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Book Reviews

Suicide and Culture: Understanding the Context

Suicide and Culture: Understanding the Context

edited by Erminia Colucci and David Lester, with Heidi Hjelmeland and B. C. Ben Park. Cambridge, MA, Hogrefe Publishing, 2013, 269 pages, $49.00 (paper).

This interesting book compares the phenomena of suicide across cultures. The authors tear us away from our monocultural, ethnocentric perspectives in the United States by pointing out the stark differences in suicidal patterns in different cultures. For example, in the United States, 90% of completed suicides occur in people who have mental disorders, but this is far from true in other cultures. Further, age and gender patterns of suicidal behavior vary in different cultures—in Western culture, suicide rates are highest in elderly men, but in China, the rates are highest in young women. Some societies have a positive view of suicide that is done for culturally approved reasons; for example, in Japan, if one shames one’s family, suicide can be an act of honor. However, Muslims see suicide as an unforgivable act (this view does not apply to suicide bombers, who are seen as martyrs). Thus, the cultural meanings of suicide vary greatly. Similarly, the authors point out the varying precipitants of suicide in different nations. They also present a puzzle to those of us in the United States, where firearms are the most common way of killing oneself: in Switzerland, where residents typically own firearms, hanging is the most common suicide method. Accordingly, suicide prevention strategies should be constructed with cultural context guiding the work.

The authors point out that suicide is classified in many different ways: as "(1) an unforgivable sin, (2) a psychotic act, (3) a human right, (4) a ritual obligation, and (5) an unthinkable act" (p 33). Moreover, the book discusses the fact that suicide rates may vary among groups of indigenous people within a nation; for example, from 15.6/100,000 in the Ami to 68.2/100,000 in the Atayal, with both groups residing in Taiwan. The authors also challenge the assumption that acculturation is a major driver of suicidal behavior. However, the absence of connection with one’s primary culture indicates the likelihood of an absence of protective factors such as identity and purpose, which are essentials for survival.

One of the editors (Colucci) provides a cross-cultural study that attempts to tease out the cultural meanings of suicide in Italy, India, and Australia and explores what keeps young people alive in spite of difficulties. There is a comparison of cultures suggesting that the dichotomies differentiating Western and Eastern (Indian) cultures are Individualism/Communalism, Cognitivism/Emotionalism, Free will/Determinism, and Materialism/Spiritualism, respectively. This section also highlights focus group findings from Chinese-, Vietnamese-, Japanese-, and Filipino-Americans regarding suicide. The other editor (Lester) provides another example of cross-cultural research on suicide in the United States and Kuwait and notes the need for more empirical research.

The East Indian event of Sati, "the custom in India of widows dying on the funeral pyre of their husbands" (p 217), is described with all of its attendant history and modern complexity. Finally, the issue of suicide in South Korea is explored, and the clash between the ancient Korean values of Confucian tradition and modern Korean tradition is highlighted. In 1989, the Korean suicide rate was 7.4/100,000, but in 2009, the rate jumped to 31.0 (largely due to the 6.8-fold increase in elderly suicide rates)—a quadrupling in just 2 decades indicating a "collective cultural ambivalence."

This book underscores the reality that behavior has many determinants. It also highlights some universal drivers of risky behavior, such as social disorganization, cultural conflict, and the breakdown of the family. However, protective factors may mitigate these pressures. In the conclusion, the editors cite 3 recent books concluding that "there is no sound research evidence that psychiatric disorders are caused by dysfunctional neurotransmitter systems in the brain, and second that psychiatric medications are no better than active placebos in helping patients" (p 265). (Ah, the dangers of books that do not require peer review.) Aside from this shortcoming, the book is full of relevant cross-cultural perspectives on the issue of suicide. The problem is that behavior is multidetermined by biology, individual psychology, and social and cultural contexts. To take a stand for one determinant at the expense of another is short-sighted. Why can’ t it be "both/and" instead of "either/or"?

My other issue with the book relates to a lesson I learned from the Institute of Medicine Board on Neuroscience and Behavioral Health study on the pathophysiology and prevention of adolescent and adult suicide.1 It turns out that, although suicide is often among the 10 leading causes of death, it is a rare occurrence. So, consider the authors’ table of suicide rates in various countries that range from a high of 80.4 to a low of 1.2/100,000 persons (p 60-61). In a sea of 100,000 people, 80 people (0.08%) are nearly as hard to find as 1 person (0.0012%), but a 66.7-fold greater difference in suicide rates sounds extraordinarily high. In terms of statistical power, though, finding significant differences between these 2 rates in order to determine causal factors and ways to prevent suicide requires a sample size of hundreds of thousands of people, and this level of science has yet to be accomplished. Despite this reality, I think it is very important to consider culture in suicide dynamics, and this book highlights some interesting issues about how culture plays into the enormously complex phenomena of an extreme of human behavior—self-destruction.

Reference

1. National Research Council. Reducing Suicide: A National Imperative. Washington, DC: National Academies Press; 2002.

Carl C. Bell, MD

carlcbell@sbcglobal.net

Author affiliation: School of Medicine and School of Public Health, University of Illinois at Chicago.

Potential conflicts of interest: None reported.

Volume: 75

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