- son. Practical measures for helping highly suici- prediction of suicide At the current time there dal persons include: reduce the pain; fill the is no definitive way to predict suicidal behavior. frustrated needs; provide a viable answer to the Although researchers have identified factors that question of life’s worth; indicate alternatives in place individuals at higher risk for suicide, very life; give transfusions of hope; play for time; few people with these risk factors will actually kill increase the options; listen; involve others; block themselves. These risk factors include MENTAL ILL- the exit (for action on the suicidal person’s part); NESS, substance abuse, previous suicide attempts, and, invoke precious positive patterns of suc- a family history of suicide or of sexual abuse, and cessful coping. impulsive or aggressive tendencies. Prevention resources include psychotherapy, While many people have at least one of these counseling, outreach groups, and private as well risk factors, most of them will not complete sui- as federal agencies. Most recently, the federal cide. Moreover, suicide is a relatively rare event government developed the NATIONAL STRATEGY and it is therefore difficult to predict which per- FOR SUICIDE PREVENTION, a program that repre- sons with these risk factors will ultimately com- sents the combined work of advocates, clini- plete suicide. cians, researchers, and survivors around the See ABUSE, SUBSTANCE. nation designed to prevent suicide and guide development of an array of preventive services and programs. It is designed to be a catalyst for pregnancy and suicide While there have social change with the power to transform atti- been cases where pregnant adult and teenage tudes, policies, and services. women have committed suicide, there is no In 1999, Surgeon General David Satcher re- indication that pregnancy is a key motivator for leased A Call to Action to Prevent Suicide, a message self-destruction. Everybody gets depressed from to the nation that included a set of recommen- time to time, and certainly pregnant women— dations derived from a national conference held especially those who did not want to have a in Reno, Nevada, in 1998. At that time, the Call child—are no exception. They may experience to Action included 15 recommendations that profound feelings of worthlessness and lack of provided the context for the development of the self-esteem (which lie at the base of many severe National Strategy for Suicide Prevention. DEPRESSIONS); they sometimes take a negative As part of his ongoing effort on the National view of both themselves and their relation to the Strategy for Suicide Prevention, on May 2, world around them; and in extreme cases, 2001, Satcher unveiled a national blueprint of depressed pregnant women have a negative goals and objectives to prevent suicide, the view of the future. If their depression grows and eighth leading cause of death in the United becomes too deep, they may give up all hope. States. The document established 11 goals and These painful feelings sometimes cause 68 measurable objectives for public and private depressed persons to blame themselves for their sector involvement to prevent suicides and condition, and they want to punish themselves attempts, as well as reduce the harmful after in various ways for the personal failings they effects on families and communities. believe they have. Sometimes the punishment “Suicide has stolen lives and contributed to takes the form of suicide. the disability and suffering of hundreds of thou- sands of Americans each year,” Satcher ex- prevention (of suicide) The best way to pre- plained. “Only recently have the knowledge and vent suicide is to learn what is causing the dis- tools become available to approach suicide 190 primitive societies as a preventable problem with realistic opportu- • Increasing the number of television programs nities to save many lives.” and movies that accurately and safely depict The public health approach laid out in his suicide and mental illness National Strategy represents a rational and orga- • Implementing a national violent death report- nized way to marshal prevention efforts and ing system that includes suicide. ensure that they are effective. The HHS collabo- rated with key advocacy groups representing Future installments of the national strategy will clinicians, researchers, and survivors to develop be released as work is completed. Currently, the goals and objectives. The goals and objectives about 25 states have begun efforts to enact their lay out a framework for action and guide devel- own suicide prevention strategies. opment of an array of services and programs. It Collaborators who developed the goals and strives to provide direction to efforts to modify objectives included the SUICIDE PREVENTION AND the social infrastructure in ways that will affect ADVOCACY NETWORK (SPAN), the Association for the most basic attitudes about suicide and that Suicide Prevention, the AMERICAN ASSOCIATION will also change judicial, educational, social ser- OF SUICIDOLOGY, and hundreds of individuals vice, and health care systems. The 68 specific working at state, tribal and local levels to pre- objectives contained in the report include: vent suicide. The U.S. Air Force contributed sig- nificantly to the effort by providing a model for • Implementing integrated community-based comprehensive community-based suicide pre- suicide prevention programs that build life vention programs and its direct support of the skills, beliefs and values, and connections to strategy development process. family and community support known to reduce the risk of suicide primitive societies Suicide is an act whose • Incorporating suicide-risk screening at the pri- primary aim is the intentional and deliberate mary health care level taking of one’s own life. Ruth S. Cavan, writing • Increasing the number of states that require in Suicide, postulates that suicides are of two health insurance plans to cover mental health types: conventional and personal. Conventional and substance abuse care on a par with cover- suicide occurs as a result of tradition plus the age for physical health care force of public opinion. That is why, among • Providing treatment for more suicidal persons some tradition-bound peoples, within certain with mental health problems situations, suicide is demanded. Notable exam- • Developing technical support centers to ples include SEPPUKU, the ritualistic suicide of a increase the capacity of states to implement Japanese man of rank faced with disgrace or and evaluate prevention programs humiliation; the SUTTEE of the Indian widow who was forced to self-immolation (by crema- • Increasing availability of comprehensive sup- tion) on her husband’s funeral pyre; and in cer- port programs for survivors of suicide tain primitive tribes, exposure to the elements of • Increasing the number of professional and the old and infirm and their abandonment—as volunteer groups as well as faith-based com- among primitive Eskimos. “Such conventional munities that integrate suicide prevention into suicides,” wrote Cavan, “are typical of societies their ongoing activities in which most problem situations are solved by • Improving suicide prevention education and strongly held customs.” training for health care professionals, coun- These types of suicides were also tradition- selors, clergy, teachers, and other key “com- al among several widely scattered primitive munity gatekeepers” tribes. Early records show that widows commit- Protestants 191 ted suicide in northwest Europe immediately Prinze, Freddie (1954–1977) American after the husband’s death. More recent anthro- comedian-actor who killed himself in January, pological studies of certain African tribes indi- 1977, at the age of 23. Friends and business asso- cate that their frequency of suicide was ciates told authorities that Prinze was despondent comparable to that of European countries with about the breakup of his marriage, which may relatively low suicide rates and that suicide have been caused by a desire for too much love. among the tribes was considered evil. Erwin Despite his early success in show business, the Stengel, author of Suicide and Attempted Suicide, young comedian, co-star of the TV series Chico and explains: the Man, seemed never to have developed an in- ternal feeling of competence and self-confidence. Physical contact with the body of a suicide is In his suicide note, Prinze wrote: “I must end it. feared to have disastrous effects, such as illness There’s no hope left. I’ll be at peace. No one had or suicide among one’s kin. The tree on which a anything to do with this. My decision totally.” person hanged himself is felled and burned. The ancestors have to be placated by sacrifices. The prisoners While many people kill themselves place where the suicide happened is believed to while in jails and state prisons, there are no reli- be a haunt of evil spirits. Suicide is dreaded in able data on rates as compared to suicides in the the community, and a threat of suicide is some- general population. Among those prisoners of times used to exert pressure on the family. institutions who do commit suicide, the majority hang themselves. Also, there appears to be a In Tikopia, a small island in the western complexity of motivations along with a mix of Pacific where pagan ideology lingers, suicide is conflicting tendencies underlying prisoners’ sui- looked at with wild disapproval. The gods will cidal acts. There is also the tendency, at times, on receive the souls of the dead, it is believed, but the part of prison or jail authorities to protect the not of suicides. Their souls are destined to wan- particular institution’s reputation and/or record der aimlessly until their ancestral spirits find by concealing the suicidal acts of prisoners. Some them. Yet the spirits have no objection to the prisons put on a special “” for pris- man who commits suicide by going off to sea in oners convicted of especially heinous crimes. a canoe, or the woman who swims out to sea. A lack of uniformity of search procedures and These suicide methods are admired. The Christ- criteria of categorization, not to mention com- ian Tikopians believe that a suicide’s soul goes parability of data, have made studies to date not to paradise, but to Satan. unreliable. Among the GISU OF UGANDA, suicides of the See also JAIL SUICIDE. aged and infirm usually took place after all means of alleviating their condition had been Protestants In the United States, Catholics tried and found ineffective. In some primitive appear to have suicide rates that are higher than societies, suicide was an act of last resort. The rates for JEWS, but lower than the rates for Pro- Joluo of Kenya, who hold attitudes toward sui- testants. This same relationship occurs in most cide not unlike the Gisu, manage to keep knowl- countries where the major religious groups are edge of a suicide within the clan, to protect the Jews, Catholics, and Protestants. An exception is community’s prestige. The Tiv of Nigeria appear Austria, primarily a Catholic country, yet with a to have the lowest incidence of suicide yet suicide rate that has consistently ranked as one recorded; so few, it seems, that one anthropolo- of the highest in the world. gist-researcher was unable to document cases of Generally speaking, the highest suicide Tiv suicide. rates—relating suicide to religious groups—are 192 Prozac and suicide found among the multidenominational, loosely patients who insist their lives were saved by the federated Protestants. Suicide rates among Jews drug. So far Lilly has won every Prozac-related in the United States, and in Israel, appear to be civil suit—more than 100 in all. gradually increasing. Experts suspect that Protes- Still, critics worry that for a very small minor- tantism contributed to suicide by favoring indi- ity of patients, Prozac and other drugs in its class vidualism, free thought, and free inquiry, appear to trigger suicidal thoughts. leading people more easily to doubt and despair. Prozac’s manufacturers insist that there is no However, there is a need for caution in scientific evidence to establish a link between the comparison and evaluation of rate differ- Prozac and suicide, and cite a 1991 study by a ences relating religion and suicide. The World U.S. Food and Drug Administration (FDA) advi- Health Organization warns: “The true incidence sory panel that unanimously agreed there was of suicide is hard to ascertain. Varying methods no credible evidence of a causal link between the of certifying causes of death, different regis- use of antidepressants, including Prozac, and tration and coding procedures, and other fac- violent behavior. Even the drug’s critics agree tors affect the extent and completeness of that the effect (which the company says does not coverage, making international comparisons exist) occurs in only a small number of cases— impracticable.” fewer than 1 percent. While the attitude of most Protestant factions But critics insist that even though the inci- remains one of general condemnation of suicide, dence seems very low, when it happens it is such the specific sanctions are not as equally severe as a serious matter that doctors should be very in the past—or in all denominations. The funeral careful in prescribing Prozac. Critics say the dan- rites accorded people who committed suicide ger is greatest during the first week or two of still differ in many cases from the rites of those Prozac use, when some patients who were who have died a natural death. Also, exemption already at risk for suicide have a rare reaction from sanctions on the ground of mental instabil- that makes them feel energized and more ready ity or disturbance is usually more readily granted to act on their self-destructive impulses. A sec- than in the past. ond period of increased risk occurs when a Overall, there seems to be a greater willing- patient, who had been virtually immobilized by ness to understand rather than to condemn sui- deep DEPRESSION, still entertains suicidal cide. However, the tendency to conceal suicidal thoughts. At this point, critics say, the drug has acts still persists, but that may well be primarily eased their depression enough so they have the out of a sense of guilt felt by those who feel they energy to carry out these thoughts. could have prevented the act. Some researchers insist that a direct link exists between SSRIs and the emergence of sui- Prozac and suicide Prozac is one of the cidal thinking in people who had never had such world’s most popular antidepressants, one of a thoughts. Dr. Martin Teicher of Harvard Medical new class of drugs with fewer side effects than School reported in 1990 that he and his col- older drugs. Yet some critics continue to charge leagues had observed suicidal thoughts emerging that Prozac makes a few patients more likely to in six patients who were taking Prozac. Other complete suicide. These accusations have per- researchers and clinicians began reporting that sisted despite repeated and categorical rebuttals they saw it, too. by the drug’s manufacturer, Eli Lilly, which Serotonin is a chemical vital to the brain’s reg- points out that patients who are depressed ulation of a wide variety of body functions, enough to need medication are also frequently including sleep, appetite, breathing, and blood suicidal. For every accusation of suicide, there circulation. Low serotonin levels have been are thousands of other, formerly depressed blamed for many mental and physical problems, psychological autopsy 193 including depression, obsessive-compulsive dis- A patent has been granted for Prozac’s succes- order, and panic disorder. Prozac and the other sor, R-fluoxetine, which the company says will SSRIs have been prescribed for all those prob- decrease side effects such as headaches, anxiety, lems, and have produced dramatic improvement and insomnia, and also “inner restlessness in most cases. (AKATHISIA), suicidal thoughts and self-mutila- Experts suggest that until more research has tion.” Akathisia, an overwhelming physical and been done, doctors should be much more care- mental restlessness, has been cited by physicians ful about prescribing SSRIs, investigating the and researchers as a frequent side effect in the patient’s history to uncover any previous indica- cases in which they believe Prozac is causing tions of suicidal thought or other instability. violent, impulsive, and sometimes suicidal Because any physician can prescribe Prozac— behavior. not just psychiatrists—general practitioners, pri- mary care doctors, and specialists in other areas pseudocide Pseudo-suicide; faked suicide. might not be as alert for danger signs as a psy- chiatrist might be. According to the Boston Globe, internal Lilly psychic blow An event that threatens a per- documents show that in 1990, corporate execu- son’s acceptable life circumstances that may lead tives pressured Lilly scientists to alter records on to suicide. physicians’ experiences with Prozac. They changed mentions of suicide attempts to “over- psychic homicide Suicide by the children of dose” and of suicidal thoughts to “depression.” abusive or hostile parents. Some of Lilly’s own studies were cited by the German equivalent of the Food and Drug psychic suicide Willing oneself to die without Administration, delaying Prozac’s approval any external physical action. there. They showed that previously nonsuicidal patients who took the drug had five times the rate of suicide or suicide attempts as patients psychodynamic theory The branch of psy- who took older antidepressants. When the drug chology that investigates motivation and emo- was finally approved for sale in Germany, the tional processes—in this instance, how psychic, manufacturer was required to add a label warn- social, and cultural factors are interwoven to ing that the drug’s use carried a risk of suicide, produce suicidal behavior in individuals from and recommended that sedatives be given along very different backgrounds. It is the systematized with it. knowledge and theory of human behaviors and The Globe reported that figures in Lilly inter- motivation in which the role of emotions is of nal documents showed that in early clinical tri- special significance. als, one in 100 previously nonsuicidal patients Psychodynamics incorporates the role of who took Prozac became anxious and agitated, unconscious motivation, as well as conscious, and either attempted or committed suicide dur- and assumes that behavior is determined by past ing the studies. Some of the previously un- experience, genetic endowment, and current known information that Eli Lilly possessed about reality. the drug has come to light during civil trials in which the company was sued for wrongful psychological autopsy A method by which deaths following suicides, or during criminal tri- coroners and medical examiners are helped in als in which defense lawyers argued that Prozac efforts to determine the cause of a death in a caused a defendant’s violent and homicidal case of suspected suicide, when a cause is not behavior. clearly indicated. 194 psychosis

In performing a psychological autopsy, analysis, nondirective or directive counseling, members of the investigative team interview psychodrama) utilized by specialists. friends, relatives, associates, teachers, and any Ultimately, the objective of any and all forms other significant associates who might have of psychotherapy is to relieve symptoms or to played a role in the person’s life. The victim’s resolve problems in living or to seek personal routine for several days and hours before the growth. death is examined. Team members then try to paint an overall picture of the person’s charac- psychotic suicide Most people who commit ter, personality, and state of mind. On the suicide do not suffer from psychotic illness; usu- strength and significance of the data, team ally, suicidal behavior stems from deep DEPRES- members try to judge whether the person’s SION and, at times, from neurotic disturbances death was suicide or not. The team then reports that are less severe or intense than psychoses. its findings to the coroner or medical examiner, Some suicides, however, are related to psychotic who includes this with the postmortem investi- illnesses. In this case, the victim suffers a break gation and determines whether to list the death with reality, loses the ability to distinguish what as a “suicide,” “homicide,” “accident,” “nat- is occurring and what is imagined. The patient ural,” or “undetermined.” acts out fantasies, not understanding that the The idea of psychological autopsy was created behavior seems weird and disorganized to other by psychologists Edwin S. Shneidman and Nor- people. Most psychotics have periods of lucidity, man L. Farberow, cofounders in 1958 of the LOS and many are able to live relatively normal lives ANGELES SUICIDE PREVENTION CENTER. until something triggers a break with reality. Psychological autopsies are also used in fo- Authorities say some psychotic illnesses are rensic investigations and legal cases where in- caused by a physical problem; some result from surance payouts have been denied because of biochemical imbalances in the body that may be suicide (and the estate challenges the determi- hereditary. Still others have deep-seated psycho- nation). PAs are also used to explain why a logical or emotional causes that result from suicide occurred and in developing an epidemio- unstable or disruptive family relationships. logical database for preventive interventions. Psychotic illnesses are usually treated with drugs, often in tandem with psychotherapy, and psychosis A major mental disorder of organic with family therapy that involves parents, sib- or emotional origin involving a person’s ability lings, and other relatives. to think, respond emotionally, remember, com- Psychotic illness may lead to suicidal thoughts municate, interpret reality, and behave appropri- and actions before family members or friends ately. It is characterized by impairment sufficient realize that the patient is deeply disturbed. Usu- enough to interfere grossly with the capacity to ally, this is because the psychotic person won’t meet the ordinary demands of life. Disturbances acknowledge the severity of the illness. may appear in the form of aggressive behavior and diminished impulse control, along with punishment, suicide as One reason for sui- delusions and hallucinations. cide is a wish to punish—either the self or some- one else. Psychologists usually understand and psychotherapy The application of specialized explain suicide in terms of various levels of pres- counseling techniques to the treatment of men- sure on the individual, which may parlay into tal disorders or to the problems of everyday killing oneself. adjustments. In a more specific sense, the term SIGMUND FREUD implied that murder is aggres- includes only those techniques (such as psycho- sion turned upon another; suicide is aggression punishment, suicide as 195 turned upon the self. Suicide, in other words, If the suicidal person feels he or she has dis- becomes “murder in the 180th degree.” appointed a loved one or a close friend by not Sometimes, confused suicidal persons, espe- living up to their expectations, the punishment cially the very young, view killing themselves as that is suicide is turned inward. a way to “punish” others, to make someone Dr. KARL MENNINGER, in MAN AGAINST HIMSELF, close to them show more respect or love for writes that everyone who attempts or completes them. They view themselves as being present to suicide is driven (consciously and uncon- enjoy the punishment their death has inflicted sciously) by three motives: the wish to kill, the or the belated love it has generated. wish to be killed, and the wish to die.

Q

Quinlan, Karen Ann (1954–1985) The first die legislation had been introduced in only five modern icon of the right-to-die debate. After the states. Shortly afterward, 50 bills were intro- 21-year-old Quinlan collapsed after swallowing duced in 38 states. alcohol and tranquilizers at a party in 1975, doc- In the years after the Quinlan case, health tors saved her life, but the young woman suf- care directives have become popular. Now every fered brain damage and lapsed into a persistent state has a law allowing some sort of health care vegetative state. Her family waged a much-pub- directive. In late 1991, the federal Patient Self licized legal battle for the right to remove her life Determination Act took effect, requiring that support machinery. any facility receiving Medicare or Medicaid Although she did not commit suicide, the case funds must discuss health care directives with of Karen Ann Quinlan laid the groundwork for their new patients. Because nearly every hospi- legislation granting terminally ill people and tal receives Medicare or Medicaid funds, patients their families the right to authorize withdrawal should now be given a written explanation of of life-sustaining procedures when death is their state’s law on health care directives and the believed imminent. The problem posed by the hospital’s policies regarding health care direc- 21-year-old woman from Morris County, New tives upon admission to a hospital. The law also Jersey, as she lay breathing mechanically day requires health care facilities to make a record of after day in a fixed death-in-life situation each patient’s health care directives as part of sparked new and enlightening discussions on their medical records. the definition of death. Quinlan’s parents went to court for permis- Qur’an, the Sacred scripture of the MUSLIMS, sion to remove her life support and lost; the New comprising 114 suras (chapters) of unequal Jersey Supreme Court overturned the lower length, nearly all of which are supposedly of court ruling, a major concern being Karen’s right divine revelation—Allah speaking directly to privacy, which was asserted in her behalf by through the angel Gabriel to Mohammed. The her family. holy scriptures of ISLAM expressly declared sui- As a result of the successful appeal, she was cide to be a more serious crime than homicide. weaned from the respirator. She did not die as Muslim belief explains this attitude: Each person expected, however, and was transferred from has his or her kismet, or destiny, which is foreor- the hospital to a nursing home, where she dained by Allah, or God, and must not be defied. remained in a coma, fed through tubes, until she Some suicides do take place in Muslim countries; died 10 years later in July 1985. Before Karen however, strong religious restrictions keep rates Ann Quinlan’s tragic case came to light, right-to- relatively low.

197

R race Although there are reputedly a few iso- of its members sought death rather than wait for lated parts of the world where no suicides are the end of the world, which they had predicted committed—or at least none are reported (such would occur before century’s end. Between as, several small South Sea islands and the 1672 and 1691, some 37 mass immolations took Hindu Kush Mountains of India)—no race or place, as more than 20,000 Raskolniki voluntar- ethnic group is exempt from the suicidal poten- ily burned to death. By these MASS SUICIDES, they tial. confirmed their belief that it was senseless to Among the world’s nations, the countries remain on Earth and risk contamination by usually high on the scale in terms of suicide rates heresy. per 100,000 population are: HUNGARY, DENMARK, FINLAND, AUSTRIA, GERMANY, SWEDEN, SWITZER- rates, suicide Suicide deaths are compiled by LAND, and JAPAN. Countries on the low end of the National Center for Health Statistics (NCHS) the suicide rate charts include: the Philippines, and published yearly. Variables on each suicide Angola, Jamaica, Mexico, the Bahamas, Kuwait, included: age, race, sex, place of residence, place Jordan, Kenya, and EGYPT. of occurrence, date of death, cause of death. Within the United States, the suicide rate for Special estimates (prepared by the U.S. African Americans is lower than the rate for Bureau of Census) were used to compute rates Caucasians. However, the figures for both groups for the years 1970 to 1980. Unpublished popula- are considerably closer in urban areas, and in tion statistics of U.S. residents provided by NCHS certain metropolitan areas, the rate for African were used to compute rates for 1979 and 1980. Americans is higher than it is for whites living in Updated population estimates for the intercensal other sections of the city. Also, the rate is higher years are based on the previous U.S. Census. for young blacks than it is for whites. Ethnic Because suicide varies by age, age-adjusted sui- groups with predominantly Catholic members cide rates are presented in some sections in this appear to have suicide rates that are higher than work to allow for comparison of rates between the rate for JEWS, but lower than the rates for populations without concern for different age ethnic members of predominantly PROTESTANT structures in the populations being compared. faiths. Data on suicide deaths for various countries A very high risk group in the United States is are compiled by the World Health Organization. the Native American. Many believe such causal Unfortunately, not all countries disclose such factors as isolation, alienation, poverty, hope- information and other countries lag behind in lessness, and drugs and alcohol play a major role providing mortality data, so a listing by country in the native suicide rate. is not exhaustive.

Raskolniki A dissenting religious group of rational suicide Some right-to-die advocacy 17th-century Russia in such despair that many groups promote the idea that suicide, including

199 200 rationalists, the

ASSISTED SUICIDE, can be a rational decision. Oth- razor blades, as suicide weapon Though ers have argued that suicide is never a rational razor blades are not a frequently used method of decision and that it is the result of DEPRESSION, suicide (based on those deaths identified accord- anxiety, and fear of being dependent or a bur- ing to cause of death codes established by Inter- den. national Classification of Disease, or ICD), any The term rational suicide was coined by Man- person—family member, friend, acquaintance— hattan artist and former social worker Jo who has doubts about a suicidal individual’s Roman, who advocated choosing the time of intentions should check for any possible lethal one’s own death—which she did at age 62 in weapon, including razor blades. Young people, 1979 before taking a fatal overdose of pills. She especially, have used this method of suicide had been diagnosed as having a breast tumor attempt or suicide. that would have been treatable by mastectomy, but she rejected the operation. Roman called her Rebel without a Cause A 1950s film starring friends in to say good-bye, had the group’s con- actor James Dean, who was killed on September versation taped, then spent the evening with her 30, 1955, in a car accident in California (many husband and a close friend before ingesting the experts called his death “AUTOCIDE”). Dean, who pills. Her videotapes on advocacy of self-termi- in real life appeared to live the characters he nation were subsequently shown in an educa- played on the screen, played the angry young tional television documentary. Rebel without a Cause who plays “chicken” with Surveys of terminally ill people indicate that another teenager as their cars race toward each very few consider taking their own life, and other along the edge of a high cliff. Tens of thou- when they do, it is usually related to their sands of teenage fans identified with the com- depression. Attitude surveys suggest that assisted plex actor’s personal rebelliousness and his open suicide is more acceptable by the public and defiance of the adult establishment. health providers for the old who are ill or dis- abled, compared to the young who are ill or dis- abled. reckless driving, as suicide clue Risky At this time, there is limited research on how behaviors, including reckless driving, are consid- often people who are terminally ill are depressed ered to be a warning sign of potential suicidal or have suicidal thoughts, whether they would behavior. In one study, about 25 percent of acci- consider assisted suicide, the characteristics of dent victims were depressed people with feelings such people, and the context of their depression of helplessness and a sense of loss typical of sui- and suicidal thoughts. Neither is it yet clear what cidal persons. Those studied had experienced effects other factors, such as the availability of fantasies and dreams of death and self-destruc- social support, access to care, and pain relief may tion shortly before their accidents. Experts have on end-of-life preferences. believe the serious accidents the victims suffered could well have resulted from underlying wishes to kill themselves. rationalists, the A group of early to mid-18th Dr. Karl Menninger interpreted most acci- century, writers, philosophers, and thinkers who dents as the result of unconscious self-destruc- steadily hammered away at the suicide taboos, tive drives. Dr. Alfred L. Moseley of the Harvard superstitions, and the primitive, punishments Medical School concludes that suicides are a still being meted out for suicide. As a result, strict “significant though unknown” proportion of the laws about suicide were gradually changed, rising number of annual auto deaths in the U.S. along with a corresponding shift in society’s AUTOCIDE occurs when a car is used as a emotional attitudes. method of self-imposed death. risk of suicide 201 recognition of suicide potential See CLUES Reserpine depression was discovered by a car- OF SUICIDE. diovascular researcher who noted an astound- ingly high incidence of suicide in patients receiving this drug. Reformation The religious reform move- ments of the 1500s in Western Europe, which had as their object the correction of abuses that revenge suicide Spite as the motivation had arisen in the Western Catholic Church. behind suicide is particularly common among Those movements resulted in the disunity of children under age 13. Notes left by some suici- that church and the foundation of Protestant dal patients indicate that the message behind the churches. Martin Luther’s teachings gave impe- act is: “It’s your fault” or “Now we’re even!” tus to the Reformation, which began in Ger- While an adult who feels unloved might con- many in 1515 with his thesis against the sale of front a spouse with his fears, suspicions, and indulgences. It was during the Renaissance and anger, a young person might make a point by Reformation that the churchly taboos against committing suicide. suicide began gradually to lose their power. Sir The youngster’s view of death usually Thomas More justified suicide as a form of includes the notion that after the act of suicide, EUTHANASIA in his Utopia. he or she will remain behind, hovering invisibly over the funeral scene, taking pleasure in wit- nessing the parents’ and friends’ grief. religion See CLERGY AND SUICIDE PREVENTION.

Renaissance Time of the great revival of art, “right to die” movement See EUTHANASIA; letters, and learning in Europe from the 14th HEMLOCK SOCIETY. through the 16th centuries, marking the transi- tion from the medieval to the modern world. “right to suicide” Every society throughout With regard to suicide, new and less stringent recorded history has had to contend with this attitudes toward suicide began to gradually complex issue. Each has had to determine when, emerge during the Renaissance. These more if ever, suicide is justifiable, and when, if ever, it lenient, understanding attitudes finally came out might be permitted. No society can survive if it into the open in the 18th century, as churchly allows widespread suicide among its members. taboos began to lose their power. And in most cultures and most times in history, people have feared, forbidden, and condemned Research on Suicide: A Bibliography Com- suicide. But at certain times, and under certain prehensive bibliography compiled by John L. conditions, they have not only tolerated, but McIntosh, assistant professor of psychology at also encouraged it. Indiana University at South Bend, and published by the Greenwood Press, Westport, Connecticut, risk of suicide There are a number of risk fac- in 1985. tors for suicidal behavior, including gender, age, race, religion, marital status, occupation, physi- reserpine Drug commonly used for treat- cal health, mental health, and previous suicidal ment of high blood pressure. Extensive clinical behavior. use revealed that it caused as many as 15 percent of patients to become depressed in a Gender fashion indistinguishable from endogenous Men commit suicide more than three times as DEPRESSION. often as do women in all age groups. Women, 202 risk of suicide however, are more likely to attempt suicide than have suicide rates twice as high as for those who are men. This means that while fewer men are married and have children. Losing a spouse, attempt suicide, more of them succeed. however, is worse than never getting married when it comes to suicide—previously married Age people have much higher suicide rates than do Suicide rates increase with age and underscore the never-married. Sometimes, people will com- the significance of the midlife crisis. Among mit anniversary suicides on the day that a loved men, suicides peak after the age of 45. Among one died. women, the greatest number of completed sui- cides occur after age 55. Older people attempt Occupation suicide less often than do younger people, but The higher a person’s social status, the greater they are often more successful. the risk of suicide, but a fall in status also While the elderly make up only about 10 per- increases the risk. Work, in general, tends to cent of the population, older people account for protect against suicide. Special at-risk popula- one quarter of all U.S. suicides. The rate for tions include: psychiatrists, psychologists, oph- those above age 75 is three times as much as for thalmologists, anesthesiologists, physicians, younger people. musicians, dentists, law enforcement officers, However, the suicide rate is rising most lawyers, and life insurance agents. Suicide rates rapidly among young people, particularly among also are higher among those without a job, and men age 15 to 24. In this age group, the rate for the rate increases during recessions and times of women is increasing at a lower rate, but it is rising unemployment, and decreases during increasing. times of high employment and during wars.

Race Climate Two of every three completed suicides are com- No significant seasonal correlation with suicide mitted by white men; the risk of suicide among has been found. Suicides decrease slightly in whites is nearly twice that of all other groups. winter. However, this general rule is changing, as the suicide rate among blacks (especially African Physical Health American men) is rising. Among young people Not surprisingly, there is a relationship between who live in inner cities, and certain Native poor physical health and suicide. Postmortem American and groups, suicide rates have studies have found that people who commit sui- greatly exceeded the national rate. Suicide rates cide are physically ill between 25 percent and 75 among immigrants are higher than for the percent of the time. It is estimated that a physi- native-born population. cal illness is a significant factor in up to half of all suicides. As many as 70 percent of suicide vic- Religion tims have some form of cancer. Historically the suicide rates among Roman In addition, seven diseases of the central ner- Catholics has been lower than among JEWS and vous system—all of which are associated with PROTESTANTS, but a person’s degree of involve- DEPRESSION—increase the risk of suicide: epi- ment in the church may be a more accurate lepsy, multiple sclerosis, head injury, cardiovas- measure of risk than simple religious affiliation. cular disease (stroke), Huntington’s disease, dementia, and AIDS. Some endocrine diseases Marital Status also are linked with a higher suicide risk, includ- Marriage and children significantly lessens the ing Cushing’s disease, Klinefelter’s syndrome, risk of suicide; single, never-married individuals and porphyria. Both peptic ulcers and cirrhosis Roman Catholic Church 203 of the liver are also linked to suicide risk. Benign of psychiatric patient suicides. Patients with prostatic hypertrophy (BPH) treated with panic disorder also are at increased risk for sui- prostate removal, and kidney disease treated cide. with hemodialysis, are both linked to suicide; mood disorders may occur in both conditions. Previous Suicidal Behavior There are several reasons why some illnesses A past suicide attempt is possibly the best indica- may contribute to a higher risk of suicide. Dis- tor that a patient is at greater risk for suicide. eases that cause loss of mobility, disfigurement Some 40 percent of depressed patients who (particularly among women), and chronic attempt suicide have made a previous attempt. intractable pain can be difficult to bear. In addi- The risk of a second attempt is highest within tion to the direct effects of illness on risk, sec- three months of the first attempt. ondary effects (such as disrupted relationships and job loss) increase the risk of suicide. ritual suicide Various cultures over the years In addition, certain medications can produce have endorsed, even encouraged, ritual suicides. depression, which may lead to suicide in some See also SEPPUKU; SUTTEE; GISU OF UGANDA. cases. Some of these drugs include RESERPINE (Serpasil), corticosteroids, high blood pressure medication, and some chemotherapy drugs. Rollin, Betty Former television reporter for ABC and NBC, and author of the book, Last Mental Health Wish, wherein Rollin admits that she secretly It’s clear that MENTAL ILLNESS plays a part in helped her terminally ill mother, Ida, commit many suicides—especially substance abuse (see suicide in 1983. In the book, the author reveals ABUSE, SUBSTANCE), depression, and SCHIZOPHRE- that her mother expressed the desire to end her NIA. As many as 95 percent of all people who own life after months of torturous and appar- attempt or complete suicide have a diagnosed ently futile chemotherapy for inoperable ovarian mental disorder, and depression accounts for cancer. Rollin maintains that her role in the drug about 80 percent of this figure. Schizophrenia overdose of 75-year-old Ida Rollin in her Man- accounts for about 10 percent, and dementia or hattan apartment did not violate a New York delirium accounts for 5 percent. Among all peo- State law against “promoting suicide.” ple with mental disorders, 25 percent are alcohol “I did not directly help my mother to commit dependent. The suicide risk in people with suicide,” Rollin told reporters. “If I did, I would depressive disorders is about 15 percent, and 25 not have written a book about it.” She said she percent of everyone with a history of impulsive “did research and gave my mother the informa- or violent acts are also at high risk of suicide. tion.” Under New York state law, “promoting sui- Previous psychiatric hospitalization for any cide” is a felony, punishable by up to four years reason increases the risk of suicide. The suicide in prison. Some legal authorities said such cases risk for psychiatric patients is three to 12 times pose difficult problems. Rollin was not indicted higher than for nonpatients, although the by the state for any wrongdoing, and Last Wish degree of risk varies according to age, sex, diag- went on to make several best-seller lists. nosis, and inpatient or outpatient status. Psychiatric patients who commit suicide tend Roman Catholic Church By the end of the to be relatively young, which may be partly fourth century, ST. AUGUSTINE had established because two early-onset disorders (schizophre- rules against suicide that would provide the basis nia and recurrent major depression) account for for Christian doctrine through the ages. He just over half of all these suicides, and reflect an argued that suicide allowed no opportunity for age and diagnostic pattern found in most studies repentance and branded all suicides as crimes. 204 romance, breakup of

St. Augustine’s teachings and those of other a poem by Arthur Brooke which in turn was early church authorities were incorporated into taken from a romance by Bendello. the laws of the Roman Catholic Church and, In the story, the Montagues and the Capulets, later, the Anglican Church, in which suicide was two powerful families in Verona, have an seen as an act inspired by the devil and was a ancient grudge. A byzantine story line filled with mortal sin. Bodies of those who committed sui- twists and turns, plus one of the most beautiful cide were denied Christian burial, and even love scenes in the English language, culminates attempters of suicide were excommunicated. in the deaths by suicide of both young lovers, Church laws did make an exception in the Romeo and Juliet, he by poison and she by case of “insane” people, and also exempted Romeo’s dagger. The alarm is spread and the young children from the severe penalties of law. feuding Montagues and Capulets meet at the These religious laws against suicide have tomb. The families are reconciled by the tragedy remained in effect in the Roman Catholic Church their feud had caused. (and in many PROTESTANT churches, as well). Today, however, many priests and ministers ropes, as suicide weapon Hanging, strangu- appear inclined to find ways in which church lation, and suffocation—closely related enough laws can be altered toward leniency in special to be regarded as a single means of self-destruc- circumstances. tion—is today the second most common method of suicide among men. It was second in popular- romance, breakup of Some people, espe- ity only to firearms and explosives. cially young people, suffer deep DEPRESSION and feelings of worthlessness following the breakup Rothko, Mark (1903–1970) Russian-born of a romance. Such persons have been known to American painter who was originally a fig- think and even talk about suicide—which is one urative painter, but whose later abstract works clue to look for in people who have been are his most famous. Always melancholy, affected by a romantic loss. Rothko said he painted “tragedy, ecstasy, doom, and so on.” As he became more famous his romantics, the A group of artists and writers— depression deepened. Rothko committed sui- led by THOMAS CHATTERTON who killed himself in cide in New York City, on February 25, 1970, at 1770 at the age of 17—thought of death as “the age 67. great inspirer” and “great consoler.” It was they who made suicide fashionable, and during the Rousseau, Jean-Jacques (1712–1778) French epidemic in France in the 1830s, practiced it as philosopher, political thinker, and novelist, who one of the most elegant of sports. For the young was born in Geneva, the son of a watchmaker. It would-be poets, novelists, dramatists, painters, was in his novel La Nouvelle Heloise (1769), a and members of countless suicide clubs, to die by famous and influential work, that he empha- suicide was a short and sure way to fame. sized a person’s natural right to complete suicide The epidemic never quite took hold in En- as long as no one else is harmed by doing so. gland, although it started there with Chatter- Rousseau established one condition, however: ton’s suicide. As the 19th century wore on, People who have responsibilities to others romanticism gradually dissipated and along with should not commit suicide. it faded the idealization of death. His notion that the “natural,” or primitive, man (“the noble savage”) was inherently good, Romeo and Juliet Play written ca. 1595 by and that evil arose from the distortions of soci- William Shakespeare, this tragedy was based on ety, was enormously influential in the rise of Ryder, Hugh 205 romanticism in literature and music, and is still a 100,000 among young Russian men and 80.3 for powerful force, in education especially. men aged 25 to 34. See also ROMANTICS, THE. In the past, Russians as part of the Soviet Union refused to provide data to the World Russian Federation The suicide rate for the Health Organization in Geneva, insisting that federation in 1997 was a whooping 39.3 per suicide was a bourgeois activity that did not 100,000, much higher than the international occur in the Soviet Union. average, but fairly typical among eastern Euro- pean countries. This represents a stunning Ryder, Hugh (fl. 1664–1693) Surgeon to average for men who kill themselves at a rate of King James II, who tells of “A young woman 66.4 per 100,000, compared to a woman’s aver- who had been at a Meetinghouse . . . in a great age of 12.3. discontent went home and fell into such When broken down by age, the highest rate despair, that being melancholy by herself in her for men is middle age, from 45 to 54—a rate of chamber, with a knife cut her throat . . .” The 100 per 100,000. For Russian women, the high- wound proved not to be lethal and under est suicide rate is over age 75 (32.7 per 100,000). Ryder’s care, the woman recovered. This While the suicide rate for Russian children account of a published case history served to age 14 and below is not high, the rate jumps reinforce the view of suicide being the result of alarmingly in the 15-to-25 age group, to 53 per a mental disorder.

S

Saint-Exupéry, Antoine-Marie-Roger de stream Christian beliefs and its articles of faith, (1900–1944) French writer and aviator who emphasizing God’s saving purposes. The Army’s was obsessed with aviation from an early age. He objects are the advancement of the Christian joined the French Army Air Force in 1921, then religion, education, and relieving poverty. The became a commercial pilot five years later. Army also is interested in preventing suicides, Throughout his career, he wrote popular books operating numerous suicide prevention centers —many were fantasies for children—about fly- in the United States and Canada. The Salvation ing. He celebrated his faith in man and life, in his Army’s night patrols, rescue and anti-suicide philosophical and mystical books, yet, all the missions helped more than 220,000 suicidal peo- while, he seemed preoccupied with thoughts of ple in 2001. death. His father died when Saint-Exupéry was The movement was founded in 1865 by only four years old, and a brother died when he William Booth, spreading from London to many was 17. parts of the world, including the United States His best-known fantasy for young readers, Le and Canada. The rapid deployment of the first Petit Prince (The Little Prince, 1943), romanticized Salvationists was boosted by the adoption of a suicide as a way of “going home,” and depicted quasi-military command structure in 1878 with death as a painless process whereby one simply the title of “Salvation Army.” shed the body like “an old abandoned shell” after Adhering to the idea of spiritual warfare, the which the freed soul would soar into the skies. Army uses certain soldierly features such as In 1944, while making a reconnaissance flight uniforms, flags, and ranks to identify and inspire during World War II over southern France, Saint- followers. Salvation Army officers have the Exupéry disappeared. His Citadelle was published status of ordained ministers and are employed posthumously in 1948, with an English-language by the Army in a professional capacity and on a edition, The Wisdom of the Sands, in 1950. full-time basis. They are members of the Salva- Authorities never determined what happened tion Army who have committed their lives to to Saint-Exupéry’s plane. Fellow pilots who saw doing God’s will and serving others. him before he took off on his final mission said that he complained of a sleepless night and ap- Samaritans A nonreligious, nonprofit volun- peared restless and depressed, and, the evening teer organization whose sole purpose is to provide before the flight he had prepared a letter to serve support to individuals in crisis, who have lost as a last will. It is not known whether his death someone to suicide, or who are feeling suicidal. was a suicide or an accident. The group was founded in London in 1953 by the See LITTLE PRINCE, THE. Rev. CHAD VARAH who wanted to “befriend” suici- dal people. Today the international humanitarian Salvation Army A religious organization that movement maintains more than 400 branches in is part of the Christian church, following main- 32 countries, including the United States.

207 208 “Samsonic” suicides

All of the workers are volunteers, them- ered honorable; to continue living would have selves former suicide attempters, who work been an act of ignominy. with suicidal people in much the same way See also SEPPUKU. that recovering alcoholics in Alcoholics Anony- mous work with new members. Samaritan San Francisco Suicide Prevention (SFSP) volunteers are caring individuals of every age One of the oldest volunteer crisis line in the and walk of life who go through intensive United States, founded in 1963 as a way to pro- training. vide telephone intervention to people experi- Typically, the Samaritans offer a hotline encing suicidal crisis. Over the years, the focus of staffed by trained volunteers who are good lis- the agency has shifted from strictly suicide teners and are available 24 hours a day for any- prevention to more general counseling services, one who is depressed, in crisis, or suicidal. The which are provided 24 hours a day by more Samaritan’s philosophy, known as “befriending,” than 150 trained volunteers. Today SFSP is provides an empathetic response to every person divided into four program areas that operate who calls no matter what the problem. Samari- eight hotlines. tans volunteers do not express personal judg- The suicidal crisis line was the first service of- ments or values and, instead, focus on the fered by SFSP. Today, 100 trained volunteers an- callers’ emotions and state of mind. swer more than 200 calls every day from people The Samaritans gain their name from the who need emotional support, with suicide pre- parable of the Good Samaritan; their approach is vention volunteers saving thousands of lives. always secular, practical, and non-sectarian. Volunteers also provide emotional support on a See also BEFRIENDERS INTERNATIONAL. daily basis to regular callers with chronic mental illness. “Samsonic” suicides Samson’s destruction of The newest program is the Survivors of Sui- the Philistines in the Temple of Dagon was an act cide group designed to help family or friends of vengeance, but it was also suicidal. Samson who lost someone to suicide. prayed, “Let me die with the Philistines,” and his For contact information, see Appendix I. wish was granted (Judges 16:23–31). This is probably the earliest historical description of a Savage God, The: A Study of Suicide Non- revenge type of suicide. Over the years, some fiction book by ALFRED ALVAREZ, published in the have described revenge suicides as “Samsonic.” United States by Random House in 1972. This book is an account of poet SYLVIA PLATH’s suicide samurai Members of the military class in and an investigation into motives for suicide, feudal Japan who performed a ritualized sui- with particular emphasis on people in the arts— cide in the form of HARA-KIRI. This was an elab- writers and poets, as well as philosophers. orate ceremonial death for the samurai warrior Alvarez, born in London in 1929, returns in the who had in some way humiliated or disgraced last section of the book to a very personal view himself, and thus his family. Often, after a of suicide as he chronicles his own suicide at- chieftain had died, the warrior would kill him- tempt. The title comes from William Butler self as a show of allegiance. Sometimes an Yeats’ “After Us the Savage God.” emperor would order a samurai warrior to commit hara-kiri to avoid the disgrace of a pub- Scandinavia Among the three western Scan- lic execution. dinavian countries (DENMARK, NORWAY, SWEDEN), Hara-kiri is an example of an ALTRUISTIC SUI- Denmark has the highest suicide rate per CIDE, in which self-inflicted death was consid- 100,000 population, according to World Health school violence and suicide 209

Organization (WHO) statistics, with a 1996 rate sometimes mixed with deep depression, occa- of 17 suicides per 100,000 (all ages, both sexes). sionally leads to complex mixes of beliefs and Sweden is in the middle with a 1996 rate of 14.2 fantasies that can bring about self-destruction. per 100,000; Norway is third with a 1995 rate There have been cases, through relatively rare, per 100,000 population of 12.6. Denmark and where schizophrenics have attacked or killed Norway have both shown rate increases in the others and then committed suicide. last decade, while Sweden’s rate has shown a slight decline. Denmark’s suicide rate in recent years has placed it in the top countries for high- school violence and suicide While inci- est rates per 100,000 population. dents of fatal multiple-victim violence in schools is rising, few teenage killers complete suicide at the site of their attacks. The most schizophrenia General name for a group of famous three incidents in recent history in psychotic reactions characterized by withdrawal, which teens killed students and teachers before disturbances in emotional and affective life and, committing suicide occurred at a high school in depending upon the type, the presence of hallu- Erfurt, Germany, on April 26, 2002; at Co- cinations, delusions, negativistic behavior; and lumbine High School in Littleton, Colorado, in progressive deterioration. The search for under- April 1999; and at an elementary school in lying causes has centered on both functional and Dunblane, Scotland, in 1996. organic factors. Suicide has become the leading The murder-suicides at Columbine High cause of death for people with schizophrenia. In School were carried out by Eric Harris, 18, and fact, some experts believe the rate of suicide Dylan Klebold, 17, two angry students who among these troubled patients ranges between killed 12 other students, one teacher, and them- 10 percent and 13 percent. Young white men selves. The young German student singled out who functioned well before becoming ill, and teachers at his school, killing 14 adults and three who have high expectations of themselves, are students before turning the gun on himself. In most at risk. Dunblane, Scotland, a man opened fire on a In chronic schizophrenia, suicide may result class of primary school students, killing 16 stu- from the episodes of DEPRESSION to which these dents, all but one of them younger than seven, a patients are prone. The suicide method is usually teacher, and himself. bizarre and often violent. There are far more incidents of school vio- Attempted suicide is uncommon, although it lence that do not involve suicide; for example, may be the first gross sign of psychiatric distur- there were 220 violent incidents in American bance, occurring early in schizophrenia, possibly schools between July 1, 1994, and June 30, when the patient becomes aware of the disorga- 1999. Most of these incidents were homicides nization of thought and volitional processes. and involved the use of firearms. Although the However, the cause or causes of schizophre- total number of events has decreased steadily nia are still obscure and may well be the result of since the 1992–93 school year, the total number the interaction of two or more factors. A better of multiple-victim events appears to have understanding of the complex disorder depends, increased. During the school years from August of course, on the results of ongoing research. 1995 through June 1999, there were an average Schizophrenia often strikes patients during of four multiple-victim events a year, compared the early or mid-teen years and at first may be to an average of one multiple-victim event per hardly noticeable. However, as the disorder pro- year in the three years from August 1992 gresses, schizophrenics may develop strong through July 1995. Thus, while the total number suicidal tendencies. The break with reality, of events of school-associated violent deaths 210 Schopenhauer, Arthur have decreased, the total number of multiple- officer as he tried to enter the building. When victim events appears to have increased. police were finally able to enter, they found 17 Nevertheless, according to the journal Crimi- dead victims and Steinhaeuser, who had com- nal Justice Ethics, it is still true that more than mitted suicide. 99.99 percent of U.S. public schools have never had a homicide or suicide on school grounds, let Columbine alone a mass killing. Angry, disenfranchised students Eric Harris, 18, Nevertheless, in the wake of the Columbine and Dylan Klebold, 17, went on a rampage at killings, the culture of high schools is changing Columbine High School in April 1999, killing 12 as some teenagers identify with the killers and classmates and a teacher. Although they used yearn for attention, making lists of their enemies guns for the murders, more than 50 homemade and warning that they will “pull a Columbine.” explosive devices were also found in and around A much larger group of teens has become more the school. Harris and Klebold shot themselves watchful and ready to report any threat, no mat- in the school library as police ringed the school. ter how unlikely. Dunblane, Scotland Erfurt, Germany Thomas Hamilton, 43, was a gun collector and In a rampage shooting eerily evoking the likes of disgraced scoutmaster who was known as “Mr. Columbine but even more deadly, a recently Creepy” by local boys in Dunblane, a little High- expelled student in Erfurt, Germany, entered his lands village 40 miles from Edinburgh. Disliked former school, killing 17 people as he went room by his neighbors, Hamilton reportedly had never to room with a shotgun and a handgun before gotten over his fury at being fired as a scoutmas- turning one on himself. It was one of the worst ter because of his fixation with young boys. Still school killings of its type. It was even more dis- seething with rage 20 years after being fired turbing that it took place in a country with gun- from the scouting position, a week before his control laws so stringent that the number of rampage he wrote to Queen Elizabeth complain- shooting deaths each year in the entire country ing about a campaign to ruin his reputation. On is barely half that of New York. In fact, in Ger- March 13, 1996, he walked to the Dunblane many—a country of nearly 80 million people— Primary School with four guns, burst into a only 15,000 private citizens have the right to gymnasium where 29 children were in class, and even own a gun for security reasons. To get per- slaughtered 16 children, their teacher, and then mission, a person has to persuade the govern- himself. Another teacher and 12 other students ment that he or she faces a threat and can pass were wounded. After the slayings and suicide, tests to properly handle a gun. Great Britain banned private possession of hand- The massacre began as students were finish- guns. ing their end-of-year exams at Gutenberg High School in Erfurt, a city of about 200,000 in eastern Germany. According to students, Robert Schopenhauer, Arthur (1788–1860) Ger- Steinhaeuser, 19, who had been expelled seve- man philosopher who formulated a philosophy ral months before, entered a mathematics class- of pessimism: Discord or strife is the central fea- room about 11 A.M. wearing black clothes and a ture of all existence, both within the individual black mask. Pulling out a shotgun and handgun, and in the universe at large, with frustration and he shot the teacher in front of other students pain as the inevitable products, and resignation, and then went from room to room, shooting as or negation of the will, as by the saint or ascetic, many teachers as he could find. A janitor called as the only solution. In his basic work, The World the police, but the student shot and killed one as Will and Idea (1818), Schopenhauer postulates self-immolation 211 that the world is the expression of the individ- In this book, published in 1998 by W. W. Nor- ual’s idea, and especially his will, which is, basi- ton & Co., Hendin investigates how euthanasia cally, an expression of a universal, blind impulse is working in the Netherlands, looking at the to exist. Art, he says, is both a means of under- issue from ethical, political, and practical view- standing existence and of escape from the sense- points. He also explores why the United States less strife. could possibly be the next country to legalize Schopenhauer wrote; “It will generally be euthanasia. found that as soon as the terrors of life reach the See also SUICIDE IN AMERICA. point where they outweigh the terrors of death, a man will put an end to his life.” He also be- self-destructive behavior Behavior aimed at lieved that suicide may be regarded as an exper- harming the self. Self-destructive behavior may iment—but “a clumsy experiment to make, for it be direct, which usually includes suicidal involves the destruction of the very conscious- thoughts, attempted suicides, and completed ness which puts the question and awaits the suicides. Or this behavior may be indirect, char- answer.” acterized by taking a life-threatening risk with- out intending to die, generally repeatedly and Scotland Northern country of Great Britain often unconsciously, with consequences that are with a suicide rate of 11.9 per 100,000 (18.2 for ultimately self-destructive. Examples of indirect men and 5.6 for women). Among Scots, the age self-destructive behavior are excessive drinking group for both men and women at highest risk and drug use, heavy smoking, overeating, for suicide is not old age but young adulthood: neglect of one’s health, self-mutilation, hunger Scottish men aged 25 to 34 have a suicide rate of strikes, criminal behavior, and reckless driving. 34.2 per 100,000; Scottish women of the same age group have a rate of 9.4. self-immolation Suicide by setting oneself on fire. Self-inflicted burn injuries make up only a second attempts (among suicidal persons) small percentage of the patients seen in burn Simply because a person shows improvement centers, and self-immolation is only a fraction of after a suicidal crisis doesn’t mean that the suici- that population. dal risk is over. In fact, most suicides occur Persons who commit self-immolation have within about three months following the begin- many motives, including suicide, impulsive be- ning of “improvement,” when the individual has havior, various psychological illnesses, sacrifi- the energy to put morbid thoughts and feelings cial religious rituals, and political protest. The into effect. Many of the tens of thousands who incidence of self-inflicted burns ranges from attempt suicide will try again and four out of five less than 1 to 9 percent of patients admitted to people who commit suicide have attempted to burn care facilities. More than half of these kill themselves at least once previously. patients have had previous psychiatric hospital- izations. People who burn themselves are among Seduced by Death: Doctors, Patients and the most difficult patients to treat because of Assisted Suicide Investigation into how the the combination of major medical trauma and Netherlands is coping with the legalization of psychiatric problems. These patients have a EUTHANASIA, by HERBERT HENDIN, M.D., medical higher-than-average incidence of MENTAL ILL- director of the AMERICAN SUICIDE FOUNDATION, NESS, substance abuse, family problems, poor and professor of psychiatry at New York Medical judgment, and poor coping skills. Preexisting College in Valhalla. psychiatric diagnoses typically include major 212 Seneca, Lucius Annaeus

DEPRESSION, SCHIZOPHRENIA, PSYCHOSIS, schizoaf- ond person ended the ceremonial death by cut- fective disorder, and BIPOLAR DISORDER (manic ting off the warrior’s head. depression). Although Japan outlawed seppuku in 1868, Self-immolation has been recorded through- the tradition of honorable suicide continues out history. In A.D. 165, the Cynic philosopher to influence Japanese practice. During World Peregrinus Proteus cremated himself on a pyre. War II, for instance, more than 1,000 young SUTTEE, a form of self-immolation popular Japanese soldiers served as KAMIKAZE PILOTS in India until outlawed in 1829, is reportedly who flew their planes at enemy warships still practiced in remote parts of the country. and certain death. Near the end of the war The practice of suttee requires a widow of and shortly before Japan’s defeat, a number an Indian husband to throw herself on her of military officers committed ritual seppuku husband’s burning funeral pyre as his body is rather than accept the humiliation of surren- cremated. der. As recently as 1970, the internationally Self-immolation as a political act has also famous author YUKIO MISHIMA committed sep- practiced through the centuries, including pro- puku as a plea to the people of his country for test of the Nazi concentration camps, the condi- the return of old values and old traditions in tions of terror in Russian gulags, and the Chinese Japan—one of which was the concept of dying political system. This type of self-immolation with honor. could be considered ALTRUISTIC SUICIDE, in which The word seppuku comes from the Japanese the group’s authority over the individual is so rendering of two Chinese characters mean- pronounced that the individual loses his or her ing “cutting of the stomach.” The same two own personal identity, and wishes to die for the characters in reverse order can also be pro- community. nounced hara-kiri, which became much more See ABUSE, SUBSTANCE. common, though considered vulgar, in spoken Japanese. Seneca, Lucius Annaeus (ca. 3 B.C.–A.D. 65) Son of the rhetorician of the same name, Seneca sex differences, suicide rates Traditionally, became entrusted with the education of NERO, women and young girls are the major suicide later became consul, was charged with plotting attempters in modern society; an estimated against Nero, and ultimately was forced to com- three to four times as many women as men mit suicide to avoid the emperor’s vengeance. attempt suicide every year, but roughly three After he stabbed himself, Seneca’s wife, Paulina, times as many men as women complete sui- not wishing to be left behind, also killed herself cide. Some experts estimate that, among young in the same way. people, as many as nine times more girls than Seneca was a major representative of Roman boys attempt suicide unsuccessfully. Stoicism; his philosophy is contained in his Moral Suicide is still more prevalent among eld-erly Essays and other works. men than among elderly women (65 and over). In the United States, in 1997, for instance, the seppuku In JAPAN, when suicide was still an suicide rate per 100,000 population for men 75 integral part of the samurai warrior’s moral and over was 44.7; for their female counter- code, the only honorable means for a disgraced parts—same age group—the rate was 5.1. warrior to redeem himself was to commit sep- Suicide involves so many variables that it is puku, or ritual suicide, in which he disembow- impossible to arrive at simple or definitive eled himself with his own sword. The elaborate answers as to how patterns change or why they procedure often took hours to complete; a sec- differ among the sexes. siblings, grief after suicide 213

Sexton, Anne Harvey (1928–1974) Ameri- Mental Health, Bethesda, Maryland. He has been can poet and good friend of SYLVIA PLATH, both of a Public Health Service special research fellow whom killed themselves. and visiting professor at Harvard, visiting profes- Anne Gray Harvey was born in Newton, sor at the Ben Gurion University of the Negev, Massachusetts, in 1928. After attending Garland clinical associate at the Massachusetts General Junior College for one year, she married Alfred Hospital and the Karlinska () Hospital, Muller Sexton II at age 19, and six years later and a fellow at the Center for Advanced Study in she gave birth to a daughter. Shortly thereafter, the Behavioral Sciences (at Stanford). she was diagnosed with postpartum DEPRESSION, Dr. Shneidman has been president of the suffered her first mental breakdown, and was Clinical and Public Service Divisions of the admitted to Westwood Lodge, a neuropsychiatric AMERICAN PSYCHOLOGICAL ASSOCIATION and hospital to which she would repeatedly return founder-president of the AMERICAN ASSOCIATION for help. Following the birth of her second OF SUICIDOLOGY (). His book, Death of Man, daughter in 1955, Sexton suffered another was nominated for a National Book Award. Dr. breakdown and was rehospitalized. Her children Shneidman has contributed chapters on suicide were sent to live with her husband’s parents, to a number of anthologies and other publica- and that same year she attempted suicide on her tions, including the Encyclopaedia Britannica birthday. It was her doctor who first encouraged (1973), Comprehensive Textbook of Psychiatry her to pursue an interest in writing poetry. (1975) and Encyclopaedia of Psychology (1984). Like other confessional poets, Sexton offered Dr. Edwin S. Shneidman has devoted a life- her readers an insider’s view of her emotional time of work to the field of suicidology and has anguish, making the experience of being a made a major contribution to the thinking of woman a central issue in her poetry. Sexton members in all disciplines who are still trying to wrote a poem titled “Wanting to Die” (1966), in prevent suicides and help suicidal persons dis- which she describes her desire as “the almost cover less drastic alternatives to life’s problems. unnameable lust.” She wrote in a memoir of her poet friend Plath, “We talked of death, and this siblings, grief after suicide The suicide of a was life to us.” It is said that the two brilliant brother or sister, whether older or younger, young poets spent many hours together going often produces not only grief but also fear, con- over details of their suicide attempts. In the end, fusion, and often guilt in surviving siblings. both finally succeeded. Although almost every youngster has wished Sexton is the author of Live or Die, which during a time of anger, envy, or jealousy for the includes the poem “Wanting to Die.” The collec- death of a brother or sister, if death actually tion won the 1967 Pulitzer Prize for poetry. occurs, the youngster is stricken with complex feelings of anguish and guilt. Shneidman, Edwin S. One of the foremost When the death is caused by suicide, the fear, authorities in the field of suicidology and profes- confusion, and guilt feelings sometimes become sor emeritus of THANATOLOGY and suicidology at unbearable. Parents will often try to hide the the UCLA School of Medicine. Shneidman, facts of a suicide from surviving children in a author and editor of numerous books on suicide family, which can only add to the child’s fears (including Definition of Suicide), was cofounder and confused grief. Sibling guilt and desolation and codirector—with Dr. Norman L. Farberow— are only made worse by half-truths, conspiracies of the LOS ANGELES SUICIDE PREVENTION CENTER.He of silence, and implications of stigma. Survivor was charter director of the Center for the Study brothers and sisters then suffer feelings of blame, of Suicide Prevention at the National Institute of wondering how they might have prevented the 214 silent suicide suicide, or in what ways they might unwittingly person and the constant dozer, will usually begin have contributed to their siblings’ self-destruc- to lose their appetites, eat little or nothing, and tive decision. become lifeless and gaunt. People who cannot sleep are not all victims of silent suicide The hidden intention to com- clinical depression. But if this is a reaction plete suicide by nonviolent means through self- noticeable with a cluster of other symptoms, starvation or not complying with essential such as loss of appetite, loneliness, unusual medical treatment. Silent suicide often is missed, silence and withdrawal from family and friends, especially in the face of an undiagnosed DEPRES- then the individual may need help in the form of SION. professional treatment. If such symptoms go Family members often think that elderly peo- unnoticed or unattended, the depressed person ple who commit silent suicide are making ratio- sometimes retreats further into himself, and sui- nal end-of-life decisions. However, the elderly cide may begin to seem a real alternative to a life committing silent suicide is different from termi- of despair and misery. nally ill patients who refuse further treatment in See also INSOMNIA. order not to prolong the act of dying. Socrates (ca. 470–399 B.C.) Greek philoso- sin, concept of While a few societies and pher who broke with earlier philosophical tradi- religions have tolerated or even looked with tions and laid the foundations for the favor on suicide, it has usually been regarded development of both ethics and logic. Although with repulsion. ST. AUGUSTINE regarded suicide he wrote nothing himself, his ideas survive in as a sin, and a number of church councils the writings of PLATO and XENOPHON. Refusing to denied religious rites to anyone who committed bow to tyranny, whether imposed by the mob or suicide. by oligarchs, Socrates was tried on the charge of Jewish law and the QUR’AN, the sacred text of corrupting the young people of Athens and sen- Islam, denounced it, and medieval law decreed tenced to death by drinking HEMLOCK. that a suicide victim’s property be confiscated and the body desecrated by being dragged by the Solar Temple, Order of the An international heels through the streets, face downward, or sect that believes ritualized suicide leads to buried at a crossroads with a stake through the rebirth on a planet called Sirius. On March 23, heart. 1997, the charred bodies of three women and It was St. Augustine’s denouncement of two men were found inside a house in Saint suicide as a sin that created an official church Casimir, Quebec. All were members of the Solar position against an act, which, he asserted, “pre- Temple. Two years earlier, 16 Solar Temple cluded the possibility of repentance.” He called it members were found dead in a burned house a form of homicide and thus a violation of the outside Grenoble, in the French Alps. In 1994, Decalogue Article, “Thou shalt not kill.” the burned bodies of 48 Solar Temple members were discovered in a farmhouse and three sleeplessness Often one of the several symp- chalets in Switzerland. At the same time, five toms of clinical DEPRESSION. Severely depressed bodies, including that of an infant, were found people may have trouble sleeping, and wake up half a world away in a chalet north of Montreal. in the middle of the night or the early morning The Temple was founded by and hours. The opposite may be the case, as well; Joseph Di Mambro in 1984. At its height of pop- they often sleep all the time, dozing off in mid- ularity in January 1989, there were 442 mem- day or early evening. Both types, the sleepless bers, 90 in Switzerland, 187 in France, 86 in South Pacific Islands and suicide 215

Canada, 53 in Martinique, 16 in the United resurgence after suicide rates dropped in the States, and 10 in Spain. However, membership 1990s. PARAQUAT, a cause of painful, inevitable had been declining around the time of the mass death, is the islanders’ method of choice. suicide in 1994. Samoans and Fiji Indians have the world’s See also CULT SUICIDE. highest female suicide rates. Among the overall figures for the Federated States of Micronesia SOLES (Survivors of Law Enforcement Sui- (FSM), the rate for the Marshall Islands, Samoa, cide) A nonprofit group focusing on support and Fiji are among the highest anywhere. Even and outreach to anyone who is grieving the French Polynesia, among the most developed loss of a loved one’s suicide. The group spon- island countries, is experiencing high rates, sors a website with numerous online mail lists, while New Zealand, with a heavy Polynesian chats, and links, together with a photo memor- population, has some of the highest suicide lev- ial page. els among youths in the developed world. Also, For contact information, see Appendix 1. indigenous Hawaiians have much higher suicide rates than others in the state. In Fiji, experts speculate that the high youth Sensational Sorrows of Young Werther, The suicide rate is a consequence of a school exami- novel by JOHANN WOLFGANG VON GOETHE, Ger- nation system that discriminates against Indians man poet, dramatist, and novelist. This romantic (44 percent of the population) in awarding of narrative (German title: Die Leiden des jungen scholarships and school placements. Some resi- Werthers, published in 1774) describes a young dents claim that Fiji students are being terrorized man who kills himself. It had a startlingly strong by annual make-it-or-break-it exams between influence on young people of the time. Men the ages of 11 and 18. began to dress like Werther, speak like Goethe’s Paraquat was first produced in 1882, but rec- protagonist, and dream of killing themselves like ognized as a herbicide in 1955. Its extreme toxi- Werther. The whole Werther phenomenon city led to its popularity as a suicide method touched off a wave of romantic notions about around the world (there were 700 cases in 10 suffering for one’s genius, struggling for art, and years in Malaysia alone, for example), despite dying young while the world mourned its ideal- bans and strict controls. istic heroes. One study found that the 2000 Fiji coup had driven suicide rates to their highest ever levels, South Carolina The state’s rate per 100,000 with a 200 percent jump in the last two years. population of suicide has remained fairly stable Suicides in FSM, Marshalls, and Palau have since 1970, when it was 10.9, and in 1999 stood increased from about 10 a year during the 1960s at 10.8. The state’s rate per 100,000 population to about 40 a year in 2001. ranks it 24th in the nation. Clinical DEPRESSION associated with suicide in the Western world is not usually a factor in South Dakota South Dakota in 1999 had a Pacific suicides, and few of the victims are men- suicide rate of 14 per 100,000 population. South tally unbalanced. Instead, experts believe that a Dakota is tied with Maine for the 10th highest major cause for the rise in the suicide rate has suicide rate in the country. been the erosion of social structures and values, leaving many young people vulnerable to sui- cide. This is exacerbated by the relatively sud- South Pacific Islands and suicide The South den contact with and domination by the Pacific might look like a paradise, but suicide is Western world to the detriment of their own its dark secret, and anecdotal evidence suggests a culture. 216 Soylent Green

In Samoa, where 70 percent of suicides are Georgia: 11.2 among men, experts also blame authoritarian Hawaii: 11.5 child rearing and the traditional view that youths Idaho: 14.5 are expected to serve and obey. They are not con- Illinois: 8.4 sulted until they become matai (chiefs or family Indiana: 10.6 heads), a status most Samoan men achieve in Iowa: 10.6 their 30s, but most women never achieve. Stud- Kansas: 11.3 ies in Micronesia show most suicides are among Kentucky: 11.9 boys and men between 15 and 24 who hang Louisiana: 11.8 themselves after fights with their parents. Maine: 14 Maryland: 8.4 Massachusetts: 7 Soylent Green A 1973 movie starring Charl- Michigan: 9.9 ton Heston and Edward G. Robinson that fea- Minnesota: 9.2 tured an overpopulated world in which people Mississippi: 11 were encouraged to go to special suicide centers Missouri: 12.8 to be assisted in dying. The film was similar to Montana: 18.4 Kurt Vonnegut’s short story, “Welcome to the Nebraska:10.6 Monkey House.” Nevada: 22.3 New Hampshire: 11.4 state-by-state suicide rates Western states New Jersey: 6.9 have the highest rate of suicide per 100,000 than New Mexico: 18.3 any other area in the country, according to the New York: 6.6 latest statistics available (1999). The state with North Carolina: 11.6 the highest suicide rate is Nevada, at 22.3 per North Dakota: 11.5 100,000, more than double the country-wide Ohio: 9.8 average of 10.7. This is followed by Wyoming Oklahoma: 14.7 (20.4), Montana (18.4), New Mexico (18.3), and Oregon: 14.4 Arizona (16). Pennsylvania: 10.7 The states with five lowest suicide rates per Rhode Island: 9.7 100,000 are all in the Northeast, headed by South Carolina: 10.8 Washington, D.C. (5.8 per 100,000). These are South Dakota: 14 followed by New York (6.6), New Jersey (6.9), Tennessee: 13.2 Massachusetts (7), and Connecticut (8.3). Texas: 10 The breakdown, which changes each year, is Utah: 13.2 as follows: Vermont: 10.6 Virginia: 11.5 Alabama: 12.7 Washington: 14.2 Arizona: 16 West Virginia: 12.7 Arkansas: 13.2 Wisconsin: 11.3 California: 9.3 Wyoming: 20.4 Colorado: 14.2 Connecticut: 8.3 status loss and suicide When image is so Delaware: 11.4 important, loss of status or identity can prove District of Columbia: 5.8 devastating. This is especially true for young Florida: 13.4 people. stress as suicide clue 217

If youngsters do find an identity and that from the sufferings of life. Suicide to them was identity is suddenly stripped from them for some not so much a matter of right and wrong as it reason before they feel secure and worthwhile, was determining the most logical way to act in a suicide may be the means they choose for coping given situation. Legend says that Zeno, founder with the loss. of the Stoic philosophy, killed himself after In certain cases, loss of status or identity may breaking his toe. He decided that God had sent be the crucial indicator of imminent suicide. his broken toe as a sign that he had lived long enough—he was 98 years old at the time. Zeno’s successor, CLEANTHES, is thought to stock market crash, 1929, and suicides On have completed suicide, too. He had developed a October 29, 1929, post–World War I prosperity boil on his gum and was advised by a doctor to came to a startling end as stock prices plum- abstain from eating for a couple of days, thus meted. Stock losses for the period from 1929 to allowing time for the boil to heal. Instead, 1931 were estimated at $50 billion, and the Cleanthes continued to starve himself after the result was the worst depression in U.S. history. A sore had healed. He argued that having gone so number of businessmen lost everything in the far on the path to death, he might as well com- precipitous crash and killed themselves, some by plete the act. jumping from tall office buildings in Manhattan. “Stoicism” gets its name from the Stoa No accurate data exist as to how many suicides (porch) in Athens where Zeno taught. were completed as a direct result of the crash.

“Stormy Monday” According to questionable Stoics Disciples of a Greek philosopher named suicide statistics, “Stormy Monday” is the ZENO. Stoic philosophy was similar to the Taoist favored day for self-destruction. For example, in philosophy of China, both of which teach fol- 1979 (an “average” year), about 82 suicides lowers to attune with their inner nature—what occurred nationwide every Monday. By contrast, the Romans called “reason,” the Chinese the Tao, Saturday statistics showed an average of 71 and the Greeks the Logos. Stoics encourage sim- suicides, the lowest rate among days of the ple living and contentment with one’s present week. Interestingly, Saturday saw the most state of being. deaths by auto accident and homicide that par- The Roman Stoic who determined that he ticular year. had enough of life had his veins severed by trained technicians of the day. SENECA, one of the leaders of the Roman Stoics, wrote that, “If life stress as suicide clue Stressful behavior— please you, live. If not, you have a right to return where a person acts nervously, irrationally, whence you came.” He and his fellow Stoics did peculiarly, “differently”—is one crucial indicator not, however, advocate suicide merely to escape of possible suicidal thoughts and/or intentions. from everyday life. They were concerned with Coupled or clustered with other verbal or people living good and rational lives, free of seri- behavioral clues, this often signals imminent ous sickness, debilitating disease, or political suicide. oppression. They urged people to think very The unbelievable stress placed on Japanese carefully before completing suicide, and to allow teenagers during examinations is one of the fac- themselves to suffer before impulsively destroy- tors that contributes to the high teen suicide rate ing themselves. in Japan—one of the highest in the world. The The Stoic philosophy started in Greece, where examination system is referred to as “Examina- advocates adopted a lenient view of suicide as a tion Hell.” result of their opinion that death is a release See also CLUES OF SUICIDE. 218 suicidal crisis, acute suicidal crisis, acute See ACUTE SUICIDES. nally published in 1897 and published in this country in 1951 as Suicide, the historical, suicidal crisis, how to help Suicidal crises groundbreaking work has had a continuing and usually concern two people: the suicidal person pervasive impact on subsequent work in the and the “significant other.” The latter may be a field of suicidology. parent, lover, associate, or friend. This “signifi- cant other” must be advised immediately of the suicide, preteen The very young—children as situation, and, where possible, become involved young as two—are also trying to commit suicide in life-saving efforts. in increasing numbers. How quickly others intervene in a suicidal cri- Yet the National Center for Health Statistics sis is crucial. If someone suspects suicidal behav- still does not compute suicide data for children ior, quick action is vital. Parents, friends, doctors, under age 10. There is a belief that experts now teachers, ministers, or any key people in the per- know is false—that suicide in children under 10 son’s life should be told immediately. The worst is so rare as to be unmeasurable. Thus, no reli- that will happen is that the person might feel able data exist for suicides of youngsters under foolish for stirring up a suicide scare where none 10. In one study of 127 Pittsburgh elementary exists. But experts say it is far better to err in the school children, 41 percent admitted to having direction of overcaution than to ignore the sig- suicidal thoughts. nals and take a chance on losing a life. Trained professional or volunteer staff mem- Suicide and Life Threatening Behavior bers of any accredited suicide prevention and Quarterly journal of the AMERICAN ASSOCIATION crisis center can predict a suicide with a fair OF SUICIDOLOGY. degree of accuracy. Active, increasingly effective suicide prevention services can offer a suicidal person a fresh outlook on life. suicide attempts There may be as many as 20 to 25 attempted suicides for every one com- suicidal ideation Having thoughts about pleted suicide; the ratio is higher for women and completing suicide. Authorities say it is not ab- youth, and lower for men and the elderly. normal to have such thoughts at one time or Risk factors for attempted suicide in adults another during the course of a lifetime. A include DEPRESSION, alcohol abuse, cocaine use, healthy, well-integrated personality, however, and separation or divorce. Risk factors for quickly dismisses such destructive thoughts as attempted suicide in youth include depression, an unacceptable alternative to life. alcohol or other drug use disorder, physical or sexual abuse, and aggressive or disruptive Suicidal Ideation Questionnaire (SIQ) Psy- behaviors. chological test that measures suicidal thoughts in Most suicide attempts are expressions of adolescents. The SIQ is a supplement to the extreme distress, and are not just harmless bids Reynolds Adolescent Depression Scale. The for attention. A suicidal person should not be left SIQ–JR is a specialized version of the SIQ that alone and needs immediate mental health treat- was developed for use with adolescents in junior ment. high school. Both versions may be administered in individual or small group settings. Suicide Awareness/Voices of Education (SAVE) A nonprofit support group composed Suicide, Le First scientific study of suicide, by mostly of suicide survivors. SAVE was started in noted French sociologist ÉMILE DURKHEIM. Origi- 1989 by six suicide survivors; until early 1998, suicide gestures 219 the organization operated solely on the efforts of tapes as the person who placed the initial bur- volunteers. glary call to police. Police later learned that the SAVE is committed to the education of the subject had been hospitalized as the result of a general public about the depressive brain dis- suicide attempt. eases such as clinical DEPRESSION and BIPOLAR DISORDER that can result in suicide if left suicide career An individual pattern of mul- untreated. tiple suicide attempts. The organization offers information, a speaker’s bureau, and school-based suicide pre- vention programs. Each spring, preceding suicide contagion The exposure to suicide or National Mental Health Month, SAVE sponsors a suicidal behaviors within the family, peer group, Suicide Awareness and Memorial Day (SAMD). or through media reports of suicide that triggers an increase in other suicides or suicidal behavior. Direct and indirect exposure to suicidal behavior suicide bombers See TERRORISM AND SUICIDE. has been shown to trigger an increase in suicidal behavior in those at risk for suicide, especially in suicide by cop A situation in which an in- adolescents and young adults. dividual who wishes to die uses the police to The risk of suicide contagion as a result of complete suicide. Typically, the person acts in media reporting can be minimized by factual and such a way as to force the police to use their concise media reports of suicide. Prolonged weapons. By initiating an assault or otherwise exposure to reports of suicide also can increase provoking a police officer, suicide-prone indi- the likelihood of suicide contagion. viduals achieve their goals without losing Because suicide is caused by many complex self-esteem. Suicide by cop is a relatively factors, experts stress that media coverage new term to describe “victim-precipitated should not: homicide.” Studies suggest that police may confront • report oversimplified explanations such as shootings motivated by suicidal subjects more recent negative life events or acute stressors often than reports indicate. In one case, an • divulge detailed descriptions of the method adult male drove his car onto the front lawn of used to avoid possible duplication or to glorify police headquarters in downtown Detroit. He the victim got out of his car, took out a handgun, and • imply that suicide was effective in achieving a began shooting at the building. Several police personal goal such as gaining media attention. officers returned fire until they killed the sub- ject. In another case, Philadelphia police Anyone who has been exposed to suicide or sui- responded to a burglary-in-progress call at a cidal behaviors within the family or among the local school. Upon arrival, the suspect fired peer group should be evaluated by a mental twice at the police. A subsequent chase through health professional in order to minimize the risk the school corridors followed. A police dog of suicide. Those deemed at risk for suicide eventually cornered the subject, and as the should then be referred for additional mental officers approached, they found the subject health services. crouched and pointing a gun at them. Police fired, killing the subject. Police later found that the subject’s gun was a starter pistol, incapable suicide gestures Initiating suicidal acts at a of firing live rounds. Furthermore, family mem- low level of lethality, such as ingesting just a bers later identified the subject’s voice on police few over-the-counter medications. No matter 220 suicide “how to” manuals how unlikely they are to result in death, sui- Suicide in America Book by psychiatrist- cide gestures should not be dismissed lightly, author Herbert Hendin, M.D., internationally since they are pleas for help that require thor- known authority on the subject of suicide. The ough evaluation and treatment to prevent book examines the personal and social factors repeated attempts. This is especially true given contributing to suicide among different groups that 20 percent of people who attempt suicide of people, including the young, in America; pub- try again within one year; 10 percent finally lished in 1982 by W. W. Norton. In 1982, Dr. succeed. Hendin received the Louis I. Dublin award of the AMERICAN ASSOCIATION OF SUICIDOLOGY. His other books include: The Age of Sensation; Black Suicide; suicide “how to” manuals Books and articles Suicide and Scandinavia; Seduced by Death: Doctors, that give explicit instructions on how to com- Patients and Assisted Suicide. plete suicide. Several controversial types of these manuals have been published over the years. LET ME DIE BEFORE I WAKE: Hemlock’s Book of Self- Suicide Information and Education Centre Deliverance for the Dying was written by DEREK (SIEC) Established in 1982, SIEC is a special HUMPHRY in 1981. First editions were sold only to library and resource center providing informa- HEMLOCK SOCIETY members; a third edition was tion on suicide and suicidal behavior. The Sui- published in 1984 by the society and distributed cide Prevention Training Programs (SPTP) by the Grove Press in New York. The book provide caregiver training in suicide INTERVEN- addresses the option of “rational suicide” only TION, awareness, bereavement, crisis manage- for a person in advanced terminal illness or seri- ment, and related topics. ous incurable physical illness. For contact information, see Appendix I. Jean’s Way was written by Humphry and his second wife, Ann Wickett, published in 1978 “Suicide Is Painless” Song also known as the and again in 1981. This book described the sui- theme song for “M*A*S*H,” long-running televi- cide of Humphry’s first wife, Jean, who was suf- sion series starring Alan Alda taken from the fering with cancer. It is considered a classic 1970 motion picture of the same name. account of what the authors call rational volun- The words are by Mike Altman, music is by tary EUTHANASIA. Johnny Mandell. FINAL EXIT: THE PRACTICALITIES OF SELF-DELI- VERANCE AND ASSISTED SUICIDE FOR THE DYING was suicide notes Between 10 percent and 35 written by Humphry and translated into 12 percent of people who complete suicide leave a major languages. The book was a New York note behind, often including concrete instruc- Times best-seller in 1991, and in the updated tions to survivors and using specific names of 1997 edition (Dell paperback) sells consistently people, places, and things. The notes appear to every year. serve as a way of reaching out to specific indi- Humphry’s Supplement to Final Exit published viduals, trying to influence and even control in 2000, provides new information to bring Final them after the writer’s death. Exit up to date politically, legally, and ethically. Notes left by elderly people often express con- The book includes an explicit chapter on how to cern for those left behind, whereas those of take one’s life with helium gas. younger people may express anger or vindictive- Exit: A Guide to Self Deliverance was published ness. The content may indicate the mental disor- by Arthur Koestler in London in 1981 and sold der that led to the suicidal act. Often, suicide only to members of the British Voluntary notes are mundane lists of instructions, final Euthanasia Society who were over age 25. wishes, and so on. suicide threats 221

In attempted suicides, a note is less common; in a fall from the Palisades in Fort Lee, New Jer- it indicates premeditation and a high risk of sey, in September 1986. repeated attempts and completed suicide. Two days after the Bergenfield tragedy, an- Many notes are destroyed by families who other suicide pact cost the lives of teenagers fear stigmatization. One study by psychologists Karen Logan, 17, and Nancy Grannan, in Alsip, Edwin Shneidman and Norman L. Farberow Illinois. They had apparently killed themselves found that it is possible to distinguish between in a garage full of auto exhaust, and police said genuine and simulated (fake) notes—and that they had probably been influenced by the news the genuine notes included more angry feelings of the joint suicides of the four New Jersey and more expressions of revenge than the simu- young people. lated notes (which were composed by carefully While suicide pacts do occur among older selected people asked to think as if they were couples, they are very rare, and make up less about to kill themselves). Most genuine suicide than one-tenth of one percent of all suicides in notes are specific as to instructions to survivors, the older population. very decisive; they give little evidence of think- ing about suicide per se, and more evidence of Suicide Prevention Advocacy Network A self-blame and hostility. nonprofit organization that links the energy of those bereaved by suicide with the expertise of suicide pacts Part of a larger phenomenon leaders in science, business, government, and known as DUAL SUICIDE, this involves the death public service to achieve the goal of significantly of two or more people who intentionally com- reducing the national rate of suicide by the year plete suicide at the same time and place. Suicide 2010. pacts (also called “love-pact suicide”) also SPAN was founded by the parents of Teri Ann include MURDER-SUICIDE between lovers in Weyrauch, M.D., who committed suicide on which both people agree to die at the same time June 17, 1987, at age 34. Filled with grief, the and place, but instead of a double suicide, one Weyrauchs volunteered with many local and kills the other and then completes suicide. national suicide prevention efforts until they One highly publicized suicide pact between decided to launch an organization to give suicide two teenagers resulted in the book CRAIG AND survivors and their supporters the chance to JOAN. In 1969, Joan Fox and Craig Badiali, both help create political will and bring suicide pre- 17, killed themselves by asphyxiation. The two vention to its rightful place in the forefront of New Jersey teens left 24 suicide notes between the American consciousness. them protesting the Vietnam War. For contact information, see Appendix I. On March 10, 1987, four Bergenfield, New Jersey, teenagers—two boys and two girls— suicide threats Any and all suicide threats, decided to complete suicide together by sitting in whether said seriously or jokingly, should be a car with the motor running inside a locked taken seriously. garage. Thomas Rizzo, 19; Thomas Olton, 18; It is a myth and misconception that people and sisters Lisa and Cheryl Burress, 16 and 17, who talk about suicide don’t follow through were discovered dead in the locked car on the with their threat. All threats must be taken as a morning of March 11, victims of carbon serious warning. monoxide poisoning; estimated time of death The slightest thing can sometimes turn the was between 3:30 and 4:00 A.M. The four young thought into reality. For instance, refusing to people were reportedly distraught over the take a suicide threat seriously can be the trigger- death of a friend, Joe Major, who had lost his life ing factor. To the suicidal person, it confirms that 222 superstition nobody cares or understands, and may serve as The survivor family is at high risk until proven the catalyst to attempt suicide. otherwise. Most communities today have mental A suicide or suicide attempt has often been health centers where active, effective survivor recognized by experts as a “cry for help.” Most assistance services offer the victims of a loved suicides are ambivalent; there’s an urge to die as one’s self-destruction a fresh grasp on life. expressed in the threat, but there’s also an urge to live. Survivors of Loved Ones Suicide (SOLOS) Nonprofit self-help organization for relatives and superstition Superstition concerning the act friends of those who have completed suicide. The of suicide was common during the Middle Ages, group provides support to survivors when suicides were relatively rare (as a result of through outreach and education to help people strict church rules). Because of superstitious deal effectively with their loss. The group tries fears, the victim’s body was degraded and often to ensure better access to existing resources, pro- was dragged through the streets and spat on or vide forums for mutual support and information, hung on public gallows. Victims were sometimes promote research, and help educate the public. buried on the spot where the act took place; at For contact information, see Appendix I. other times, the body was left unburied in an area set aside for public executions. Often a sui- suttee A practice in ancient India in which cide’s corpse was superstitiously buried at a widows, motivated by the pressure from society, crossroads with a stake driven through its heart threw themselves on their dead husband’s and a heavy stone placed on its face to prevent funeral pyre or drowned themselves in the holy the dead person’s spirit from rising. Ganges River. In England as late as 1823, the body of a man They were encouraged to do this by Hindu known as Mr. ABEL GRIFFITHS was dragged priests and their own relatives. The widows were through London’s streets and buried at a cross- taught that a faithful wife could atone for her roads. His was the last such suicide to be treated husband’s sins on earth and open to him the in that manner. gates of paradise. Women who practiced suttee were venerated survivor guilt After a suicide, the emotions by the populace. Those who refused were not of the survivors are often as intense and un- only condemned but also often threatened with bearable as were those of the person who com- harsh physical punishment. pleted the act. Those left behind experience the The Mahasati (the great suttee) or the pain of sudden loss, but they also have exagger- Sahagamana (joint departure) system of a cre- ated feelings of shame, guilt, and self-blame. mating the woman alive on the death of her The suicide itself immediately raises obvious husband is an ancient custom in India. Scholars questions, such as “Why?” and “What could of the Puranas trace the origins to the suicide of I have done to prevent it?” As Rabbi Earl A. Satidevi in the sacrificial fireplace of Lord Grollman writes in Suicide: Prevention, Interven- Brahma, while a few attribute it to the pre-caste tion, Postvention: “Death is a robber. Death by Vedic system of Indian society. In the Indian suicide brings the greatest of all affronts to mythology of the Mahabharat, there is the those who remain.” instance of Madri dying on the funeral pyre of Survivors who have experienced the loss of a husband Pandu, leaving the children to the care loved one through suicide need meaningful sup- of the first wife, Kunti. port in what experts call “postvention”—self- Feminists proclaim the suttee system as a help groups and neighborhood support. cruel institution established by men against the Synod of Nîmes 223 women, while the lower caste in India have felt Switzerland Tiny, peace-loving Switzerland it as another means of torture placed on them by has one of the highest suicide rates per 100,000 upper-caste Brahmins. population in the world. In 1996, World Health There is no simple answer as to how the sut- Organization statistics revealed that the total sui- tee system originated. In a time when people cide rate for all ages was 20.4; the male rate was believed that a woman’s path to heaven is 29.2; the female rate was 11.6. through her character and devotion to her hus- The highest rate among men was from ages band, it was perhaps thought that a woman’s life 75 and up, with a rate of 80.2. For women, those served no purpose after the death of her hus- over 75 also had the highest rate per 100,000 band. The practice might have come into prac- population, with 23.5. tice as a family conspiracy against the widow to benefit from her assets. Moreover, the life of a widow was so bad, the women perhaps favored Synod of Nîmes Voluntary martyrdom death to humiliation. In addition, women who among Christians was discouraged by church participated in suttee were glorified, and so the leaders as Christianity spread and became toler- attraction of instant fame and immortality were ated as a recognized state religion in the Roman also important. Empire. However, it was not until the Council Some women believed that if they died with of Braga in A.D. 563 that voluntary martyrdom their husband, they would be united with him in and suicide as an act were condemned by the heaven in an eternal marriage. church. This position was confirmed by the The ancient practice continued in India for Councils of Auxerre (578) and Antisidor (590) hundreds of years. Even after suttee was out- and remained the canon law until 1284, when lawed in 1829 by the British rulers of the coun- the Synod of Nîmes refused burial in consecrated try, slow-changing customs kept it going well ground to suicides. into the 1900s.

T

Tabachnick, Norman Psychiatrist who, with Fortunately, there is evidence in recent years colleagues at the LOS ANGELES SUICIDE PREVENTION that ancient myths and misconceptions are CENTER, studied the psychology of fatal accidents. slowly being removed as more people come to The researchers learned that roughly 25 percent understand suicide. of accident victims among those studied were depressed and had feelings of helplessness and a Tacitus, Publius Cornelius (ca. A.D. 55– sense of loss similar to that in suicidal people. ca. 120) Roman historian and a distinguished The subjects admitted to fantasies and dreams of lawyer. Best known for such historical works as death and self-destruction just prior to their acci- the Historiae, in which he gives an account of dents. Researchers concluded that the serious Otho’s death and how some soldiers killed them- accidents may have resulted from unconscious selves near his pyre, prompted by a desire to imi- desires to destroy themselves. tate his “glorious example and moved by Opposite traits characterized the remaining 75 affection for their emperor.” Tacitus explains that percent of accident cases studied. These people after this many of every rank chose suicide at were self-reliant and thought of themselves as Bedriacum, Placentia, and other camps as well. strong and forceful. Under pressure, they reacted It was Tacitus who reported, also, the ancient to difficulty quickly and impulsively, and gave practice of bog burials—of pinning down the little or no thought to the consequences of their body of suicides. The practice antedates Chris- actions. tianity among the Germanic peoples of Europe. Other studies into teenagers’ driving habits This was done to prevent the spirits of the dead have confirmed the combined role of personal- from returning to haunt or do harm to the ity traits and emotions in influencing serious living. accidents. teachers, role in suicide prevention Be- taboos It is because suicide is still such a taboo cause they usually spend more hours with the topic—one that stigmatizes not only the suicidal child than do most parents, teachers are in a victim but the survivors as well—that so many position to observe and be aware of what the people have difficulty discussing it openly and individual child’s life is really like. They can spot honestly. Religions condemn it as a sin, and for drug users, loners, depressed students, mood years law books listed it as a crime. Long ago, swings, and those who cut classes or are disrup- courts actually punished the families of sui- tive. All these are possible red flags that should cides, and rulers confiscated all the victim’s alert teachers that something could be wrong. property. Churches denied suicides burial in In some communities across the United consecrated sites. States, teachers undergo training on how to rec- Today, for the most part, such arcane laws and ognize early warning signs, how to approach the church practices have disappeared. suicidal child, and how to assess his/her poten-

225 226 Teasdale, Sara tial to complete suicide. School counselors and final collection, Strange Victory, appeared posthu- nurses are usually included in the training mously that same year. courses. Teachers, properly trained to the clues She left a suicide note in the form of a poem of suicide, can be a valuable pipeline to students to a lover who had left her: because young people reveal their despair and anguish in their school work. When I am dead, and over me bright April Shakes out her rain drenched hair, Tho you should lean above me broken hearted, Teasdale, Sara (1884–1933) American poet I shall not care. famous for works of delicate and personal lyrics, For I shall have peace. this extraordinarily sensitive, almost reclusive As leafy trees are peaceful woman eventually became despondent and When rain bends down the bough. completed suicide at the age of 48. And I shall be more silent and cold hearted Sara Trevor Teasdale was born in St. Louis, Than you are now. Missouri, into an old established devout family who taught her at home until she was nine. teenage suicide Over the last several decades, Upon graduation from high school, between the suicide rate in adolescents has increased dra- 1904 and 1907 Teasdale and a group of friends matically, until by 1997 suicide was the third published a monthly literary magazine called The leading cause of death for 15- to 24-year-olds Potter’s Wheel. As she grew older, she traveled (11.4 of every 100,000 persons) following unin- often to Chicago, where she joined the circle of tentional injuries and homicide. Suicide also was writers surrounding Poetry magazine and wrote the third leading cause of death for 10- to 14- several well-received books, including Helen of year-olds, with 303 deaths among 19,097,000 Troy and Other Poems (1911) and Rivers to the Sea children in this age group. In 1998, among (1915). youth ages 10 to 19, there were 2,054 suicides. After rejecting the poet Vachel Lindsay and For those age 15 to 19, there were 1,802 suicide several other men as suitors, she married St. deaths among 19,146,000 teens. Louis businessman Ernst Filsinger in 1914. Although the overall suicide rate has In 1918, she won the Columbia University declined over the past 20 years, from 12.1 per Poetry Society Prize (which became the Pulitzer 100,000 in 1979 to 11.3 per 100,000 in 1998, Prize for poetry) and the Poetry Society of Amer- the suicide rate for teens 15 to 19 years old has ica Prize for Love Songs, which had appeared in increased by 6 percent. For adolescents 10 to 14 1917. She published three more volumes of years old, the suicide rate increased by more poetry during her lifetime: Flame and Shadow than 100 percent over that time period. And (1920), Dark of the Moon (1926), and Stars Tonight while youth suicide rates did decrease signifi- (1930). cantly between 1993 and 1998, suicide was still Teasdale’s work was praised for its classic sim- the third leading cause of death for young plicity and clarity, in addition to her passionate people 10 to 19 years old in 1998. More subject matter. These later books trace her grow- teenagers died from suicide than from cancer, ing finesse and poetic subtlety. heart disease, AIDS, birth defects, stroke, pneu- She divorced in 1929 (against her husband’s monia and influenza, and chronic lung disease will) and lived the rest of her life as a semi- combined. invalid. Weakened after a difficult bout with pneumonia and increasingly depressed and Gender Issues reclusive, Teasdale completed suicide on January Teenage boys are about four times more likely to 29, 1933, with an overdose of sleeping pills. Her kill themselves than are teenage girls. Among teenage suicide 227 young people 20 to 24 years of age, there were ing risk factors for suicide completion where an 2,384 suicide deaths among 17,488,000 people attempt was made to assess sexual orientation, in this age group, and the gender ratio in this age the risk for gay or lesbian persons did not appear range was about six boys to every one girl. any greater than among heterosexuals, once But while more boys die from suicide, more mental and substance abuse disorders were girls attempt suicide and report higher rates of taken into account. DEPRESSION. Experts believe the gender differ- Several state and national studies have ence in suicide completion is most likely due to reported that high school students who report the differences in suicide methods, since boys homosexual or bisexual activity have higher are more likely to use firearms, which are more rates of suicide thoughts and attempts compared likely to lead to a fatal outcome. to youth with heterosexual experience. Experts do not agree about the best way to measure Culture Issues reports of adolescent suicide attempts on sexual In 1998, white boys accounted for 61 percent of orientation, however, so the data are subject to all suicides among youth age 10 to 19, and white question. boys and girls together accounted for more than See ABUSE, SUBSTANCE. 84 percent of all youth suicides. However, the suicide rate among Native American teenage Suicide Attempts boys is exceedingly high in comparison with the A far greater number of youths attempt suicide overall rate for boys age 10 to 19 (19.3 per each year. Suicide attempts are difficult to count 100,000 vs. 8.5 per 100,000). because many may not be treated in a hospital or The suicide rate has been increasing most may not be recorded as self-inflicted injury. Sur- rapidly among African-American boys age 10 to vey data from 1999 indicate that 19.3 percent of 19—more than doubling from 2.9 per 100,000 high school students had seriously considered to 6.1 per 100,000 from 1981 to 1998. On the attempting suicide, 14.5 percent had made plans other hand, a 1999 national survey of high to attempt suicide, and 8.3 percent had made a school students found that Hispanic boys and suicide attempt during the year preceding the girls were significantly more likely than white survey. All suicide attempts should be taken seri- students to have reported a suicide attempt (12.8 ously. percent vs. 6.7 percent). Among Hispanic stu- dents, girls (18.9 percent) were almost three Warning Signs times more likely than boys (6.6 percent) to The challenge for family and friends of teens is to have reported a suicide attempt. The most likely be able to tell the difference between normal explanation for ethnic rate differences are varia- teen angst and actual despair. Luckily, many tions in cultural factors that promote or inhibit experts agree that there are recognizable warn- suicide. ing signs. Sixty percent of suicidal teens are depressed, and depression tends to cause certain Homosexuality types of behavioral changes—a cluster of It has been widely reported in the media that gay changes in behavior and mood, in sleep and eat- and lesbian youth are at higher risk to complete ing patterns, and energy level. Other warning suicide than other youth and that a significant signs of depression include dramatic changes in percent of all attempted or completed youth sui- behavior or appearance, in weight, or in perfor- cides are related to issues of . mance in school. Any talk about wanting to die However, there are no national statistics for sui- or complete suicide should be seen as a real risk cide completion rates among gay, lesbian, or factor. Another strong signal is continuing alco- bisexual persons, and in the few studies examin- hol or drug use because one of the first things 228 teenage suicide troubled teens try to do is to medicate them- police, fighting, or breaking up with a friend. selves by drinking or taking drugs instead of Rarely a sufficient cause of suicide, these events seeking psychological help. may act as precipitating factors in young people. Gun access There is a direct link between Risk Factors the accessibility and availability of firearms in Suicide is a complex behavior that is usually the home and the risk for youth suicide. The caused by a combination of factors. Researchers more guns there are and the easier they are to have identified a number of risk factors associ- retrieve, the higher the risk. ated with a higher risk for suicide, and factors Exposure to suicidal behavior Whether a that may reduce the likelihood of suicidal behav- real or fictional account of suicide, research sug- ior. It is important to note, however, that the gests this can trigger suicide in vulnerable teens. importance of risk and protective factors can In addition, local epidemics of suicide have a vary by age, gender, and ethnicity. contagious influence. Suicide clusters nearly Previous attempts If a teen has attempted always involve previously disturbed young peo- suicide in the past, there is a higher chance of ple who knew about each other’s death but recurrence in the future. If a teenage boy has rarely knew the other victims personally. attempted suicide in the past, he is more than 30 Incarceration Data suggest a high preva- times more likely to complete suicide, while a lence of suicidal behavior in juvenile correc- female with a past attempt has about three times tional facilities. One study found that suicide in the risk. About a third of teenage suicide victims juvenile detention and correctional facilities was have made a previous suicide attempt. more than four times greater than youth suicide Mental disorders or substance abuse Re- overall. According to another recent study, more search shows that more than 90 percent of than 11,000 juveniles engage in more than teenagers who complete suicide have a mental 17,000 incidents of suicidal behavior in juvenile or substance abuse disorder or both, and that facilities each year. most are depressed. In a 10- to 15-year study of Other identified risk factors include a family 73 adolescents diagnosed with major depression, history of mental or substance abuse disorders, a 7 percent of the adolescents had completed sui- history of physical and/or sexual abuse, low lev- cide sometime later. The depressed adolescents els of communication with parents, the posses- were five times more likely to have attempted sion of certain cultural and religious beliefs suicide as well, compared with a control group about suicide (for instance, the belief that suicide of age peers without depression. is a noble resolution of a personal dilemma), and Almost half of teenagers who complete sui- lack of access or an unwillingness to seek mental cide have been seen by a mental health profes- health treatment. sional. In addition, aggressive, disruptive, and The impact of some risk factors can be impulsive behavior is common in youth of both reduced by INTERVENTIONS (such as providing sexes who complete suicide. effective treatments for depressive illness). Those Family history A high proportion of suicides risks factors that cannot be changed (such as a and attempters have had a close family member previous suicide attempt) can alert others to the who attempted or completed suicide, which heightened risk of suicide during periods of the may be either linked to imitation or genetics. recurrence of a mental or substance abuse disor- Many of the mental illnesses which contribute to der, or following a significant stressful life event. suicide risk appear to have a genetic component. Stressful life event or loss Stressful life Protective Factors events often precede a suicide or suicide at- Factors that protect against suicide include a tempt, such as trouble at school or with the teen’s genetic or neurobiological makeup, atti- television, effect on suicide 229 tude and behavior characteristics, and environ- Although it’s not possible to prevent every ment. Problem-solving skills, impulse control, case of suicide, parents who closely watch their conflict resolution, and nonviolent handling of teenagers and work hard at maintaining com- disputes all help reduce risk, together with fam- munication have the best chance of saving their ily and community support, access to effective child’s life. mental health care and support, restricted access A relatively recent phenomenon has been the to guns, and cultural and religious beliefs that so-called CLUSTER SUICIDES, surges of copycat self- discourage suicide and support self-preservation destruction. Since 1982, clusters of suicides instincts. among teens have occurred in Omaha, Ne- Measures that enhance resilience or protec- braska; Cheyenne, Wyoming; three cities in tive factors are as essential as risk reduction in Texas—Plano, Clear Lake City, and Richardson; preventing suicide. Positive resistance to suicide and Westchester County, New York. In Bergen- is not permanent, so programs that support and field, New Jersey, a middle-class suburb 10 miles maintain protection against suicide should be west of New York City, two teenage boys and ongoing. two teenage sisters sat together in an idling car while it filled a garage with lethal carbon Methods monoxide. The day after the quartet’s suicide Firearms are the most common method of sui- pact, two depressed teenage girls in Alsip, Illi- cide by both boys and girls, and younger and nois, killed themselves in much the same way, older teens for all races. More than 60 percent of their bodies recovered in an exhaust-filled youth suicides between the ages of 10 and 19 in garage. 1998 were firearm related. The rate of youth sui- cides involving a firearm increased 38 percent telephone intervention Telephone crisis between 1981 and 1994, and although firearm- intervention service usually staffed 24 hours a involved suicides declined more than 20 percent day to counsel suicidal callers. from 1994 to 1998, these numbers are still high. The first phone interview is crucial and often Prevention spells the difference between life and death. The caller must be made to feel he is being inter- Despite this very real threat during the teen viewed by an empathetic, knowledgeable years, many families feel uncomfortable about authority who not only wants to but can help. discussing the topic with their children, fearing The AMERICAN ASSOCIATION OF SUICIDOLOGY that if they bring up the subject it will plant a and the NATIONAL COMMITTEE ON YOUTH SUICIDE suggestion where none before existed. In fact, PREVENTION both publish suicide prevention and talking with a teenager about their negative feel- crisis center listings of hotlines and counseling ings can help ease the sense of hopelessness the services. child may have. Parents who worry that their child might be suicidal should seek help from a mental television, effect on suicide Many experts health professional (either a psychologist, psy- believe that TV watching may be a catalyst for chiatrist, psychiatric nurse, school counselor, suicide on the part of some impressionable religious counselor, or social worker). Pediatri- young people who see news stories concerning cians and family doctors also can help, teenage suicides. Others believe that incidents although they may have less training in suicidal directly linked to TV are isolated cases. crises. In case of a suicide emergency, parents The medium of television is often accused of can call 911 or take the child to a hospital exacerbating the problem and effects of teen sui- emergency room. cide by publicizing and sometimes sensationaliz- 230 temporal factors ing the facts. While this may be true in certain Weather, holidays, phases of the moon, and cases, someone doesn’t become suicidal just by the occurrence of sunspots seem not to affect watching TV and seeing that someone else has suicidal tendencies. While the word lunacy done it. Experts agree that the suicide decision derives from the Latin word for “moon,” no reli- is not impulsive; it is, in fact, usually premedi- able evidence exists to indicate that more sui- tated. While it might be done on impulse, gener- cides than usual occur during a full moon. On ally suicide is an action that is given long the other hand, some believe there is a global consideration. geographical correlation: Northerly places, such A far greater danger than television lies in pre- as Scandinavia, show higher suicide rates than venting discussion of the subject of suicide. In do more tropical countries. In the United States, fact, the element of candid discussion—educa- the Rocky Mountain region has the highest sui- tional, factual, informational—is the best cide rate, while New England has the lowest rate weapon available to combat teenage self- per 100,000 population. destruction. Television, properly done, provides that vital, valuable forum. terminal illness See EUTHANASIA; HEMLOCK SOCIETY. temporal factors The idea that suicide occurs more often during certain times of day or season. terrorism and suicide An age-old tactic in One California study showed that about 14 which the very act of the attack is dependent percent of suicides occur between 9 A.M. and 10 upon the death of the perpetrator. In suicide ter- A.M., while 13 percent take place from 1 P.M.to rorism, the terrorist fully understands that if he 2 P.M. Others have found that more suicides does not kill himself, the planned attack will not occur between noon and 6 P.M. and that fewer be implemented. Terrorists use suicide attacks to happened between midnight and 6 A.M. instill a feeling of helplessness in a population— As for the relation of suicide to seasons, spring the idea that there is no way of protecting them- is traditionally the most suicidal time of year. selves against attack, creating fear and panic. Some authorities think that because spring is a As many terrorist groups in the 20th century time of “rebirth” and most people feel happier, conquered their inhibitions about killing large the suicidal person may regress and feel more numbers of innocent victims indiscriminately, depressed because he sees others being more suicide terrorism has reemerged in the last two cheerful—and such feelings may lead to sui- decades as a favored tactic of certain terrorist cide. According to suicide rates from 1980 to groups because of the fear it generates and the 2000, April is the peak month for suicides in ability to execute accurate, large-scale attacks general, February is the month when SUICIDE without sophisticated technology. CLUSTERS peak. The largest number of suicide terrorist attacks The suicide rate among the general popula- in recent years have come from the Liberation tion reaches a low point in November and Tigers of Tamil Eelam (LTTE, or Tamil Tigers), a December. Clearly, suicide does not peak during separatist group fighting the government of Sri the holidays. Lanka. Using suicide attackers, the Tigers man- Monday appears to be the day on which most aged to kill two heads of state, Indian Prime suicides occur. In an average year, an estimated Minister Rajiv Gandhi, in 1991, and Sri Lankan 82 suicides take place nationwide every Monday. President Ranasinghe Premadasa, in 1993. Other Saturday statistics, by contrast, showed an aver- groups using suicide terrorism include the Kur- age of 71 suicides, the lowest rate among days of distan Workers’ Party (PKK), a Kurdish, Marxist the week. separatist group fighting the government of terrorism and suicide 231

Turkey; Hezbollah, an Iranian-backed group of tus after death. The family of the shahid is hon- Shiite Islamists based in Lebanon; and al-Qaeda, ored and paid a financial reward for the attack. Osama bin Laden’s network of radical Sunni In addition to the religious mission and the fam- Islamists. ily rewards, the shahid also receives some per- While not technically terrorism, the kamikaze sonal benefits, including eternal life in paradise, attacks of Japanese pilots during World War II the chance to see the face of Allah, the loving also showed a willingness to use suicide as a kindness of 72 virgins who will serve him in weapon. This indicates that the concept of self- heaven, and a chance to promise a life in heaven sacrifice is not specific to any given culture, but to 70 of his relatives. it is becoming more common. The typical suicide bomber is young (usually The most recent wave of suicide terrorism between 18 to 27), unmarried, unemployed, and began with attacks by Hezbollah in Lebanon in poor. He has usually completed high school, 1983. The tactic was adopted by the Tamil Tigers usually becoming a student at Islamic funda- in Sri Lanka in 1987, by the Palestinian Islamist mentalist education centers. Most shahids com- group Hamas in Israel in 1994, and by the PKK plete a because of a combination in Turkey in 1996. Al-Qaeda embraced suicide of religious fanaticism and nationalist extrem- terrorism in the mid-1990s when the network ism—a wish for revenge, not personal despair. began planning the 1998 bombings of the U.S. Usually a shahid does not volunteer for his embassies in Kenya and Tanzania, and the 2001 missions, but is selected by his Islamic religious attack on the World Trade Center and the Penta- teacher after a close examination by the teachers gon. The second Palestinian intifada (uprising), over a long period of time. After he is selected, which began in 2000, has featured numerous he usually participates in long training sessions suicide attacks from both religious and secular in order to test his attitudes and performance Palestinian terrorist groups. In May 2002, FBI under pressure and in life-threatening situa- director Robert S. Mueller III said future suicide tions. Only the best trainees subsequently disap- attacks on American soil are “inevitable.” pear from home, beginning several days of The Islamist movement has strongly encour- intensive training in order to understand all aged many Muslims to accept a theology in operational aspects of his mission and to learn which becoming a suicide bomber is not consid- how to deal with the explosive device. At this ered suicide, but instead is a form of religious time the shahid also undergoes a process of phys- “struggle.” Therefore, in the view of some ical and mental purification. Islamists, a Muslim can effectively commit sui- Suicides are generally thought of as self- cide without violating Islamic law. Dozens of inflicted death to escape a painful or unbearable Muslims have died in this fashion over the last life. Individuals who are highly suicidal have 20 years. reached a point where death my be perceived as Among the Hamas, an organization that has preferable to a continued existence. Although carried out a number of suicide attacks against the term suicidal is currently being used to Israeli buses, markets, and other civilian targets, describe the individuals responsible for the the perpetrator of a suicide attack is not consid- recent tragedies in New York, Washington, and ered to have completed suicide. Instead, he is Pennsylvania, it is important to remember that rather perceived to be a shahid—a martyr who the vast majority of suicidal persons are no died while fulfilling a religious command, the threat to others. jihad or “holy war.” Terrorists who kill themselves in fulfillment of Suicide attacks may provide the shahid and his their mission are not primarily suicidal, but may family with substantial rewards. Most shahids are be willing to sacrifice their lives for a cause, to poor, and his actions will improve his social sta- advance an ideology, or to martyr themselves in 232 thanatology service to a charismatic leader against a per- who drank himself to death before his 40th ceived enemy, such as the terrorist attacks on birthday. He exhibited death-oriented behavior September 11, 2001. In these cases, individuals much of his life by engaging in what many who take their lives and the lives of others are experts deemed “life-shortening activities.” not necessarily suffering from mental illness. Thomas’s compulsive drinking, and his entire lifestyle, appeared to involve an inexorable thanatology Study of death and dying. movement, whether intentioned or subinten- Thanatos is the Greek name for a mythical tioned, toward the brink of self-destruction. personification of death, borrowed by SIG- One of his most famous works, “Do Not MUND FREUD to represent the death instinct. In Go Gentle Into That Good Night” (1952) was New York City, there is a Foundation of Tha- written for his father. Thomas died in New natology. York while directing the final production of Under Milk Wood, which he described as a “play for voices.” He is generally considered one of Thanatos Ancient Greek personification of the finest English-speaking poets of the 20th death. Thanatos, the son of Nyx, was often century. accompanied his twin brother, Hypnos; the two lived in a cave along the river Lethe. When the Fates cut the thread of a person’s life, Thanatos Thracians Natives of ancient Thrace who would claim the spirit as his own. In art, he was practiced polygamy. After the man’s death, his pictured as a young winged man with a sword wives vied for the honor of being judged the one and an extinguished or inversed torch. he loved most. The wife accorded this honor Psychoanalyst SIGMUND FREUD adopted this was slain over the grave and buried with her term to describe the death, destructive, and husband. aggressive drive—the opposite of the life This is a form of what experts call INSTITU- instinct, which Freud called Eros. Freud believed TIONAL SUICIDE, analogous to the Hindu custom that there is a constant shift between the power of SUTTEE, in which the widow immolated her- of the Eros and Thanatos in every person. Eros self with the corpse of her husband. ages, he believed, while ageless Thanatos may assert itself “until it, at length, succeeds in doing time of day See TEMPORAL FACTORS. the individual to death.” See also THANATOLOGY. Tiv of Nigeria African people who appear to have the lowest incidence of suicide yet Thebes In ancient Greece, capital of Boeotia, recorded. So few, in fact, that an expert was and scene of many legends, such as those of unable to document cases of Tiv suicide. Yet they Cadmus and Oedipus. People in Thebes openly realize that it is something that does sometimes condemned a person who completed suicide, happen and they discussed the means by which and refused to allow that person funeral rites. it is typically accomplished. theological views on suicide See listings Tojo, Hideki (1885–1948) Japanese gen- dealing with specific major religions; SAINT eral and prime minister from 1941 to 1944 who AUGUSTINE. attempted suicide prior to his execution as a war criminal. Tojo was instrumental in plan- Thomas, Dylan (1914–1953) British poet ning the December 7, 1941, attack on Pearl and prose writer born in Swansea, South Wales, Harbor. Treblinka 233

Tom Sawyer Mark Twain’s famous novel them subintentionally by careless, excessive (1876) in which he showed a clear understand- risk-taking. ing of the childhood fantasy of making a point See also AUTOCIDE. by killing oneself. Frustrated by his Aunt Polly, Tom found com- tranquilizers A group of depressant drugs that fort in the fantasy of drowning himself in the act selectively on the brain and spinal cord. They nearby Mississippi. He imagined with relish his are not unlike BARBITURATES in many ways, espe- limp body being brought to his aunt and her say- cially in their sedative effect, but in normal doses ing, “Oh, if I had only loved him more. How dif- they do not induce sleep or cause drowsiness. ferently I would have treated him if we had only Tranquilizers are divided into two classes— known.” The vision brought tears of self-pity to major and minor. The major tranquilizers (also his eyes. called neuroleptics), include haloperidol and chlorpromazine, and are used to treat serious Too Young to Die: Youth and Suicide One of mental illness. Minor tranquilizers, which in- the truly important works dealing with the sub- clude meprobamate (Miltown), chlordiazepox- ject of adolescent and teenage suicide, by ide (Librium) and diazepam (VALIUM), can Francine Klagsbrun. Elisabeth Kübler-Ross, produce euphoria and are all too often abused or M.D., calls Klagsbrun’s book “an important misused—not only for their own effects, but also work . . . Let us hope that parents and coun- to offset the effects of alcohol, amphetamines, selors, teachers and ministers will read this book and other drugs. in order to understand the cry for help that so The minor tranquilizers have been used in a many children send out, before their despair number of suicide attempts, especially by exceeds their wish to live.” Mrs. Klagsbrun’s females—both adult and teenager—but fatalities husband, Dr. Samuel C. Klagsbrun, was an advi- are rare when used alone. Successful suicides are sor for the NATIONAL COMMITTEE ON YOUTH SUICIDE generally the result of a synergistic effect PREVENTION. between the tranquilizer and another drug such as alcohol. Combining tranquilizers with alcohol Toronto Distress Centre One of several key or other depressant drugs is dangerous since centers in Canada’s nationwide network of sui- each drug increases the effect of the other so that cide prevention and crisis hotlines that service the combined effect is more powerful than the large population areas. Other centers are found effect of either alone. In addition, tolerance can in Montreal, Quebec, and Vancouver, British develop with regular prolonged use and Columbia. increased doses may be needed to produce the original tranquilizing effects. Long-term heavy use can result in psychological and even physical traffic accidents Authorities say that many dependence, although physical dependence is deaths recorded by medical examiners as acci- infrequent when one considers the large num- dents are actually suicides in disguise. In fact, ber of people who use tranquilizers. They are many coroners routinely list the death as an legally available only on prescription. accident when the cause of death is not known. The Federal Center for Studies of Suicide Pre- vention, Bethesda, Maryland, states that many treatment See COUNSELING; POSTVENTION. reckless, speeding drivers are playing uncon- scious roles in hastening their own deaths. Treblinka One of the most notorious World Some experts believe that fully 25 percent War II Nazi concentration camps, located in of the drivers who die in auto accidents cause Poland, where thousands of Jews were extermi- 234 Trosse, George nated. Many chose to kill themselves as an affir- lent throughout the long history of the Jewish mation of the freedom to control their own des- people. tiny. These suicidal acts, closely paralleling the situation at MASADA in A.D. 73, sparked the start Trosse, George (1631–1713) British clergy- of a rebellion that ultimately became an open man who suffered a psychotic breakdown in the revolt, one of the few such revolts that took mid-17th century. His autobiography, published place in a Nazi concentration camp. The coura- after his death, contains a vivid account of his geous action was in keeping with the theme of experiences, including strong suicidal impulses. death with honor to preserve one’s beliefs preva- U

Ulysses See JOYCE, JAMES. The poet SYLVIA PLATH is a well-known example of an unfortunate and tragic death that many experts think resulted accidentally—unintention- unemployment and suicide Suicide rates ally—from a suicide attempt. Until he or she dies, increase when unemployment is high. Psycholo- experts believe a suicide is pleading to be saved. gists have postulated possible reasons for such increases. They include: DEPRESSION among those unable to get work; tendency toward abuse of United Kingdom See ENGLAND; IRELAND; family members; dissolution of the family; SCOTLAND; WALES. increased abusive drinking and drug use; increased anguish and anxiety; and cultural frus- See MARITAL STATUS AND tration described generally as loss—loss of family unmarried, singles SUICIDE. love, loss of control over one’s own destiny, loss of identity (alienation), loss of self-esteem, and, in general, loss of meaning in life. unusual methods of suicide While most peo- While social disorganization, which greatly ple kill themselves by using guns, HANGING, or impressed French sociologist ÉMILE DURKHEIM poisoning, there are occasionally quite unusual has an important bearing on suicide rates, psy- ways of completing suicide. chic aspects must also be considered. Unfortu- People have ended their lives by swallowing nately, the manner in which these processes poisonous spiders, by power-drilling holes in operate is not all that clear. What is clear is that their heads, by sticking hot pokers down their suicide is such a complex of causes—social, psy- throats, by choking on underwear, by injecting chological, family interactions—that no single peanut butter into their veins, by crushing their theory is sufficient to account for the intricacies necks in vises, and by hurling themselves into of the suicide act. vats of beer.

Unfinished Business: Pressure Points in the urban suicide The state with the highest sui- Lives of Women A study of women and cide rate is a western state, relatively low in DEPRESSION by noted American writer Maggie population density: Nevada (1999 rate was 22.3 Scarf. Scarf won a Niéman Fellowship at Har- per 100,000 while the U.S. rate that year was 12 vard University and was twice a Fellow at the per 100,000). Other states with the highest sui- Center for Advanced Study in the Behavioral cide rates are: Arizona, Colorado, Idaho, Mon- Sciences at Stanford University. tana, New Mexico, Oklahoma, Oregon, and Wyoming. In 1999, the state with the lowest unintentional death Accidental death from suicide rate was New York, at only 6.6 per suicidal attempt. 100,000.

235 236 Uses of Enchantment, The

Highest U.S. regional rates are those of the ships or who never experienced a real trusting West Coast and the Rocky Mountain areas. The relationship. region with the lowest rate is the northeast. It was felt for several decades in the 20th cen- U.S. law See LAW AND SUICIDE; LEGAL ASPECTS tury that the rural suicide rate was much lower OF SUICIDE. than that of urban areas. In recent years, since the decline of the nation’s small- and medium- U.S. suicide statistics The most up-to-date sized farms and the rise of corporate agribusi- and reliable suicide statistics available to nesses, it appears that the rural suicide rate in researchers and others interested in the field of the U.S. is now on a level with the urban rate. suicidology come from the Centers for Disease Additionally, however, the suicide rates have Control (CDC) in Atlanta. They analyze vital sta- been found to be positively correlated with these tistics from the National Center for Health Statis- factors: male gender, increasing age, widow- tics for use by clinicians, health planners and hood, single and divorced status, childlessness, evaluators, and other public health professionals high density of population, residence in big interested in the number and characteristics of towns, a high standard of living, economic crisis, suicide, both among youths and adults. drug and alcohol consumption, history of a bro- The suicide data specified in the national vital ken home in childhood, mental disorder and statistics reflects the judgments and professional physical illness. Again, many authorities say the opinions of the physicians, coroners, or medical validity of statistical data concerning suicide and examiners who certify the medical/legal cause of the correlation of suicide rates to geographical death on the death certificate. Most authorities area and other related factors are questionable are of the opinion that suicide statistics based on and ought not to be generalized. death certificates probably understate the true number of suicides for several reasons: Uses of Enchantment, The Nonfiction work by BRUNO BETTELHEIM in which he explains the 1. Inadequate information on which to make a unbridled power that fairy tales and myths have determination of suicide as the cause of over children. Bettelheim’s contention: that chil- death. dren love them so because the stories embody 2. Certifier bias or error. their strongest hopes and fears. One almost uni- 3. No death certificate filed on the victim. versal fear in fairy tales is the fear of being se- parated from one’s parents. Called separation Utopia Book written by English author and anxiety; the younger we are, the more excruci- statesman SIR THOMAS MORE (1478–1535), ating is our anxiety when we feel deserted, for depicting an ideal commonwealth. In the work, the young child actually perishes when not ade- More justified suicide as a form of EUTHANASIA. quately protected. More was beheaded in 1535 by command of Experts say that the typical suicidal adolescent Henry VIII for refusing to take an oath impugn- is likely to be a teenager who quite early in his ing the authority of the pope (for which martyr- life was literally separated from vital relation- dom he was canonized in 1935). V

Valium Trade name for diazepam, a TRANQUIL- amount of marvelous work, such as the sun- IZER and sedative hypnotic used to treat tension, flower series. anxiety, and alcohol withdrawal. It is also a com- In 1889, he became a voluntary patient at the mon method for committing suicide. St. Remy asylum, where he continued to paint, Users can develop tolerance along with a often making copies of artists he admired. As he potential for physical and psychological depen- descended into madness, his brushwork became dence. Valium, or diazepam, is one of the most increasingly agitated, the dashes constructed widely prescribed drugs in the United States, and into swirling, twisted shapes. He moved to has a significant potential for abuse when taken Auvers, to be closer to his brother, Theo, in with alcohol or other central nervous system 1890, and his last 70 days were spent in a hectic depressants. program of painting. He left the asylum in May 1890 to stay a short time with his brother in Vancouver Crisis Centre One of Canada’s Paris, and then went to stay with a friend of established “distress centres” that serves large Cezanne and Gauguin. Two months later, he population areas with suicide prevention hot- shot himself and died sometime thereafter. lines. Varah, Chad (1911– ) British clergyman van Gogh, Vincent (1853–1890) Dutch who founded the SAMARITANS in 1953. Born in painter and one of the world’s great pre-mod- 1911, Varah was ordained as Anglican clergy- ernists, who killed himself at age 37. Vincent van man in 1936. One of his first duties was to offi- Gogh was born near Brabant, the son of a min- ciate at the funeral of a 14-year-old girl who had ister. Largely self-taught, he became one of the completed suicide when she became shocked at elemental forces of impressionist art. the first visible signs of puberty. Because she had Originally intending to enter the ministry, nobody with whom she could discuss these most of his life was characterized by restlessness. symptoms, she became convinced she was suf- His move to Paris in 1886 brought van Gogh into fering from an incurable illness and taking her contact with Paul Gauguin, Camille Pissarro, own life seemed the only way out. Georges Seurat, and Henri de Toulouse-Lautrec. Varah was profoundly shocked at this tragedy, Two years later, he moved to Arles, in the south and from that day onward he resolved to elimi- of France, hoping to establish an artists’ colony nate the taboo against public discussion of sexu- there. He was joined briefly by Gauguin in Octo- ality and bodily functions. It was as a sex ber 1888, but the visit was not a success. A final therapist that he first offered the Samaritans argument led to the infamous episode in which telephone counseling service, recognizing that in van Gogh cut off his ear. Although he experi- 1953 a great deal of human misery could be enced his first attack of insanity in Arles, he linked to problems with sexuality and sexual painted every day and produced an astonishing relationships. The telephone service began with

237 238 Vatel just a single telephone, but within 10 years there some young men aggressively create violence, were 41 branches of the Samaritans in the hurt others in the process, but manage to get United Kingdom. Just three years later, in 1966, themselves killed—dying as heroes, preserving there were 6,537 Samaritan volunteers based in their definition of masculinity. 80 branches. In 1974, Chad founded BEFRIEN- See also SUICIDE BY COP. DERS INTERNATIONAL, the worldwide body of Samaritans branches that spread across the Vienna Psychoanalytical Society Members globe. By 1993, there were more than 18,000 of this group met on April 27, 1910, in Vienna, volunteers counseling suicidal callers. Calls to Austria, to try to learn more about the mysteri- the Samaritans have continued to go up every ous causes of suicide among that famed city’s year, and there are now 203 branches around high school students. Leading psychoanalysts the world, including the United States. met with educators to discuss the problem. It Throughout his long life, Varah has cam- was SIGMUND FREUD, the father of psychoanaly- paigned tirelessly for a more rational, humane sis, who came away from the historic meeting society, without sacrificing his deep religious admitting that they had accomplished very lit- principles. In his 80s, he began a campaign to tle, and that much more work was necessary in discourage East African immigrants from contin- this area of concern. He said too little was uing their tradition of female genital mutilation known about suicide, but that perhaps the act and was able to note several successes achieved was a repudiation of life because of the craving not by political action but by actually going to for death. This observation foreshadowed the homes of the families and explaining how Freud’s ultimate belief in a death instinct—a the lives of their daughters would be more ful- theory of suicide still accepted by many schol- filled and happy if they were not subjected to ars—as set forth in his later paper, Mourning and this practice. Melancholia.

Vatel (ca. 1622–1671) The maître d’hôtel of Louis II de Bourbon, prince de Condé, Vatel Vigne, Pier delle (1190–1249) Longtime killed himself out of shame when a dinner and chief counselor of Emperor Friedrich II Hohen- entertainment for Louis XIV apparently turned staufen who was accused of treachery by con- out badly. It seems Vatel misunderstood a fish- spiring against his lord in 1247 and was monger concerning the quantity of fish available imprisoned and blinded. In despair, and to avoid for his use. further torture, delle Vigne took his own life. “I cannot endure the disgrace,” he cried. Going His suicide is significant in history primarily to his room, he fixed his sword to the door and because it is the one suicide to which DANTE ran upon the point. Vatel was highly praised for refers specifically. Dante, in fact, actually talked his courage and resolution, even though the with Pier delle Vigne. praise was mingled somewhat with reproach. Villechaize, Hervé (1943–1993) Actor best “victim-precipitated” murders When vic- known for playing Tattoo on Fantasy Island, who tims, appear to deliberately provoke others into was despondent over his health when he shot killing them, sometimes flashing knives or himself to death in 1993. Villechaize stopped wielding guns or goading others with threats of growing very early in life, but despite the efforts violence. The theory is that many men consider of his surgeon father to find a cure, none was suicide as a weak, cowardly way out of their possible—so the boy had to live with his small problems. Rather than self-inflicted destruction, height and undersized lungs. volunteers 239

Villechaize studied at the Beaux-Arts School steadily attacked the taboos, superstitions, and in Paris and exhibited his own paintings, which primitive punishments still being imposed for were well received. At 21 he left France for the suicide victims. As a result, he and others laid United States, where he continued to paint, take the foundation for a secular approach to the photos, and started acting. He was quickly problem of suicide; saw laws slowly changed; offered several roles for plays and films. His first and were instrumental in a gradual shift in soci- big success was as a killer in The Man with the ety’s emotional attitudes. Golden Gun (1974). This was followed by his role on the successful TV series Fantasy Island (1978), Volteius A Roman tribune who, with his in which he played Tattoo, the faithful servant of friends, found themselves surrounded by Pom- Mr. Roarke (Ricardo Montalban). peian troops in their attempt to cross the However, he was fired in 1983 after argu- Adriatic. They had defended themselves coura- ments about his salary, and he subsequently geously, but realized that escape was impossible. lost his model-actress wife. The series contin- Vulteius thus called upon his men to die by their ued without him but was canceled a year after own hands rather than to fall alive into the he left. At this point, Villechaize became enemy’s hands. Not one soldier survived to depressed, began drinking, and was beset by become a prisoner of Pompey. As Lucan noted in health problems; he nearly died of pneumonia The Civil War, “How simple a feat it is to escape in 1992. A year later, after watching a movie, slavery by suicide.” he wrote a farewell note, made a tape record- ing, and shot himself in his backyard. His com- Voluntary Euthanasia Society A nonprofit mon-law wife, Kathy Self, discovered his body group organized in 1935, by a group of doctors, and called the ambulance, but he later died at lawyers, and clergymen. It was followed in 1938 the hospital. Hervé Villechaize was cremated, by Euthanasia Society of America. The society is and his ashes were scattered off Point Fermin, seeking to make it legal for competent adults, in Los Angeles. who are suffering unbearably from a terminal illness, to be allowed to request medical help to Vivienne: The Life and Suicide of an Adoles- die at their own informed and persistent request. cent Girl Book by authors John E. Mack and Today, a number of countries have such soci- Holly Hickler that describes in detail the months eties, including Australia, South Africa, and the leading to Vivienne’s suicide by HANGING. While Netherlands. the signals and clues to her suicidal thinking and behavior were evident, nobody noticed or volunteers Ideally, suicide prevention and cri- did anything to help the young girl. She was sis centers will be staffed with at least one, or crying out for help—but her cries proved to be perhaps two professionals, such as psychiatrists, in vain. psychologists, or psychiatric social workers. The remainder of the staff are usually nonprofes- Voltaire (François-Marie Arouet) (1694– sional volunteers. Experts believe lay volunteers 1778) French philosopher, writer, and wit can be very effective staff members if they are whose inquiring mind and skeptical views, par- carefully selected and rigorously trained. ticularly on matters of religion, epitomize the Many experts believe it may not be a good French Enlightenment. One of the leaders of the idea to select people who have suffered psy- Enlightenment, along with d’Holbach, Hume, chotic breakdowns or who themselves at one Rousseau, and Beccaria, Voltaire condemned the time attempted suicide, or who appear overly existing conventional treatment of suicides. He interested in suicide. 240 Vonnegut, Kurt, Jr.

An efficient suicide prevention service relies Vonnegut, Kurt, Jr. (1922– ) American heavily on volunteer staff members who offer author of numerous novels, who wrote in God consultation, training, and seminars to high Bless You, Mr. Rosewater, “Sons of suicides seldom schools, universities, hospitals, and mental do well.” In fact, both sons and daughters of sui- health agencies. Their direct, person-to-person cides have a higher than average rate of suicide services are the foundation for suicide interven- themselves. Experts believe this is not due to any tion and prevention programs available at cen- genetic inheritance factors, but because they ters across the country. They provide a ready grow up in an environment of guilt, anger, and contact between the community’s disturbed, sui- with a sense of low self-esteem. cidal persons and the many helping agencies that are available to them. And they often spell vulnerability See CLUES OF SUICIDE. the difference between life and death. W

Wales The World Health Center (WHO) statis- the armistice, the suicide rates began to return to tics combine suicide rate numbers for ENGLAND prewar levels. As noted British clergyman and and Wales. The suicide rate per 100,000 totals author William Ralph Inge observed: “The statis- for the two United Kingdom countries in 1997 tics of suicide show that, for non-combatants at was 6.6 among males, the rate was 10.3; for least, life is more interesting in war than in women, 2.9. The age groups with the highest peace.” total suicide rate were over age 75, with a total rate of 10.4 per 100,000; suicide rate for men in warning signs See CLUES OF SUICIDE. this age bracket was 16.9, and for women was 3.9. However, the second-highest age group was slightly skewed in 1997 by the incredibly high Washington According to Centers for Disease suicide rate among young men in England and Control (CDC) statistics, Washington’s suicide Wales (15.7 per 100,000) for a total rate for the rate per 100,000 rose from 13.3 in 1980 to 14.2 25–34 age group of 9.4 per 100,000. in 1997. The 1997 suicide rate for the state was higher than the U.S. rate of 12 per 100,000. Wallace, Samuel E. In his book, After Suicide, sociologist Samuel Wallace explains the vital weather Studies have shown that oppressive need suicide survivors have for the sympathetic weather has little to do with causing suicide. The understanding of friends, associates, and rela- same studies indicate that suicide rates tend to tives. “Listening to someone else talk. How sim- rise during the spring months, reaching a peak ple,” writes Wallace, “and how few do it.” He in April, June, and July, then falling back during conducted in-depth interviews with 12 widows winter months, with low points during Decem- of suicides over a one-year period after their ber and January. spouses’ deaths. The interviewers taped the wid- However, suicide “clusters” (where several ows’ words, saying little themselves. After the persons, usually teens, kill themselves in a study, the survivor women agreed that just being relatively short time frame) tend to peak in able to talk out their feelings had helped them February. enormously. One woman observed that, “It Experts suspect that the notion of dull, dis- saves your life, really.” mal, inclement weather causing suicides goes back to the superstition that suicide is a dark and war, effect on suicide rate Ironically, suicide mysterious, devil-inspired act. rates tend to drop in time of war. During World See also GEOGRAPHIC FACTORS; TEMPORAL FAC- War I, for example, suicide rates dropped in TORS. Europe both in the countries involved (such as, FRANCE, GERMANY, BELGIUM) and in countries that will, loss of One of several distress signals or were neutral (such as SWITZERLAND). Following warning signs is a sudden loss or lack of the will

241 242 withdrawal or desire to do anything, such as go to school or mental breakdown that lasted for three years. work, be with friends or family, any activity. Sui- During this time she completed a novel, The Voy- cidal people often suffer a lethargic feeling. Life age Out, but its publication was delayed by her becomes a useless struggle, they can’t get mov- breakdown and World War I. It was finally pub- ing, they feel everything is too much trouble, lished in 1915 by her half brother, Gerald Duck- and there’s not that much worth doing. worth. When World War II was declared, the Woolfs withdrawal Another warning signal that prepared to complete suicide if England was something is wrong and suicide may be impend- invaded. During the Battle of Britain, her Lon- ing. This clue usually follows periods of unchar- don home was destroyed by bombs. Depressed acteristic irritability, fighting, then DEPRESSION. and hearing voices, she feared she was going Along with withdrawal come other suicidal tell- mad again and that this time she would not tales, such as loss of will, sudden lack of interest recover. She could not concentrate, read, or in appearance, and irregular sleeping habits. write, and despairing, she filled her pockets with stones and drowned herself in the River Ouse on March 28, 1941, leaving suicide notes for her women Women attempt suicide about three husband and sister. The notes read in part: “I feel times as often as men, but men complete suicide certain that I’m going mad again. I feel we can’t about three times as often as do women. This go thru another of those terrible times. And I has been the case ever since suicide records have shan’t recover this time. I begin to hear been kept. In 1980, the highest rate of suicide for voices . . .” women was in the age group 30 to 34; the sui- After her death, her husband, Leonard, pub- cide rate for the same year was 10.3 in the age lished various essays, short stories, letters, and group 50 to 54. The suicide rate per 100,000 diaries, as well as several volumes of autobiogra- dropped for women from 6.5 in 1979 to 5.9 in phy that detail their life together. 1980, lowest in the past decade. Men in the Woolf had a convincing life history of bipo- United States have a markedly higher risk of sui- lar disorder, culminating in suicide at the age of cide than do women, and the differential 59, and including a suicidal attempt in her 30s between men and women rates is widening that was almost successful. She had her first even more. breakdown at the age of 13, and others when she was 22, 28, and 30. From 1913 to 1915, Woolf, Virginia (1882–1941) Gifted English from the age of 31 to 33, she was ill so often writer who killed herself after struggling all her and for so long that permanent insanity was life with recurrent bouts of severe BIPOLAR DIS- feared. These attacks were severe, requiring ORDER (manic depression). Woolf was born in many weeks of medical treatment and bed rest. London on January 25, 1882, to statesman During the rest of her life she had milder mood Leslie Stephen and Julia Duckworth Stephen. swings. She was homeschooled by her parents until her Her mental problems were almost certainly mother died and her father went into deep genetic. For generations her family history is mourning; at this point Woolf had her first filled with gloomy men and eccentric women. severe mental breakdown. In 1904, Woolf’s The family was also very creative, not only in father died, and she had a second mental break- literature. down, attempting suicide by jumping out of a Her brother Thoby was an emotionally dis- window. turbed child, and her sister, Vanessa, experi- Eight years later, she married writer and edi- enced an episode of DEPRESSION in her 30s after a tor Leonard Woolf, after which she had a third miscarriage. The attack lasted two years, and was wrist-slashing 243 regarded by the family as similar to Virginia’s WHO gathers suicide statistics from around the depressions. Her brother Adrian also suffered globe. from episodes of nervousness and depression. Likewise, her father was a gloomy man who wrist-slashing Both men and women who experienced two mild attacks of depression, and attempt suicide without fatal results usually do her grandfather had three serious depressions not use such violent methods as guns and HANG- that affected his career. Her first cousin devel- ING. Most, it appears, will take pills or poisons, or oped severe mania in his 20s and died within a slash their wrists with ordinary razor blades—all few years in an asylum. methods that generally allow time for rescue. In fact, the Centers for Disease Control includes World Health Organization (WHO) Inter- this method in the classification “all other national organization headquartered in Geneva, means” in its surveillance methods. SWITZERLAND, that was founded in 1948. The

X

Xenophon (ca. 430–ca. 355 B.C.) Athenian Xerxes pillaged Athens, but retired to Asia when soldier, historian and wealthy disciple of his fleet was destroyed at Salamis, in 480 B.C. His SOCRATES whose principal historical work was army, under Mardonius, was defeated at Plataea, the Anabasis. His other writings included 479 B.C. On his retreat from Greece, a number of Memorabilia, a defense of Socrates, and Hellenica, his men threw themselves overboard to lighten a history of Greece. According to Xenophon, the overloaded vessel and the ship came safely to HEMLOCK—the poison drunk by Socrates—was harbor. introduced in 403 B.C. After he landed, Xerxes ordered that a golden crown be presented to the pilot for saving the king’s life. He also commanded that the man’s Xerxes I (ca. 519–465 B.C.) Son of Darius I head be cut off, as he had caused the loss of so and King of Persia, 486–465 B.C., he conquered many Persian lives. Egypt and invaded Greece over a bridge of boats at the Hellespont. Victorious at Thermopylae,

245

Y

Yeats, William Butler (1865–1939) Irish youth and the very young See CHILDREN AND poet, one of the great writers of modern times, SUICIDE. who won the Nobel Prize in literature in 1923. It was Yeats who penned the line, “After us the Yuit Eskimos Among the Yuit Eskimos, an Savage God”—from whence ALFRED ALVAREZ got individual may decide to die in order for his the title for his well-known book, THE SAVAGE spirit to be able to save the life of a close rela- GOD: A STUDY OF SUICIDE. Yeats meant that the ulti- tive—or to earn the prestige that this society mate concern of art was, inevitably, the end of affords the person who “honorably” ends his life self-death. while still at the peak of his powers. His death is a public ceremonial with the actual act being Young, Gig (1913–1978) Oscar-winning performed by his closest kinsman, who is ritually actor who was an insecure alcoholic when he purified afterwards. married for the fifth time in 1978, taking as his According to anthropologist Jean La Fontaine, bride Kim Schmidt, a German actress 33 years “In this society the decision to die and its imple- his junior, whom he met in Hong Kong while mentation are separate acts, but the man who filming The Game of Death. Three weeks after the deals the death blow is an agent of his victim, wedding, at their New York apartment, Young which makes a public performance essential to shot his bride in the head with a .38 and then demonstrate this.” Dr. La Fontaine explains: turned the gun on himself. “The Eskimo case thus comes under the defini- The Game of Death was Young’s last film, and tion of suicide that is usually recognized by also that of its star, Bruce Lee. (Young had been anthropologists: a death for which responsibility cast to play the Waco kid in Blazing Saddles; after is socially attributed to the dead person.” his death, he was replaced by Gene Wilder.)

247

Z

Zealots See JAIR, ELEAZAR BEN; MASADA. KARL MENNINGER’s assertion that the drives in suicide are made up of the wish to kill; the wish Zeno (of Citium) (ca. 363–264 B.C.) Greek to be killed; and the wish to die. philosopher born at Citium, Cyprus, who trained Dr. Zilboorg once wrote, “Statistical data on at Athens under Cynic teachers and later suicides as compiled today deserve little cre- founded the school of Stoicism around 300 B.C. dence. All too many suicides are not reported as Legend has it that Zeno committed suicide after such.” breaking his toe. He was 98 years old at the time and decided that God had sent the broken toe as Zimri General who usurped the throne of a sign that he had lived long enough. Israel in 876 B.C. for a few days. After the cap- ture of the city of Tirzah, Zimri realized the Zilboorg, Gregory (1890–1959) Psychia- hopelessness of his situation and this led him to trist-in-chief of the United Nations who stated seek death. “He went into the citadel of the that every suicidal case contained not only king’s house and burned the king’s house over unconscious hostility but also an unusual lack of him with fire, and died” (I Kings 16:18). capacity to love others. This is a refinement of

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APPENDIXES

I. National Associations, Institutions, Organizations, and Government Agencies II. Suicide Prevention and Crisis Intervention Agencies in the United States III. International Suicide Rates Per 100,000

APPENDIX I NATIONAL ASSOCIATIONS, INSTITUTIONS, ORGANIZATIONS, AND GOVERNMENT AGENCIES

American Association of P.O. Box 1004-300 Pleasant Association for Death Edu- Suicidology Street cation & Counseling 2459 South Ash Street Dartmouth, Nova Scotia 342 North Main Street Denver, CO 80222 Canada B2Y 2Z9 West Hartford, CT 06117-2507 (303) 692-0985 or (202) 237- (902) 426-4959 (860) 586-7503 2280 http://www.adec.org http://www.suicidology.org American Psychiatric Website provides information on cur- Association Boys Town rent research, prevention, ways to 1400 K Street, NW (800) 448-3000 (crisis hotline) help a suicidal person, and surviv- Washington, DC 20005 or (800) 545-5771 ing suicide. A list of crisis centers is (888) 357-7924 or (202) 682- http://www.boystown.org also included. 6000 An organization that cares for trou- http://www.psych.org bled children—both boys and girls American Foundation for Call for information and referrals to —and for families in crisis. Their Suicide Prevention psychiatrists in your area, or visit hotline staff is trained to handle 120 Wall Street their website. calls and questions about violence 22nd Floor and suicide. New York, New York 10005 American Psychological (888) 333-AFSP; (212) 363- Association (APA) Canadian Association for 3500 750 First Street, NE Suicide Prevention http://www.afsp.org Washington, DC 20002 c/o The Support Network Their website provides research, edu- (202) 336-5500 11456 Jasper Avenue cation, and current statistics re- http://www.apa.org #301 garding suicide; links to other APA’s website provides information Edmonton, Alberta T5K 0M1 suicide and mental health sites are about who is at risk, suicide warn- (780) 482-0198 offered. Information and help is ing signs, and steps toward suicide www.suicideprevention.ca also available by calling 1-888- prevention. Call APA if you have Center for Suicide Research 333-AFSP (2377). questions about their website or any other mental health issues. and Prevention American Foundation for Rush-Presbyterian-St. Luke’s Suicide Prevention/Canada American Sociological Medical Center Halifax Chapter Association 1753 West Congress Parkway Jennifer Langille 1722 North Street, NW Chicago, IL 60612 Nova Scotia Hospital Washington, DC 20036 (312) 942-7208

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Center for Thanatology http://www.nami.org (202) 296-8071 or (800) 989- Research & Education, Inc. Group provides information about 9455 (Hotline) 391 Atlantic Avenue family support and self-help http://www.partnershipforcaring Brooklyn, NY 11217 groups. Their website includes .org (718) 858-3026 links to information about teen San Francisco Suicide http://www.thanatology.org suicide, child suicide, brain biol- Prevention Center ogy, and suicide, as well as general Compassionate Friends (415) 781-0500 (crisis line) suicide information links. P.O. Box 3696 Suicide Awareness-Voices of Oak Brook, IL 60522-3696 National Mental Health Education (SA\VE) (630) 990-0010 Association (NMHA) (612) 946-7998 http://www.compassionate- (800) 228-1114 or (800) 969- http://www.save.org friends.org NMHA (6642); (800) 433- Website provides suicide education, Nonprofit self-help organization to 5959 (TTY) facts, and statistics on suicide and counsel families of those who have http://www.nmha.org depression. It links to information died. Organization that provides informa- on warning signs of suicide and tion on depression and its treat- CONTACT USA the role a friend or family mem- ment, and for referrals to local 4 North Circle Drive ber can play in helping a suicidal screening sites. Harrisburg, PA 17110 person. (717) 232-3501 National Mental Illness http://www.contactusa.org Screening Project/Suicide Suicide Information & Education Centre (SIEC) Dying With Dignity Division (800) 573-4433 1615-10th Avenue SW 55 Eglinton Avenue East #201 Suite 705 http://www.nmisp.org Hotline counselors can help callers Calgary, Alberta Canada T3C Toronto, Ontario M4P 1G8 0J7 CANADA locate a free, local confidential screening. (403) 245-3900 (416) 486-3998 or (800) 495-6156 http://www.siec.ca or http:// http://www.web.apc.org National Organization of www.suicideinfo.ca/siec.htm Foundation for Thanatology People of Color Against A special library and resource center 630 West 168th Street Suicide providing information on suicide New York, NY 10032 http://www.nopcas.com and suicidal behavior. (212) 928-2006 National Suicide Hotline Suicide Prevention Advocacy Kristin Brooks Hope Center 800-SUICIDE Network (SPANUSA) 5034 Odins Way 609 East Main Street Parents Anonymous, Inc. Marietta, GA 30068 Unit 112 675 West Foothill Boulevard (770) 998-8819 or (888) 649- Purcellville, VA 20132 Suite 220 1366 (540) 338-5756 Claremont, CA 91711 http://www.spanusa.org www.livewithdepression.org (909) 621-6184 A nonprofit organization dedicated http://www. Lifekeeper Foundation to creating an effective national parentsanonymous.org 3740 Crestcliff Court suicide prevention strategy. SPAN Tucker, GA 30084 Partnership for Caring: links the energy of those bereaved (678) 937-9297 America’s Voices for the by suicide with the expertise of http://www.lifekeeper.org Dying leaders in science, business, gov- National Alliance for the 1620 I Street NW ernment, and public service to Mentally Ill (NAMI) Suite 202 significantly reduce the national (800) 950-NAMI (6264) Washington, DC 20006 suicide rate by the year 2010. Appendix I 255

Survivors of Loved Ones Division of Violence Prevention Yellow Ribbon Suicide Suicides (SOLOS) Mailstop K65 Prevention Program P.O. Box 592 4770 Buford Highway, NE P.O. Box 644 Dumfries, VA 22026 Atlanta GA 30341 Westminster, CO 80036-0644 (703) 580-8958 (770) 488-4362 (303) 429-3530 http://www.solos.org http://www.cdc.gov/ncipc/ http://www.yellowribbon.org Visit their website for links to suicide Tears of a Cop statistics, the SafeUSA website, http://www.tearsofacop.com and safety information. Website designed to promote aware- ness of suicide and PTSD in police World Health Organization work. Avenue Appia 20 1211 Geneva 27 U.S. Centers for Disease Switzerland Control and Prevention (+00 41 22) 791 21 11 National Center for Injury http://www.who.int Prevention and Control

APPENDIX II SUICIDE PREVENTION AND CRISIS INTERVENTION AGENCIES IN THE UNITED STATES

* Member, American Association Crisis Phone 1: (256) 547-9505 ALASKA of Suicidology Business Phone: (256) 547-8971 Anchorage Hrs Avail: 24 South Central Counseling ALABAMA Huntsville Center Auburn Crisis Services of N. Alabama, 4020 Folker Street Crisis Center of E. Alabama, Inc. Anchorage, AK 99508 Inc. P.O. Box 368 Crisis Phone 1: (907) 563-3200 P.O. Box 1053 Huntsville, AL 35804 Business Phone: (907) 563-1000 Auburn, AL 36831 Crisis Phone 1: (800) 691-8426; Hrs Avail: 24 (256) 716-1000 Crisis Phone 1: (334) 821-8600 Fairbanks Business Phone: (334) 821-8600 Business Phone: (256) 716-4052 http://www.CSNA.org * Fairbanks Crisis Line Birmingham Hrs Avail: 24 P.O. Box 70908 Fairbanks, AK 99707 * Crisis Center, Inc. Mobile 3600 8th Avenue S. Crisis Phone 1: (907) 452-4357; Suite 501 Contact Mobile Helpline, (800) 898-5463 Birmingham, AL 55512 Inc. Business Phone: (907) 451-8600 Crisis Center: (205) 323-7777 P.O. Box 66608 Hrs Avail: 24 Mobile, AL 36660 http://www.crisiscenterbham.com Kenai Hrs Avail: 24 Crisis Phone 1: (334) 431-5111; (800) 239-1117 Central Peninsula Counseling Decatur Business Phone: (334) 431-5100 Services Mental Health of North http://www.helpline_ir.org 506 Lake Street Central Alabama Hrs Avail: 24 Kenai, AK 99611 4110 Highway 31 South Crisis Phone 1: (907) 283-7511 Tuscaloosa Decatur, AL 35603 Business Phone: (907) 283-7501 Crisis Phone 1: (256) 355-5904 Indian River Mental Health Hrs Avail: 24 Business Phone: (256) 355-6091 Center Ketchikan http://www.mhcnca.org Tuscaloosa Crisis Line P.O. Box 2190 Center for Human Services Gadsden Tuscaloosa, AL 35401 3050 5th Avenue Thirteenth Place, Inc. Crisis Phone 1: (205) 345-1600 Ketchikan, AK 99901 405 South 12th Street (after 5 P.M.) Crisis Phone 1: (907) 225-4135; Gadsden, AL 35901 Business Phone: (205) 345-1600 (907) 225-5170; (907) 225-2802

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Business Phone: (907) 225-4135 Springdale http://www.crisissupport.org http://www.city.ketchikan.ak.us Hrs Avail: 24 * NW Arkansas Crisis Inter- Hrs Avail: 24 vention Center Burlingame Wasilla 614 E. Emma Crisis Intervention and Sui- Suite 213 Life Quest cide Prevention Center Springdale, AR 72764 P.O. Box 873388 1860 El Camino Real Crisis Phone 1: (800) 798-8336 230 E. Paulson Suite 400 (teen line) Suite 68 Burlingame, CA 94010 Crisis Phone 2: (888) 274-7472 Wasilla, AK 99654 Crisis Phone 1: (650) 368-6655 (adults) Crisis Phone 1: (800) 478-2410; Crisis Phone 2: (650) 692-6655 Crisis Phone 3: (888) 723-3225 (907) 225-5170 Crisis Phone 3: (650) 726-6655 (latchkey/youth) Business Phone: (907) 376- Business Phone: (650) 692-6662 Business Phone: (501) 756-1995 2411 http://www.YFA.org Hrs Avail: 24 Tucson Hrs Avail: 24 ARIZONA * Southern Arizona Mental Capitola Health Corp. SPS of Santa Cruz County Phoenix 1930 E. 6 Street P.O. Box 1222 Tucson, AZ 85719 * Alternative Behavioral Capitola, CA 95010 Crisis Phone 1: (520) 662-6000 Services of Arizona Crisis Phone 1: (831) 458-5300 Business Phone: (520) 617- 444 N. 44th Street Crisis Phone 2: (831) 649-8008 0043 Suite 400 Business Phone: (831) 459- Hrs Avail: 24 Phoenix, AZ 85008 9373 Crisis Phone 1: (602) 222-9444; Hrs Avail: 24 (800) 631-1314 ARKANSAS Business Phone: (602) 685- Hot Springs Culver City 3881 * Suicide Prevention Center, Hrs Avail: 24 Community Counseling Services Didi Hirsch Community SW Behavioral Health Cen- 505 W. Grand Avenue Mental Health Center ter Hot Springs, AR 71902 4760 S. Sepulveda Boulevard 3707 North 7th Street Crisis Phone 1: (501) 624-7111; Culver City, CA 90230 Suite 100 (800) 264-2410 Crisis Phone 1: (877) 7CRISIS Phoenix, AZ 85014 Business Phone: (501) 623- Crisis Phone 2: (310) 391-1253 Crisis Phone 1: (602) 222-9444 5510 Business Phone: (310) 751-5373 Business Phone: (602) 257- Hrs Avail: 24 http://www.suicidecrisisline.org 9339 Hrs Avail: 24 Hrs Avail: 24 CALIFORNIA Davis Safford Berkeley * Suicide Prevention of Yolo Safford Crisis Line Crisis Support Services of County P.O. Box 956 Alameda County P.O. Box 622 Safford, AZ 85546 P.O. Box 9102 Davis, CA 95617 Crisis Phone 1: (602) 428-4550 Berkeley, CA 94709 Crisis Phone 1: (530) 756-5000 Business Phone: (602) 428- Crisis Phone 1: (510) 849-2212 Crisis Phone 2: (530) 753-0797 4550 Crisis Phone 2: (510) 889-1333 Crisis Phone 3: (530) 666-7778 Hrs Avail: 24 Business Phone: (510) 848-1515 Crisis Phone 4: (530) 668-8445 Appendix II 259

Crisis Phone 5: (916) 371-3779 Crisis Phone 1: (562) 596-5548 Newark Crisis Phone 6: (916) 372-6565 Crisis Phone 2: (714) 894-4242 Second Chance, Inc. Business Phone: (530) 756-7542 Business Phone: (323) 594- P.O. Box 643 Hrs Avail: 24 0960 Newark, CA 94560 Hrs Avail: 8 A.M.–midnight Fairfield Crisis Phone 1: (510) 792-4357 Los Angeles Business Phone: (510) 792- Suicide Prevention/Crisis 4357 Line of Volunteer Foundation for Religious Hrs Avail: 24 210 Courage Drive Freedom Fairfield, CA 94533 1680 North Vine Pacific Grove Crisis Phone 1: (707) 428-1131 Los Angeles, CA 90028 Family Service Agency of Business Phone: (707) 435-2080 Crisis Phone 1: (800) 556-3055 the Central Coast Hrs Avail: 24 Business Phone: (323) 468- P.O. Box 52078 0567 Garden Grove Pacific Grove, CA 03950 http://www. Crisis Phone 1: (831) 649-8008 New Hope Teen Line Hrs Avail: 9–5 P.M.; 24 hr voice Business Phone: (831) 375- 12141 Lewis Street mail 6966 Garden Grove, CA 92840 Psychological Trauma Hrs Avail: 24 Crisis Phone 1: (714) 639-8336 Center Crisis Phone 2: (714) 441-2099 Pasadena 8730 Alden Drive http://www.newhopeonline.org Room C-212 * Kaiser Permanente Behav- http://www.newhopenow.org Los Angeles, CA 90048 ioral Healthcare Helpline http://www.teenline.org Crisis Phone 1: (310) 423-3514 393 East Walnut Street Business Phone: (714) 441-2099 Business Phone: (310) 423- Pasadena, CA 91188 Hrs Avail: 24 3506 Crisis Phone 1: (800) 900-3277 Lafayette http://www.ptcweb.org Business Phone: (626) 405- Hrs Avail: 8 A.M.–5:30 P.M. 5669 CONTACT Care Center http://www.kp.org P.O. Box 901 Teen Line Hrs Avail: 24 Lafayette, CA 94549 P.O. Box 48750 Crisis Phone 1: (925) 284-2273 Los Angeles, CA 90048 Pasadena Crisis Phone 2: (925) 235-5244 Crisis Phone 1: (800) 852-8336 Pasadena Mental Health Crisis Phone 3: (925) 837-1181 Crisis Phone 2: (310) 855-4673 Center Crisis Phone 4: (925) 284-2350 Business Phone: (310) 423- 1495 North Lake Crisis Phone 5: (925) 284-2274 0456 Pasadena, CA 91104 Crisis Phone 6: (925) 754-8111 http://www.teenlineonline.org Crisis Phone 1: (213) 798-0907 Crisis Phone 7: (925) 945-8336 Hrs Avail: 24 Business Phone: (213) 681- Business Phone: (925) 284- 1381 Modesto 2207 Hrs Avail: 9 A.M.–12 A.M. http://www.contactcare.net Stanislaus Co. Behavioral Hrs Avail: 24 Health & Recovery Center Redding 1501 Claus Road * Help, Inc. Los Alamitos Modesto, CA 95355 P.O. Box 992498 Hotline of Southern Califor- Crisis Phone 1: (209) 558-4600 Redding, CA 96099 nia Crisis Phone 2: (209) 525-6225 Crisis Phone 1: (530) 225-5255 P.O. Box 32 Business Phone: (209) 558- Business Phone: (530) 225-5255 Los Alamitos, CA 90720 4700 Hrs Avail: 24 260 The Encyclopedia of Suicide

Sacramento http://www.sfsuicide.org http://www.sccsacs.org Hrs Avail: 24 Hrs Avail: 24 * Suicide Prevention/Crisis Services Center for Elderly Suicide San Luis Obispo 8912 Volunteer Lane Prevention and Grief Hotline of San Luis Obispo Sacramento, CA 95826 3626 Geary Boulevard County Crisis Phone 1: (916) 368-3111 San Francisco, CA 94118 P.O. Box 5456 Crisis Phone 2: (916) 773-3111 Crisis Phone 1: (415) 752-2314 San Luis Obispo, CA 93403 Crisis Phone 3: (916) 885-2300 (geriatrics) Crisis Phone 1: (805) 544-6065 Crisis Phone 4: (916) 645-8866 Crisis Phone 2: (415) 752-3778 Crisis Phone 2: (805) 549-8989 Business Phone: (916) 368- (elderly) Crisis Phone 3: (800) 549-8989 3118 Business Phone: (415) 750- Crisis Phone 4: (805) 544-0566 Hrs Avail: 24 4180 Business Phone: (805) 544-6016 http://www.gioa.org http://slohotline.org San Bernardino Hrs Avail: 24 Hrs Avail: 24 Family Helpline Service San Joaquin Agency San Rafael 1669 North E Street San Joaquin Co. Mental Suicide Prevention & Comm. San Bernardino, CA 92405 Health Counseling Service of Crisis Phone 1: (909) 886-4889 1212 North California Marin Crisis Phone 2: (909) 475-5200 Stockton, CA 95202 P.O. Box 4369 Crisis Phone 3: (800) 832-9119 Crisis Phone 1: (209) 468-8686 San Rafael, CA 94913-4369 Crisis Phone 4: (866) 475-1411 Business Phone: (209) 468- Crisis Phone 1: (415) 499-1100 Business Phone: (909) 886-6737 8700 Business Phone: (415) 499-1193 Hrs Avail: 24 http://www.healthcareservices. Hrs Avail: 24 San Diego com Hrs Avail: 24 Santa Cruz United Behavioral Health Access and Crisis Line San Jose Suicide Prevention Service P.O. Box 1370 of the Central Coast Contact Santa Clara Co. San Diego, CA 92160 P.O. Box 1222 P.O. Box 8021 Crisis Phone 1: (619) 641-6890 Santa Cruz, CA 95061 San Jose, CA 95155 Crisis Phone 2: (800) 479-3339 Crisis Phone 1: (831) 458-5300 Crisis Phone 1: (408) 279-0111 Business Phone: (619) 641- Crisis Phone 2: (831) 649-8008 Crisis Phone 2: (408) 279-8228 6889 Business Phone: (831) 459- Crisis Phone 3: (888) 247-7717 Hrs Avail: 24 9373 Business Phone: (408) 275-6176 San Francisco http://www.contactcares.org Stockton Hrs Avail: 24 * San Francisco Suicide San Joaquin Co. Mental Prevention * Santa Clara Suicide & Cri- Health P.O. Box 191350 sis Service 1212 North California San Francisco, CA 94119 2221 Enborg Lane Stockton, CA 95202 Crisis Phone 1: (415) 362-3400 San Jose, CA 95128 Crisis Phone 1: (209) 468-8686 Crisis Phone 2: (415) 781-0500 Crisis Phone 1: (408) 279-3312 Business Phone: (209) 468- Crisis Phone 3: (845) 485-9700 Crisis Phone 2: (408) 633-2482 2399 Crisis Phone 4: (845) 486-2866 Crisis Phone 3: (408) 885-6250 http://www.healthcareservices. Business Phone: (845) 486- Business Phone: (408) 885- com 2705 6250 Hrs Avail: 24 Appendix II 261

Ventura P.O. Box 913 Littleton Aurora, CO 80040 * Behavioral Health Crisis Living Support Network Crisis Phone 1: (303) 343-9890 Team P.O. Box 170 Business Phone: (303) 341-9160 200 North Hillmont Avenue Littleton, CO 80160 Hrs Avail: 24 Ventura, CA 93003 Crisis Phone 1: (303) 894-9000 Crisis Phone 1: (805) 652-6727 Boulder (teenline) (mobile team) Crisis Phone 2: (303) 860-1200 Mental Health Center of Crisis Phone 2: (805) 371-8375 Business Phone: (303) 861- Boulder Business Phone: (805) 652-6565 4262 1333 Iris Avenue Hrs Avail: 24 http://www.livingsupportnet- Boulder, CO 80304 work.org Walnut Creek Crisis Phone 1: (303) 447-1665 Business Phone: (303) 447- Pueblo * Contra Costa Crisis Center 1665 P.O. Box 3364 www.mhcbc.org * Pueblo Suicide Prevention Walnut Creek, CA 94598 Hrs Avail: 24 Center, Inc. Crisis Phone 1: (800) 718-4357 1925 East Orman Business Phone: (925) 939-1916 Colorado Springs Suite G-25 http://www.crisis-center.org Pikes Peak Mental Health Pueblo, CO 81004 Hrs Avail: 24 Center Crisis Phone 1: (719) 544-1133 Crisis Phone 2: (719) 564-5566 Yuba City 115 South Park Side Colorado Springs, CO 80905 Business Phone: (719) 564- Sutter-Yuba MH Crisis Clinic Crisis Phone 1: (719) 596-5433 6642 1965 Live Oak Boulevard Business Phone: (719) 572- Hrs Avail: 24 Yuba City, CA 95991 6250 CONNECTICUT Crisis Phone 1: (530) 673-8255 Hrs Avail: 24 Crisis Phone 2: (888) 923-3800 Derby Business Phone: (530) 822- Suicide Prevention 7200 Partnership Griffin Hospital-Psychiatric http://www.co.sutter.ca.us 3595 East Fountain Boulevard Crisis Team Hrs Avail: 24 Suite J-1 130 Division Street Colorado Springs, CO 80910 Derby, CT 06418 COLORADO Crisis Phone 1: (719) 596-5433 Crisis Phone 1: (203) 732- 7550 Arvada Crisis Phone 2: (719) 596-2575 Business Phone: (719) 573- Business Phone: (203) 735- Jefferson Center for Mental 7447 7421 Health http://www.codenet.net/sui- http://www.griffinhealth.org 5265 Vance Street cideprevention Hrs Avail: 24 Arvada, CO 80002 Hrs Avail: 24 Hartford Crisis Phone 1: (303) 452-0300 Business Phone: (303) 425- Greely * The Samaritans of the 0300 * North Range Behavioral Capital Region www.jeffersonmentalhealth.org Health P.O. Box 12004 Hrs Avail: 24 1306 11th Avenue Hartford, CT 06112 Greely, CO 80631 Crisis Phone 1: (860) 232-2121 Aurora Crisis Phone 1: (888) 296-5827 Business Phone: (860) 232- Comitis Crisis Center Business Phone: (970) 353- 9559 9840 East 17th Avenue 3686 Hrs Avail: 24 262 The Encyclopedia of Suicide

Meriden Crisis Phone 1: (203) 974-7713 Crisis Phone 1: (203) 573-6500 Business Phone: (203) 974-7713 Business Phone: (203) 573- Midstate Behavioral Health Hrs Avail: M-F 9 A.M.–10 P.M.; 6500 System S-S 9 A.M.–8 P.M. http://waterburyhospital.org 883 Paddock Avenue Meriden, CT 06450 New London DELAWARE Crisis Phone 1: (203) 630-5309 Crisis Phone 2: (203) 630-5308 Contact of Southeast Milford Connecticut Crisis Phone 3: (800) 567-0902 * Kent/Sussex Community (toll free) 2 Union Plaza Suite 300 Mental Health Services Business Phone: (203) 630-5305 P.O. Box 912 Hrs Avail: 24 New London, CT 06320 Crisis Phone 1: (860) 848-1281 Milford, DE 19963 Middletown Crisis Phone 2: (860) 433-8697 Crisis Phone 1: (800) 345-6785 Business Phone: (302) 422- Middlesex Hospital-Crisis Crisis Phone 3: (860) 848-1282 1133 Assessment and Triage Business Phone: (860) 447- Hrs Avail: 24 Service 1126 28 Crescent Street Hrs Avail: 24 Wilmington Middletown, CT 06457 Plainville Crisis Phone 1: (860) 344-6496 * CONTACT Delaware, Inc. Crisis Phone 2: (860) 344-7047 * The Wheeler Clinic P.O. Box 9525 Business Phone: (860) 344-6765 Emergency Service Wilmington, DE 19809 Hrs Avail: 24 91 Northwest Drive Crisis Phone 1: (302) 761-9100 Plainville, CT 06062 Deaf Contact: (302) 761-9700 River Valley Services Mobile Crisis Phone 1: (860) 747-3434 Business Phone: (302) 761-9800 Crisis Team (TTY) www.contactdelaware.org P.O. Box 351 Silver Street Crisis Phone 2: (860) 747-8719 Hrs Avail: 24 Middletown, CT 06457 Business Phone: (860) 747- Mobile Crisis Intervention Crisis Phone 1: (860) 344-2100 3434 Service Crisis Phone 2: (860) 388-0668 http://www.wheelerclinic.org 809 Washington Street Business Phone: (860) 262- Hrs Avail: 24 5218 Wilmington, DE 19801 Hrs Avail: 24 Rocky Hill Crisis Phone 1: (800) 345-6785 Crisis Phone 2: (302) 577-2484 New Haven * United Way of Crisis Phone 3: (800) 652-2929 Connecticut/INFOLINE Clifford W. Beers Guidance Business Phone: (302) 577- 1344 Silas Deane Highway Clinic-CAMPES 2484 Rocky Hill, CT 06067 93 Edwards Street Hrs Avail: 24 Crisis Phone 1: (800) 203-1234 New Haven, CT 06511 Crisis Phone 2: (860) 522-4636 Tressler Brandywine Crisis Phone 1: (888) 979-6884 Business Phone: (860) 571-7500 Program Center of Crisis Phone 2: (888) 97-YOUTH http://www.ctunitedway.org Delaware Business Phone: (203) 772- Hrs Avail: 24 240 North James Street 1270 Suite 200 Hrs Avail: 24 Waterbury Wilmington, DE 19804-3132 Conn. Mental Health Center- Waterbury Hospital Psychi- Crisis Phone 1: (302) 633-5128 Acute Care Services atric Center Business Phone: (302) 995- 34 Park Street 64 Robin Street 2002 New Haven, CT 06519 Waterbury, CT 06708 Hrs Avail: 24 Appendix II 263

WASHINGTON, DC Daytona Beach Ft. Walton Beach Comprehensive Psychiatric ACT Corp. Crisis Line/Bridgeway Cen- Emergency Program- 1220 Willis Avenue ter, Inc. Commission on Mental Daytona Beach, FL 32114 137 Hospital Drive Health Services Crisis Phone 1: (800) 539-4228 Ft. Walton Beach, FL 32548 1905 E Street, SE Business Phone: (904) 947- Crisis Phone 1: (850) 244-9191 Building 14 4270 Crisis Phone 2: (850) 682-0101 Washington, DC 20003 http://www.actcorp.org Business Phone: (850) 833- Crisis Phone 1: (888) 793-4357 Hrs Avail: 24 9204 Crisis Phone 2: (202) 561-7000 Hrs Avail: 24 Business Phone: (202) 673-9307 De Funiak Springs Gainesville FLORIDA Cope Center 3686 Highway 31 South * Alachua County Crisis Bartow De Funiak Springs, FL 32433 Center 218 Southeast 24th Street Peace River Center Crisis Crisis Phone 1: (850) 892-4357 Gainesville, FL 32641 Line Business Phone: (850) 892-8045 Crisis Phone 1: (352) 264-6789 1255 Golf View Avenue www.copecenter.org Business Phone: (352) 264-6777 Bartow, FL 33830 Hrs Avail: 24 Hrs Avail: 24 Crisis Phone 1: (863) 519-3744 Fort Lauderdale Crisis Phone 2: (863) 519-3745 Meridian Behavioral Health- Business Phone: (863) 519- First Call for Help/Broward care 3747 Co. P.O. Box 2818 Hrs Avail: 24 16 Southeast 13th Street Gainesville, FL 32641 Fort Lauderdale, FL 33316 Crisis Phone 1: (800) 330-5615 Bradenton Crisis Phone 1: (954) 467-6333 Crisis Phone 2: (800) 732-0315 Manatee Glens Corp. Business Phone: (954) 524-8371 Business Phone: (904) 758-0670 391 6th Avenue Hrs Avail: 24 Hrs Avail: 24 Bradenton, FL 34205 Ft. Myers Jacksonville Crisis Phone 1: (948) 741-3117 Business Phone: (941) 741- Ruth Cooper Center First Call for Help 3111 2789 Ortiz Avenue SE P.O. Box 41428 www.manateeglens.com Ft. Myers, FL 33905 Jacksonville, FL 32203 Hrs Avail: 24 Crisis Phone 1: (941) 275-4242 Crisis Phone 1: (904) 632-0600 Business Phone: (941) 275-3222 Crisis Phone 2: (800) 346-6185 Cocoa Hrs Avail: 24 Business Phone: (904) 387- Crisis Services of Brevard, 5641 Ft. Pierce Inc. www.NEFLSurvivors.org P.O. Box 417 New Horizons of the Trea- Hrs Avail: 24 Cocoa, FL 32923-0417 sure Coast Key West/Monroe County Crisis Phone 1: (321) 632-6688 4500 West Midway Road Crisis Phone 2: (321) 631-8944 Ft. Pierce, FL 34981 Helpline, Inc. 211 Crisis Phone 1: (561) 468-5600 P.O. Box 2186 Business Phone: (321) 631- Crisis Phone 2: (888) 468-5600 Key West, FL 33045 9290 Business Phone: (561) 468- Crisis Phone 1: (305) 296-4357 http://www.crisis-services.org 5600 Crisis Phone 2: (800) 273-4558 Hrs Avail: M-F 8 A.M.–5 P.M. Hrs Avail: 24 Crisis Phone 3: (305) 292-8440 264 The Encyclopedia of Suicide

Business Phone: (305) 292- Middleburg Crisis Phone 1: (407) 425-2624 8445 Business Phone: (407) 425- Clay County Behavioral Hrs Avail: 24 5201 x124 Health Center-Access www.wecarecrisiscenter.org Lantana Team Hrs Avail: 24 3292 County Road 220 * Center for Information & Middleburg, FL 32068 Crisis Services-Crisis Line Panama City Crisis Phone 1: (904) 291-5290 P.O. Box 3588 Business Phone: (904) 291-5290 Panama City Crisis Line Lantana, FL 33465 Hrs Avail: 8 A.M.–4:30 P.M. Life Management Center Crisis Phone 1: (561) 930-1234 Panama City, FL 32405 Crisis Phone 2: (561) 930-TEEN Naples Crisis Phone 1: (850) 769-9481 Crisis Phone 3: (561) 930-5040 Hotline & Referral/Project Business Phone: (850) 769- (Elder Help) Help, Inc. 9481 Business Phone: (561) 547- P.O. Box 7804 Hrs Avail: 24 8637 x1071 Naples, FL 34101 Hrs Avail: 24 Pensacola Crisis Phone 1: (941) 262-7227 Maitland Business Phone: (941) 649- Pensacola Help Line- 5660 Lakeview Center, Inc. Central Florida Helpline Hrs Avail: 24 1221 West Lakeview Street P.O. Box 941524 Pensacola, FL 32501 Maitland, FL 32794-1524 New Port Richey Crisis Phone 1: (850) 438-1617 Crisis Phone 1: (407) 740-7477 The Harbor Behavioral Business Phone: (850) 432- Crisis Phone 2: (407) 740-TALK Health Care 8336 Business Phone: (407) 740- P.O. Box 428 Hrs Avail: 24 7408 New Port Richey, FL 34656 www.centralfloridahelpline.org Crisis Phone 1: (727) 849-9988 Pinellas Park Hrs Avail: M-F 10 A.M.–4 P.M. Business Phone: (727) 841- * Personal Enrichment Miami 4455 x417 Through MHS, Inc. Hrs Avail: 24 11254 58th Street North Metro Dade Advocates for Pinellas Park, FL 33782 Victims Ocala Crisis Phone 1: (727) 541-4658 P.O. Box 380817 Marion-Citrus Mental Health Crisis Phone 2: (727) 791-3131 Miami, FL 33238-0817 Center Business Phone: (727) 545- Crisis Phone 1: (305) 758-2546 P.O. Box 771942 6477 Business Phone: (305) 758- Ocala, FL 34478 http://www.pemhs.org 2804 Crisis Phone 1: (352) 629-9595 Hrs Avail: 24 Hrs Avail: 24 Crisis Phone 2: (352) 726-7155 Rockledge , Inc. Crisis Phone 3: (352) 629-6586 701 SW 27th Avenue Business Phone: (352) 620- Circles of Care, Inc. Suite 1000 7300 1770 Cedar Street Miami, FL 33135 Hrs Avail: 24 Rockledge, FL 32956 Crisis Phone 1: (305) 358-4357 Crisis Phone 1: (321) 722-5257 Orlando Business Phone: (305) 358- Business Phone: (321) 722- 1640 * We Care Crisis Center, Inc. 5200 www.switchboardmiami.org 112 Pasadena Place www.circlesofcare.org Hrs Avail: M-F 9 A.M.–5 P.M. Orlando, FL 32803 Hrs Avail: 24 Appendix II 265

Starke Tampa Help Line/Christian Business Phone: (706) 327- Helpline 0199 Meridian Behavioral P.O. Box 9565 www.contact211.org Healthcare, Inc. Tampa, FL 33674 Hrs Avail: 24 945 Grand Street Crisis Phone 1: (813) 286-7064 Starke, FL 32091 Business Phone: (813) 286- Decatur Crisis Phone 1: (904) 964-8382 7064 Crisis Phone 2: (800) 330-5615 Central Access Hrs Avail: 24 (toll free) 445 Winn Way Business Phone: (904) 964- Vero Beach Decatur, GA 30034 8382 Crisis Phone 1: (404) 892- Mental Health Association http://www.meridian- 4646 Crisis Line healthcare.org Business Phone: (404) 294- 2001 9th Avenue Hrs Avail: 24 0499 Suite 301 Hrs Avail: 24 St. Petersburg Vero Beach, FL 32960-3431 Crisis Phone 1: (561) 562-2000 Jonesboro Pinellas Care-Family Business Phone: (561) 569-9788 Resources Inc. Clayton County Mental Hrs Avail: 24 P.O. Box 11538 Health Center St. Petersburg, FL 33733 GEORGIA 853 Battlecreek Crisis Phone 1: (727) 344-5555 Jonesboro, GA 30236 Atlanta Business Phone: (727) 550- Crisis Phone 1: (770) 996-4357 4052 Emergency Mental Health Crisis Phone 2: (770) 994-1064 www.pinellascares.org Services Business Phone: (770) 478- Hrs Avail: 24 141 Pryor Street, SW 2280 Suite 4035 Hrs Avail: 24 Tallahassee Atlanta, GA 30303 Marietta * Telephone Counsel. & Crisis Phone 1: (404) 730-1600 Referral Serv. Business Phone: (404) 730-1600 Cobb-Douglas Counties P.O. Box 10950 Hrs Avail: 24 Commission Tallahassee, FL 32302 Services Board Augusta Crisis Phone 1: (850) 224-6333 361 North Marietta Parkway Business Phone: (850) 681- Access Center-Integrated Marietta, GA 30060 9131 Health Resources Crisis Phone 1: (770) 422-0202 www.tcrs211.org 945 Broad Street 400 Business Phone: (770) 429- Hrs Avail: M-F 9 A.M.–5 P.M. Augusta, GA 30901 5014 Crisis Phone 1: (706) 560-2943 Hrs Avail: 24 Tampa Business Phone: (706) 826- Warner Robins * Hillsborough County 4677 Crisis Center, Inc. of Hrs Avail: 24 Helpline Georgia Tampa Bay 2762 Watson Boulevard Columbus Crisis Center Plaza Warner Robins, GA 31093 Tampa, FL 33613 * Contact Helpline Crisis Phone 1: (800) 338- Crisis Phone 1: (813) 236-TEEN Chattahoochee Valley 6745 Business Phone: (813) 964-1964 P.O. Box 12002 Business Phone: (912) 953- www.crisiscenter.com Columbus, GA 31917 5675 Hrs Avail: 24 Crisis Phone 1: (706) 327-3999 Hrs Avail: 24 266 The Encyclopedia of Suicide

HAWAII Crisis Phone 1: (208) 267-5211 ILLINOIS Business Phone: (208) 267- Honolulu Anna 5211 * Helping Hands Hawaii Hrs Avail: 24 Union County Counseling 2100 North Nimitz Highway Service Honolulu, HI 96819 Idaho Falls 204 South Street, Box 248 Crisis Phone 1: (808) 521-4556 Region VII Mental Health Anna, IL 62906 Crisis Phone 2: (808) 521-4555 150 Shoup Crisis Phone 1: (618) 833-8551 Business Phone: (808) 536- Suite 19 Business Phone: (618) 833- 7234 Idaho Falls, ID 83402 8551 Hrs Avail: 24 Crisis Phone 1: (800) 708-3474 www.uccounseling.org Business Phone: (208) 528- Hrs Avail: 24 Wailuku 5700 Batavia * Maui Kokua Services, Inc. Hrs Avail: 24 P.O. Box 1237 * Suicide Prevention Wailuku, HI 96793 Lewiston Service/Crisis Line of The Crisis Phone 1: (808) 244-7407 YWCA Crisis Services Fox Valley Business Phone: (808) 244-7405 300 Main Street 528 S. Batavia Avenue Hrs Avail: 24 Lewiston, ID 83501 Batavia, IL 60510 Crisis Phone 1: (208) 746-9655 Crisis Phone 1: (630) 482-9696 IDAHO Business Phone: (208) 743- Crisis Phone 2: (630) 482-9393 Boise 1535 Crisis Phone 3: (630) 482-9595 Hrs Avail: 24 (teen line) Emergency Line Region IV Business Phone: (630) 482- Services/Mental Health Sandpoint 9185 Center Region I Mental Health http://www.spsfv.org 1720 Westgate Drive 1717 West Ontario Hrs Avail: 24 Boise, ID 83704 Sandpoint, ID 83864 Crisis Phone 1: (208) 334-0808 Bloomington Crisis Phone 1: (888) 769- Business Phone: (208) 334- 1405 Emergency Crisis Interven- 0808 Crisis Phone 2: (208) 265-4535 tion Team Hrs Avail: 24 (weekdays 8–5) 108 West Market Street * Idaho Suicide Prevention Business Phone: (208) 265- Bloomington, IL 61701 Hotline 4535 Crisis Phone 1: (309) 827-4005 1810 West State Street, 122 Hrs Avail: 24 Crisis Phone 2: (800) 570-PATH Boise, ID 83702 Business Phone: (309) 827- Crisis Phone 1: (800) 526-2120 Twin Falls 5351 Hrs Avail: 24 Business Phone: (208) 426- Twin Falls Emergency 3532 Services PATH-Providing Access To Hrs Avail: 24 Region 5 Mental Health Help 823 Harrison 201 East Grove Bonners Ferry Twin Falls, ID 83301 Bloomington, IL 61701 Boundary County Youth Crisis Phone 1: (208) 734-4000 Crisis Phone 1: (309) 827-4005 Crisis and Domestic Business Phone: (208) 736- Crisis Phone 2: (800) 570-7284 Violence Hotline 2177 Business Phone: (309) 828- P.O. Box 633 Hrs Avail: M-F 5 P.M.–8 A.M.; 1022 Bonners Ferry, ID 83805 S-S 24 hrs. Hrs Avail: 24 Appendix II 267

Carbondale Clinton Galesburg South Illinois Regional Dewitt City Human Bridgeway, Inc. Social Services Resource Center 2323 Windish Drive 604 East College P.O. Box 616 Galesburg, IL 61401 Suite 101 Clinton, IL 61727 Crisis Phone 1: (800) 322-7143 Carbondale, IL 62901-3399 Crisis Phone 1: (217) 935-9496 Business Phone: (309) 344- Crisis Phone 1: (618) 549-3351 Business Phone: (217) 935-9496 2323 Crisis Phone 2: (618) 985-3313 Hrs Avail: 24 Hrs Avail: 24 Crisis Phone 3: (618) 549-3352 Du Quoin Crisis Phone 4: (618) 457-7814 Hillsboro (TDD/TTY) Perry County Counseling Montgomery Co. Health Dept. Crisis Phone 5: (800) 269-9981 Center 11191 Illinois Route 185 (toll free Frank./Will. Co.) 1016 South Madison Street Hillsboro, IL 62049 Business Phone: (618) 457- Suite A Crisis Phone 1: (888) 324-5052 6703 Du Quoin, IL 62832 Business Phone: (217) 532- http://www.sirss.org Crisis Phone 1: (618) 542-4357 2001 Hrs Avail: 24 Business Phone: (618) 542- Hrs Avail: 24 4357 Joliet Champaign Hrs Avail: 24 * Center of Champaign Will County Mental Health Edgemont Mental Health Center 202 W. Park Avenue Call for Help, Suicide & 501 Ella Avenue Champaign, IL 61820 Crisis Intervention Joliet, IL 60433 Crisis Phone 1: (217) 359-4141 9400 Lebanon Road Crisis Phone 1: (815) 727-8512 Business Phone: (217) 373- Edgemont, IL 62203 Business Phone: (815) 727-8512 2430 Crisis Phone 1: (618) 397-0992 www.willcountyhealth.org Hrs Avail: 24 Crisis Phone 2: (618) 397-0963 Hrs Avail: 24 Business Phone: (618) 397-0968 Lincoln Chicago, North Hrs Avail: 24 Connection Resource Lincoln Crisis Clinic/Logan- Elgin Services Mason Mental Health 3001 Greenbay Road Ecker Center for Mental Center Chicago, IL 60064 Health 304 8th Street Crisis Phone 1: (800) 310-1234 1845 Grandstand Place Lincoln, IL 62656 Business Phone: (847) 689- Elgin, IL 60123 Crisis Phone 1: (217) 732-3600 4357 Crisis Phone 1: (847) 888-2211 Business Phone: (217) 732-2161 Hrs Avail: 24 Business Phone: (847) 695-0484 Hrs Avail: 24 Hrs Avail: 24 Chicago Lombard Freeport In Touch Helpline Dupage County Health Dept. University of Illinois Contact Stephenson Co. MH Division-Access & 2010 Student Service Building P.O. Box 83 Crisis Center Chicago, IL 60607 Freeport, IL 61032 440 South Finley Road Crisis Phone 1: (312) 996-5535 Crisis Phone 1: (815) 233-4357 Lombard, IL 60148 Business Phone: (312) 996- Business Phone: (815) 233- Crisis Phone 1: (630) 627-1700 3490 4402 Crisis Phone 2: (630) 932-1447 Hrs Avail: M-F 9 A.M.–5 P.M. Hrs Avail: 24 (TTY) 268 The Encyclopedia of Suicide

Business Phone: (630) 627- Peoria Business Phone: (217) 824- 1700 4905 Mental Health Assn. of Illi- Hrs avail: 24 Hrs Avail: 24 nois Valley Mattoon 5407 North University Woodstock Peoria, IL 61614 McHenry County Crisis Pro- Coles County Mental Health Crisis Phone 1: (309) 673-7373 gram Center Business Phone: (309) 692-1766 P.O. Box 1990 P.O. Box 1307 http://www.mhaiv.org Woodstock, IL 60098 Mattoon, IL 61938-1307 Hrs Avail: 24 Crisis Phone 1: (217) 234-6405 Crisis Phone 1: (800) 892-8900 Crisis Phone 2: (217) 234-6421 Quincy Business Phone: (815) 338-2910 http://www.mchenry-crisis.org (TTY) Transitions of Western Illi- Business Phone: (217) 234- nois INDIANA 6405 4409 Maine Hrs Avail: 24 Quincy, IL 62301 Anderson Moline Crisis Phone 1: (217) 222-1166 Contact/Help of Madison Business Phone: (217) 223-0413 County The Robert Young Center www.twi.org P.O. Box 303 4600 3rd Street Hrs Avail: 24 Anderson, IN 46015 Moline, IL 61265 Crisis Phone 1: (765) 649-5211 Rockford Crisis Phone 1: (800) 322-1431 Business Phone: (765) 649-4939 (toll free) Contact of Rockford Hrs Avail: 24 Crisis Phone 2: (309) 779-2999 P.O. Box 1976 Business Phone: (309) 779- Rockford, IL 61110 Evansville 2043 Crisis Phone 1: (815) 636-5000 * Southwestern Indiana Hrs Avail: 24 Business Phone: (815) 636- MHC, Inc. 5001 Mt. Vernon 415 Mulberry Hrs Avail: 24 Evansville, IN 47713 Mt. Vernon Crisis Line Crisis Phone 1: (812) 423-7791 Sullivan Comprehensive Services Business Phone: (812) 423- P.O. Box 428 Sullivan Crisis Line 7791 Mt. Vernon, IL 62864 Moultree Co. Counseling Center Hrs Avail: 24 Crisis Phone 1: (618) 242-1512 2 West Adams Business Phone: (618) 242- Sullivan, IL 61951 Gary 1510 Crisis Phone 1: (217) 728-7611 Rape Line—Crisis Center Hrs Avail: 24 Business Phone: (217) 728-4358 101 North Montgomery Hrs Avail: 24 Gary, IN 46403 Paris Crisis Phone 1: (219) 938-0900 Taylorville Human Resources Center Business Phone: (219) 938-7070 P.O. Box 1118 Taylorville Helpline—Christ- Hrs Avail: 24 Paris, IL 61944 ian Co. Mental Health Cen- Greenwood (217) 465-4141 ter Business Phone: (217) 465- 730 North Pawnee Valle Vista Hospital Access 4118 Taylorville, IL 62568 Center www.hrcec.org Crisis Phone 1: (217) 824-4905 898 East Main Street Hrs Avail: 24 Crisis Phone 2: (217) 824-3335 Greenwood, IN 46143 Appendix II 269

Crisis Phone 1: (317) 887-1348 www.indy.net/~Lafcc Crisis Phone 1: (812) 235-8333 Business Phone: (317) 887- Hrs Avail: 24 Crisis Phone 2: (877) 377-5433 1348 (toll free) Lawrenceburg www.bhcvallevista.com Crisis Phone 3: (812) 234-5672 Hrs Avail: 24 Community Mental Health (teen line) Center Business Phone: (812) 238- Indianapolis 285 Bielby Road 2620 Custer Center-Tri Meridian Lawrenceburg, IN 47025 Hrs Avail: 24 P.O. Box 44757 Crisis Phone 1: (812) 537-1302 Indianapolis, IN 46208 Crisis Phone 2: (877) 849-1248 IOWA Crisis Phone 1: (877) (toll free) Cedar Rapids NOGAMBLE Business Phone: (812) 537-1302 Business Phone: (317) 929- www.CMHCINC.org * Foundation 2, Crisis Center 1010 Hrs Avail: 24 1540 2nd Avenue www.trimeridian.com Cedar Rapids, IA 52403 Hrs Avail: 24 Lebanon Crisis Phone 1: (319) 362-2174 Mental Health Assoc. in Business Phone: (319) 362- Indianapolis Community Boone County 2176 Hospital, Inc. Access 227 W. Main Street Hrs Avail: M-F 8 A.M.–6 P.M. Services Suite 314 7150 Clearvista Drive Davenport Lebanon, IN 46052 Indianapolis, IN 46256 Crisis Phone 1: (765) 482-1599 Genesis Medical Center Crisis Phone 1: (317) 621-5700 Business Phone: (765) 482-3020 1227 East Rusholme Crisis Phone 2: (800) 662-3445 Hrs Avail: 24 Davenport, IA 52803 (toll free) Crisis Phone 1: (563) 421-2975 Business Phone: (317) 621- Merrillville Business Phone: (563) 421- 5100 Contact—Cares of NW 2948 www.commhospiny.org Indiana Hrs Avail: 24 Hrs Avail: 24 P.O. Box 10247 Des Moines * Mental Health Assoc. of Merrillville, IN 46411 Marion Co. Crisis Phone 1: (219) 769-3141 * Community Telephone Crisis & Business Phone: (219) 769-0611 Service Crisis Line Service Hrs Avail: 24 Service of the Amer. Red Cross 2506 Willowbrook Parkway 100 2116 Grand Avenue Monticello Indianapolis, IN 46205 Des Moines, IA 50312 Crisis Phone 1: (317) 251-7575 Twin Lakes Contact—Help Crisis Phone 1: (515) 244-1000 Business Phone: (317) 251- P.O. Box 67 Crisis Phone 2: (800) 244-7431 0005 Monticello, IN 47960 Business Phone: (515) 244- www.MCMHA.org Crisis Phone 1: (219) 583-4357 6700 Hrs Avail: 24 Business Phone: (219) 583- Hrs Avail: 24 4357 Lafayette Dubuque Hrs Avail: 24 * Lafayette Crisis Center Phone A Friend Crisis Line 1244 North 15th Street Terre Haute 3505 Stoneman Road Lafayette, IN 47904 Vigo Co. Lifeline Inc. Suite 5 Crisis Phone 1: (765) 742-0244 P.O. Box 1017 Dubuque, IA 52002 Business Phone: (765) 742-0247 Terre Haute, IN 47808-1017 Crisis Phone 1: (319) 588-4016 270 The Encyclopedia of Suicide

Business Phone: (319) 557- Garden City Crisis Phone 1: (785) 841- 8331 2345 Garden City Area MHC Hrs Avail: 24 Business Phone: (785) 841- 11111 East Spruce 2345 Iowa City Garden City, KS 67846 www.hqcc.lawrence.ks.us Crisis Phone 1: (316) 276-7689 Iowa City Crisis Center Hrs Avail: 24 Business Phone: (316) 276- 1121 Gilbert Court 7689 Salina Iowa City, IA 52240 www.amhc.org Crisis Phone 1: (319) 351-0140 Hotline Crisis Info. & Hrs Avail: 24 Business Phone: (319) 351- Referral 2726 Humboldt 227 North Sante Fe www.johnsoncountycrisiscenter. Suite 203 SE Kansas MHS Emer. Line org Salina, KS 67401 1106 South 9th Street Hrs Avail: 24 Crisis Phone 1: (785) 827-4747 Humboldt, KS 66748 Business Phone: (785) 827- Crisis Phone 1: (316) 223-5030 Sioux City 4803 Crisis Phone 2: (316) 431-7890 Hrs Avail: 24 Aid Center Business Phone: (316) 473- 715 Douglas Street 2241 Scott City Sioux City, IA 51101 Hrs Avail: 24 Crisis Phone 1: (712) 252-5000 Scott City Area Mental Business Phone: (712) 252- Kansas City Health Center 1861 210 West 4th The Mental Health Assoc. of Hrs Avail: 24 Scott City, KS 67871 the Heartland Crisis Phone 1: (316) 334-5619 739 Minnesota Avenue Waterloo Business Phone: (316) 872- Kansas City, KS 66101-2703 5338 Family Service League Crisis Crisis Phone 1: (913) 281-1234 Hrs Avail: 24 Service Crisis Phone 2: (913) 281-2299 3830 West 9th Street (teen line) Topeka Waterloo, IA 50702 Business Phone: (913) 981- The Consortium Inc. Crisis Phone 1: (319) 233-8484 2221 534 S. Kansas Avenue Business Phone: (319) 233- Hrs Avail: 9 A.M.–9 P.M. 8484 Suite 600 Hrs Avail: 24 Wyandotte Mental Health Topeka, KS 66603 Center Crisis Phone 1: (866) NOBETOO KANSAS 36th and Eaton Business Phone: (785) 232- Kansas City, KS 66103 1196 Emporia Crisis Phone 1: (913) 831-1773 Hrs Avail: 24 Emporia Emergency Services Business Phone: (913) 831- Ulysses MH Center of E. Central Kansas 9500 1000 Lincoln www.WMHCI.org Ulysses Area Mental Health Emporia, KS 66801 Hrs Avail: 24 Center Crisis Phone 1: (316) 343- P.O. Box 757 Lawrence 2626 Ulysses, KS 67880 Business Phone: (316) 342- * Headquarters Counseling Crisis Phone 1: (316) 356-3198 0548 Center Business Phone: (316) 356- www.MHCECK.org P.O. Box 999 3198 Hrs Avail: 24 Lawrence, KS 66044 Hrs Avail: 24 Appendix II 271

Wichita Hopkinsville Business Phone: (270) 689-6500 www.rvbh.com COMCARE of Sedgwick Co. Hopkinsville Crisis Line— Hrs Avail: 24 934 North Water Pennyroyal Regional Wichita, KS 67203 Mental Health Prestonsburg Crisis Phone 1: (316) 356-3198 735 North Drive Mountain Comprehensive Business Phone: (316) 356- Hopkinsville, KY 42240 Care Center 3198 Crisis Phone 1: (270) 881-9551 150 South Front Avenue Hrs Avail: 24 Business Phone: (270) 886- Prestonsburg, KY 41653 5163 Crisis Phone 1: (800) 422-1060 KENTUCKY Hrs Avail: 24 Business Phone: (606) 886-8572 Ashland Jackson Hrs Avail: 24 Pathways Inc. of Ashland P.O. Box 790 Kentucky River Community LOUISIANA Care Ashland, KY 41144 Baton Rouge Crisis Phone 1: (608) 324-1141 3775 Highway 15 South * Baton Rouge Crisis Inter- Business Phone: (608) 324- Jackson, KY 41339 vention Center 1141 Crisis Phone 1: (800) 262-7491 4837 Revere Avenue Hrs Avail: 24 Business Phone: (606) 666- 9278 Baton Rouge, LA 70808 Bowling Green Hrs Avail: 24 Crisis Phone 1: (225) 924-3900 Business Phone: (225) 924-1431 * Life Skills Helpline Lexington www.brcic.org 707 East Main Street Hrs Avail: 24 Bowling Green, KY 42101 Bluegrass Regional MH Crisis Phone 1: (270) 843-4357 201 Mechanic Street De Ridder Business Phone: (270) 843- Lexington, KY 40507 Beauregard De Ridder Com- 4357 Crisis Phone 1: (800) 928-8000 munity Help-line Hrs Avail: 24 Business Phone: (859) 253-2737 Hrs Avail: 24 P.O. Box 815 Corbin De Ridder, LA 70634 Louisville Crisis Phone 1: (337) 462-0609 Cumberland River Compre- Crisis Phone 2: (800) 54 ABUSE hensive Care Center Crisis & Information Center Business Phone: (337) 462- P.O. Box 568 101 West Muhammad Ali 1452 Corbin, KY 40702 Boulevard Hrs Avail: 24 Crisis Phone 1: (606) 528-7010 Louisville, KY 40202 Business Phone: (606) 528- Crisis Phone 1: (502) 568-2325 Monroe 7010 Business Phone: (502) 589- Mainline Hrs Avail: 8 A.M.–4:30 P.M. 8630 P.O. Box 1322 www.sevencounties.org Monroe, LA 71210 Elizabethtown Hrs Avail: 24 Crisis Phone 1: (318) 387-5683 Elizabethtown Crisis Line Owensboro Business Phone: (318) 343-3585 1311 North Dixie Hrs Avail: 6 P.M.–6 A.M. Elizabethtown, KY 42701 River Valley Behavioral Crisis Phone 1: (270) 769-1304 Health Young Womens Christian Business Phone: (270) 765- 1100 Walnut Street Association (YWCA) 2605 Owensboro, KY 42301 1515 Jackson Street Hrs Avail: 24 Crisis Phone 1: (270) 684-9466 Monroe, LA 71202 272 The Encyclopedia of Suicide

Crisis Phone 1: (318) 323-4112 Crisis Phone 2: (800) 660-8500 Crisis Phone 1: (207) 774-4357 Crisis Phone 2: (318) 323-1505 (toll free) Crisis Phone 2: (888) 568-1112 Crisis Phone 3: (318) 325-3611 Crisis Phone 3: (888) 568-1112 Business Phone: (207) 874- Crisis Phone 4: (318) 323-9034 (toll free) 1055 (teen line) Business Phone: (202) 237- www.ingraham.org Business Phone: (318) 323- 2280 Hrs Avail: M-F 8 A.M.–5 P.M. 1505 http://www.suicidology.org http://www.ywcanela.org Hrs Avail: 24 Rumford Hrs Avail: 8 A.M.–5 P.M. Farmington * GRAMI-Oxford County New Orleans MH * Evergreen Behavioral 150 Congress Street * River Oaks Admission and Services Rumford, ME 04276 Referral RR4 Box 5122A Crisis Phone 1: (207) 364-3030 1525 River Oaks Road West Farmington, ME 04938 Crisis Phone 2: (800) 335-9999 New Orleans, LA 70123 Crisis Phone 1: (800) 394-1900 (toll free) Crisis Phone 1: (504) 734-1740 Business Phone: (207) 778-0035 Crisis Phone 3: (888) 568-1112 Crisis Phone 2: (800) 366-1740 http://www.fchn.org (toll free) Business Phone: (504) 734- Business Phone: (207) 364- Lewiston 2199 3549 www.riveroakshospital.com Tri Co. MH Service, Crisis http://www.grami.org Hrs Avail: 24 Intervention Unit Hrs Avail: 24 484 Main Street * VIA LINK Saco 928 Calhoun Street Lewiston, ME 04240-2008 New Orleans, LA 70118 Crisis Phone 1: (888) 568-1112 * Cumberland County Crisis Crisis Phone 1: (504) 895-5502 Crisis Phone 2: (207) 783-4680 Response Inc. Business Phone: (504) 895- Crisis Phone 3: (207) 783-4681 50 Moody Street 5550 Crisis Phone 4: (207) 783-4682 Saco, ME 04072 Crisis Phone 5: (207) 783-4696 Crisis Phone 1: (207) 774-4357 Hrs Avail: M-F 8 A.M.–5 P.M. Business Phone: (207) 783- Crisis Phone 2: (207) 282-6136 MAINE 4695 Business Phone: (207) 284-5981 Hrs Avail: 24 www.ingraham.org Augusta Hrs Avail: 24 Machias Kennebec Somerset Crisis Skowhegan Response Northeast Crisis 32 Wintrap Street Service/Phone Help * Crisis Stabilization Unit Augusta, ME 04330 P.O. Box 29 P.O. Box 588 Crisis Phone 1: (888) 568-1112 Machias, ME 04654-0558 Skowhegan, ME 04976 Business Phone: (207) 626- Crisis Phone 1: (888) 568-1112 Crisis Phone 1: (207) 474-2506 3448 Business Phone: (207) 255- Crisis Phone 2: (888) 568-1112 Hrs Avail: 24 6904 Business Phone: (207) 474-2564 www.wcpa.net Hrs Avail: 24 Biddeford Hrs Avail: 24 Waterville * Crisis Response Services Portland 4201 Connecticut Avenue, NW * Kennebec Valley Mental Suite 408 * Ingraham Health Center Biddeford, ME 04005 P.O. Box 1868 67 Eustis Parkway Crisis Phone 1: (207) 282-6136 Portland, ME 04104 Waterville, ME 04901 Appendix II 273

Crisis Phone 1: (888) 568-1112 Easton Business Phone: (301) 864-7095 Crisis Phone 2: (207) 873-2136 http://www.pghotline.org For All Seasons, Inc. (weekdays only) Hrs Avail: 24 300 Talbot Street Business Phone: (207) 873- Easton, MD 21601 Lanham 2136 Crisis Phone 1: (410) 820-5600 Hrs Avail: 24 * Prince Georges Co. Crisis Crisis Phone 2: (800) 310-7273 Response Team/Affiliated Business Phone: (410) 822- MARYLAND Sante Group 1018 8200 Corporate Drive Baltimore Hrs Avail: 24 Lanham, MD 20785 * First Step Frederick Crisis Phone 1: (410) 768-5522 8303 Liberty Road Business Phone: (301) 429- Baltimore, MD 21244 * Frederick County Hotline 2181 Crisis Phone 1: (410) 521-3800 263 West Patrick Street http://www.thesantegroup.org Business Phone: (410) 628-6120 Frederick, MD 21701 Hrs Avail: 24 http://www.firststepmd.org Crisis Phone 1: (301) 662-2255 Rockville Hrs Avail: M-Th 9 A.M.–9 P.M.; F Crisis Phone 2: (800) 422-0009 9 A.M.–4 P.M.; S 9 A.M.–1 P.M. (youth crisis) * Montgomery County Hot- Crisis Phone 3: (301) 694-8255 line c/o MH Association Baltimore Crisis Line Crisis Phone 4: (301) 662-2255 1000 Twinbrook Parkway Sinai Hospital Business Phone: (301) 663-0011 Rockville, MD 20851 Belvedere and Greenspring Hrs Avail: 24 Crisis Phone 1: (301) 424-CALL Avenue Crisis Phone 2: (301) 738-9697 Baltimore, MD 21215 Glen Burnie (teen line) Weekdays: (410) 601-5457 Anne Arundel Co. Crisis Business Phone: (301) 424- Evenings & Weekends: (410) Response System 0656 601-5902 7493 Baltimore-Annapolis http://www.mhamc.org Business Phone: (410) 601-5457 Boulevard Hrs Avail: 24 Hrs Avail: 24 Glen Burnie, MD 21061 * Baltimore Crisis Response, Crisis Phone 1: (410) 768-5522 Salisbury Inc. Business Phone: (410) 768- Life Crisis Center 1105 Light Street 1875 P.O. Box 387 Baltimore, MD 21230 http://www.thesantegroup.org Salisbury, MD 21803 Crisis Phone 1: (410) 752-2272 Hrs Avail: 24 Crisis Phone 1: (410) 749-4357 Business Phone: (410) 576- Crisis Phone 2: (410) 749-4363 5097 x310 Hyattsville Crisis Phone 3: (410) 749-0688 Hrs Avail: 24 * Prince Georges County (TTY) Hotline & Suicide Crisis Phone 4: (800) 422-0009 Columbia Prevention Center (toll free) * Grassroots Crisis P.O. Box 149 Business Phone: (410) 749-0632 Intervention Center Hyattsville, MD 20781-0149 Hrs Avail: 24 6700 Freetown Road Crisis Phone 1: (301) 864-7130 Waldorf Columbia, MD 21044 (teens) Crisis Phone 1: (410) 531-6677 Crisis Phone 2: (800) 422-0009 Center for Abused Persons Business Phone: (410) 531-6006 Crisis Phone 3: (301) 864-7130 2670 Crane Highway www.grassrootscrisis.org Crisis Phone 4: (301) 864-7161 Suite 303 Hrs Avail: 24 Crisis Phone 5: (301) 927-4500 Waldorf, MD 20601 274 The Encyclopedia of Suicide

Crisis Phone 1: (301) 843-1110 Crisis Phone 1: (508) 999-7267 Methuen (DC metro line) Business Phone: (508) 679- * Samaritans of Merrimack Crisis Phone 2: (301) 645-3337 9777 Valley Crisis Phone 3: (301) 645-3336 Hrs Avail: 8 A.M.–11 P.M. 169 East Street Crisis Phone 4: (301) 645-9389 Methuen, MA 01844 (teen line) Falmouth Crisis Phone 1: (888) 767-8336 Business Phone: (301) 645- * Samaritans on (teen line) 8994 and the Islands, Inc. Crisis Phone 2: (978) 452-6733 Hrs Avail: 24 P.O. Box 65 Crisis Phone 3: (978) 465-6100 White Marsh Falmouth, MA 02541 Crisis Phone 4: (978) 372-7200 Crisis Phone 1: (508) 548-8900 Crisis Phone 5: (978) 688-6607 Baltimore Co. Crisis Crisis Phone 2: (800) 893-9900 Business Phone: (978) 688-0030 Response System Business Phone: (508) 548- Hrs Avail: 24 7939 Honeygo Boulevard 7999 White Marsh, MD 21236 www.capesamaritans.org Northampton Crisis Phone 1: (410) 931-2214 Hrs Avail: 24 Service Net-Emergency Crisis Phone 2: (410) 931-2116 Services of Northampton Business Phone: (410) 931- Framingham 129 King Street 2116 * Samaritans Suburban West Northampton, MA 01702 http://www.thesantegroup.org 235 Walnut Street Crisis Phone 1: (413) 586-5555 Hrs Avail: 24 Framingham, MA 01702 Business Phone: (413) 586- Crisis Phone 1: (877) 875-4500 MASSACHUSETTS 5555 Business Phone: (508) 872- Hrs Avail: 24 Attleboro 1780 Hrs Avail: M-F 9 A.M.–5 P.M. Norwood New Hope/Attleboro 140 Park Street Haverhill * Riverside Community Care Attleboro, MA 02703 190 Lenox Street Crisis Phone 1: (800) 323-4673 N. Essex MH Center-Crisis Norwood, MA 02062 Business Phone: (508) 226- Service & Central Intake Crisis Phone 1: (781) 769-8674 4015 60 Merrimack Street Business Phone: (781) 769-8670 www.new-hope.org Haverhill, MA 01830 www.riversidecc.com Hrs Avail: 24 Crisis Phone 1: (978) 521-7763 Hrs Avail: 24 Crisis Phone 2: (800) 281-3223 Boston Business Phone: (978) 521- Southbridge * The Samaritans of Boston 7777 Y.O.U. Inc. Family Services 654 Beacon Street http://www.hes.com 52 Charlton Street Boston, MA 02215 Hrs Avail: 24 Southbridge, MA 01550 Crisis Phone 1: (617) 247-0220 Crisis Phone 1: (800) 435-9990 Holyoke Business Phone: (617) 536- Business Phone: (508) 765- 2460 Mt. Tom Mental Health 9101 Hrs Avail: 24 Center http://www.youinc.org 40 Bobala Road Hrs Avail: 24 Fall River Holyoke, MA 01040 * Samaritans of Fall River- Crisis Phone 1: (413) 536-2251 Springfield New Bedford, Inc. Business Phone: (413) 536- Psychiatric Crisis Services P.O. Box 9642 5473 503 State Street Fall River, MA 02720 Hrs Avail: 24 Springfield, MA 01109 Appendix II 275

Crisis Phone 1: (413) 733-6661 Cadillac The Listening Ear, Inc. Business Phone: (413) 746- 1017 East Grand River North Central Community 3758 East Lansing, MI 48823 M.H. Hrs Avail: 24 Crisis Phone 1: (517) 337-1717 527 Cobbs Business Phone: (517) 337- Cadillac, MI 49601 Westfield 1728 Crisis Phone 1: (231) 775-3463 Hrs Avail: 24 Westfield Crisis Team Crisis Phone 2: (800) 492-5742 77 Mill Street Crisis Phone 3: (800) 442-7315 Flint Westfield, MA 01085 Business Phone: (231) 775- Mental Health Crisis Clinic— Crisis Phone 1: (413) 568-6386 3463 Genesee Co. Mental Health (TTY) Hrs Avail: 24 Hrs Avail: 24 918 Patrick Street Coldwater Flint, MI 48503 Worcester Crisis Phone 1: (810) 257-3740 Crisis Center Y.O.U. Inc. Pines Behavioral Health Business Phone: (810) 232- 81 Plantation Street Services 5850 Worcester, MA 01604 200 Orleans Boulevard www.gencmh.org Crisis Phone 1: (508) 791-6562 Coldwater, MI 49036 Hrs Avail: 24 Crisis Phone 1: (517) 279-1193 Business Phone: (508) 849- Holland 5600 Crisis Phone 2: (888) 725-7534 www.youinc.org Business Phone: (517) 279-8404 Ottawa County Helpline Hrs Avail: 24 http://www.pinesbhs.org 12265 James Street Hrs Avail: 24 Holland, MI 49424 MICHIGAN Detroit Crisis Phone 1: (616) 396-4357 Crisis Phone 2: (616) 393-4357 Ann Arbor * Neighborhood Service (TTY) University of Michigan Organization Business Phone: (616) 392- Health Systems 220 Bagley 1873 1500 East Medical Center Drive Suite 200 Hrs Avail: 24 Ann Arbor, MI 48109 Detroit, MI 48226 Kalamazoo Crisis Phone 1: (734) 996-4747 Crisis Phone 1: (313) 224-7000 Business Phone: (734) 936- Crisis Phone 2: (800) 241-4949 * Gryphon Place 5900 Business Phone: (313) 961-1060 1104 South Westnedge Hrs Avail: 24 Hrs Avail: 24 Kalamazoo, MI 49008 Crisis Phone 1: (616) 381-4357 Bloomfield Hill East Lansing Business Phone: (616) 381- Common Ground Sanctuary Gateway Community 1510 1410 South Telegraph Services www.gryphon.org Bloomfield Hills, MI 48302 910 Abbott Road Hrs Avail: 24 Crisis Phone 1: (800) 231-1127 Suite 100 Lapeer (toll free) East Lansing, MI 48823 Crisis Phone 2: (248) 456-0909 Crisis Phone 1: (800) 292-4517 Lapeer Co. Comm. MHC Crisis Phone 3: (248) 292-0194 Crisis Phone 2: (800) 292-4357 1570 Suncrest Drive Business Phone: (248) 456-8150 (parent helpline) Lapeer, MI 48446 www.commongroundsanctu- Business Phone: (517) 351-4000 Crisis Phone 1: (888) 225-4447 ary.org http://www.gatewayservices.org Business Phone: (810) 667-0500 Hrs Avail: 24 Hrs Avail: 24 Hrs Avail: 24 276 The Encyclopedia of Suicide

Mt. Pleasant Crisis Phone 1: (616) 983-0430 Apple Valley Crisis Phone 2: (800) 312-5454 Listening Ear Crisis Center, Dakota County Crisis Business Phone: (616) 983- Inc. Response Unit 5465 P.O. Box 800 14955 Galaxie Avenue www.link4teens.org Mt. Pleasant, MI 48804 Apple Valley, MN 55124 Hrs Avail: 24 Crisis Phone 1: (989) 772-2918 Crisis Phone 1: (952) 891-7171 Business Phone: (989) 773- Three Rivers Business Phone: (952) 891- 6904 7171 Hrs Avail: 24 St. Joseph County CMH Hrs Avail: 24 210 South Main Street Muskegon Three Rivers, MI 49093 Austin Comm. MH Services of Crisis Phone 1: (616) 273-2000 Crime Victims Resource Muskegon Co. Crisis Phone 2: (800) 622-3967 Center 376 East Apple Business Phone: (616) 273- 101 14th Street, NW Muskegon, MI 49442 5000 Suite 5 Crisis Phone 1: (231) 720-3200 Hrs Avail: 24 Austin, MN 55912 Crisis Phone 1: (507) 437-6680 Business Phone: (231) 720- Traverse City 3200 Business Phone: (507) 437-6680 Hrs Avail: 24 * Third Level Crisis Center Hrs Avail: 24 P.O. Box 1035 Port Huron Traverse City, MI 49685 Brainerd * St. Clair County Crisis Phone 1: (231) 922-4800 Crisis Line & Referral Community MH Services Crisis Phone 2: (800) 442-7315 Service 1007 Military Street Business Phone: (231) 922- P.O. Box 192 Port Huron, MI 48060 4802 Brainerd, MN 56401 Crisis Phone 1: (810) 987-6911 Hrs Avail: 24 Crisis Phone 1: (218) 828-4357 Business Phone: (810) 987- Crisis Phone 2: (800) 462-5525 Ypsilanti 7050 Business Phone: (218) 828- www.scccmh.org SOS Crisis Center 4515 Hrs Avail: 24 101 South Huron Hrs Avail: 24 Ypsilanti, MI 48197 Grand Rapids Saginaw Crisis Phone 1: (734) 485-3222 Crisis Intervention Services- Business Phone: (734) 485- Northland Recovery Center Saginaw City MH Center 8730 1215 South East 7th Avenue 500 Hancock Hrs Avail: 24 Grand Rapids, MN 55744 Saginaw, MI 48602 Crisis Phone 1: (800) 652-9025 Crisis Phone 1: (517) 792-9732 MINNESOTA Business Phone: (218) 327-1026 Crisis Phone 2: (800) 233-0022 Hrs Avail: 24 Alexandria Business Phone: (517) 797- Minneapolis 3400 Listening Ear Crisis Center Hrs Avail: 24 700 Cedar Street Crisis Connection Suite 266 P.O. Box 19550 St. Joseph Alexandria, MN 56308 Minneapolis, MN 55419 The Link Crisis Intervention Crisis Phone 1: (320) 763-6638 Crisis Phone 1: (612) 379-6363 Center Business Phone: (320) 763- Business Phone: (612) 379- 2002 South State Street 6638 6369 St. Joseph, MI 49085 Hrs Avail: 24 Hrs Avail: 24 Appendix II 277

* Hennepin County Crisis Maryland Heights * Life Crisis Services, Inc. Intervention Center 1423 South Big Bend Boulevard * Behavioral Health 701 Park Avenue South St. Louis, MO 63117 Response Minneapolis, MN 55415 Crisis Phone 1: (314) 647-4357 Suicide: (612) 347-2222 P.O. Box 1125 Business Phone: (314) 647- Business Phone: (612) 347-3164 Maryland Heights, MO 63043- 3100 Hrs Avail: 24 9881 www.lifecrisis.org Crisis Phone 1: (314) 469-6644 Hrs Avail: 24 Owatonna (St. Louis) Crisis Phone 2: (800) 811-4760 Owatonna—Steele Co. Con- MONTANA Crisis Phone 3: (800) 811-4760 tact Business Phone: (877) 469- Billings P.O. Box 524 4908 Owatonna, MN 55060 Mental Health Center http://www.bhrstl.org Crisis Phone 1: (507) 451-9100 1245 North 29th Street Hrs Avail: 24 Business Phone: (507) 451-1897 Billings, MT 59103 Hrs Avail: 24 Springfield Crisis Phone 1: (406) 252-5658 Business Phone: (406) 252- St. Paul * Burrell Center, Inc./Crisis 5658 Ramsey County Adult Crisis Assist Team Hrs Avail: 24 Center 930 South Robberson Bozeman 1919 University Springfield, MO 65807 St. Paul, MN 55101 Crisis Phone 1: (417) 862-6555 Bozeman Help Center Crisis Phone 1: (651) 523-7900 Crisis Phone 2: (800) 494-7355 421 East Peach Business Phone: (651) 523-7999 Business Phone: (417) 269- Bozeman, MT 59715 http://www.co.ramsey.mn.us/ 5400 Crisis Phone 1: (406) 586-3333 Hrs Avail: 24 Hrs Avail: 24 Business Phone: (406) 587- 7511 MISSISSIPPI St. Joseph www.bozemanhelpcenter.com Jackson Family Guidance Center for Hrs Avail: 24 Behavioral Health Care * Contact Crisis Line 510 Francis Street Great Falls P.O. Box 5192 Suite 200 Crisis Line-Voices of Hope Jackson, MS 39296 St. Joseph, MO 64501 P.O. Box 6644 Crisis Phone 1: (601) 713-HELP Crisis Phone 1: (888) 279-8188 Great Falls, MT 59405 Business Phone: (601) 713-4099 Business Phone: (816) 364-1501 Crisis Phone 1: (406) 453-4357 Hrs Avail: 24 Hrs Avail: 24 Business Phone: (406) 771- MISSOURI 8648x3336 St. Louis Hrs Avail: 24 Cape Girardeau * Kids Under Twenty One Helena Community Counseling 2718 South Brentwood Center St. Louis, MO 63144 Golden Triangle Community 402 South Silver Springs Road Crisis Phone 1: (314) 644-KUTO MH Center Cape Girardeau, MO 63703 Business Phone: (314) 963- 1101 Missoula Crisis Phone 1: (800) 356-5395 7571 Helena, MT 59601 Business Phone: (573) 334- http://www.KUTO.org Crisis Phone 1: (406) 443-5353 1100 Hrs Avail: Su-Th 4 P.M.–10 P.M.; Business Phone: (406) 443-4922 Hrs Avail: 24 F-Sa 4 P.M.–12 A.M. Hrs Avail: 24 278 The Encyclopedia of Suicide

Kalispell Crisis Phone 1: (877) 885-HOPE Business Phone: (603) 447- Business Phone: (775) 784- 3347 Lamplighter Health 8085 http://www.nnhmhds.org 860 North Meridian Hrs Avail: 24 Hrs Avail: 24 Kalispell, MT 59901 Crisis Phone 1: (406) 752-6262 NEW HAMPSHIRE Dairy Business Phone: (406) 257-1336 * CLM Behavioral Health Hrs Avail: 24 Berlin Systems Berlin Mental Health Center NEBRASKA 43 Birch Street 3 12th Street Dairy, NH 03038 Boys Town Berlin, NH 03570 Crisis Phone 1: (603) 434-1577 Crisis Phone 1: (603) 752-7404 Girls & Boys Town National (after 5pm) Business Phone: (603) 752- Crisis Phone 2: (800) 762-8191 Hotline 7404 13940 Gutowski Road (toll free) http://www.nnhmhds.org Business Phone: (603) 434- Boys Town, NE 68010 Hrs Avail: 24 Crisis Phone 1: (800) 448-3000 1577 (national hotline) Concord Hrs Avail: 24 Crisis Phone 2: (800) 448-1833 * Riverbend Community MH Dover (national TDD) services Business Phone: (402) 498-1831 * Strafford Guidance Center, P.O. Box 2032 http://www.boystown.org Inc. Concord, NH 03302 Hrs Avail: 24 Emergency Crisis Team Crisis Phone 1: (603) 226-0817 103 Central Avenue Lincoln Business Phone: (603) 226-0817 Dover, NH 03820 www.riverbendcmhc.org Crisis Phone 1: (603) 742-0630 Community Mental Health Hrs Avail: 24 2200 St. Marys Business Phone: (603) 742-0630 Lincoln, NE 68502 Conway Hrs Avail: 24 Crisis Phone 1: (402) 441-7940 Carroll Co. MH Keene Business Phone: (402) 441- 25 West Main Street 7940 * The Samaritans of the Conway, NH 3818 Hrs Avail: 24 Monadnock Region Crisis Phone 1: (603) 447-2111 103 Roxbury Street North Platte Business Phone: (603) 447- Suite 304 2111 Heartland Counseling and Keene, NH 03431 Hrs Avail: 9 A.M.–5 P.M. Consulting Clinic Crisis Phone 1: (603) 357-5505 110 North Bailey Northern New Hampshire Business Phone: (603) 357- North Platte, NE 69103 MH & Development 5510 Crisis Phone 1: (308) 534-6963 87 Washington Street Hrs Avail: 24 Business Phone: (308) 534-6029 Conway, NH 03818 Laconia Hrs Avail: 24 Crisis Phone 1: (603) 447-2111 (Carroll Co.) * Genesis—The Counseling NEVADA Crisis Phone 2: (603) 237-4955 Group (Colbrook) 111 Church Street Reno Crisis Phone 3: (603) 752-7404 Laconia, NH 03246 * Crisis Call Center (Aderscogen Valley) Crisis Phone 1: (603) 528-0305 P.O. Box 8016 Crisis Phone 4: (603) 636-2555 Business Phone: (603) 528-0305 Reno, NV 89507 (Groveton) Hrs Avail: 5 P.M.–8 A.M. Appendix II 279

Lebanon Atlantic City Medical Center Hoboken 1941 Pacific Avenue * Headrest, Inc. St. Marys Community MH Atlantic City, NJ 08401 P.O. Box 247 506 3rd Street Crisis Phone 1: (609) 344-1118 Lebanon, NH 03766 Hoboken, NJ 07030 Business Phone: (609) 344- Crisis Phone 1: (603) 448-4400 Crisis Phone 1: (201) 795-5505 1118x2883 Business Phone: (603) 448- Business Phone: (201) 792- Hrs Avail: 24 4872 8200 www.headrest.org Bridgeton Hrs Avail: 24 Hrs Avail: 24 Crisis Hotline-Cumberland Lyndhurst Manchester Co. Guidance Center Comprehensive Behavioral 333 Irving Avenue * MHC of Greater Manches- Healthcare Inc. Bridgeton, NJ 08302 ter 516 Valley Brook Avenue Crisis Phone 1: (856) 455-5555 401 Cypress Street Lyndhurst, NJ 07071 Crisis Phone 2: (856) 455-7621 Manchester, NH 03103 Crisis Phone 1: (201) 935-3322 (TTY) Crisis Phone 1: (603) 668-4111 Crisis Phone 2: (201) 646-0333 Business Phone: (856) 455- (TTY) Business Phone: (201) 935- 5555 Business Phone: (603) 668-4111 3322 Hrs Avail: 24 Hrs Avail: 24 http://www.comcare.org Ewing Hrs Avail: M-Th 9 A.M.–9 P.M.; F Pembroke 9 A.M.–5 P.M. Contact Mercer Co. Community Services Council 1985 Pennington Road Morrestown of NH Ewing, NJ 8618 P.O. Box 2338 Contact Burlington Co. Crisis Phone 1: (609) 896-2120 Pembroke, NH 03275 P.O. Box 333 Business Phone: (609) 883- Crisis Phone 1: (603) 225-9000 Moorestown, NJ 08057 2880 Crisis Phone 2: (800) 852- 3388 Crisis Phone 1: (609) 234-8888 Hrs Avail: 24 Business Phone: (603) 225- Business Phone: (856) 234- 9694 Flemington 5484 http://www.nhhelpline.org www.contactburlco.org Hrs Avail: 24 Hunterdon Helpline Hrs Avail: 24 P.O. Box 246 Portsmouth Flemington, NJ 08822 Morristown Crisis Phone 1: (908) 782- Seacoast Mental Health Ser- Crisis Hotline 4357 vices 100 Madison Avenue Business Phone: (908) 735- 1145 Sagamore Avenue Morristown, NJ 07962 4357 Portsmouth, NH 03801 Crisis Phone 1: (973) 540-0100 Hrs Avail: 24 Crisis Phone 1: (603) 431-6703 Business Phone: (973) 540- 0100 Business Phone: (603) 431- Glassboro 6703 Hrs Avail: 24 Hrs Avail: 24 Center for Family Services 250 S. Delsea Drive Mt. Holly NEW JERSEY Glassboro, NJ 08028 Screening and Crisis Interv. Crisis Phone 1: (856) 728-1085 Program Atlantic City Business Phone: (856) 728- Co. Memorial Hospital Psychiatric Intervention 7045 175 Madison Avenue Program Hrs Avail: 24 Mt. Holly, NJ 08060 280 The Encyclopedia of Suicide

Crisis Phone 1: (609) 261-8000 Scotch Plains NEW MEXICO Business Phone: (609) 261- * Contact We Care, Inc. Albuquerque 8000 P.O. Box 952 Hrs Avail: 24 AGORA Scotch Plains, NJ 07076 The Univ. of New Mexico Crisis Newark Crisis Phone 1: (908) 232-3333 Center Crisis Phone 2: (908) 232-2880 Emergency Psychiatric Student Union, SUB 105 Business Phone: (908) 490- Services P.O. Box 29 1480 100 Bergen Street Albuquerque, NM 87131 http://www.contactwecare.org Newark, NJ 07103 Crisis Phone 1: (505) 277-3013 Hrs Avail: 24 Crisis Phone 1: (973) 623-2323 Business Phone: (505) 277- Business Phone: (973) 972- Somers Point 3013 0480 Hrs Avail: 9 A.M.–midnight Hrs Avail: 24 Contact Cape Atlantic P.O. Box 296 Portales Paramus Somers Point, NJ 08244 Mental Health Resources, 262 Help County Crisis Crisis Phone 1: (609) 646-6616 Inc. Hotline (Atlantic Co.) 300 East First Street 610 Industrial Boulevard Crisis Phone 2: (609) 390-3333 Portales, NM 88130 Paramus, NJ 07652 (Cape May Co.) Crisis Phone 1: (505) 359-1221 Crisis Phone 1: (201) 262-4357 Crisis Phone 3: (609) 266-8228 (8 A.M.–6 P.M.) Crisis Phone 2: (201) 795-5505 (Atlantic Co.) Crisis Phone 2: (800) 432-2159 Crisis Phone 3: (201) 262-7462 Crisis Phone 4: (609) 823-2109 (toll free 6 P.M.–8 A.M., M-F 5 Business Phone: (201) 262- (Reassurance Contact) P.M.–8 A.M.) 7108 Business Phone: (609) 823- Business Phone: (505) 359-1221 http://www.careplusnj.org 1850 Hrs Avail: 24 Hrs Avail: 24 Santa Fe Crisis Response of Santa Fe Pequannock Voorhees P.O. Box 2267 Contact Hotline Contact Community Santa Fe, NM 87504-2267 P.O. Box 219 Helpline Crisis Phone 1: (800) 477-7633 Pequannock, NJ 07440 P.O. Box 714 Crisis Phone 2: (505) 820-6333 Crisis Phone 1: (973) 831-1870 Voorhees, NJ 08043 Business Phone: (505) 982- Business Phone: (973) 831- Crisis Phone 1: (856) 795-2155 5565 1879 (voice/TDD) http://www.pmsnet.org Hrs Avail: 24 Crisis Phone 2: (856) 935-4357 Hrs Avail: 24 (Cumberland) Red Bank Crisis Phone 3: (856) 795-2119 NEW YORK Helpline-Crisis Unit (M-F 9-5 (Sept-June)) Albany Riverview Medical Center Crisis Phone 4: (888) 375-TEEN 1 Riverview Plaza Crisis Phone 5: (856) 765-1991 Capitol Dist. Psychiatric Red Bank, NJ 07701 Crisis Phone 6: (856) 881-6200 Center Crisis Phone 1: (732) 219-5325 (Salem) 75 New Scotland Avenue Business Phone: (732) 530- Business Phone: (856) 795- Albany, NY 12208 2438 5073 Crisis Phone 1: (518) 447-9650 www.meridianhealth.com http://www.snj.com/contact Business Phone: (518) 447-9611 Hrs Avail: 24 Hrs Avail: 24 Hrs Avail: 24 Appendix II 281

Batavia Crisis Phone 1: (607) 272-1616 Crisis Phone 1: (212) 532-2400 Business Phone: (607) 272- Business Phone: (212) 684- * Regional Action Phone, Inc. 1505 4480 P.O. Box 281 Hrs Avail: 24 Hrs Avail: M-F 9 A.M.–6 P.M. Batavia, NY 14021 Crisis Phone 1: (716) 343-1212 Jamestown * Samaritans of NYC Crisis Phone 2: (716) 345-9406 P.O. Box 1259-Madison Square Jamestown Crisis Line-Jones Crisis Phone 3: (800) 889-1903 Garden Memorial Health Center (Orleans Co.) New York, NY 10159 57 Glasgow Avenue Crisis Phone 4: (800) 359-5722 Crisis Phone 1: (212) 673-3000 Jamestown, NY 14701 (Genisee) Crisis Phone 2: (877) SUICIDE Crisis Phone 1: (716) 484-1314 Business Phone: (716) 343-1212 Business Phone: (212) 677- Business Phone: (716) 664- Hrs Avail: 24 3009 8326 http://www.samaritansnyc.org Hrs Avail: 24 Buffalo Hrs Avail: 9 A.M.–6 P.M. * Crisis Services, Inc. New Paltz 2669 Main Street North Bellmore Family of New Paltz Buffalo, NY 14214 51 North Chesnut Street Long Island Crisis Center Crisis Phone 1: (716) 834-3131 New Paltz, NY 12561 2740 Martin Avenue Business Phone: (716) 834-2310 Crisis Phone 1: (845) 255-8801 North Bellmore, NY 11710 Hrs Avail: 24 Business Phone: (845) 255-8801 Crisis Phone 1: (877) 796-4673 Hrs Avail: 24 (children of hope) Elmsford Crisis Phone 2: (516) 549-8700 Sterling Center of the MHA Psychological Counseling Crisis Phone 3: (516) 679-1111 of Westchester Co. Center Crisis Phone 4: (516) 679-1113 2269 Saw Mill River Road VLC 10 State Univ. College Crisis Phone 5: (516) 679-1112 Elmsford, NY 10523 New Paltz, NY 12561 Business Phone: (516) 826-0244 Crisis Phone 1: (914) 347-6400 Crisis Phone 1: (845) 257-4945 http://www. Business Phone: (914) 345-5900 Business Phone: (845) 257-2920 longislandcrisiscenter.org Hrs Avail: 24 Hrs Avail: 24 Hrs. Avail: 24 Goshen New York City Plattsburgh Orange County Help Line Covenant House Nineline * Crisis Center of Clinton, Mental Health in Orange 346 West 17th Street Essex and Franklin County Inc. New York, NY 10011 Counties 20 Walker Street Crisis Phone 1: (800) 999-9999 36 Brinkerhoff Street Goshen, NY 10924 (toll free) Plattsburgh, NY 12901 Crisis Phone 1: (845) 294-9355 Crisis Phone 2: (800) 999-9915 Crisis Phone 1: (518) 561-2330 Crisis Phone 2: (800) 832-1200 (TTY) Business Phone: (518) 561- Business Phone: (845) 294-7411 Business Phone: (212) 727- 2330 Hrs Avail: 24 4021 Hrs Avail: 24 http://www.covenanthouse.org Ithaca Hrs Avail: 24 Potsdam * Suicide Prevention & Crisis Help-Line Telephone Services * REACHOUT of St. Service 3 West 19th Street Lawrence County, Inc. P.O. Box 312 10th floor P.O. Box 5051 Ithaca, NY 14851 New York, NY 10001 Potsdam, NY 13676 282 The Encyclopedia of Suicide

Crisis Phone 1: (315) 265-2422 Crisis Phone 1: (716) 285-3515 NORTH CAROLINA Business Phone: (315) 265-2422 Business Phone: (716) 285- Ahoskie Hrs Avail: 24 3519 Hrs Avail: 24 Roanoke-Chowan Human Poughkeepsie Service Center Stony Brook The Dutchess County 144 Community College Road Department of Mental * Response of Suffolk Co., Ahoskie, NC 27910 Hygiene Inc. Crisis Phone 1: (252) 332-4442 230 North Road P.O. Box 300 Crisis Phone 2: (877) 685-2415 Poughkeepsie, NY 12601 Stony Brook, NY 11790 Business Phone: (252) 332- Crisis Phone 1: (518) 462-0181 Crisis Phone 1: (631) 751-7500 4137 Crisis Phone 2: (845) 485-9700 Business Phone: (631) 751- Hrs Avail: 24 7620 Crisis Phone 3: (845) 486-2866 Asheboro Business Phone: (845) 486-2705 www.responsehotline.org http://www.timesunion.com/ Hrs Avail: 24 Randolph Helpline P.O. Box 4397 communities/samaritans Utica Hrs Avail: 24 Asheboro, NC 27203 Crisis Evaluation Team-St. Crisis Phone 1: (336) 633-7209 * Dutchess County Elizabeth Medical Center Crisis Phone 2: (800) 742-2572 HELPLINE 2209 Genesee Street Business Phone: (336) 633- 230 North Road Utica, NY 13501 7223 Poughkeepsie, NY 12601-1328 Crisis Phone 1: (315) 734-3456 Hrs Avail: 24 Crisis Phone 1: (845) 485-9700 Crisis Phone 2: (315) 732-0473 Burlington Crisis Phone 2: (845) 485-9700 Business Phone: (315) 734- Crisis Phone 3: (877) 485-9000 3456 * Suicide & Crisis Serv/Ala- Crisis Phone 4: (845) 486-2866 Hrs Avail: 24 mance Co. (TTY) P.O. Box 2573 Valhalla Business Phone: (845) 486-2750 Burlington, NC 27215 Hrs Avail: 24 Crisis Intervention Unit Crisis Phone 1: (336) 227-6220 Rochester Westchester Country Medical Business Phone: (336) 228- Center 1720 * Lifeline/Health Assn. of Grasslands Road Hrs Avail: 24 Rochester Valhalla, NY 10595 Chapel Hill 1 Mt. Hope Avenue Crisis Phone 1: (914) 493-7075 Rochester, NY 14620 Business Phone: (914) 493- Crisis Central Crisis Phone 1: (716) 275-5151 7075 412a Caldwell Street Business Phone: (716) 423-9490 Hrs Avail: 24 Chapel Hill, NC 27516 Hrs Avail: 24 Crisis Phone 1: (800) 974-0479 Woodstock Business Phone: (919) 913- Rockport Family of Woodstock 4000 Niagara Co. MH Hotline & 16 Rock City Road Hrs Avail: 24 Crisis Intv.-Troll Access Woodstock, NY 12498 Charlotte Center Crisis Phone 1: (914) 338-2370 5467 Upper Mountain Road Business Phone: (914) 331- The Relatives, Inc. Shaw Building-Mt. View 7080 P.O. Box 30186 Campus www.familyofwoodstockinc.org Charlotte, NC 28203 Rockport, NY 14094 Hrs Avail: 24 Crisis Phone 1: (704) 377-0602 Appendix II 283

Business Phone: (704) 335-0203 Greensboro Morehead Hrs Avail: 24 Switchboard Crisis Center Helpline Carteret County Clyde 330 South Greene 209 North 35th Street Greensboro, NC 27402 Morehead, NC 28557 * Parents Against Teen Sui- Crisis Phone 1: (919) 275-0896 Crisis Phone 1: (252) 247-3023 cide/T.E.A.C.H. Business Phone: (919) 275-9341 Business Phone: (252) 240- P.O. BOX 129 Hrs Avail: 24 0540 Clyde, NC 28721 Hrs Avail: 24 Crisis Phone 1: (800) 367-7287 Teen Crisis Line Business Phone: (828) 627- 301 East Washington Street Raleigh 1001 Suite 201 http://www.teachhotline.org Greensboro, NC 27401 Hopeline, Inc. Hrs Avail: 24 Crisis Phone 1: (336) 387-6161 P.O. Box 10490 Business Phone: (336) 333- Raleigh, NC 27605 Durham 6853 Crisis Phone 1: (919) 231-4525 Business Phone: (919) 832- Hrs Avail: 4 P.M.–midnight CONTACT Helpline 3326 2706 North Roxboro Road Greenville Hrs Avail: 24 Durham, NC 27704 Crisis Phone 1: (919) 683-1595 REAL Crisis Intervention, Roanoke Rapids Business Phone: (919) 220- Inc. Riverstone Counseling 2534 600 East 11th Street 210 Smith Church Road Hrs Avail: 24 Greenville, NC 27858 Crisis Phone 1: (252) 758-4357 Roanoke Rapids, NC 27870 Durham Center Hotline (TTY) Crisis Phone 1: (252) 537- 501 Willard Street Crisis Phone 2: (252) 758-1976 2909 Durham, NC 27701 (teens) Business Phone: (252) 537- Crisis Phone 1: (919) 560-7100 Business Phone: (252) 758- 6174 Business Phone: (919) 560- 4357 Hrs Avail: 24 7100 Hrs Avail: 24 Hrs Avail: 24 Salisbury Lexington Piedmont Behavioral Fayetteville Hope Helpline Ministries Healthcare Contact of Fayetteville, Inc. 21 Sunrise Avenue 1807 East Innes Street 509 Person Street Lexington, NC 27292 Salisbury, NC 28146 Fayetteville, NC 28301 Crisis Phone 1: (336) 249-8974 Crisis Phone 1: (704) 633-3616 Crisis Phone 1: (910) 485-4134 Business Phone: (336) 249- Business Phone: (704) 633- Business Phone: (910) 483- 8824 3616 8970 Hrs Avail: 24 Hrs Avail: 24 Hrs Avail: 24 Manteo Sanford Goldsboro Outer Banks Hotline Lee County MH Crisis Line Wayne Co. MHC Hotline 602 Amadas Street 130 Carbonton Road 301 North Herman Street Manteo, NC 27954 Sanford, NC 27330 Goldsboro, NC 27530 Crisis Phone 1: (252) 473-3366 Crisis Phone 1: (919) 774-4520 Crisis Phone 1: (919) 735-4357 Business Phone: (252) 473- Business Phone: (919) 774- Business Phone: (919) 731-1133 5121 6521 Hrs Avail: 24 Hrs Avail: 24 Hrs Avail: 24 284 The Encyclopedia of Suicide

Smithfield Business Phone: (701) 255-3692 Crisis Phone 1: (701) 235-7335 Hrs Avail: 24 Crisis Phone 2: (701) 232-4357 Contact Johnston Co. Business Phone: (701) 293- 140 Market Street West Central Human Service 6462 Smithfield, NC 27577 Center Hrs Avail: 24 Crisis Phone 1: (919) 934-6161 600 South 2nd Street Business Phone: (919) 934- Suite 5 South East Human Service 6979 Bismarck, ND 58504-5731 Center Hrs Avail: 24 Crisis Phone 1: (701) 328-8899 2624 9th Avenue SW Crisis Phone 2: (888) 328-2112 Fargo, ND 58103-2350 Statesville (toll free-Bismarck) Crisis Phone 1: (701) 298-4450 The Counseling Center of Crisis Phone 3: (800) 366-6888 (TTY) Iredell (TDD & TTY) Crisis Phone 2: (888) 342-4900 125 West Bell Street Crisis Phone 4: (800) 366-6889 (toll free) Statesville, NC 28677 (TDD) Business Phone: (701) 298-4500 Crisis Phone 1: (704) 872-7638 Business Phone: (701) 328-8888 Hrs Avail: 24 Business Phone: (704) 872- http://www.discovernd.com Grand Forks 7638 Hrs Avail: 24 Northeast Human Service Hrs Avail: 24 Lake Region Human Service Center Center Wilmington 151 South 4th Street 200 Highway 2, SW Suite 401 * Crisis Line/Open House of Devils Lake, ND 58301 Grand Forks, ND 58201 Coastal Horizons Center Crisis Phone 1: (701) 665-211 Crisis Phone 1: (701) 775-0525 3333 Wrightsville Avenue (TDD & TTY) Business Phone: (701) 795-3000 Suite 102 Crisis Phone 2: (800) 755-2745 Hrs Avail: 24 Wilmington, NC 28403 (toll free) Crisis Phone 1: (910) 392-7408 Crisis Phone 3: (701) 662-5050 Jamestown Business Phone: (910) 343- Business Phone: (701) 665-2200 South Central Human 0145 Hrs Avail: 24 www.coastalhorizons.org Service Center Hrs Avail: 24 Dickenson 520 3rd Street, NW Jamestown, ND 58402 Wilson Badlands Human Service Crisis Phone 1: (701) 253-6304 Center Wilson Crisis Center Crisis Phone 2: (800) 260-1310 200 Pulver Hall (toll free) P.O. Box 8026 Dickenson, ND 58601-4857 Wilson, NC 27894 Business Phone: (701) 253-6300 Crisis Phone 1: (701) 227-7574 Hrs Avail: 24 Crisis Phone 1: (252) 237-5156 (TTY & TDD) Business Phone: (252) 237- Crisis Phone 2: (888) 227-7525 Minot 5156 (toll free) Hrs Avail: 24 Minot Suicide Prevention Crisis Phone 3: (888) 225-5009 Service-Unimed Medical NORTH DAKOTA Business Phone: (701) 227-7500 Ctr. Hrs Avail: 24 407 3rd Street, NE Bismarck Fargo Minot, ND 58701 * Helpline Crisis Phone 1: (701) 857-2700 P.O. Box 160 * Firstlink Hotline Business Phone: (701) 857- Bismarck, ND 58503 P.O. Box 447 2000 Crisis Phone 1: (800) 472-2911 Fargo, ND 58107 Hrs Avail: 24 Appendix II 285

North Central Human Bowling Green Cleveland Service Center The Link of Behavioral Con- Mental Health Services, Inc. 400 22nd Avenue NW nections 1736 Superior Avenue Minot, ND 58703 315 Thurstin Avenue Cleveland, OH 44114 Crisis Phone 1: (701) 857-8666 Bowling Green, OH 43402 Crisis Phone 1: (216) 623-6888 (TDD) Crisis Phone 1: (419) 352-1545 Business Phone: (216) 623- Crisis Phone 2: (888) 470-6968 Crisis Phone 2: (800) 472-9411 6555 (toll free) Business Phone: (419) 352-5387 Hrs Avail: 24 Business Phone: (701) 857- Hrs Avail: 24 8500 Columbus Hrs Avail: 24 Bucyrus * Suicide Prevention Williston CONTACT Crawford Co. Services NW Human Service Center P.O. Box 631 1301 North High Street 316 2nd Avenue West Bucyrus, OH 44820 Columbus, OH 43201 Williston, ND 58802 Crisis Phone 1: (419) 562-9010 Crisis Phone 1: (614) 221-5445 Crisis Phone 1: (701) 774-4692 Crisis Phone 2: (419) 468-9081 Business Phone: (614) 299- (TDD) Business Phone: (419) 562- 6600 Crisis Phone 2: (800) 231-7724 9099 Hrs Avail: 24 (toll free) Hrs Avail: 24 Crisis Phone 3: (701) 572-9111 Dayton Canton Business Phone: (701) 774- * Suicide Prevention Center, 4600 * Crisis Intervention Center Inc. Hrs Avail: 24 of Stark Co. P.O. Box 1393 2421 13th Street, NW Dayton, OH 45401 OHIO Canton, OH 44708 Crisis Phone 1: (800) 320-4357 Crisis Phone 1: (330) 452-6000 Akron Business Phone: (937) 226- Business Phone: (330) 452-9812 0818 * Portage Path Community Hrs Avail: 24 Hrs Avail: 24 MH Center 10 Penfield Chillicothe Delaware Akron, OH 44310 Chillicothe Crisis Center * Helpline of Delaware & Crisis Phone 1: (330) 434-9144 4449 State Route 159 Morrow Counties Business Phone: (330) 434- Chillicothe, OH 45601 11 North Franklin Street 1214 Crisis Phone 1: (740) 773-4357 Delaware, OH 43015 Hrs Avail: 24 Business Phone: (740) 773- Crisis Phone 1: (740) 369-3316 4357 Crisis Phone 2: (800) 684-2324 Athens Hrs Avail: 24 Business Phone: (740) 363-1835 Tri-County Mental Health Hrs Avail: 24 and Counseling Services Cincinnati Kent 90 Hospital Drive * 281-CARE/Crisis Care Cen- Athens, OH 45701 ter Townhall II Helpline Crisis Phone 1: (740) 593-3344 3891 Reading Road 155 North Water Street (TDD) Cincinnati, OH 45229 Kent, OH 44240 Business Phone: (740) 592- Crisis Phone 1: (513) 281-2273 Crisis Phone 1: (330) 678-4357 3091 Business Phone: (513) 281-2866 Business Phone: (330) 678-3006 Hrs Avail: 24 Hrs Avail: 24 Hrs Avail: 24 286 The Encyclopedia of Suicide

Lancaster Mt. Gilead Toledo Info. & Crisis Serv. Info. & * Helpline of Delaware & * Rescue Mental Health Referral Morrow Counties Services P.O. Box 1054 950 Meadown Drive 3350 Collingwood Boulevard Lancaster, OH 43130 Suite B Toledo, OH 43610 Crisis Phone 1: (710) 687-0500 Mt. Gilead, OH 43338 Crisis Phone 1: (419) 255-9585 Business Phone: (740) 687- Crisis Phone 1: (419) 947-2520 Business Phone: (419) 255-9585 0500 Business Phone: (419) 946- Hrs Avail: 24 Hrs Avail: 24 1350 Warren Hrs Avail: 24 Mansfield * CONTACT Community Help Line/Adapt Connection 741 Sholl Road * First Call for Help, Inc. 1569 Woodland NE Mansfield, OH 44907 1330-A North Scott Street Suite 10 Crisis Phone 1: (419) 522-4357 Napoleon, OH 43545 Warren, OH 44483 Business Phone: (419) 756- Crisis Phone 1: (877) 419-7233 Crisis Phone 1: (330) 393-1565 1717 (teen line) Crisis Phone 2: (330) 545-4371 Hrs Avail: 24 Crisis Phone 2: (877) 419-7233 Business Phone: (330) 395-5255 Crisis Phone 3: (800) 468-4357 Hrs Avail: 24 Marion Business Phone: (419) 599- Xenia CONTACT Care Line-Marion 1660 Area http://www.firstcallnwo.org Greene County Crisis 320 Executive Drive Hrs Avail: 24 Services Marion, OH 43302 452 West Market New Philadelphia Crisis Phone 1: (740) 383-2273 Xenia, OH 45385 Business Phone: (740) 387- Cornerstone Support Ser- Crisis Phone 1: (937) 426-2302 5210 vices Crisis Phone 2: (937) 376-8702 Hrs Avail: 24 344 West High Avenue (TTY) New Philadelphia, OH 44663 Business Phone: (937) 376-8701 Martins Ferry Crisis Phone 1: (330) 343-1811 Hrs Avail: 24 Hillcrest of Ohio Valley Med- Crisis Phone 2: (330) 627-5240 Youngstown ical Center (Carroll Co.) 9090 North Fourth Street Crisis Phone 3: (330) 254-4530 * Help Hotline Crisis Center, Martins Ferry, OH 43935 (Tuscarawas Co.) Inc. Crisis Phone 1: (304) 242-2908 Business Phone: (300) 339- P.O. Box 46 Hrs Avail: 24 7850 Youngstown, OH 44501 Hrs Avail: 24 Crisis Phone 1: (330) 747-2696 Medina Crisis Phone 2: (800) 427-3606 Oxford * Alternative Paths, Inc. Crisis Phone 3: (330) 747-2697 246 Northland Drive Community Counseling and Business Phone: (330) 747-2696 Suite 200A Crisis Center Hrs Avail: 24 Medina, OH 44256 110 South College Avenue Zanesville Crisis Phone 1: (330) 725-9195 Oxford, OH 45056 Business Phone: (330) 725- Crisis Phone 1: (513) 523-4149 * Six County, Inc. Crisis 9195 Business Phone: (513) 523- Hotline www.alternativepaths.org 4146 3405 Dillon Acres Road Hrs Avail: 24 Hrs Avail: 24 Zanesville, OH 43701 Appendix II 287

Crisis Phone 1: (800) 344-5818 Crisis Phone 1: (541) 888-5911 PENNSYLVANIA Business Phone: (740) 455- Crisis Phone 2: (541) 828- Allentown 5755 6728 Hrs Avail: 24 Business Phone: (541) 266- Warmline 0250 P.O. Box 4116 OKLAHOMA Hrs Avail: 24 Allentown, PA 18105 Lawton Crisis Phone 1: (610) 820-8451 Eugene Business Phone: (610) 435- United Way Helpline Whitebird Clinic 9651 P.O. Box 66 341 East 12th Avenue Hrs Avail: 24 Lawton, OK 73502 Eugene, OR 97401 Crisis Phone 1: (580) 355-7575 Altoona Crisis Phone 1: (541) 687- Business Phone: (580) 355-7575 4000 Altoona Hospital Center for Hrs Avail: 24 Business Phone: (541) 342- Mental Health Services Oklahoma City 8255 620 Howard Avenue Hrs Avail: 24 Altoona, PA 16601-4899 * Contact Telephone Hotline Crisis Phone 1: (814) 946-2279 P.O. Box 12832 Grants Pass Business Phone: (814) 946- Oklahoma City, OK 73157 RSVP of Josephine County 2141 Crisis Phone 1: (405) 848-2273 Hrs Avail: 24 Business Phone: (405) 840- 1505 Northwest Washington 9396 Boulevard Contact Altoona Grants Pass, OR 97526 Hrs Avail: M-F 8 A.M.–5 P.M. P.O. Box 11 Crisis Phone 1: (541) 479-help Altoona, PA 16603 Ponca City Business Phone: (541) 955- Crisis Phone 1: (814) 946-9050 5547 Helpline/Ponca City Business Phone: (814) 946- www.rsvpjoco.org P.O. Box 375 0531 Hrs Avail: 24 Ponca City, OK 74602 Hrs Avail: 24 Crisis Phone 1: (740) 765-5552 Medford Bala Cynwyd Business Phone: (740) 765-5552 Hrs Avail: 24 Community Works Helpline Contact Careline for Greater 900 East Main Street Philadelphia Tulsa Medford, OR 97504 P.O. Box 2516 Tulsa Helpline Crisis Phone 1: (541) 779-4357 Bala Cynwyd, PA 19004-6516 P.O. Box 52847 Business Phone: (541) 779- Crisis Phone 1: (610) 649-5250 Tulsa, OK 74152 2393 Crisis Phone 2: (215) 877-9099 Crisis Phone 1: (918) 836-4357 Hrs Avail: 24 Crisis Phone 3: (215) 877-2140 Crisis Phone 4: (215) 879-4402 Business Phone: (918) 838- Salem 0698x2 Crisis Phone 5: (215) 879-8887 Hrs Avail: M-F 8 A.M.–6 P.M.; Northwest Human Services, Business Phone: (215) 877- Sat 9 A.M.–5 P.M. Inc. 9099 1049 Oak Street, SE http://www.contactcareline.org OREGON Salem, OR 97303 Hrs Avail: 11 A.M.–7 P.M. Crisis Phone 1: (503) 581-5535 Coos Bay Beaver Business Phone: (503) 588- Helpline of the South Coast 5822 CONTACT Beaver Valley 365 D Street www.open.org/chl P.O. Box 584 Coos Bay, OR 97420 Hrs Avail: 24 Beaver, PA 15009 288 The Encyclopedia of Suicide

Crisis Phone 1: (724) 728-3650 Business Phone: (814) 453- Indiana Crisis Phone 2: (724) 728-6878 5656 The Open Door Business Phone: (724) 728- Hrs Avail: 24 20 South Sixth Street 9511 Gettysburg Indiana, PA 15701 http://www.teenhelpline.org Crisis Phone 1: (724) 465-2605 http://www.call-contact.org Adams/Hanover Counseling Business Phone: (724) 456- Hrs Avail: M-F 9 A.M.–4 P.M. Service 2605 44 South Franklin Street www.theopendoor.org Butler Gettysburg, PA 17325 Hrs Avail: 24 * Irene Stacy Community Crisis Phone 1: (717) 334-2121 Mental Health Center Business Phone: (717) 334-9111 Johnstown 112 Hillvue Drive Hrs Avail: 24 Contact Community Butler, PA 16001 Hanover Telephone Helpline Crisis Phone 1: (724) 287-0440 P.O. Box 5086 Business Phone: (800) 292- Adams/Hanover Counsel Johnstown, PA 15909 3866 Service Crisis Phone 1: (800) 307-1177 Hrs Avail: M-Th 9 A.M.–9 P.M. 625 West Elm Avenue Hanover, PA 17331 (toll free) Camp Hill Crisis Phone 1: (717) 632-4900 Business Phone: (814) 534- 3889 Community Mental Health Crisis Phone 2: (717) 637-3711 Center (Hanover Hospital) Lancaster 503 North 21st Street Crisis Phone 3: (717) 334-0468 (9 A.M.–5 P.M.) Contact Lancaster Helpline Camp Hill, PA 17011 447 East King Street Crisis Phone 1: (717) 763-2222 Crisis Phone 4: (717) 334-2121 (Gettysburg Hospital) Lancaster, PA 17602 Crisis Phone 2: (800) 722-5385 Crisis Phone 1: (717) 299-4855 (toll free teen line) Crisis Phone 5: (800) 673-2426 Business Phone: (717) 632- Business Phone: (717) 291- Crisis Phone 3: (717) 763-2345 2261 (teen line) 4900 Hrs Avail: 24 www.contactlancaster.org Business Phone: (717) 763- Hrs Avail: 24 2219 Harrisburg Hrs Avail: 24 Lancaster County Helpline Contact Helpline 1120 Francis Avenue Easton P.O. Box 90035 Lancaster, PA 17601 Harrisburg, PA 17109 Northampton County Crisis Crisis Phone 1: (717) 394-2631 Crisis Phone 1: (717) 652-4400 Intervention Crisis Phone 2: (717) 399-7417 Business Phone: (717) 652- 45 North 2nd Street (TTY) 4987 Easton, PA 18042 Business Phone: (717) 394- www.contacthelpline.org Crisis Phone 1: (610) 252-9060 2631 Hrs Avail: 24 Business Phone: (610) 252- Hrs Avail: 24 9060 * Dauphin County Crisis New Castle Hrs Avail: 24 Intervention 100 Chestnut Street Contact E.A.R.S. Helpline Erie Harrisburg, PA 17101 P.O. Box 7804 Erie Hotline, Inc. Crisis Phone 1: (717) 232-7511 New Castle, PA 16107 P.O. Box 6556 Crisis Phone 2: (888) 596-4447 Crisis Phone 1: (724) 658-5529 Erie, PA 16512 Business Phone: (717) 255-2705 Business Phone: (724) 652-0333 Erie Hotline: (814) 453-5656 Hrs Avail: 24 Hrs Avail: 24 Appendix II 289

Norristown Crisis Phone 1: (412) 255-1155 Crisis Phone 1: (610) 447-7600 Business Phone: (412) 578- Business Phone: (610) 565-6000 Montgomery Co. Emerg. 2450 http://www.cgrc.com Serv. Inc. www.unitedwaypittsburgh.org 50 Beech Drive West Chester Hrs Avail: 24 Norristown, PA 19401 Chester County Mental Crisis Phone 1: (610) 279-6100 Plaines Health-Crisis Intervention Business Phone: (610) 279- Helpline Services 6100 1095 Highway, 315 222 North Walnut Street Hrs Avail: 24 Plaines, PA 18705 West Chester, PA 19380 Philadelphia Crisis Phone 1: (570) 829-1341 Crisis Phone 1: (610) 918-2100 Business Phone: (570) 829- Crisis Phone 2: (879) 918-2100 Contact Philadelphia 1341 (toll free) P.O. Box 12586 Hrs Avail: 24 Business Phone: (610) 918-2100 Philadelphia, PA 19151 Hrs Avail: 24 Crisis Phone 1: (215) 879-4402 Richboro Business Phone: (215) 877- Wilkes Barre 9099 Contact Bucks County Hrs Avail: 24 P.O. Box 167 Community Counseling Ser- Richboro, PA 18954-0167 vice of Northeastern Penn- Philadelphia Suicide & Crisis Crisis Phone 1: (215) 547-1889 sylvania Center (Lower Bucks Co.) 110 South Pennsylvania 1101 Market, 7th Floor Crisis Phone 2: (215) 536-0911 Avenue Philadelphia, PA 19107 (Upper Bucks Co.) Wilkes Barre, PA 18701 Crisis Phone 1: (215) 686-4420 Crisis Phone 3: (215) 340-1998 Crisis Phone 1: (570) 823-2155 Business Phone: (215) 685- (Central Bucks Co.) Business Phone: (570) 552-6000 6440 Crisis Phone 4: (215) 355-6000 Hrs Avail: 24 Hrs Avail: 24 Business Phone: (215) 355- Williamsport Pittsburgh 6611 Hrs Avail: 24 Williamsport YWCA * Contact Pittsburgh, Inc. Helpline Scranton P.O. Box 111294 815 West 4th Street Pittsburgh, PA 15238-0694 Voluntary Action Center of Williamsport, PA 17701 Crisis Phone 1: (412) 820-4357 Northeastern Pennsylvania Crisis Phone 1: (570) 327-2870 Crisis Phone 2: (412) 469-9999 538 Spruce Street Crisis Phone 2: (800) 326-9577 Crisis Phone 3: (412) 361-8336 Suite 420 Business Phone: (570) 323-8555 (teen line) Scranton, PA 18503 Hrs Avail: 24 Crisis Phone 4: (412) 864-4357 Crisis Phone 1: (570) 961-1234 York Crisis Phone 5: (800) 578-5100 Business Phone: (570) 347- Crisis Phone 6: (412) 373-4357 5616 CONTACT York Crisis Phone 7: (412) 787-4357 Hrs Avail: 24 P.O. Box 1865 Crisis Phone 8: (412) 343-4357 York, PA 17405-5802 Upland Business Phone: (412) 820- Crisis Phone 1: (717) 757-0733 0100 Delaware County Crisis Crisis Phone 2: (717) 757-0739 Hrs Avail: 24 Intervention Crisis Phone 3: (800) 826-3277 Helpline Crozer Medical Center-Access (toll free) P.O. Box 111249 Center Business Phone: (717) 854-5802 Pittsburgh, PA 15238 Upland, PA 19013 Hrs Avail: 24 290 The Encyclopedia of Suicide

Crisis Intervention-York Crisis Phone 1: (864) 226-0297 http://www.lowcountryhelp.org Hospital Crisis Phone 2: (800) 868-4870 Hrs Avail: 24 1001 South George Street Business Phone: (864) 226- York, PA 17405 0297 SOUTH DAKOTA Crisis Phone 1: (717) 851-5320 Hrs Avail: 24 Sioux Falls Business Phone: (717) 851- 3500 Columbia * HELP!line Center 1000 West Avenue www.wellspan.org * Helpline of the Midlands Suite 310 Hrs Avail: 24 Inc. Sioux Falls, SD 57104 P.O. Box 152 RHODE ISLAND Crisis Phone 1: (605) 339-4357 Columbia, SC 29202 Business Phone: (605) 334- Providence Crisis Phone 1: (803) 790-4357 6646 Business Phone: (803) 733- * The Samaritans of Rhode www.helplinecenter.org 5448 Island Hrs Avail: 24 www.uway.org 2 Magee Street Hrs Avail: 24 Providence, RI 02906 TENNESSEE Crisis Phone 1: (401) 272-4044 Gaffney Athens Business Phone: (401) 272- Helpline 4243 McMinn/Meigs Monroe P.O. Box 1231 Hrs Avail: 24 CONTACT Gaffney, SC 29342 P.O. Box 69 Wakefield Crisis Phone 1: (864) 487-4357 Athens, TN 37371 Business Phone: (864) 487-4357 Sympatico/Phoenix House of Crisis Phone 1: (423) 337-3800 Hrs Avail: 24 New England Business Phone: (423) 745- 1042 1058 Kingstown Road Greenville Wakefield, RI 02879 Hrs Avail: 24 Mental Health Association Crisis Phone 1: (401) 539-7474 of Greenville Co. Chattanooga Business Phone: (401) 783- 301 University Ridge 0782 Contact of Chattanooga Greenville, SC 29601 Hrs Avail: 24 6221 Vance Road Crisis Phone 1: (864) 582-1100 Chattanooga, TN 37421 SOUTH CAROLINA Business Phone: (864) 271- Crisis Phone 1: (423) 266-8228 8888 Crisis Phone 2: (423) 266-4862 Aiken Hrs Avail: 24 Business Phone: (423) 629- Aiken County Help Line, 0039 N. Charleston Inc. Hrs Avail: 24 P.O. Box 2712 * Hotline Clarksville Aiken, SC 29802 P.O. Box 71583 Crisis Phone 1: (803) 648-9900 N. Charleston, SC 29415-1583 Clarksville/Montgomery Co. Business Phone: (803) 641- Crisis Phone 1: (843) 744-4357 Crisis Intervention Center 4143 Crisis Phone 2: (843) 747-8336 P.O. Box 212 Hrs Avail: Sa-S 9 A.M.–5 P.M. Crisis Phone 3: (800) 922-2283 Clarksville, TN 37041 Crisis Phone 4: (800) 922-2283 Crisis Phone 1: (931) 648-1000 Andersen Crisis Phone 5: (800) 273-TALK Crisis Phone 2: (931) 552-4636 Crisis Ministries (teen line) (info line) P.O. Box 1925 Business Phone: (843) 747- Business Phone: (931) 647-8099 Andersen, SC 29622 3007 Hrs Avail: 24 Appendix II 291

Johnson City Memphis www.Korrnet.org/orhelp Hrs Avail: 24 Contact Ministries * The Crisis Center P.O. Box 1403 P.O. Box 40068 Tullahoma Johnson City, TN 37605 Memphis, TN 38174 Crisis Phone 1: (423) 926-1044 Crisis Phone 1: (901) 274-7477 Contact-Life Line of the Business Phone: (423) 926- Business Phone: (901) 276- Highland Rim 0145 1111 P.O. Box 1614 Tullahoma, TN 37388 Hrs Avail: 24 Hrs Avail: M-F 9 A.M.–5 P.M. Coffee County: (931) 455-7133 Kingsport Lakeside Behavioral System Franklin Co.: (931) 967-7133 2911 Brunswick Road CONTACT-CONCERN of Bedford Co.: (931) 684-7133 Memphis, TN 38133 Northeast Moore Co.: (931) 759-7133 Crisis Phone 1: (901) 377-4733 P.O. Box 3336 Business Phone: (931) 455-7150 Crisis Phone 2: (800) 232-5253 Kingsport, TN 37664 www.centerstonecmhc.org Business Phone: (901) 377- Crisis Phone 1: (423) 246-2273 Hrs Avail: 24 4700 Business Phone: (423) 246- Hrs Avail: 24 2273 TEXAS www.contactconcern.org Nashville Abilene Hrs Avail: M-F 8 A.M.–5 P.M. * Centerstone Community Mental Health Assoc. in Abi- Knoxville Health Centers, Inc. lene P.O. Box 40406 Contact Helpline of 3305 North 3rd Street Nashville, TN 37204 Knoxville Suite 302 Crisis Phone 1: (800) 681-7444 P.O. Box 11234 Abilene, TX 79608 Business Phone: (615) 463- Knoxville, TN 37939-1234 Crisis Phone 1: (915) 677-7773 6600 Crisis Phone 1: (865) 523- Business Phone: (915) 673-2300 www.centerstonecmhc.org 9124 http://www. Hrs Avail: M-F 8 A.M.–5 P.M. Business Phone: (865) 523- abilenementalhealth.org 9108 * Crisis Intervention Center, Hrs Avail: 24 www.Korrnet.org/helpline/ Inc. Amarillo Hrs Avail: 24 P.O. Box 40752 Nashville, TN 37204-0752 * Texas Panhandle MH Kelen Ross McNabb Center Crisis Phone 1: (615) 269-4357 Authority 1520 Cherokee Trail (helpline) P.O. Box 3250 Knoxville, TN 37920 Crisis Phone 2: (615) 244-7444 Amarillo, TX 79116 Crisis Phone 1: (865) 637-9711 Business Phone: (615) 298- Crisis Phone 1: (806) 359-6699 Business Phone: (865) 637- 3359 Toll Free In-State: (800) 692- 9711 http://www. 4039 Hrs Avail: 24 crisisinterventioncenter.org Business Phone: (806) 359- Overlook Mobile Crisis Unit Hrs Avail: 24 2025 6800 Baum Drive www.tpmhmr.org Knoxville, TN 37919 Oak Ridge Hrs Avail: 24 Crisis Phone 1: (865) 539-2409 CONTACT Helpline Austin Business Phone: (865) 539- P.O. Box 4641 2409 Oak Ridge, TN 37831 * Hotline to Help http://www.covenanthealth. Crisis Phone 1: (865) 482-4949 P.O. Box 3548 com Business Phone: (865) 482-5040 Austin, TX 78705 292 The Encyclopedia of Suicide

Crisis Phone 1: (512) 472-4357 * Suicide & Crisis Center Crisis Phone 1: (713) 970-7070 Business Phone: (512) 703- 2808 Swiss Avenue Business Phone: (713) 970- 1332 Dallas, TX 75204 4600 Hrs Avail: 24 Crisis Phone 1: (214) 828-1000 Hrs Avail: 24 Business Phone: (214) 824-7020 Texas Youth Hotline West Oaks Hospital www.sccenter.org P.O. Box 149030 6500 Hornwood Hrs Avail: M-F 9 A.M.–5 P.M. Austin, TX 78714-9030 Houston, TX 77074 Crisis Phone 1: (888) 580-4357 Ft. Worth Crisis Phone 1: (713) 995-0909 Crisis Phone 2: (800) 210-2278 Crisis Phone 2: (713) 778-5250 * Family Service Business Phone: (512) 833- Crisis Phone 3: (800) 777-7160 Intervention 3477 Business Phone: (713) 995- 1424 Hemphill http://www.texasyouth.org 0909 Ft. Worth, TX 76104 Hrs Avail: 24 http://www.brownschools.com Crisis Phone 1: (817) 927-5544 Hrs Avail: 24 Beaumont Business Phone: (817) 927- 8884x274 Laredo * Life Resources Community Hrs Avail: 24 2750 South 8th Street * Lifeline of Laredo, Inc. Building C Houston 1803 Juarez Avenue Laredo, TX 78040 Beaumont, TX 77701 * Crisis Intervention of Crisis Phone 1: (956) 722-5433 Crisis Phone 1: (409) 838-1818 Houston, Inc. Business Phone: (956) 722-5433 Business Phone: (409) 839- 3015 Richmond Avenue Hrs Avail: 24 1080 Suite 120 Hrs Avail: 24 Houston, TX 77098 Lubbock * Rape & Suicide Crisis of Crisis Phone 1: (281) 461-9992 Contact Lubbock Southeast Texas Crisis Phone 2: (713) 468-5463 P.O. Box 6477 P.O. Box 3208 Business Phone: (713) 527- Lubbock, TX 79493-6477 Beaumont, TX 77704 9864 Crisis Phone 1: (806) 765- Crisis Phone 1: (409) 835- www.crisishotline.org 8393 3355 Hrs Avail: M-F 9 A.M.–5 P.M. Teen Line: (806) 765-7272 Business Phone: (409) 832- Cypress Creek Hospital Business Phone: (806) 765- 6530 17750 Cali 7272 Hrs Avail: 24 Houston, TX 77090 www.contactlubbock.org Crisis Phone 1: (800) 666-3878 Hrs Avail: 24 Dallas Business Phone: (281) 586-7600 Midland * Contact Counseling and Hrs Avail: 24 Crisis Line Permian Basin Comm. Intracare Hospital P.O. Box 800742 Centers 7601 Fannin Dallas, TX 75380-0742 401 East Illinois Houston, TX 77054 Crisis Phone 1: (972) 233-2233 Suite 403 Crisis Phone 1: (713) 790-0949 Crisis Phone 2: (972) 233-8336 Midland, TX 79701 Crisis Phone 2: (713) 222-2121 (teen line) Crisis Phone 1: (915) 570-3300 Hrs Avail: 24 Business Phone: (972) 233- (Midland Co.) 0866 NeuroPsychiatric Center of Crisis Phone 2: (877) 475-7322 http://www.teencontact.com MHMRA of Harris Cty (Pecos Co.) http://www.contactdallas.org 1502 Taub Loop Crisis Phone 3: (915) 333-3265 Hrs Avail: 24 Houston, TX 77030 (Ector Co.) Appendix II 293

Crisis Phone 4: (800) 542-4005 Wichita Falls Crisis Phone 1: (802) 524-6554 (Big Bend Area) Business Phone: (802) 524- Concern, Inc. Business Phone: (915) 570- 6554 P.O. Box 1945 3333 Hrs Avail: 24 Wichita Falls, TX 76307 http://www.pbmhmr.com Crisis Phone 1: (940) 723-0821 Hrs Avail: 24 VIRGINIA Business Phone: (940) 723-8231 Richmond Hrs Avail: 24 Arlington

Fort Bend County Womens UTAH * CrisisLink Center Administrative Office P.O. Box 183 Salt Lake City Arlington, VA 22207 Crisis Phone 1: (703) 527-4077 Richmond, TX 77406-0183 Valley Mental Health Crisis (TTY & TTD) Crisis Phone 1: (281) 342-4357 Service Business Phone: (703) 527- Business Phone: (281) 342- 1228 South 900 East 6603 0251 Salt Lake City, UT 84105 www.crisislink.org http://www.fortbendwomen- Crisis Phone 1: (801) 483-5444 Hrs Avail: M-F 9 A.M.–5 P.M. scenter.org Business Phone: (801) 483-5444 Hrs Avail: 24 www.VMH.com Blacksburg San Angelo Hrs Avail: 24 New River Valley * Concho Valley Crisis VERMONT Community Hotline 700 University City Boulevard 244 North Magdalen Brattleboro Blacksburg, VA 24060 San Angelo, TX 76903 Healthcare and Crisis Phone 1: (540) 961-8400 Crisis Phone 1: (915) 655-5933 Rehabilitation Service of Business Phone: (540) 961- Business Phone: (915) 655- Southeast Vermont 8400 8965 4 High Street Hrs Avail: 24 Hrs Avail: 24 Suite 5 Bristol Brattleboro, VT 05301 San Antonio Crisis Phone 1: (802) 257-7989 Bristol Crisis Center * United Way Help Line Business Phone: (802) 257-4011 P.O. Box 642 700 South Alamo www.unitedwaywindham.org Bristol, VA 24203-0642 San Antonio, TX 78293-0898 Hrs Avail: 9 A.M.–5 P.M. Crisis Phone 1: (540) 466-2312 Crisis Phone 1: (210) 227-4357 Crisis Phone 2: (540) 628-7731 Business Phone: (210) 352- Randolph (Washington Co.) 7000 Clara Martin Center Business Phone: (540) 466- www.unitedwaysatx.org P.O. Box G 2218 Hrs Avail: 24 Randolph, VT 05060 Hrs Avail: 24 Crisis Phone 1: (800) 639-6360 Charlottesville Victoria Business Phone: (802) 728-4466 Hope of South Texas Hrs Avail: 24 Madison House 314 East Rio Grande 170 Rugby Road St. Albans Victoria, TX 77901 Charlottesville, VA 22903 Crisis Phone 1: (361) 573-3600 St. Albans Emer. & Crisis Crisis Phone 1: (804) 295-8255 Crisis Phone 2: (800) 365-7345 Service Business Phone: (804) 977- Business Phone: (361) 573-5868 107 Fisher Pond Road 7051 Hrs Avail: M-F 8 A.M.–5 P.M. St. Albans, VT 05478 Hrs Avail: 24 294 The Encyclopedia of Suicide

Danville Martinsville Business Phone: (540) 344-4691 Hrs Avail: 24 Contact Crisis Line Contact Martinsville-Henry P.O. Box 41 Co. Winchester Danville, VA 24543 P.O. Box 1287 Concern Hotline, Inc. Danville: (804) 792-4357 Martinsville, VA 24114 P.O. Box 2032 Business Phone: (804) 793-4940 Crisis Phone 1: (540) 632-7295 Winchester, VA 22601 Hrs Avail: 8 A.M.–10 P.M. Business Phone: (540) 638- Winchester: (540) 667-0145 8980 Dumfries Warren County: (540) 635- Hrs Avail: 24 4357 * ACTS Helpline Shenandoah County: (540) P.O. Box 74 Newport News 459-4742 Dumfries, VA 22026 Contact Peninsula Business Phone: (540) 667- Crisis Phone 1: (703) 368-4141 P.O. Box 1006 8208 Crisis Phone 2: (703) 368-6544 Newport News, VA 23601 Hrs Avail: 24 (Spanish M-F 6 P.M.–10 P.M.) Crisis Phone 1: (757) 245-0041 Crisis Phone 3: (703) 368-8069 Business Phone: (757) 244- WASHINGTON (teen line) 0594 Bremerton Business Phone: (703) 368- Hrs Avail: 24 4141 Crisis Clinic of Penninsulas Hrs Avail: 24 Norfolk 5455 Almira Drive, NE Glenn Allen * The Crisis Line of the Bremerton, WA 98311 Planning Counsel Crisis Phone 1: (360) 479-3033 Henrico Mental Health P.O. Box 3278 Business Phone: (360) 415- 10299 Woodman Road Norfolk, VA 23514-3278 5816 Glenn Allen, VA 23060 Crisis Phone 1: (757) 622-1126 Hrs Avail: 24 Crisis Phone 1: (804) 261-8484 Business Phone: (757) 622-1309 (Henrico Co.) Kitsap MH Services Hrs Avail: 24 Crisis Phone 2: (804) 748-6356 5455 Almira Drive, NE (Chesterfield Co.) Richmond Bremerton, WA 98311 Crisis Phone 3: (804) 556-3716 Crisis Phone 1: (360) 479-3033 (Goochland Co.) Richmond Behavioral Crisis Phone 2: (360) 373- Crisis Phone 4: (804) 752-4200 Healthcare Authority 3425 (Hanover Co.) 107 South 5th Street Crisis Phone 3: (800) 843- Crisis Phone 5: (804) 598-2697 Richmond, VA 23219 4793 (Powattan Co.) Crisis Phone 1: (804) 819-4100 Business Phone: (360) 373- Business Phone: (804) 261- Business Phone: (804) 819- 5031 8500 4000 http://www.kitsapmentalhealth. Hrs Avail: 24 Hrs Avail: 24 org Hrs Avail: 24 Lynchburg Roanoke Cathlamet Crisis Line of Central Trust: Crisis Hotline & Virginia Shelter Wahkiakum County Mental P.O. Box 3074 404 Elm Avenue Health Lynchburg, VA 24503 Roanoke, VA 24016 42 Elochoman Valley Road Crisis Phone 1: (804) 947-4357 Crisis Phone 1: (540) 344-1948 Cathlamet, WA 98612 Business Phone: (804) 947-5921 Crisis Phone 2: (540) 982-8336 Crisis Phone 1: (360) 795-8630 Hrs Avail: 24 (teen line 6 P.M.–10 P.M.) Crisis Phone 2: (800) 635-5989 Appendix II 295

Business Phone: (360) 795-8630 Crisis Phone 1: (509) 382-2527 Kennewick Hrs Avail: M-S 7 A.M.–6 P.M. Business Phone: (509) 382- B-F Counties Crisis Response 2527 Clarkston 2635 West Deschutes Hrs Avail: 24 Kennewick, WA 99336 * Rogers Counseling Center Ellensburg Crisis Phone 1: (800) 548-8761 900 7th Street Business Phone: (509) 783- Clarkston, WA 99403 * Crisis Line of Kittitas 0500 Crisis Phone 1: (509) 758-4665 County Hrs Avail: 24 Crisis Phone 2: (509) 758-3341 110 West 6th Avenue Business Phone: (509) 758-3341 Ellensburg, WA 98926 Long Beach Hrs Avail: M-F 8:30 A.M.–5:30 Crisis Phone 1: (509) 925-4168 Willapa Counseling Center P.M. Business Phone: (509) 925- 2166 P.O. Box 863 Colville Hrs Avail: 24 Long Beach, WA 98631 Crisis Phone 1: (800) 884-2298 Stevens County Counseling Everett Business Phone: (360) 642- Services 3787 165 East Hawthorne * Volunteers of Hrs Avail: 24 Colville, WA 99114 America/Care-Crisis Crisis Phone 1: (509) 684-4597 Response Services Longview (8 A.M.–4:30 P.M.) P.O. Box 839 Crisis Phone 2: (800) 767-6081 Everett, WA 98206 * Lower Columbia Mental (weekends/after hrs.) Crisis Phone 1: (425) 258-4357 Health Business Phone: (509) 684-4597 Business Phone: (425) 259- 1538 11th Avenue Hrs Avail: 24 3191 Longview, WA 98632 Hrs Avail: 24 Crisis Phone 1: (360) 425- Coupeville 6064 Friday Harbor * Island Mental Health Crisis Phone 2: (360) 423-5380 P.O. Box 160 * North Islands Mental http://www.peachealth.org Coupeville, WA 98239 Health Hrs Avail: 24 Crisis Phone 1: (800) 584-3578 P.O. Box 247 Moses Lake http://www.voa.org Friday Harbor, WA 98250 Hrs Avail: 24 Crisis Phone 1: (800) 584-3578 * Grant Mental Healthcare Business Phone: (360) 378- P.O. Box 1057 Davenport 2669 Moses Lake, WA 98837 * Lincoln County Counseling Hrs Avail: M-F 8 A.M.–5 P.M. Crisis Phone 1: (509) 765-1717 Center Business Phone: (509) 765- Hoquiam 1211 Merriam 9239 Davenport, WA 99122 * Evergreen Counseling Hrs Avail: M-F 8 A.M.–5 P.M. Crisis Phone 1: (800) 767-6081 Center Mt. Vernon Crisis Phone 2: (509) 725-3001 615 8th Street Business Phone: (509) 725-3001 Hoquiam, WA 98550 * Community Mental Health Hrs Avail: M-F 8 A.M.–5 P.M. Crisis Phone 1: (800) 685-6556 208 West Kincaid Street Crisis Phone 2: (360) 538-5327 Mt. Vernon, WA 98273 Dayton Crisis Phone 3: (360) 538-2889 Crisis Phone 1: (800) 584-3578 * Columbia County Services Business Phone: (360) 538- Business Phone: (360) 416- P.O. Box 30 2889 7500 Dayton, WA 99328 Hrs Avail: 24 Hrs Avail: 24 296 The Encyclopedia of Suicide

Newport Crisis Phone 1: (360) 452- Seattle 4500 * Pend Oreille County * Crisis Clinic of King Business Phone: (360) 457- Mental Health County 0431 P.O. Box 5055 1515 Dexter Avenue North Hrs Avail: M-F 8 A.M.–5 P.M. Newport, WA 99156 Suite 300 Crisis Phone 1: (800) 404-5151 Port Townsend Seattle, WA 98109 Business Phone: (509) 447- Crisis Phone 1: (800) 244-5756 * Jefferson MH-Community 5651 Business Phone: (206) 461- Counseling Service Hrs Avail: 24 3210 P.O. Box 565 www.crisisclinic.org Port Townsend, WA 98368 Olympia Hrs Avail: 24 Crisis Phone 1: (360) 385-0321 * Crisis Clinic Resource Crisis Phone 2: (800) 659-0321 Seattle Counseling Service Network Business Phone: (360) 385- for Sexual Minorities P.O. Box 2463 0321 112 East Broadway Avenue Olympia, WA 98506 http://www.jmhs.org Seattle, WA 98102 Crisis Phone 1: (360) 586-2800 Hrs Avail: 24 Crisis Phone 1: (206) 461-3222 Business Phone: (360) 586-2888 Business Phone: (206) 323- www.crisis-clinic.org Pullman 1768 Hrs Avail: 24 The Palouse Regional Crisis Hrs Avail: M-F 9 A.M.–5 P.M. Line/Nightline Omak Spokane 340 Northeast Maple * Okanogan County Suite 1 * First Call for Help Counseling Service Pullman, WA 99163 107 South Division P.O. Box 3208 Crisis Phone 1: (509) 332-1505 Spokane, WA 99202 Omak, WA 98841 Business Phone: (509) 332- Crisis Phone 1: (509) 838-4428 Crisis Phone 1: (509) 826-6191 1505 Business Phone: (509) 838- Crisis Phone 2: (866) 826-6191 Hrs Avail: 24 4651 Business Phone: (509) 826-6191 Hrs Avail: 24 Hrs Avail: 24 Republic Stevenson Othello * Ferry County Community Services Skamania County * Community Counseling 42 Klondike Road Counseling Center Services of Adams County Republic, WA 99166 P.O. Box 790 165 North 1st Street Crisis Phone 1: (800) 269-2380 Stevenson, WA 98648 Othello, WA 99344 Business Phone: (509) 775- Crisis Phone 1: (509) 427-9488 Crisis Phone 1: (509) 659-4357 3341 Business Phone: (509) 427- Crisis Phone 2: (509) 488-5611 Hrs Avail: 24 9488 (teen line) Hrs Avail: 24 Business Phone: (509) 488-5611 Richland Tacoma Hrs Avail: 24 * Contact Tri-Cities P.O. Box 684 * Crisis Clinic of Pierce Port Angeles Richland, WA 99352 1201 South Proctor * Peninsula Community Crisis Phone 1: (509) 943-6606 Tacoma, WA 98405 Mental Health Center Business Phone: (509) 943- Crisis Phone 1: (253) 272-9882 118 East 8th 9017 Business Phone: (253) 404- Port Angeles, WA 98362 Hrs Avail: 24 3503 Appendix II 297 www.compmh.org WEST VIRGINIA Crisis Phone 1: (920) 832-4646 Hrs Avail: 24 Business Phone: (920) 832- Huntington 4646 Walla Walla Contact Huntington, Inc. Hrs Avail: 24 P.O. Box 2963 * Inland Counseling Center Cedarburg 209 South Second Street Huntington, WV 25728 Walla Walla, WA 99362 Crisis Phone 1: (304) 523-3448 Cope Ozaukee County Crisis Phone 1: (509) 522- Business Phone: (304) 523- Hotline 4278 3447 P.O. Box 723 Business Phone: (509) 525- www.CONTACTHUNTINGTON. Cedarburg, WI 53012 0241 com Crisis Phone 1: (414) 377-2673 Hrs Avail: 24 Hrs Avail: 24 Crisis Phone 2: (414) 377- 2673 Lewisburg Wenatchee Business Phone: (414) 377- * Chelan-Douglas Behavioral Seneca Health Services 1477 Health Clinic 100 Church Street http://www.coperesources.net 701 North Miller Street Lewisburg, WV 24901 Hrs Avail: 24 Crisis Phone 1: (304) 645-3319 Wenatchee, WA 98801 Eau Claire Crisis Phone 1: (509) 662-7105 Business Phone: (304) 645-3319 Crisis Phone 2: (800) 852-2923 www.SHSINC.org * Omni Clinic Business Phone: (509) 662- Hrs Avail: 24 221 West Madison Street Eau Claire, WI 54703 7195 Oak Hill Hrs Avail: 24 Crisis Phone 1: (715) 832- Contact-Care of Southern 5030 Yakima WV Business Phone: (715) 832- 5030 Behavioral Health P.O. Box 581 Hrs Avail: 24 Services Oak Hill, WV 25901 Crisis Phone 1: (304) 877-3535 918 East Mead Avenue Elkhorn Yakima, WA 98903 Business Phone: (304) 877-3535 Walworth Co. Dept. of Crisis Phone 1: (509) 576-0934 Hrs Avail: 24 Human Services Statewide Toll Free: (800) 572- Wheeling P.O. Box 1005 W4051 8122 Elkhorn, WI 53121 Business Phone: (509) 453- Hillcrest of Ohio Valley Crisis Phone 1: (262) 741-3200 1344 Medical Business Phone: (262) 741- Hrs Avail: 24 111 Parkview Lane Wheeling, WV 43935 3200 * Central WA Crisis Phone 1: (304) 242-2908 Hrs Avail: 24 Comprehensive Mental Business Phone: (304) 242-2908 Fond Du Lac Health-Open Line Hrs Avail: 24 P.O. Box 959 CIC/Fond Du Lac County Yakima, WA 98907 WISCONSIN Health Center Crisis Phone 1: (509) 575- 459 East 1st Street Appleton 42002 Fond Du Lac, WI 54935 Business Phone: (509) 576- Appleton County Crisis Crisis Phone 1: (920) 929-3535 4084 Intervention Center Business Phone: (920) 929- http://www.cwcmh.org 401 Elm Street 3500 Hrs Avail: 24 Appleton, WI 54911 Hrs Avail: 24 298 The Encyclopedia of Suicide

Grafton Crisis Phone 1: (414) 257-7222 Business Phone: (414) 257- CANADA The County Hotline of Cope 7260 Ozaukee PROVINCIAL AND Hrs Avail: 24 885 Badger Circle TERRITORIAL AGENCIES Grafton, WI 53024 Sturgeon Bay Crisis Phone 1: (262) 377-2673 ALBERTA HELP of Door County, Inc. Crisis Phone 2: (262) 377-7786 332 Pennsylvania Avenue Canadian MH ASSN (teen line/senior support) Sturgeon Bay, WI 54235 723 14th Street NW Business Phone: (262) 377-1477 Crisis Phone 1: (920) 743-8818 Suite 103 http://www.coperesources.net Business Phone: (920) 743- Calgary, Alberta T2N 2A4 Hrs Avail: 24 8785 Tel: (403) 266-1605 Green Bay www.helpofdoorcounty.org Distress Centre Hrs Avail: 24 * Family Services of North- 112 11th Avenue SE east Wisconsin, Inc. Waukesha Calgary, Alberta T2G 0X5 P.O. Box 22308 Tel: (403) 264-8336 MHA in Waukesha Co., Inc. Green Bay, WI 54305 c/o First Call for Help PACE Crisis Phone 1: (920) 436-8888 S22 West 22660 Broadway 201 10118-101 Avenue Business Phone: (920) 436-6813 Suite 5S Grand Prairie, Alberta T8V www.familyservicesnew.org Waukesha, WI 53186-8199 0Y2 Hrs Avail: 24 Crisis Phone 1: (262) 547-3388 Tel: (780) 539-6666 La Crosse (TTY) Salvation Army Suicide Business Phone: (262) 547- First Call For Help Prevention Bureau 0769 1910 South Avenue 9620-101A Avenue http://www.mhawauk.org La Crosse, WI 54601 Edmonton, Alberta T5H 0C7 Hrs Avail: 24 Crisis Phone 1: (608) 791-4344 Tel: (780) 428-TEEN Crisis Phone 2: (800) 362-8255 WYOMING Samaritans of Southern Business Phone: (608) 791-6335 Alberta Cheyenne Hrs Avail: 24 P.O. Box 939 Madison Cheyenne Helpline Lethbridge, Alberta T1J 3Z1 P.O. Box 404 Tel: (403) 320-1212 * Emergency Services MHC Cheyenne, WY 82003 of Dane County Crisis Phone 1: (307) 634-4469 Suicide Prevention 625 West Washington Avenue Business Phone: (307) 632- Program Madison, WI 53703 4132 9912 Manning Avenue Crisis Phone 1: (608) 280-2600 Hrs Avail: 24 Fort McMurray, Alberta Business Phone: (608) 280- T9H 2B9 2700 Worland Tel: (780) 743-4357 Hrs Avail: 24 Victims of Violence Center BRITISH COLUMBIA 101 North 19th Street Milwaukee Worland, WY 82401 The Crisis Center Psychiatric Crisis Service Crisis Phone 1: (307) 347-4991 763 East Broadway 9499 West Watertown Plank Business Phone: (307) 347- Vancouver, British Columbia Road 4992 V5T 1X8 Milwaukee, WI 53226 Hrs Avail: 24 Tel: (604) 872-1811 Appendix II 299

MANITOBA Distress Centre # 1 QUEBEC Toronto Klinic Community Health Centre De Prevention Du P.O. Box 243 Centre, Inc. Suicide Toronto, Ontario M5C 2J4 870 Portage Avenue 1535 Chemin Ste. Foy Tel: (416) 598-1121 Winnipeg, Manitoba R3G OP1 Suite 100 Tel: (888) 322-3019 Distress Centre # 2 Quebec, P.Q. G15 2P1 Toronto Tel: (418) 683-0933 NEW BRUNSWICK P.O. Box 243 Suicide Action Toronto, Ontario M5C 2J4 Chimo Help Line 2345 Belangereast Tel: (416) 486-6766 P.O. Box 1033 Montreal, Quebec H2G 1C9 Fredericton, New Brunswick Distress Centre Ottawa Tel: (514) 723-3594 E3B 5C2 160 Elgin Street Tel: (506) 450-4357 Ottawa, Ontario K2P 2M3 SASKATCHEWAN NOVA SCOTIA Tel: (613) 238-1089 Saskatoon Crisis Help Line Distress Centre Windsor Intervention Services 5670 Spring Garden Road P.O. Box 2025 1410 20th Street West Halifax, Nova Scotia B3J 1H6 Windsor, Ontario N8Y 4R5 Saskatoon, Saskatchewan Tel: (902) 421-1188 Tel: (519) 256-5009 S7M 024 Tel: (306) 933-6200 ONTARIO Toronto East General Hospital Canadian Medical 825 Coxwell Avenue Association Toronto, Ontario M4C 3E7 P.O. Box 8650 Tel: (416) 469-6286 Ottawa, Ontario K1G 0G8 Tel: (613) 731-9331

APPENDIX III INTERNATIONAL SUICIDE RATES PER 100,000

Country Year Men Women Total Country Year Men Women Total Albania 1998 6.3 3.6 4.9 Kuwait 1999 2.7 1.6 2.1 Argentina 1996 9.9 3.0 6.4 Kyrgyzstan 1999 19.3 4.0 11.6 Armenia 1999 2.7 0.9 1.8 Latvia 1999 52.6 13.1 32.8 Australia 1997 22.7 6.0 14.3 Lithuania 1999 73.8 13.6 43.7 Austria 1999 28.7 10.3 19.5 Luxembourg 1997 29.0 9.8 19.4 Azerbaijan 1999 1.1 0.2 0.65 Macedonia FYR 1997 11.5 4.0 7.7 Bahamas 1995 2.2 0.0 1.1 Malta 1999 11.7 2.6 7.1 Bahrain 1988 4.9 0.5 2.7 Mauritius 1998 21.9 7.8 14.8 Barbados 1995 9.6 3.7 6.6 Mexico 1995 5.4 1.0 3.2 Belarus 1999 61.1 10.0 35.5 Mexico 1995 5.4 1.0 3.2 Belgium 1995 31.3 11.7 21.5 Netherlands 1997 13.5 6.7 10.1 Belize 1995 12.1 0.9 6.5 New Zealand 1998 23.7 6.9 15.3 Brazil 1995 6.6 1.8 8.4 Nicaragua 1994 4.7 2.2 3.4 Bulgaria 1999 24.1 8.1 16.1 Norway 1997 17.8 6.6 12.2 Canada 1997 19.6 5.1 12.3 Paraguay 1994 3.4 1.2 2.3 Chile 1994 10.2 1.4 5.8 Philippines 1993 2.5 1.7 2.1 China (partial) 1998 13.4 14.8 14.1 Poland 1996 24.1 4.6 14.3 Hong Kong SAR 1996 15.9 9.1 12.5 Portugal 1998 8.7 2.7 5.7 Colombia 1994 5.5 1.5 3.5 Puerto Rico 1992 16 1.9 8.9 Costa Rica 1995 9.7 2.1 5.9 Republic of Korea 1997 17.8 8.0 12.9 Croatia 1999 32.7 11.5 22.1 Republic of Moldova 1999 27.6 5.1 16.3 Cuba 1996 24.5 12.0 18.2 Romania 1999 20.3 4.4 12.3 Czech Republic 1999 25.7 6.2 15.9 Russian Federation 1998 62.6 11.6 37.1 Denmark 1996 24.3 9.8 17.0 Singapore 1998 13.9 9.5 11.7 Ecuador 1995 6.4 3.2 4.8 Slovakia 1999 22.5 3.7 13.1 Egypt 1987 0.1 0.0 0.1 Slovenia 1999 47.3 13.4 30.3 El Salvador 1993 10.4 5.5 7.9 Spain 1997 13.1 4.2 8.6 Estonia 1999 56.0 12.1 34.0 Sri Lanka 1991 44.6 16.8 30.7 Finland 1998 38.3 10.1 24.2 Surinam 1992 16.6 7.2 11.9 France 1997 28.4 10.1 19.2 Sweden 1996 20.0 8.5 14.2 Georgia 1992 6.6 2.1 4.3 Switzerland 1996 29.2 11.6 20.4 Germany 1998 21.5 7.3 28.8 Tajikistan 1995 5.1 1.8 3.4 Greece 1998 6.1 1.7 3.9 Thailand 1994 5.6 2.4 4 Guatemala 1984 0.9 0.1 0.5 Trinidad/Tobago 1994 17.5 5.1 11.3 Guyana 1994 14.6 6.5 10.5 Turkmenistan 1998 13.8 3.5 8.6 Hungary 1999 53.1 14.8 33.9 Ukraine 1999 51.2 10.0 30.6 Iceland 1996 20.8 3.7 12.2 United Kingdom 1998 11.7 3.3 7.5 India 1998 12.2 9.1 10.6 USA 1998 18.6 4.4 11.2 Iran 1991 0.3 0.1 0.2 Uruguay 1990 16.6 4.2 10.4 Ireland 1996 19.2 3.5 11.3 Uzbekistan 1998 10.5 3.1 6.8 Israel 1997 10.5 2.6 6.5 Venezuela 1994 8.3 1.9 5.1 Italy 1997 12.7 3.9 8.3 Yugoslavia 1990 21.6 9.2 15.4 Japan 1997 26.0 11.9 18.9 Zimbabwe 1990 10.6 5.2 7.9 Kazakhstan 1999 46.4 8.6 27.5

301

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INDEX

Boldface page numbers indicate Adkins, Janet 142 in psychosis 194 major treatment of a subject. Adler, Alfred xxxi, 176 and “victim-precipitated” adolescent suicide. See teenage murders 219, 238 suicide aggressive suicide 155 A adoption 3–4 agitation 6 AAS. See American Association adults and suicide 4. See also Ahitophel xvii, 6, 26–27, 163 of Suicidology elder suicide akathisia 6 Abimelech xvii, 26 “Advocate of Death” 115 Alabama 216 Absalom xvii AEA. See autoerotic asphyxia- Alaskan Natives 87 abuse, child 1, 95 tion Albania 6, 107 abuse, substance 1–2, 73–74. Aeneas xix Albigenses xxiii See also specific substance Africa 4 alcohol and attempted suicide 18, African Americans and suicide with barbiturates 23 119 4–5, 199, 202 with marijuana 157 in college students 51 economic cycles and 82 with tranquilizers 233, 237 personality disorders and in elderly 79 with tricyclic antidepressants 183 prevention of 169–170 79 in police officers 187 in teenagers 227 alcohol myopia 8 in teenagers 1, 74, 227–228 AFSP. See American Foundation alcoholism, and suicide 6–8, Academy of Certified Social for Suicide Prevention, The 203 Workers (ACSW) 2 After Suicide (Wallace) 241 in college students 51 accident prone 2, 63–64, 225 age in Native Americans 171 accidents, automobile. See auto- and attempted suicide 18, personality disorders and cide 79, 80 183 Accutane 2–3 and suicide 5, 202. See also in police officers 187 acedia 64 elder suicide risk factors for 6, 7–8 acetaminophen 73, 162 Age of Sensation, The (Hendin) serotonin and 7 ACSW. See Academy of Certified 73 in teenagers 227–228 Social Workers age-adjusted suicide rates 5 treatment of 8 acting out 3, 41 agenerative suicide 5 alliance for safety 8 active euthanasia 90, 181 aggression 5–6 al-Qaeda 231 acute domestic anomie 12 aggressive behavior 6 Altman, Mike 220 acute economic anomie 11 in acting out 3 altruistic suicide xxix, 6, 8–9, acute suicides 3 and attempted suicide 18, 47, 76. See also kamikaze ADA. See American Dental 124 pilots; loyalty suicides Association in children 41 Alvarez, Alfred 9, 186, 208, 247 ADEC. See Association for Death gender and 104 AMA. See American Medical Education and Counseling with impulsiveness 128 Association

307 308 The Encyclopedia of Suicide ambivalence 9 anorexia nervosa 12, 78 assisted suicide 14–17. See also American Association of Suici- Another Country (Baldwin) 23 Kevorkian, Jack dology (AAS) 9 antidepressants 12, 69. See also AMA on 17 founder of 182 Prozac in Belgium 14, 15, 25, guidelines for suicide inter- for adults 4 89–90 vention by 133–134 for alcoholics 8 in cancer patients 35, 36 suicide prevention centers of for bulimics 30 vs. euthanasia 14, 17, 89 115–116 for cancer patients 35 Hemlock Society and American Dental Association MAO inhibitors 156–157 117–118, 125 (ADA) 68 for prevention of suicide 12, Hippocrates on 119 American Foundation for Suicide 74 in Holland 14, 15, 89–90, Prevention, The (AFSP) 10–11 selective serotonin reuptake 121–122 American Medical Association inhibitors 74, 192–193 laws on 14–17 (AMA) 10 and serotonin 44 in Oregon 14, 15, 89–90, on assisted suicide 17, 184 tricyclic 74, 78–79 143, 144, 176–179, on suicide in doctors 71 Antigua and Barbuda 107 183–184 American Nurses Association Antinous 113 as rational suicide 199–200 184 antiseizure medications 86 Association for Death Education American Psychiatric Associa- Antisidor, Council of xxii, 31, and Counseling (ADEC) tion 10 223 17–18 goals of 10 Antisthenes 12, 69 astrological prophecies, and sui- on suicide in doctors 71 Antisuicide Bureau 12 cide 32, 37 American Psychological Associa- Antony, Mark (Marcus Anto- attempted suicide 18–19, 218 tion (APA) 10 nius) 13, 47–48 accidents as 2 amitriptyline 78–79 anxious suicidality 13 in adopted teenagers 3–4 amobarbital 24 APA. See American Psychologi- alcohol and 7–8 amphetamines 73 cal Association in children 40 amputation metaphor 11 Apaches, White Mountain 13 in elderly 79, 80 Amytal 24 apostasy 138 as felony xxxii, 19, 141, 148 Anabasis (Xenophon) 245 Applewhite, Marshall 115 and help in emergency room Anatomy of Melancholy, The (Bur- April suicides 13, 241 81–82, 124 ton) xxv, 11, 32 Aquinas, Saint Thomas xxiii, with heroin 119 ancient times. See also Egypt 13, 20, 45 in homosexuals 122, 227 (ancient); Greece (ancient); Argentina 13, 107 hostile behavior and 18, 124 Rome (ancient) Aristotle xix, 13–14, 110, 186 impulsiveness and 128 attitudes toward suicide in Arizona 216 methods of 92, 162 xvi–xxi Arkansas 216 in Middle Ages xxii burial for suicides in xviii, Arles, Council of xxii vs. parasuicide 181 xxxii Armenia 14, 89, 107 second 211 law on suicide in xxxii Arouet, François-Marie. See and suicide notes 221 Andreyev, Catherine 142 Voltaire and suicide risk 203, 228 Anglican Church xxii, 83, 91 Arria xxi, 14 in teenagers 227, 228 anniversaries 11 art, literature, and suicide 14. tranquilizers in 233 “anniversary reaction” 11 See also specific book; specific unintentional death from anniversary trigger 11 poem 235 anomic suicide xxix, 11–12, 47, Ashcroft, John 178 in women 1, 3, 18, 19, 95, 76, 152 Asinof, Eliot 58–59 119, 155, 212 Index 309 attitudes xv–xvi, 19–20. See also Baldwin, James 23 bipolar disorder 27, 156, 161 burial (for suicides); law and Ball, Hugo 63 in college students 51 suicide Balzac, Honoré de 23, 182 depression in 27, 68, 156 in 19th century xxvii–xxix Barbados 23, 107 birthdays and suicide 27–28 in 20th century xxix–xxxii barbiturates 23–24 Black Sabbath 179 in ancient times xvi–xxi action of 23 Blackstone, William xxxii concept of sin and 214 with alcohol 23 “blocked communication” 53 Eastern xxiii–xxiv in assisted suicide 176, 178, bloodless means 29 Industrial Revolution and 184 bog burials 31, 225 xxv–xxvi long-acting 24 bonding 28 in Middle Ages xxi–xxiii, 31, short-acting 24 Bonhoeffer, Dietrich 20, 45, 162 as suicide method 23–24, 73, 183 Renaissance and Reformation 162 Booth, William 207 and xxiv–xxv, 201 Barnard, Christiaan 24, 90 Boyer, Charles 28 romantics and xxvi–xxvii, Baxter, John Clifford 24 Bracton, Henry de xxxii 204 Befrienders International 24, Braga, Council of xxii, 31, 45, superstition and 222 238 58, 223 Attwater, Donald 88 “befriending centers” 24 Brahmanism xxiv, 20, 28–29 Augustine of Hippo, Saint 20 behavioral direct communica- Branch Davidians 60–61, 159 City of God by xxi, 20, 44 tion 52 Brand, John 56 on Donatists 71, 72 behavioral indirect communica- Brazil 29, 107 on suicide xxi, 44–45, 66, tion 52 Bridge, The (Crane) 59 115, 123, 203, 214 Belarus 24–25, 89, 107 Brierre de Boismont. Alexandre- Australia 21 Belgium 25 Jacques-François xxviii, 75, euthanasia in 90 assisted suicide in 14, 15, 25, 99 suicide rate for 21, 107 89–90 broken homes and suicide 5, Austria 21, 89, 107 suicide rate for 89, 107 26, 29, 40, 70 authoritarianism 21 Belize 107 Brooke, Arthur 204 Autobiography (Russell) 151 Bell Jar, The (Plath) 25, 185 Browne, Sir Thomas 88 autocide 2, 21, 57, 160, 200 bereavement groups 25 Bruce, Lenny 29 autoerotic asphyxiation (AEA) Bergenfield tragedy 221 Buddhism xxiv, 20, 29–30, 138 21–22 Berman, Alan L. 55 Bulgaria 107 auto-euthanasia 22 Berryman, John 25–26 bulimia 12, 30, 78 autopsy 16 Bettelheim, Bruno 26, 236 bullycide 30 autopsy, psychological. See psy- Beyond the Pleasure Principle Bullycide: Death at Playtime (Marr chological autopsy (Freud) xxx, 100 and Field) 30 Auxerre, Council of xxii, 31, Biathanatos (Donne) xv, xxv, Bunzel, Bessie xxx 223 14, 26, 72, 83, 186 burial (for suicides) 31–32, 78 Azerbaijan 22, 89, 107 biblical suicides 26–27 in ancient times xviii, xxxii in New Testament xvii, 140, in England xxii, 31, 83, 172 110–111, 162, 222 B in Old Testament xvii, in France xxii, xxxii–xxxiii, bachelors 12 26–27, 115, 136, 138, 208, 99, 100, 162 Badiali, Craig 59, 221 249 in Middle Ages xxii, Baechler, Jean 23 bin Laden, Osama 231 xxxii–xxxiii, 31, 45, 162, Bahamas 23, 107 “binge-purge syndrome” 30 222 Bahrain 107 biological aspects of suicide 172 Burnett v People 32 310 The Encyclopedia of Suicide

Burress, Cheryl 221 Cardano, Girolamo 36–37 rates for 39 Burress, Lisa 221 CASP. See Canadian Association revenge suicide 201 Burton, Robert xxv, 11, 32 for Suicide Prevention risks of 40–41 business cycles 32, 82, 132, 217 Cassius Longinus, Gaius 37 sense of immortality and Butler, H. Reese, II 145 catalytic converters 83, 103 127–128 Byron, Lord (George Gordon) Cato the Younger xix, 37–38, and suicide notes 201 xxvii 183 treatment of 42 Cavan, Ruth S. xxx, 190 Chile 107 CDC. See Centers for Disease Chin, Larry Wu Tai 42 C Control and Prevention China 42–43 calcium channel blockers 33 celebrity suicides 38, 160. See honor and suicide in 123 California also specific celebrity suicide in xxiv, 42–43, 107, involuntary commitment in Centers for Disease Control and 132 147 Prevention (CDC) 5, 38, 50 chlordiazepoxide 233 suicide rate for 216 Charles I, king of Spain (Holy chlorpromazine 233 voting on assisted suicide in Roman Emperor Charles V) Choice in Dying. See Euthanasia 15 xxxii Education Council Call to Action to Prevent Suicide Charondas xix, 38 cholesterol-serotonin hypothesis 170, 189 Chateaubriand, René de 44 Calvinism xxiv xxvi–xxvii Christianity 44–46. See also Camus, Albert 33–34, 92 Chatterton, Thomas xxvi, martyrdom; specific denomina- The Myth of Sisyphus by 33, 38–39, 204 tions 88, 167 Cheyenne Indians 123 on burial for suicides xxii, Notebooks by 33, 173 Cheyne, George xxvi, 84 30–31, 45, 91 on suicide 14, 89 child abuse 1, 95 on euthanasia 46 Canada 34 children and suicide 39–42 on suicide xxi–xxiii, 13, crisis hotlines in 69–70, 116 abuse and 1, 95 19–20, 44–46, 58, 66, 83, distress centres in 69–70, anxious suicidality and 13 91, 95–96, 157–158, 214 233, 237 broken homes and 5, 26, 29, chronic domestic anomie 12 law on assisted suicide in 40, 70 chronic economic anomie 11 183 bullycide 30 chronic suicide 46 Suicide Information and Edu- competition and 54 coroner and 57 cation Centre in 34 decline in grades and 109 in daredevils 63 suicide rate for 34, 107 and distress signals 41–42 in diabetes patients 69 Canadian Association for Sui- expendable child syndrome Menninger on xxxi, 46, 64 cide Prevention (CASP) 34 and 92, 152 substance abuse and 2, 29 Canadian Mental Health Associ- fear of punishment and 95 chronic suicider 46 ation (CMHA) 34, 70 gender differences in 41 Citadelle (Saint Exupéry) 207 cancer and suicide 35–36 in gifted children 106 City of God (Augustine) xxi, 20, Cannabis sativa 157 in “hurried” children 126 44 car accidents. See autocide lack of communication from Civil War, The (Lucan) 239 car exhaust 36, 103 parents and 53 classification of suicides 46–47 carbon monoxide poisoning 36 loneliness and 151 Cleanthes xxi, 47, 110, 217 diagnosis of 36 methods of 40 Cleombrotus 37, 47 in England 83 in preteens 218 Cleopatra 13, 47–48 symptoms of 36, 103 prevention of 42 clergy and suicide prevention used by Kevorkian 142, 143 family therapy for 94 48–49 Index 311 climate 84–85, 202 Confessions of a Mask (Mishima) in Canada 69–70, 116 Clinton, Bill 99 163 CONTACT USA 48, 56 clues of suicide 49–50. See also coniine 117 for elderly 101 distress signals Connecticut 216 and follow-up 98 cluster suicides 50, 56–57, 219 conspiracy, laws of 16 National Hopeline Network celebrity suicides and 38, Constantine, Thomas 177 169 164 constriction 56 by Samaritans 207–208, media and 160 CONTACT USA 48, 56 237–238 in teenagers 50, 56, 229, 241 contagion 56–57, 219. See also San Francisco Suicide Pre- weather and 241 cluster suicides vention 208 CMHA. See Canadian Mental cop, suicide by 219 volunteers at 56, 207–208, Health Association cop suicide 187 239 coal gas 103 coping mechanisms 57 Critique of Pure Reason (Kant) Cobain, Kurt 50–51 copycat suicide 57. See also clus- 141 cocaine 51, 74 ter suicides Croatia 107 Cole, John 179 coroner 57–58, 65, 130 Crocker, Gretchen 118, 125 Coleridge, Samuel Taylor 66–67 Costa Rica 107 Cry for Help (Giffin) 53 Collected Living Wills (EXIT publi- Council for Telephone Ministries crying 60 cation) 92 56 Cuba 107 college students 51–52 Council of Antisidor xxii, 31, cult suicide 60–61, 158–159 as daredevils 63–64 223 Branch Davidians 60–61, drug abuse in 73 Council of Arles xxii 159 Colombia Council of Auxerre xxii, 31, 223 Falun Gong 61 assisted suicide in 90 Council of Braga xxii, 31, 45, Heaven’s Gate 60, 115, 158 suicide rate for 107 58, 223 Jonestown Massacre 61, Colorado 216 Council of Hereford 45 139, 159 Colt, George Howe 84 Council of Orleans (Second) Mexican Cult 61, 159 Columbine High School, vio- xxii, 45, 58 Solar Temple 60, 159, lence in 209, 210 Council of Toledo xxii 214–215 Common Sense Suicide: The Final Council of Troyes xxii Tijuana Cult 61 Right (Portwood) 46, 52, 188 Council of Valence xxii Vietnamese Suicide 61, 159 communication of suicidal counseling 58. See also crisis culture 61 intent 52–53 hotlines; psychotherapy Curphey, Theodore xxxi community-based suicide pre- crack 74 Cushing, Richard Cardinal 32 vention 53 Craig and Joan (Asinof) 58–59, Cynics 12, 69, 153, 249 Compassion in Dying 177 221 Cynosarges 12 Compassionate Friends 53–54 Crane, Harold Hart 59 Cyrenaics 115 competition 54–55 crime 59–60 Czech Republic 61–62, 107 Comprehensive Textbook of Suicidol- Crime and Custom in Savage Society ogy 55 (Malinowski) 155 compulsory suicide 14, 55 Criminal Justice Ethics (journal) D concentration, loss of 56 210 dada 63 Concern for Dying. See Euthana- Crisis: The Journal of Crisis Inter- “Danse Macabre” xxv sia Education Council vention and Suicide 60, 131 Dante Alighieri xxiii, 63, 67 Confessions (Augustine) 20 crisis hotlines 53, 60, 229 daredevils 63–64 Confessions of a Child of His Age by American Association of Darkness at Noon (Koestler) 144 (Musset) 166 Suicidology 115–116 Daube, David 88 312 The Encyclopedia of Suicide

David of Augsburg 64 cause of 69 disbelief stage of grief process DEA. See Drug Enforcement in children 40 110 Administration cholesterol and 44 Dispossessed, The (Berryman) 25 Dean, James B. 64–65, 200 cocaine and 51 Dispute over Suicide, A (ancient Death: The Final Stage of Growth in college students 51 papyrus) xvi (Kübler-Ross) 43 crying in 60 distress centres (Canada) death certificates 57, 65, 165 electroconvulsive treatment 69–70, 233, 237 death education 17–18, 65 for 80–81 distress signals 49–50, 70. See Death of Man (Shneidman) 213 in epilepsy 86 also risk of suicide Death of Peregrinis, The (Lucian) gender and 68 abnormal coping mechanisms 65–66, 153 insomnia in 130, 214 as 57 death wish 66 loss of humor in 125 acting out as 3 “death with dignity” 90 “masked” 124 in adults 4 Death with Dignity law. See Ore- melatonin and 81 aggressive behavior as 6 gon law neurobiology of 172 in alcoholics 6 “Death-Persuader” 115 reserpine and 201 attempted suicide as. See Decalogue Article 20, 66 in schizophrenia 209 attempted suicide Decius the Younger xix sense of loss in 151 change in eating habits as 78 Deer Hunter, The (film) 56 serotonin and 44 in children 41–42 “Defense of legal suicide, A” in teenagers 227, 228 communication of suicidal (Montaigne) 164 treatment of 69. See also intent as 52–53 Definition of Suicide (Shneidman) antidepressants crying as 60 66 in unemployed 235 death wish as 66 “Dejection: An Ode” (Coleridge) in victims of bullying 30 decline in grades as 109 66–67 warning signs of 68 in doctors 71 Delaware 216 withdrawal in 242 in elderly 80 delle Vigne, Pier. See Vigne, Pier in women 95, 235 irrationality as 135 delle diabetes 69 isolation as 136 Democritus xx Dialogue of a Misanthrope with His loss of concentration as 56 Demosthenes xix, 67 Own Soul, A (ancient papyrus) loss of will as 241–242 Denmark 67, 107, 208–209 xvi mood swings as 164 Dentist Well-Being Program 68 Diary of a Writer, The (Dosto- obsession with death as 175 dentists and suicide 67–68 evsky) 72 reckless driving as 200 departing drugs 68 diazepam 233, 237 stress as 217 Departing Drugs (EXIT publica- dichotomous thinking 69 substance abuse and 2 tion) 92 Dictionnaire de Trevoux xv teachers recognizing depression 68–69, 161, 203 Dido xix 225–226 Accutane and 2–3 “dignity, death with” 90 in teenagers 227–228 in alcoholics 7, 8 Diogenes 12, 69 watching for 133 and attempted suicide 18 direct and indirect self-destruc- withdrawal as 242 in bipolar disorder 27, 68, tive behavior (ISDB) 69, 87, District of Columbia 216 156 119, 129, 211 Divine Comedy (Dante) xxiii breakup of romance and 204 direct communication 52 divorce and suicide 70, 157 bulimia in 30 direct euthanasia 90 “Do Not Go Gentle Into That calcium channel blockers and Directory of Suicide Prevention and Good Night” (Thomas) 232 33 Crisis Intervention Agencies in the Doctor Death. See Kevorkian, in cancer patients 35 U.S. 9 Jack Index 313 doctor-assisted suicide. See on group conscience 111 risk factors of 80 physician-assisted suicide Le Suicide by xxix, 46–47, 75, and suicide notes 220 doctors 70–71, 184–185. See 100, 218 electroconvulsive treatment also physician-assisted suicide dutiful suicide 76 (ECT) 80–81 domestic anomie 12 dyadic death 72, 165–166 electromagnetic fields (EMF) Dominican Republic 107 Dying with Dignity 76 81 Donatists 71–72 “dying with dignity” 90 Elkind, David 126 Donne, John 20, 45, 72, 183 dysphoria 76 emergency rooms, help in Biathanatos by xv, xxv, 14, 81–82, 124 26, 72, 83, 186 EMF. See electromagnetic fields on Donatists 71 E Empire State Building 82 Dostoevsky, Feodor East, John P. xxxi, 77 employment 82 Mikhailovich 72 Eastman, George 77–78 England 82–84 double suicide 72 eating disorders 12, 30, 78 assisted suicide in 15 Douglas, Jack D. 73 eating habits 78 attempted suicide in 19, 148 Dream Songs, The (Berryman) 25 Ecclesiastical History, The (Euse- burial for suicides in xxii, drop-in centers 73 bius) 89 31, 83, 110–111, 162, 222 drug abuse 1–2, 73–74. See also economic anomie 11 carbon monoxide poisoning specific substance economic class 78, 82 in 83 and attempted suicide 18, economic cycles 32, 82, 132, farmers in, suicide in 95 119 217 female suicides in 83 in college students 51 ECT. See electroconvulsive treat- as “land of melancholy” personality disorders and ment xxvi, 105 183 Ecuador 107 male suicides in 83 in police officers 187 educational competition 54 poison, as suicide method in in teenagers 1, 74, 227–228 EEC. See Euthanasia Education 83 Drug Enforcement Administra- Council suicide prevention in 48 tion (DEA) 177, 178 Egbert, Archbishop of York 78, suicide rates for 82–84, 151 drug treatments for suicide pre- 182 Engler, John 142 vention 74 egoistic suicide xxix, 46–47, 76, English Malady, The (Cheyne) druids 74 78 xxvi, 84 Du Suicide et de la Folie Suicide egotic suicide 78 Enigma of Suicide, The (Colt) 84 (Brierre de Boismont) 74–75, Egypt 78, 107 Enlightenment, Period of 84 99 Egypt (ancient), suicide in xvi, Enron scandal 24 dual suicide 75, 173, 221 78 environment 84–85, 105–106, Dublin, Louis I. xxx, 75 El Salvador 107 202, 230, 241 Dunblane, Scotland, school vio- Elavil (amitriptyline) 78–79 Epictetus xx, 66, 85–86 lence in 209, 210 elder suicide 5, 79–80, 202 Epicureans xix, 19, 86, 183 Durkheim, Émile 75–76 attempted suicide and 79, Epicurus 86 on altruistic suicide xxix, 80 epilepsy 86 8–9, 47, 76 cluster suicides 50 Epistles (Seneca) xx, 66, 86–87 on anomic suicide xxix, 11, global 107 equivalents of suicide 87 47, 76 hidden 119 equivocal deaths 87 on egoistic suicide xxix, loss of identity and 127 Erasmus, Desiderius xxiv, 87, 46–47, 76, 78 methods of 79, 80 101 on fatalistic suicide xxix, 47, murder-suicide and 165–166 Erfurt, Germany, school vio- 76 prevention of 80, 101 lence in 209, 210 314 The Encyclopedia of Suicide

ERGO!. See Euthanasia Research “Examination Hell” 217 fear of punishment 95 & Guidance Organization excommunication 91 Federal Center for Studies of Eros xxx, 232 exile 91 Suicide Prevention 233 Eskimos and suicide xv, xvi, 87, existential suicide 92 Federated States of Micronesia 247 existentialism 92 (FSM) 215 Esprit des Iois (Montesquieu) EXIT 92 female genital mutilation 238 87–88 Exit: A Guide to Self Deliverance female suicides 95, 104, Esquirol, Jean-Etienne xxviii, (Koestler) 220 201–202, 212. See also women 88 expendable child syndrome 92, in African Americans 5 Essais (Montaigne) xxiv, 14, 88 152 in Apaches 13 Estonia 89, 107 explosives 92, 162 in Canada 34 Ethics (Aristotle) 13 extended family 92 in children 41 ethics and morality of 43 88–89 depression and 68 Euripides xx F divorce and 70 Europe 89. See also specific coun- facilitated suicide 93 in doctors 71, 185 try facilitating suicide 93 economic cycles and 82 divorce and suicide in 70 Fadlan, Ibn 93 in elderly 79 suicide rates for 89 fairy tales, and children 26, 236 in England 83 European Court of Human fallacies about suicide. See in Fiji Islands 96 Rights 15 myths, concerning suicide menstruation and 161 Eusebius, bishop of Caesarea Falret, Jean-Pierre xxvii, 93 and methods of suicide 92, 45, 89, 158 Falun Gong 61 103, 104, 114, 162, 185 euthanasia 68, 89–90. See also fame 93–94 during pregnancy 189 Kevorkian, Jack familicide suicide 94 rates for 4, 95, 242 active 90, 181 family history of suicide in teenagers 226–227 vs. assisted suicide 14, 17, 89 104–105 Field, Tim 30 in Belgium 15, 25, 89–90 Family Service Association of Fifth Commandment 95–96, in cancer patients 35, 36 America 58 138. See also Sixth Command- Christianity on 46 family therapy 94 ment Dying with Dignity promot- Farberow, Norman L. Fiji Islands 96, 215 ing 76 on impulsiveness 123 filicide-suicide 96 Hemlock Society and at Los Angeles Suicide Pre- Filsinger, Ernst 226 117–118, 125 vention Center 66, 151 Final Exit: The Practicalities of Self- in Holland 15, 89–90, The Many Faces of Suicide by Deliverance and Assisted Suicide 121–122 156 for the Dying (Humphry) 96, nonvoluntary 25 and psychological autopsy 220 in Oregon 15, 89–90, 143, xxxi, 58, 150, 194 Fine, Carla 174 144, 176–179, 183–184 on suicide equivalents 87 Finland 89, 96–97, 107 passive 90, 181–182 Suicide in Different Cultures by firearms suicide 97, 162 Euthanasia Education Council 173 in African Americans 5 (EEC) 90–91 on suicide notes 221 availability and 53, 132, 228 Euthanasia Research & Guid- farmers 94–95 in Canada 34 ance Organization (ERGO!) fatalistic suicide xxix, 47, 76 in children 40 118, 125 fathers. See parents in elderly 79, 80 Euthanasia Society of America FDA. See Food and Drug Admin- gender and 92, 104, 155, 90, 239 istration 185 Index 315

in Hispanic Americans 120 frustration 101 Germany 106 in police officers 187 FSM. See Federated States of educational competition in in teenagers 228, 229 Micronesia 54 first degree intent 131 Full Inquiry into the Subject of Sui- suicide rate for 89, 106, 107 Five Young American Poets (Berry- cide, A (Moore) xxvi gestured suicide. See suicide ges- man) 25 “Fundus Oculi and the Determi- tures Flaubert, Gustave 97–98 nation of Death, The” Giffin, Mary 53 Florida 216 (Kevorkian) 142 gifted children 106 flupenthixol 74 funerals. See burial (for suicides) Gisu of Uganda, the 106–107, focal suicide xxxi, 156 Funus (The Funeral) (Erasmus) 191 follow-up, of suicidal persons 87, 101 global suicide 107–108, 98 Furst, Sidney 101–102 132–133 Food and Drug Administration Globe (newspaper) 193 (FDA) “goal-gradient” phenomenon on Accutane 3 G 108 on Prozac 192 Gale, Hugh 142 God Bless You, Mr. Rosewater “fool’s parsley.” See hemlock Gandhi, Rajiv 230 (Vonnegut) 240 foreign students, suicide in 51 Garcellano, Erika 143 Goethe, Johann Wolfgang von forfeiture, law of xxxii, 98, 148 Garfinkel, Lili Frank 174 xxvii, 50, 108, 179, 215 Forrestal, James 98–99 Garrish, Margaret 143 Gogh, Vincent van 237 Foster, Vincent Walker, Jr. 99 Garroway, Dave 103 Golden Gate Bridge 108–109 Fox, Joan 59, 221 Gartner, Alan 170 Good Life, Good Death (Barnard) France 99–100 gas 83, 103–104, 185. See also 90 burial for suicides in xxii, carbon monoxide poisoning Göring, Hermann Wilhelm 109 xxxii–xxxiii, 99, 100, 162 gatekeepers 104, 160, 174 grades 109 suicide rates for 100, 107 gays, suicide in. See homosexu- Grannan, Nancy 221 French Criminal Ordinance of ality and suicide Great Britain. See England; Scot- August 1670 100 gender differences in suicide 4, land; Wales French Polynesia 215 95, 104, 155, 201–202, 212 Greece 89, 107, 109–110 Freud, Sigmund xxx, 100–101 aggressive behavior and 104 Greece (ancient) 109–110 Beyond the Pleasure Principle by attempted suicide and 1, 3, burial for suicides in xxxii xxx, 100 18, 19, 95, 119 Cynics in 12, 69, 153, 249 on bonding 28 in children 41 Cyrenaics in 115 on death instinct xxx, 232 depression and 68 Epicureans in xix, 19, 86, on “grief work” 110 and methods of suicide 92, 183 on “hurried” children 126 103, 104, 114, 162, 185 Stoicism in xix, xx, xxi, 19, Mourning and Melancholia by and seeking help 53, 60, 104 85, 110, 157, 183, 217 165, 238 “General William Booth Enters suicide in xix–xx, 38, 47, on self-destructive behavior Into Heaven” (Lindsay) 149 65–66, 67, 109–110, 117, xxx, 64, 87, 100 genetics and suicide 104–105, 163 on suicide as punishment 172 grief, of suicide survivors 110 194–195 geographic factors 84–85, Grief Counseling Program 101 and Vienna Psychoanalytical 105–106, 230 “grief work” 110 Society 176, 238 Georgia (country) 89, 107 Griffiths, Abel xxii, 110–111, friends 101 Georgia (state) 216 222 Friendship Line for the Elderly, geriatric suicide. See elder sui- Grollman, Earl A. 222 The 101 cide group conscience 111 316 The Encyclopedia of Suicide group therapy 111 hemlock (Conium maculatum) Honduras 107 Growing Up Faster (Elkind) 126 xx, 110, 117, 159, 214, 245 honor and suicide xix, 123. See Gruhle, Hans W. xxxi Hemlock Quarterly (newsletter) also hara-kiri Guatemala 107 118 hopelessness 123–124 Guest, Judith 111, 176 Hemlock Society 96, 117–118, in cancer patients 35 guns. See firearms suicide 125 in gifted children 106 Guyana 107 Henderson, Billy 54 Horney, Karen xxxi Hendin, Herbert 73, 101–102, hospitalization, involuntary 118, 211, 220 124, 133–134, 147 H Henry, Andrew F. 82 hospitals Hadrian 113–114 heredity and suicide 104–105 help in 81–82, 124 Halbwachs, Maurice xxx Hereford, Council of 45 suicide in 129–130 hallucinogenic drugs. See LSD Hero xix hostile behavior 124. See also haloperidol 233 Herod xviii aggressive behavior Hamas 231 Herodotus xx, 118–119, 130 How to Die with Dignity (EXIT Hamilton, Thomas 210 heroin and suicide 73–74, 119 publication) 92 Handbook for the Study of Suicide, Hezbollah 231 Huelsenbeck, Richard 63 The (Perlin) 182 Hickler, Holly 239 Hughes, Ted 185 handgun. See firearms suicide hidden suicide 119 Hume, David xxvi, 14, 45, 83, hanging 114, 162, 204 Himmler, Heinrich 120, 121 124–125, 176, 186 in children 40 Hinduism xxiv, 20, 128 humor, loss of 125 gender and 92, 185 Hippocrates 119, 182 Humphry, Derek 118, 125 in Mayan culture 136 Hippocratic oath 119 Final Exit: The Practicalities of Hankoff, L. D. xvi Hispanics and suicide 119–120, Self-Deliverance and Assisted Hannibal 114 227 Suicide for the Dying by 96, hara-kiri 20, 55, 91, 114, 123, Historiae (Tacitus) 225 220 137–138, 163, 208, 212 history of suicide xv–xxxiii Jean’s Way by 118, 125, 220 Harris, Eric 209, 210 Hitler, Adolf 120–121 Let Me Die Before I Wake by Harvard Medical School Guide to holidays and suicide 121, 230 148, 220 Suicide Assessment and Interven- holidays and survivors 121 Right to Die, The: Understanding tion 114–115 Holland 121–122 Euthanasia by 118 HASW News (newsletter) 169 assisted suicide in 14, 15, Supplement to Final Exit by Hawaii 215, 216 89–90, 121–122 220 Hawes, Lois 142 suicide rate for 107, 121 Hungary 62, 89, 107, 125–126 Hawton, Keith 132 Homage to Mistress Bradstreet “hurried” children 126 healing stage of grief process 110 (Berryman) 25 Hyde, Thomas 143 Heaven’s Gate 60, 115, 158 home, suicide-proof 42 hypomania 27 Hebrew Bible, suicides in xvii, Homer xix 26–27, 115, 136, 138, 208, 249 homicide vs. suicide rate 59, 122 Heeringen, Kees van 132 homicide-suicide. See murder- I Hegesias 115 suicide IASP. See International Associa- Heidegger, Martin 92 homosexuality and suicide tion for Suicide Prevention helium 103–104 122–123 iatrogenic suicide 93 Hellenica (Xenophon) 245 Baldwin on 23 Iceland 107, 127 help for suicidal people 115–116 Furst-Ostrow theory on Idaho 216 Hemingway, Ernest 116 101–102 ideation, suicidal 218 Hemingway, Margaux 116–117 in teenagers 227 identity 127 Index 317

Ignatius of Antioch 45, 127 international suicide rates Mihara-Yama volcano in 163 Iguliic Eskimos 87 107–108, 132–133 seppuku in 190 Illinois 216 interpersonal suicide 133 suicide in xxiv imitation. See cluster suicides Interpretation of Dreams, The in children 54, 217 immortality 127–128 (Freud) 100 suicide rates for 107, 138 impulsiveness 40, 123, 128, intervention 133–134 Jaspers, Karl 92 172 involuntary commitment 124, jaubar 128 In a Darkness (Wechsler) 175 134–135, 147 JCAH. See Joint Commission index suicide 128 Iowa 216 on the Accreditation of Hospi- India 128–129 Iran 135 tals jaubar in 128 Ireland 135 Jean’s Way (Humphry and Wick- johar in 139 irrationality 135 ett) 118, 125, 220 suicide rate for 128–129 “Is Life Worth Living?” (James) Jewish Antiquities (Josephus) suttee in xxiv, 128, 130, xxix, 135–136, 137 140 153, 190, 212, 222–223 ISDB. See indirect self-destruc- Jewish War, The (Josephus) 140 Indiana 216 tive behavior Jews 138–139 indirect communication 52 Islam xxiv, 78, 91, 135, 166, on burial for suicides xviii, indirect euthanasia 90 197, 214, 231 31, 91 indirect self-destructive behav- isocarboxazid 156 on suicide xvii–xviii, 19, 31, ior (ISDB) 69, 87, 119, 129, isolation 136 91, 138, 139–140, 214 211 isotretinoin 2–3 suicide in 136, 192. See also indirect suicide 129, 156 Israel 136 Masada individual suicide xvi suicide rate for 107, 136 in ancient times Industrial Revolution xxv–xxvi suicide terrorism in 231 xvi–xviii, 138 infant, bonding to mother 28 Italy 107, 136. See also Rome in Bible xvii, 26–27, Inferno (Dante) xxiii (ancient) 115, 136, 138, 208, Inge, William Ralph 241 Ixtab 136 249 inmates, suicide in 137, 191 honor and 123 inpatient suicide 129–130 in Middle Ages J inquest 130 xxii–xxiii insecticide 181 Jacobs, Douglas 114 Treblinka 91, 159, insomnia 52, 130, 214 JADA. See Journal of the American 233–234 institutional suicide 93, 130 Dental Association jihad 91, 135, 231 institutions, suicide in 129–130, jail suicide 137, 191 johar 139 228 Jair, Eleazar ben xviii, 137, 158 Joint Commission on the insurance and suicide 130–131 JAMA. See Journal of the American Accreditation of Hospitals intent 131 Medical Association (JCAH) 129 intentional underreporting Jamaica 107 Joluo (of Kenya) 139, 191 131 James, William xxix, 135–136, Jones, Reverend Jim 61, 139, International Association for 137 159 Suicide Prevention (IASP) Japan 137–138 Jonestown Massacre 61, 139, 131–132 hara-kiri in 20, 55, 91, 114, 159 International Encyclopedia of the 123, 137–138, 163, 208, Joplin, Janis 139 Social Sciences (Parsons) 47 212 Jordan 107 International Handbook of Suicide kamikaze pilots in 47, 91, Josephus, Flavius xviii, 137, and Attempted Suicide (Hawton 123, 130, 138, 141, 212, 139–140, 158 and van Heeringen) 132 231 Jouret, Luc 214 318 The Encyclopedia of Suicide

Journal of the American Academy Kuwait 107 Let Me Die Before I Wake of Child and Adolescent Psychiatry Kyrgyzstan 107 (Humphry) 148, 220 96 Lettres Persanes (Montesquieu) Journal of the American Dental xxvi, 148–149, 164 Association (JADA) 67–68 L Levy, Jerrold E. 149 Journal of the American Medical La Fontaine, Jean 247 Liberation Tigers of Tamil Eelam Association (JAMA) 10 “Lady Lazarus” (Plath) 147 (LTTE) 230 Joyce, James 140 Lamartine, Alphonse de xxvii Librium 233 Judaism. See Jews Lamia and Other Poems (Keats) life insurance 130–131 Judas Iscariot xvii, 45, 138, 141 Life Line International 48, 56 140, 172 Lanterman-Petrie-Short Act Lifekeeper Foundation 149 Jung, Carl xxxi (LPS) 147 Life’s Preservative against Self- juvenile correctional facilities, “Last Fearsome Taboo, The: Killing (Sym) 149 suicide in 228 Medical Aspects of Planned Lincoln, Mary Todd 149 Death” (Kevorkian) 142 Lindsay, Vachel 149–150, 226 Last Wish (Rollin) 203 literature, suicide in 14. See also K Latin America 147. See also spe- specific book; specific poem kamikaze pilots 47, 91, 123, cific country lithium 74, 156 130, 137–138, 141, 212, 231 Latvia 107 Lithuania 89, 107 Kansas 216 Law, Liberty and Psychiatry Litman, Robert E. xxxi, 150 Kant, Immanuel xxvi, 19, 141, (Szasz) 147–148 Little Prince, The (Saint Exupéry) 183 law and suicide xxxii–xxxiii, 150, 207 Kawabata, Yasunari 141 148 Littleton, Colorado, school vio- Kazakhstan 107 in ancient times xxxii lence in 209, 210 Keats, John xxvii, 141 assisted suicide 14–17, Live or Die (Sexton) 213 Kennedy, John F. 187 89–90 Locke, John 150 Kentucky 141, 216 attempted suicide xxxii, 19, Logan, Karen 221 Kevorkian, Jack 141–144 141, 148 London 151 carbon monoxide used by Burnett v People and 32 loneliness 151 142, 143 in England xxxii, 19, 31, in children 151 nitrous oxide used by 104 111, 148 in elderly 79, 80 Kierkegaard, Søren 92 in Middle Ages xxxii, 162 Loneliness of Children, The Killinger, John 151 Sanders v State and 32 (Killinger) 151 kindling 144 suicide as felony xxxii, 31 long-acting barbiturates 24 Klagsbrun, Francine 144, 233 law enforcement officers 187 Los Angeles Suicide Prevention Klebold, Dylan 209, 210 law of forfeiture xxxii, 98, 148 Center 66, 150, 151, 213, 225 Koestler, Arthur 144, 220 Lawley, Kenneth 54 loss 151–152 Korea 108 Leander xix LOSS (Loving Outreach to Sur- Koresh, David 61, 159 Lectures on Clinical Psychiatry vivors of a Suicide) 58, 152 Kraepelin, Emil 144–145 (Kraepelin) 144–145 loss of concentration 56 Kreitman, Norman 181 legal aspects of suicide 148 loss of humor 125 Kristin Brooks Hope Center Leiden des jungen Werthers, Die loss of identity 127 145, 169 (Goethe). See Sorrows of Young loss of physical health 183 Kübler-Ross, Elisabeth 43, 145, Werther, The (Goethe) loss of will 241–242 233 Lennon, John 38 Louisiana 216 Kurdistan Workers’ Party (PKK) lesbians, suicide in. See homo- love 152, 204 230–231 sexuality and suicide Love Songs (Teasdale) 226 Index 319

“love-pact suicide” 221 in children 41 Masaryk, Thomas G. xxix Loving Outreach to Survivors of depression and 68 M*A*S*H (television series) 220 a Suicide (LOSS) 58, 152 divorce and 70 “masked depression” 124 Lowell, Robert 152 in doctors 71, 185 mass suicide 158–159. See also low-frequency electromagnetic economic cycles and 82 cult suicide; Masada; Treblinka fields 81 in elderly 79 in India 128 Lowry, Malcolm 153 in England 83 in Middle Ages xxiii loyalty suicides 55, 130, 153. honor and 123 Massachusetts 216 See also altruistic suicide and methods of suicide 92, matai 216 LPS. See Lanterman-Petrie-Short 104, 114, 155, 162, 185 Mauritius 107 Act in teenagers 226–227 Maximus Valerius 159 LSD 73, 153 Malinowski, Bronislaw 4, Mayan culture 136 LTTE. See Liberation Tigers of 155–156 McClure, Guy 83 Tamil Eelam Malta 107 McCollum, John 179 Lucan (Marcus Annaeus Man Against Himself (Menninger) McIntosh, John L. 88, 159–160, Lucanus) xxi, 153, 172, 239 46, 156, 160, 195 201 Lucian 65–66, 153 Mandell, Johnny 220 media, effects of suicide cover- Lucrece xxi, 123 mania 27, 156 age 53, 160, 219, 229–230 Lucretius 86 manic depression 27, 156, 161 medical personnel 160 lunar changes, and suicide in college students 51 Mein Kampf (Hitler) 120 84–85, 230 depression in 27, 68, 156 melancholy 11, 32, 64, 84, 105 Lutheran Church xxiv, 58, 91 manipulative suicide 156 melatonin 81 Luxembourg 107 Many Faces of Suicide, The (Far- Memorabilia (Xenophon) 245 lysergic acid diethylamide. See berow) 156 Menninger, Karl xxx–xxxi, LSD MAO inhibitors 156–157 160–161 Marcus Aurelius 157 on accidents 200 marijuana 157 on chronic suicide xxxi, 46, M Maris, Ronald W. 55, 111 64 Macedonia 107 marital status and suicide 70, on drives of suicide Mack, John E. 239 157, 202 xxx–xxxi, 249 Madame Bovary (Flaubert) 97 Marplan 156 Man Against Himself by 46, magical thinking and suicide Marr, Neil 30 156, 160, 195 155 Marshall Islands 215 The Vital Balance by 161 Mahasati 222 Martin, Sandy 149 Menninger Clinic 161 Mahayana 30 martyrdom 96, 157–158. See menstruation and suicide 161 Maine also kamikaze pilots; terrorism mental illness 161. See also spe- suicide rate for 216 and suicide cific illness voting on assisted suicide 15 of Donatists 71–72 in alcoholics 7 Major, Joe 221 of early Christians xxi, 44 in college students 51 major tranquilizers 233 Eusebius on 45, 89 in Hispanic Americans 120 male suicides 4, 104, 155, Ignatius on 45, 127 with impulsiveness 128 201–202, 212 Synod of Nîmes on 223 and suicide risk 203 in African Americans 4–5 Martyrs of Palestine (Eusebius) in teenagers 228 aggressive behavior and 104 89 meprobamata 233 in Apaches 13 Maryland 216 mercy killing. See 34 Masada xviii, 91, 96, 137, 138, methadone 119 cancer and 35 140, 158, 159, 163 methane 103 320 The Encyclopedia of Suicide

Methodist Church 56 moon phases, and suicide National Institute of Mental methods of suicide 162. See also 84–85, 230 Health (NIMH) 169 specific methods Moore, Charles xxvi National Mental Health Associa- availability and 162 Moral Essays (Seneca) 212 tion 169 in children 40 morality of suicide 88–89 National Organization of People gender and 92, 103, 104, More, Sir Thomas xxiv, 164, of Color Against Suicide 114, 155, 162, 185 201, 236 169–170 restriction of 53 morphine 182 National Right to Life Commit- in teenagers 229 Morselli, Enrico xxviii–xxix tee 176–177, 184 unusual 235 Morselli, Henry 84 National Save-a-Life League 76 Mexican Cult 61, 159 mortality, sense of 127–128 National Self-Help Clearing- Mexico 107, 132 mortality statistics 164–165 house 170 Meynard, Léon xxvii Moseley, Alfred L. 200 National Strategy for Suicide Michigan mother(s) 28. See also parents Prevention 170–171, 189–190 suicide rate for 216 Mourning and Melancholia National Suicide Data Bank 11 voting on assisted suicide 15 (Freud) 165, 238 Native Americans 123, 149, Middle Ages xxi–xxiii, 31, 64, “mourning work” 110 171, 199 162–163, 222 Mueller, Robert S., III 231 Navajo Suicide (Levy) 149 midlife crisis 202 multiple suicides. See cluster sui- Nazi concentration camps Mieko Ueki 163 cides; mass suicide 171–172. See also Treblinka Mihara-Yama volcano 163 murder-suicide 165–166 NCHS. See National Center for Miletus, maidens of 163 in elderly 165–166 Health Statistics military defeat 6, 163 in schools 209–210 Nebraska 216 Miller, Sherry 142 suicide pacts and 221 Nembutal 24 Miltown 233 Murphy, Kenneth B. 49 Nero xx–xxi, 44, 172, 212 Minnesota 216 Mus, P. Decius xix Neser, Johannes xxv minor tranquilizers 233 Muslims xxiv, 78, 91, 135, 166, Netherlands. See Holland Mishima, Yukio 123, 138, 163, 197, 214, 231 Netsilik Eskimos xv 212 muso-kan 138 neurobiology of suicide 172 Mississippi 216 Musset, Alfred de 166–167 neuroleptics 233 Missouri 216 Myers, Hardy 178 Nevada 216 Mithradates 163–164 Myth of Sisyphus, The (Camus) New Hampshire 216 “mixed state” 27 33, 88, 167 New Jersey 172, 216 Moldova 108 myths New Mexico 216 Mondays, suicides committed and children 26, 236 New Testament, suicide in xvii, on 85, 217, 230 concerning suicide 167, 225 45, 140, 172 Monroe, Marilyn 38, 164 New World of Words (Philips) xv Montaigne, Michel de xxiv, 14, New York 216 88, 164 N New Zealand 107, 215 Montana 216 Nardil 156 news coverage of suicide 53, Montesquieu, Charles-Louis de National Association of Police 160, 219, 229–230 Secondat, baron de la Brède et Chiefs 187 Newslink (newsletter) 9 de xxvi, 45, 164 National Association of Social Nicaragua 107 Esprit des Iois by 87–88 Workers 169 Nicholas of Damascus 130 Lettres Persanes by xxvi, National Center for Health Sta- Nicol, Neal 142 148–149, 164 tistics (NCHS) 169, 199 Nietzsche, Friedrich Wilhelm mood swings 164 National Hopeline Network 169 172–173 Index 321

‘night, Mother (Norman) 173 Old Testament, suicides in xvii, Partnership for Caring. See night time and suicide 173 26–27, 115, 136, 138, 208, 249 Euthanasia Education Council NIMH. See National Institute of Olton, Thomas 221 passive euthanasia 90, 181–182 Mental Health Omega: Journal of Death and Dying Patient Self Determination Act Nimitz, Admiral Chester W., Jr. 175 (1991) 197 173 On Death and Dying (Kübler- Patients’ Rights Organization 9/11 terrorist attack 231 Ross) 145 (PRO-USA) 117 nitrous oxide (NO2) 104 On Suicide (Hume) xxvi, 14, 83, Peau de Chagrin, La (Balzac) 23, No One Saw My Pain: Why Teens 124, 176 182 Kill Themselves (Slaby and Opffer, Emil 59 penacide 182 Garfinkel) 173–174 Oppenheim, David E. 176 Penguin Dictionary of Saints No Time to Say Goodbye: Surviving Ordinary People (Guest) 111, (Attwater) 88 the Suicide of a Loved One (Fine) 176 Penitentials (Egbert) 182 174 Oregon, suicide rate for 216 Pennsylvania 216 NO2. See nitrous oxide Oregon law 14, 15, 89–90, 143, pentobarbital 24 nonvoluntary euthanasia 25 144, 176–179, 183–184 People, Burnett v 32 Norman, Marsha 173 organic suicide xxxi, 156, 179 People v. Roberts 16 North Carolina 173, 216 Origen of Alexandria 157, 179 People’s Temple 139 North Dakota 173, 216 Orleans, Council of xxii, 45, 58 Peregrinus 65–66, 153, 212 North Sea gas 103 Osbourne, Ozzy 179 Peri parthenion (Hippocrates) Norway 107, 173, 209 Ostrow, Mortimer 101 182 Notebooks (Camus) 33, 173 other-driven suicide 179 Perlin, Seymour 182 notes, suicide. See suicide notes Otto, Emperor 179 Persian Letters (Montesquieu). Nouvelle Heloise, La (Rousseau) Oxford English Dictionary xv See Lettres Persanes (Mon- 174, 204 tesquieu) nurses 174 personality 182 P personality disorders 161, PA. See psychological autopsy 182–183 O Paetus, Cecina xxi, 14 Peru 107 obligatory suicide 175 Panama 107 Petit Prince, Le (Saint-Exupéry) obsession with death 175 paracetamol 83 150, 207 in early Christians xxi Paraguay 107 Petronius 172 occupation and suicide risk paraquat 181, 215 Phaedo (Plato) 37, 47 175, 202. See also unemploy- parasuicide 181 Phasael xviii ment and suicide parents. See also broken homes phenelaine 156 dentists 67–68 and suicide; survivors of sui- Philippines 107 doctors 70–71, 184–185 cide Philips, Edward xv electricians 81 communicating with chil- Phillips, David 160 farmers 94–95 dren, lack of 53 philosophers and suicide 183 law enforcement officers hiding facts of suicide in sib- Philosophy and Public Affairs 187 ling 213 (Daube) 88 nurses 174 punishment from 95 physical health Ohio 216 in suicide prevention 42 loss of 183 O’Keefe, Donald 143 of suicides 181 and suicide risk 202–203 Oklahoma 175, 216 Parnate 156 physician-assisted suicide 14–17, old age and suicide. See elder Parsons, Talcott 47 183–184. See also assisted sui- suicide partial suicide 87, 181 cide; Kevorkian, Jack 322 The Encyclopedia of Suicide physicians 70–71, 184–185 postvention 181, 188, 222 Protestants 191–192, 201 pills, as suicide method 162, potential suicides 188 on suicide xxiv, 46, 91, 192 185. See also poison, as suicide poverty 188–189 suicide in xxix, 191–192 method Praise of Folly, The (Erasmus) PRO-USA. See Patients’ Rights acetaminophen 73, 162 xxiv, 87, 101 Organization antiseizure medications 86 prediction of suicide 189. See Prozac 12, 74, 192–193 barbiturates 23–24, 73, 162 also risk of suicide psychedelic drugs 73 in cancer patients 35 predisposition to commit suicide psychic blow 193 in elderly 79 172 psychic homicide 193 paracetamol 83 pregnancy and suicide 189 psychic suicide 193 in physicians 185 presidential elections, and sui- psychodynamic theory 193 tranquilizers 233 cide 187 “Psychodynamics of Suicide, in women 92 Pretty, Diane 15 The” (Furst and Ostrow) 101 PKK. See Kurdistan Workers’ prevention of suicide 189–190. psychological autopsy (PA) 87, Party See also crisis hotlines 193–194 Plath, Sylvia 185, 213 in African Americans coroners using 58 The Bell Jar by 25, 185 169–170 Litman and 150 “Lady Lazarus” by 147 antidepressants for 12, 74 Los Angeles Suicide Preven- suicide of 104, 175, 235 associations for 10–11, 34, tion Center and 151 Plato 186 131–132 personality disorders in 183 on bonding 28 of cluster suicides 50 sexual orientation in 122 on death of Socrates 110, community-based 53–54 of survivors of suicide 105 186 drop-in centers for 73 psychosis xxxi, 194 Phaedo by 37, 47 drug treatments for 74 psychotherapy 194 on suicide xix, 19, 45, 183, in elderly 80, 101 for adults 4 186 in England 48 after attempted suicide 82 Plato, Dana 186 family therapy for 94 for alcoholics 8 Poems (Berryman) 25 follow-up in 98 for bulimics 30 poets 186 guidelines for 133–134 in group therapy 111 poison, as suicide method 162, involuntary hospitalization in for survivors of suicide 110, 185, 186. See also pills, as sui- 124 111 cide method national strategy for psychotic suicide 194 in England 83 170–171, 189–190 psychotropic medications, and paraquat 181, 215 objectives for 190 suicide 6 poisoning, “accidental” 2 prevention centers for 66, PTSD. See post-traumatic stress Pokorny, Alex D. 187 109, 115–116, 150, 151 syndrome Poland 107 psychotherapy in 189 Puerto Rico 107 police, suicide by 219 in teenagers 229 punishment, suicide as police suicide 187 drop-in centers for 73 194–195 politics 187 drug treatments for Pollock, Jackson 187 74 pontifex maximus 187–188 family therapy for 94 Q Portugal 107 volunteers in 239 al-Qaeda 231 Portwood, Doris 46, 52, 188 primitive societies xv, xvi, “quasi-suicidal attempt” 181 Possessed, The (Dostoevsky) 72 190–191 Quinlan, Karen Ann 197 post-traumatic stress syndrome Prinze, Freddie 38, 191 Qur’an, The 78, 91, 135, 166, (PTSD) 187 prisoners 137, 191 197, 214 Index 323

R for Czech Republic 61–62, for Jordan 107 107 for Kansas 216 race 199 for Delaware 216 for Kazakhstan 107 and elder suicide 79 for Denmark 67, 107, for Kentucky 216 and suicide 202 208–209 for Kuwait 107 economic cycles and 82 for District of Columbia 216 for Kyrgyzstan 107 and teenage suicide 227 for Dominican Republic 107 for Latin America 147 Raskolniki xxiii, 159, 199 for Ecuador 107 for Latvia 107 rates, suicide 107–108, 199 for Egypt 78, 107 for Lithuania 89, 107 for Africa 4 for El Salvador 107 for Louisiana 216 for African Americans 5, for England 82–84, 151 for Luxembourg 107 199, 202 for Eskimos 87 for Macedonia 107 age-adjusted 5 for Estonia 89, 107 for Maine 216 for Alabama 216 for Europe 89 for Malta 107 for Albania 6, 107 for Fiji Islands 96, 215 for Maryland 216 for Antigua and Barbuda for Finland 89, 96–97, 107 for Massachusetts 216 107 for Florida 216 for Mauritius 107 for April 13 for France 100, 107 for men 155 for Argentina 13, 107 for Georgia (country) 89, for Mexico 107, 132 for Arizona 216 107 for Michigan 216 for Arkansas 216 for Georgia (state) 216 for Minnesota 216 for Armenia 14, 89, 107 for Germany 89, 106, 107 for Mississippi 216 for Australia 21, 107 for Greece 89, 107, 109 for Missouri 216 for Austria 21, 89, 107 for Guatemala 107 for Montana 216 for Azerbaijan 22, 89, 107 for Guyana 107 for Native Americans 171, for Bahamas 23, 107 for Hawaii 215, 216 199 for Bahrain 107 for Hispanic Americans for Nebraska 216 for Barbados 23, 107 119–120 for Nevada 216 for Belarus 24–25, 89, 107 for holidays 121 for New Hampshire 216 for Belgium 89, 107 for Holland 107, 121 for New Jersey 172, 216 for Belize 107 vs. homicide rate 59, 122 for New Mexico 216 for Brazil 29, 107 for Honduras 107 for New York 216 for Bulgaria 107 for Hungary 62, 89, 107, for New Zealand 107, 215 business cycles and 32, 132 125–126 for Nicaragua 107 calculation of 165 for Iceland 107, 127 for North Carolina 173, 216 for California 216 for Idaho 216 for North Dakota 173, 216 for Canada 34, 107 for Illinois 216 for Norway 107, 173, 209 celebrity suicides and 38 for India 128–129 for Ohio 216 for children 39 for Indiana 216 for Oklahoma 175, 216 for Chile 107 international 132–133 for Oregon 216 for China 42–43, 107, 132 for Iowa 216 for Panama 107 for Colombia 107 for Iran 135 for Paraguay 107 for Colorado 216 for Ireland 135 for Pennsylvania 216 for Connecticut 216 for Israel 107, 136 for Peru 107 for Costa Rica 107 for Italy 107, 136 for Philippines 107 for Croatia 107 for Jamaica 107 for Poland 107 for Cuba 107 for Japan 107, 138 for Portugal 107 324 The Encyclopedia of Suicide

for Puerto Rico 107 for Utah 216 revenge suicide 201 race and 199, 202 for Uzbekistan 108 Reynolds Adolescent Depression for Republic of Korea 108 for Venezuela 108 Scale 218 for Republic of Moldova 108 for Vermont 216 Rhode Island 216 for Rhode Island 216 for Virginia 216 Riessman, Frank 170 for Romania 108 for Wales 83, 151, 241 rifle. See firearms suicide for rural areas 236 wars and 241 Rigaut, Jacques 63 for Russian Federation 89, for Washington (state) 216, Right to Die, The: Understanding 108, 132, 205 241 Euthanasia (Humphry and for Saint Kitts and Nevis for West Virginia 216 Wickett) 118 108 for Wisconsin 216 “right to die” movement. See for Saint Lucia 108 for women 4, 95, 242 assisted suicide; euthanasia; for St. Vincent and The for Wyoming 216 Hemlock Society Grenadines 108 for Yugoslavia 108 “right to suicide” 201 for São Tomé and Príncipe for Zimbabwe 108 Risala (Fadlan) 93 108 rational suicide 199–200 risk of suicide 201–203. See also for Scandinavia 85, 106, Rationalists, the 26, 200 distress signals 208–209 Razis xvii age and 5, 202 for Scotland 211 razor blades, as suicide weapon in children 40–41 for Seychelles 108 200 climate and 84–85, 202 for Singapore 108 Reaching Young Europe 24 electromagnetic fields and for Slovakia 108 Rebel without a Cause (film) 65, 81 for Slovenia 108 200 gender and 104, 201–202 for South Carolina 215, 216 reckless driving, as suicide clue marital status and 157, 202 for South Dakota 215, 216 74, 200 mental illness and 161, 203 for South Pacific Islands 215 recognition of suicide potential. occupation and 175, 202 for Spain 108 See distress signals; risk of sui- physical health and 183, for spring months 13 cide 202–203 for Sri Lanka 108 Reformation xxiv–xxv, 201 race and 199, 202 for Suriname 108 Regulus xix religion and 202 for Sweden 108, 209 Rehfisch, Eugen xxix in teenagers 228 for Switzerland 89, 108, 223 Rehnquist, William Hubbs 178 ritual suicide 203. See also hara- for Syrian Arab Republic Religio Medici (Browne) 88 kiri 108 religion. See also specific religion johar as 139 for Tajikistan 89, 108 and suicide 202 in primitive societies for teenagers 226 and suicide as taboo 225 190–191 for Tennessee 216 and suicide prevention Rizzo, Thomas 221 for Texas 216 48–49 Roberts, People v. 16 for Thailand 108 Renaissance xxiv–xxv, 201 Robinson, John 20 for Trinidad and Tobago 108 Reno, Janet 177, 178 Rollin, Betty 203 for Turkmenistan 108 “Request for Medication to End Roman, Jo 200 for Ukraine 108 my Life in a Humane and Dig- Roman Catholic Church for United States 108, 132, nified Manner” form 177 203–204 236 Rescue, Incorporated 49 on burial for suicides xxii, state-by-state 216 Research on Suicide: A Bibliog- 30–31, 91 for urban areas 235–236 raphy(McIntosh) 88, 201 on Oregon law 176–177, for Uruguay 108 reserpine 201 184 Index 325

on suicide xxiii, 13, 20, 46, salicylates 73, 162 holism; autocide; chronic sui- 58, 66, 91, 158, 203–204, sallekhana 128 cide; drug abuse 214 Salvation Army 12, 48, 76, in children 41 support group sponsored by 207 in college students 51 58 Samaritans 48, 58, 207–208, of daredevils 63–64 romance, breakup of 204 237–238 death wish and 66 Romania 108 Samoa 215, 216 in diabetes patients 69 romantics, the xxvi–xxvii, 204 Samson xvii, 26, 208 direct 69, 129, 211 Rome (ancient) “Samsonic” suicides 208 Freud on 64, 87, 100 burial for suicides in 31, samurai 208. See also hara-kiri indirect 69, 119, 129, 211 188, 225 San Francisco Suicide Preven- self-help groups 25. See also law on suicide in xx, xxxii tion (SFSP) 109, 208 counseling philosophers on suicide in Sanders v State 32 self-immolation 211–212 183 São Tomé and Príncipe 108 self-mutilation 181 on suicide xx, 157 Sartre, Jean-Paul 92 self-. See altruistic sui- suicide in xix–xxi, 13, Satcher, David 170, 189 cide 37–38, 113–114, 153, 172, sati. See suttee Seneca, Lucius Annaeus xx, 239 Saul xvii, 26, 138 172, 212, 217 hemlock and 159 Savage God, The: A Study of Suicide Epistles by 66, 86–87 honor and xix, 123 (Alvarez) 9, 186, 208, 247 Moral Essays by 212 Romeo and Juliet (Shakespeare) SAVE. See Suicide seppuku 190, 212. See also 14, 204 Awareness/Voices of Education hara-kiri “Romeo and Juliet Factor” 152 Savitz, David 81 September 11 terrorist attack ropes, as suicide weapon 204 Scandinavia 85, 106, 208–209, 231 Rosen, George 179 230. See also specific countries serotonin 7, 44, 105, 172, 192 Rossell-Butler, Kristin Brooks Scarf, Maggie 235 77 Dream Songs (Berryman) 25 145 schizophrenia 161, 203, 209 sex differences, suicide rates 4, Rothko, Mark 204 Schmidt, Kim 247 95, 104, 155, 201–202, 212 Rousseau, Jean-Jacques xv, school violence and suicide aggressive behavior and 104 xxvi, 45, 174, 204–205 209–210 attempted suicide and 1, 3, Rowley, Thomas 38–39 Schopenhauer, Arthur xxviii, 18, 19, 95, 119 Rubey, Charles T. 152 210–211 in children 41 rural suicide 236 Schur, Max 100–101 depression and 68 Russell, Bertrand 151 Scotland 211 and methods of suicide 92, Russian Federation 89, 108, secobarbital 24, 178 103, 104, 114, 162, 185 132, 205 secobarbital-amobarbital 24 and seeking help 53, 60, Russian roulette 56 Seconal 24 104 Ryan, Leo 139 second attempts 211 Sexton, Anne Harvey 175, 213 Ryder, Hugh 205 second degree intent 131 sexual hanging. See autoerotic Seduced by Death: Doctors, Patients asphyxiation and Assisted Suicide (Hendin) sexual orientation, and suicide. S 211 See homosexuality and suicide Sahagamana 222 selective serotonin reuptake Seychelles 108 Saint-Exupéry, Antoine de 150, inhibitors (SSRIs) 74, SFSP. See San Francisco Suicide 207 192–193. See also Prozac Prevention Saint Kitts and Nevis 108 self-destructive behavior 211. shahid 231 Saint Lucia 108 See also abuse, substance; alco- Shakespeare, William 14, 204 326 The Encyclopedia of Suicide

Shelley, Percy Bysshe xxvii SOLOS. See Survivors of Loved Suicide, Le (Durkheim) xxix, Shneidman, Edwin S. 213 Ones Suicide 46–47, 75, 100, 218 American Association of Sui- Sophocles xx suicide, preteen 218 cidology founded by 9 Sorrows of Young Werther, The Suicide: An Essay on Comparative Death of Man by 213 (Goethe) xxvii, 50, 108, 179, Moral Statistics (Morselli) 84 Definition of Suicide by 66 215 Suicide: Prevention, Intervention, at Los Angeles Suicide Pre- South Carolina 215, 216 Postvention (Grollman) 222 vention Center 151 South Dakota 215, 216 Suicide and Attempted Suicide on postvention 181, 188 South Pacific Islands and suicide (Stengel) 191 and psychological autopsy 215–216 Suicide and Life-Threatening xxxi, 58, 194 Soylent Green (movie) 216 Behavior (journal) 9, 84, 111, on suicide notes 221 Spain 108 218 Short, James F. 82 SPAN. See Suicide Prevention Suicide and the Meaning of Civiliza- short-acting barbiturates 24 Advocacy Network tion (Masaryk) xxix shotgun. See firearms suicide SPTP. See Suicide Prevention suicide attempts 18–19, 218 siblings, grief after suicide in Training Programs accidents as 2 213–214 Sri Lanka 108, 230 in adopted teenagers 3–4 SIEC. See Suicide Information SSRIs. See selective serotonin alcohol and 7–8 and Education Centre reuptake inhibitors in children 40 significant other 218 St. Vincent and The Grenadines in elderly 79, 80 “silent killer” 36 108 as felony xxxii, 19, 141, silent suicide 214 Staël, Madame de xxvii 148 Silverman, Morton M. 55 State, Sanders v 32 and help in emergency room sin, concept of 214 state-by-state suicide rates 216 81–82, 124 Singapore 108 status loss and suicide 216–217 with heroin 119 SIQ. See Suicidal Ideation Ques- Steinhaeuser, Robert 210 in homosexuals 122, 227 tionnaire Stekel, Wilhelm 176 hostile behavior and 18, Sixth Commandment (King Stengel, Erwin xxxi, 191 124 James Version) xxi, 45, 66. See stock market crash, 1929, and impulsiveness and 128 also Fifth Commandment suicides 217 methods of 92, 162 Slaby, Andrew E. 174 Stoics xix, xx, xxi, 19, 47, 85, in Middle Ages xxii sleeping pills 24 110, 157, 183, 212, 217 vs. parasuicide 181 sleeplessness 52, 130, 214 “Stormy Monday” 217 second 211 Slovakia 108 Strange Victory (Teasdale) 226 and suicide notes 221 Slovenia 108 stress as suicide clue 217 and suicide risk 203, 228 Smith, Richard xxv–xxvi in Japan 217 in teenagers 227, 228 Social Meanings of Suicide, The in teenagers 101, 228 tranquilizers in 233 (Douglas) 73 Sturm und Drang 108 unintentional death from social suicide xvi subintentioned suicide 87 235 social workers 2, 169 submeditated suicide 87 in women 1, 3, 18, 19, 95, Society for the Right to Die 91 substance abuse. See abuse, sub- 119, 155, 212 Socrates xx, 12, 110, 117, 214, stance Suicide Awareness/Voices of 245 suicidal crisis, how to help 218 Education (SAVE) 218–219 Solar Temple, Order of the 60, suicidal ideation 218 suicide bombers. See terrorism 159, 214–215 Suicidal Ideation Questionnaire and suicide SOLES (Survivors of Law (SIQ) 218 suicide by cop 219 Enforcement Suicide) 215 Suicide (Cavan) 190 suicide career 219 Index 327

“suicide clinic” 143 superstition 222 Tacitus, Publius Cornelius 31, suicide contagion 219. See also Supplement to Final Exit 225 cluster suicides (Humphry) 220 Tajikistan 89, 108 suicide equivalents 87 Supreme Court, on Oregon law Talmud 138 suicide gestures 219–220 178, 184 teachers, role in suicide preven- suicide “how-to” manuals 96, Suriname 108 tion 42, 225–226 220 survivor guilt 176, 181, 222 Teasdale, Sara 226 Suicide in America (Hendin) 101, Survivors of Law Enforcement teenage suicide 226–229 220 Suicide (SOLES) 215 Accutane and 2–3 Suicide in Different Cultures (Far- Survivors of Loved Ones Suicide in adopted teenagers 3–4 berow) 173 (SOLOS) 222 in African Americans 5 Suicide Information and Educa- survivors of suicide aggressive behavior and 6 tion Centre (SIEC) 34, 70, anniversary of suicide and 11 attempted suicide and 227 220 bereavement groups for 25 autoerotic asphyxiation and “Suicide Is Painless” (song) on campus 52 21–22 220 children as 40 “blocked communication” “suicide machine” 142 destroying suicide note 221 and 53 suicide notes 220–221 family therapy for 94 cluster suicides 50, 56, 229, by children 201 grief of 110 241 destroyed by families 221 guilt in 222 cocaine abuse in parents and by elderly 220 holidays and 121 51 by teenagers 220 parents 181 culture and 227 suicide pacts 23, 166, 221 postvention for 181, 188, 222 daredevils and 63–64 suicide prevention, Befrienders psychological autopsy of 105 in death education students International and 24 psychotherapy for 110, 111 65 Suicide Prevention Advocacy siblings 213–214 death wish and 66 Network (SPAN) 221 suicide in 56–57, 105, 110, divorce of parents and 70 Suicide Prevention Training Pro- 240 drug abuse and 1, 74, grams (SPTP) 220 support groups for 53–54, 227–228 “Suicide Rates in Various Psy- 58, 152, 215, 218–219, expendable child syndrome chiatric Disorders” (Pokorny) 222 and 92, 152 187 teenagers as 228 with firearms 97 Suicides (Baechler) 23 Survivors of Suicide program frustration and 101 “Suicide Solution” (song) 179 208 gender and 226–227 suicide statistics suttee xxiv, 128, 130, 153, 190, in Hispanic Americans 120 limited reliability of 165 212, 222–223 in homosexuals 122, 227 underestimated 65 Sweden 108, 209 impulsiveness and 128 suicide survivors. See survivors Switzerland 89, 108, 223 loss of identity and 127 of suicide Sym, John xxv, 149 love and 152 suicide terrorism. See terrorism Synod of Nîmes xxii, 31, 45, 223 measuring thoughts of 218 and suicide Syrian Arab Republic 108 and methods of suicide 229 suicide threats 221–222 Szasz, Thomas 147 and parents 181 “suicide watch” 191 during pregnancy 189 suicide-proof home 42 prevention of 229 Sullivan, Henry Stack xxxi T drop-in centers for 73 Summa Theologica (St. Thomas Tabachnick, Norman 225 drug treatments for 74 Aquinas) xxiii, 13 taboos xvi, 4, 19, 52, 225, 237 family therapy for 94 328 The Encyclopedia of Suicide

profiles of 173–174, 233 traffic accidents 233. See also Utah 216 protective factors of autocide Utopia (More) xxiv, 201, 236 228–229 tranquilizers 233, 237 Uzbekistan 108 rates of 226 tranylepromine 156 risk factors of 228 Treatise of Human Nature (Hume) status loss and 217 124 V stress and 101, 228 treatment. See counseling; Valence, Council of xxii and suicide notes 220 postvention Valium 233, 237 warning signs of 227–228 Treblinka 91, 159, 233–234 Van Dusen, Henry Pitney 46 Teicher, Martin 192 tricyclic antidepressants 74, Van Eirland, Corlenia 109 telephone intervention 229. See 78–79 Vancouver Crisis Centre 237 also crisis hotlines Trinidad and Tobago 108 Varady, Geza 62, 126 television, effect on suicide 53, Trobriand Islanders xv, xvi, 55 Varah, Chad 48, 207, 237–238 160, 219, 229–230 Trosse, George 234 Vatel 238 temporal factors 85, 230 Troyes, Council of xxii Venezuela 108 “Ten Commandments of Sui- Truman, Harry S. 98–99 verbal direct communication 52 cide” 66 Tuinal 24 verbal indirect communication Tennessee 216 Turkmenistan 108 52 terrorism and suicide 91, 135, Twain, Mark 233 Vermont 216 166, 230–232 twin studies of suicide 105 “victim-precipitated” murders tetrahydrocannabinol 157 Two Treaties of Government 219, 238 Texas 216 (Locke) 150 Vienna Psychoanalytical Society Thailand 108 tyramine 157 76, 100, 126, 176, 238 thanatology 232 Vietnamese Suicide 61, 159 Thanatos xxx, 232 Vigne, Pier delle 228 thanatron 142 U Villechaize, Herve 238–239 THC 157 Ukraine 108 Virginia 216 Thebes 232 Ulysses (Joyce) 140 Vital Balance, The (Menninger) Theognis of Megara xx Under Milk Wood (Thomas) 232 161 Theseus xix Under the Volcano (Lowry) 153 Vivienne: The Life and Suicide of an third degree intent 131 unemployment and suicide Adolescent Girl (Mack and Hick- Thomas, Dylan 232 132, 175, 235 ler) 239 Thracians 232 Unfinished Business: Pressure Voltaire (François-Marie threats, suicide 221–222 Points in the Lives of Women Arouet) xxvi, 45, 186, 239 Thucydides xix (Scarf) 235 Volteius 239 Tijuana Cult 61 unintentional death 235 Voluntary Euthanasia Society Tikopia xv, 191 United Kingdom. See England; 90, 144, 239 time of day, and suicide 85, Scotland; Wales Voluntary Euthanasia Society of 230 unusual methods of suicide Scotland. See EXIT Tiv of Nigeria 191, 232 235 volunteers 239–240 Tojo, General Hideki 232 urban suicide 235–236 of Befrienders International Toledo, Council of xxii Uruguay 108 24 Tom Sawyer 233 U.S. suicide statistics 108, 132, clergy 48 Too Young to Die: Youth and Sui- 236 at crisis hotlines 56, 98, 101, cide (Klagsbrun) 144, 233 state-by-state 216 207–208, 239 Torah xvii Uses of Enchantment, The (Bettel- in support groups 219 Toronto Distress Centre 233 heim) 26, 236 Vonnegut, Kurt, Jr. 240 Index 329

Voyage Out, The (Woolf) 242 WHO. See World Health Organi- World Health Organization Vulteius xix, 163 zation (WHO) 243 Wickett, Ann 118, 125, 220 on divorce and suicide 70 widowhood 12 global suicide rates by 107, W and suicide 80, 157, 133 Wagner, Adolph xxviii 190–191, 232 wrist-slashing 243 Wales 83, 151, 241 and suttee xxiv, 128, 130, Wyoming 216 Walker, Alan 56 153, 190, 212, 222–223 will, loss of 241–242 Wallace, Samuel E. 241 X Walpole, Horace 39 Williams, Susan 142 “Wanting to Die” (Sexton) 175, “winner depression” 54–55 Xenophon 245 213 Wisconsin 216 Xerxes I 245 Wantz, Marjorie 142 Wisdom of the Sands, The (Saint- Exupéry) 207 war, effect on suicide rate 241 Y warning signs of suicide. See dis- withdrawal 242 tress signals women 242. See also female sui- Yeats, William Butler 247 Warren, Henry 76 cides Youk, Thomas 144 Warton, Thomas 39 amphetamine use in 73 Young, Gig 247 Washington 216, 241 anorexia nervosa in 12, 78 Yugoslavia 108 weather 85, 105–106, 202, 230, attempted suicide in 1, 3, 18, Yuit Eskimos 247 241 19, 95, 119, 155, 212 Wechsler, James 175 bulimia in 12, 30, 78 Z weekdays, and suicide 85, 217, depression in 95, 235 230 seeking help 53, 60, 104 Zealots xviii, 137, 158 “Werther syndrome” 50 Woolf, Leonard 242 Zeno (of Citium) xxi, 47, 110, West Virginia 216 Woolf, Virginia 242–243 183, 217, 249 Weyrauch, Teri Ann 221 World as Will and Idea, The Zilboorg, Gregory xxxi, 249 Whetstone, Ross 56 (Schopenhauer) 210–211 Zimbabwe 108 White Mountain Apaches. See World Federation of Right-to- Zimri xvii, 27, 249 Apaches, White Mountain Die Societies 90 Zoloft 74