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Suicidal Behaviour Among Youth: A Cross- Cultural Comparison

Louise Jilek-Aall Transcultural Psychiatry 1988 25: 87 DOI: 10.1177/136346158802500201 The online version of this article can be found at: http://tps.sagepub.com/content/25/2/87

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Division of Social & Transcultural Psychiatry, Department of Psychiatry, McGill University

World Psychiatric Association

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OVERVIEW
Suicidal Behaviour Among Youth: A CrossCultural Comparison
LOUISE JILEK-AALL
In 1973 the World Health Organization (WHO) Regional Office for Europe held a workshop in Yugoslavia to discuss the problem of escalating suicide rates, especially among the young in industrialized countries. Over the following decade many Third World countries were to have a similar, if not worse, record of suicide and suicide attempts among their younger populations. At the 1973 WHO workshop it was decided to define the age range of adolescence and young adulthood as 10 to 25 years. (Most official statistics divide youth into
two age groups: 15 to 19 and 20 to 25). The WHO group extended the age limit downward because an increasing number of younger adolescents were becoming involved in suicidal behaviour (Brooke, 1974). Fortunately it is suicide attempts rather than completed suicides that have increased most in the youngest age group (Eastwood, 1980). This trend has given rise to an intensive search for better methods of suicide prevention in many countries. Alcohol abuse has emerged as a distinct contributing factor in the suicidal behaviour of youth. When violent crime, reckless driving and accidents occurring under the influence of alcohol are included, the figures for self-destructive behaviour among the young become alarm-

ingly higher.
In Western countries it is generally believed that youth involved in suicide behaviour must be considered mentally disturbed and should therefore be managed within the medical system. Large sums of money have been allotted to suicide prevention clinics, community mental health teams, counselling services (as well as to psychiatric research projects). Vast amounts of data have accumulated and many controversial theories have been formulated to explain the data. Medical professionals and para-professionals are beginning to realize that their efforts have had little influence on the number of young people killing themselves, and that there is no evidence of mental
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disorder among most suicides or among those who attempt suicide. It is generally stated that suicidal behaviour among the young is unpredictable; it is seemingly unprovoked or triggered by minor stress situations. In many countries today suicide is one of the major causes of death of young people (age 19-25 years); this fact suggests that suicide is a problem for the entire society rather than only the responsibility of the medical profession. In this overview, I will try to clarify why young people in increasing numbers are adopting self-destructive behaviour instead of more constructive approaches to solving their problems. I will review several societies with contrasting juvenile suicide rates to attempt to discern factors which might contribute to differences in problem solving abilities. I will also compare social factors facilitating or inhibiting self-destructive behaviour, such as adult attitudes, availability of helping resources, and cultural options for problem solving. This comparative analysis may enable us to envisage preventive measures that are culture-congenial to a particular society.
NORWAY AND DENMARK

for

Norway and Denmark have had relatively reliable suicide statistics more than a century. A comparison of the rates of suicide in

and Denmark for the period 1830-1970 indicates that the suicide rate in Norway has been surprisingly constant over that period (between 6.3 and 10 per 100,000) (Retterstol, 1972). Norways rate has been significantly lower than Denmarks, which also shows greater variation (between 12.8 and 29.9 per 100,000). In 1970 the suicide rate for Denmark was three times higher than that of Norway, the ratio being 21:7 per 100,000 (Paerregaard, 1980). During these 140 years only a small and fairly constant fraction were suicides of young people. For example, in the period 1961-65 the suicide rate for Norwegian boys aged 15 to 19 was 2.9 and that for Norwegian girls of the same age group was 0.7 per 100,030 (Retterst6l, 1975b). Statistical analyses by Bolander (1972) revealed that Danish youth killed themselves approximately 2 to 4 times more often than Norwegian youth of the same age group. Since the two countries have similar cultural backgrounds and languages, comparable sociocultural and technological development, practically the same political system and religious beliefs, and very similar social systems, the significant and persistent differences in suicide rates has prompted much research. Some of the best known contributions are

Norway

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those by Hendin (1960, 1964, 1978), Farber (1968), Block and Christiansen (1966), Retterstol (1975a,b), Lavik (1976), and Otto (1971, 1972). These sources will be interpreted in the light of the authors personal knowledge of Scandinavian countries and cultures. The findings will then be compared with those of other- societies with high suicide rates. The geographical differences between Norway and Denmark are striking. Denmark is a small, flat and fertile country with a high population density. Proximity to central Europe has greatly influenced the world view and life-style of her people. Except for the southern part, Norway consists of a vast mountain massif with little arable land. The majority of the people live in small, isolated communities along the rugged coastline which stretches more than 2,000 km. to the North; they must struggle with the powerful adverse forces of nature and climate. Even the townspeople must endure the harsh, cold winters, heavy snow falls, and long, dark nights. Since, in contrast to the Danes, the Norwegians have always been independent landowners and fishermen, social class differences are much less marked than in Denmark and upward social mobility struggles have not been a dominant issue. Living in isolated pockets in the most remote country of Europe has helped Norwegians preserve old customs and traditions. Upon establishing a new family, young people usually settle down in one place. The population is ethnically homogenous and 95 percent have belonged to the Lutheran Church since the 16th century. These factors combine to give a sense of consistency, cultural identity, and continuity which engenders emotional stability in the nations youth. Because the Protestant ethic still dominates family life and child rearing in Norway, the modern sexual &dquo;liberation&dquo; and weakening of family structure which is widespread in Denmark has not made significant inroads in Norway. Pornography and violence displayed in the cinema and popular literature are frowned upon by most Norwegians and are stricly outlawed in the media. Suicide, which in old Norwegian law was classified as &dquo;dishonorable homicide&dquo;, is still regarded as a shameful, meaningless act and a sin against God. Suicide is therefore looked upon as an evil deed. In folk belief suicides and murderers are said to find no rest in their graves; they roam the earth as dangerous ghosts seeking revenge and bringing misfortune to the living. Danes in general have a more sympathetic view of suicide and tend to consider a suicidal act as the product of a sick mind. Danish society
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offers generous medical and psychiatric help to individuals and families with suicidal tendencies. Attitudes towards life and death develop during childhood and may facilitate or inhibit suicidal behaviour in the adolescent. In Norway social isolation makes access to medical facilities difficult, with the result that children see their sick relatives cared for at home and their elderly dying there. They often experience the loss of friends or family members in storms at sea or in other natural disasters and experience the grief and sadness which death provokes. Children learn to look upon life as a precious gift and to view death realistically as an irreversible blow dealt by fate. In Denmark, as in most industrialized Western countries, caring for the sick and dying takes place away from home, in hospitals. Adults avoid talking directly about death and children are left to their own fantasies. Since most information about life and death derives from TV shows, killing and dying becomes part of leisure-time entertainment. Children watch an actor die as a hero in one show, only to see him reappear alive in the next. Thus the majority of Danish children grow up with the unrealistic belief that death is a reversible process which can be used to manipulate and impress those around them. Modem views on family life and child rearing have been slow to reach Norway. Until quite recently, most families were still traditional, holding the view that children need a stable home in which both parents are involved in their upbringing to assure the child develops a basic feeling of security. Ideally the father, or his substitute, should be the firm parent, teaching his children to become assertive and self-reliant individuals with a solid sense of self-worth and self-confidence. The mothers are expected to be playful and emotionally close, instilling in the children a sense of loving acceptance. Norwegian parents and educators emphasize the virtue of cooperative rather than competitive attitudes. In increasing numbers, Danish families are one parent units. Child rearing emphasizes dependency, politeness, and. smooth social functioning. At the same time it induces in the children strong feelings of guilt for misbehaviour and a sense of obligation to become a social and economic success in order to gratify the hard-working parent (Hendin, 1964; Farber, 1968). Block and Christiansen (1966) who studied Scandinavian family life and dynamics by administering detailed questionnaires to normal university students and to juveniles who attempted suicide, found that in general Norwegian youth maintain a brighter outlook on life than do their Danish counter90

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parts. Norwegian probands were more often confident that there was always a way out of a difficult situation and that in a crisis they
could fall back on family members, friends, and even neighbours for support. Danish probands stated that they were often depressed and felt nothing could be done to help them out of an unsatisfactory life situation eight times more often than did the Norwegians. Block and Christiansen (1966) found that Danish youth more often perceived their mothers as being overly protective and as putting restrictive demands on their children by emphasizing cleanliness and restraint in showing emotions. Guilt promoting techniques were frequently used in punishment. Norwegian mothers were described as allowing children much physical freedom and as showing tolerance of emotional outbursts. The Norwegian father administered punishment more often than the mother and was both a feared and respected authority by the children. According to most investiga-

tors, fathers in Denmark are perceived as distant and have little influence on their childrens upbringing. An indifferent or helpful community attitude may have a decisive influence upon the future behaviour of youngsters displaying suicidal behaviour. Murphy (1982:159) comments on this theme:

Compared with the other two peoples (Swedes and Danes) the Norwegians more widely share the ideas that suicide is wrong, that neighbours will support someone in any attempt to speak out against injustices which he feels to be done to him, and that although independent striving is desirable, there are numerous social standards which all individuals should abide by. In consequence it could be expected that so deviant a solution as suicide would less often come into a Norwegians mind, and that he would have great faith in other answers to lifes problems, including some in which neighbours could be expected to assist. Retterst6l (1975a), in a 5-10 year follow-up study of attempted suicides in Norway, found that the suicide attempt had been a positive turning point in the young persons life; 81 percent of those surveyed were functioning well at the time of follow-up contact. However, if the suicide attempt was associated with bona fide mental illness, alcohol or drug abuse, the suicide risk was 60 - 80 percent higher than in the general population (Retterstbl and Sund, 1965; Sundby, 1972). There is a group of young men in the Norwegian population which is particularly vulnerable to suicide and whose psycho-social con91

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stellation may illuminate the phenomenon of suicidal behaviour in young people in general. Arner (1970) found that the rate of suicide among seamen, especially in the age group 15-29, is three times higher than the rate for comparable groups in the general population. The lower ranks in the navy are traditionally filled by young men who have had difficulty in adjusting at home, are school dropouts, cannot find other jobs, or derive from broken homes. Many have committed misdemeanours for which they are punished by being sent to sea. The seafaring life is associated with special stresses: the youngster is away from home, he endures hard physical work and is confined to a very limited space; working and sleeping hours are irregular; there is little leisure time; he is exposed to much drinking ; and there is little emotional support. The result is that accidental (or non-accidental) drowning and clearcut suicide constitute the highest mortality risk for seamen in the Norwegian merchant fleet.
JAPAN

recently Japan has had one of the highest suicide rates for young people among industrialized countries. This trend diminished in the 1970s, but nevertheless Japanese suicide rates are still significantly higher than those in Scandinavia. In 1973 the Japanese rate was 16.5 per 100,000 in the age group 15-24 years, as compared to Denmarks 9.0 and Norways 3.5. Japan can be used as an example to demonstrate that religious and cultural attitudes influence suicide behaviour. Iga (1967), Fuse (1980), and Tseng and McDermott (1981) among others, have pointed out that suicide has always been viewed in Japan as an honourable solution in difficult situations, especially when performed in a culturally prescribed way and as a means of wiping out shame or dishonour to onself, ones family, ones superior, or the country. Ritualized suicide, such as seppuku, is a culturally approved way to achieve self-esteem and honour. Suicide was glorified as recently as 1970 when the famous author, Yukio Mishima, performed this act publicly, as both a protest against the secularization of Japanese society and a truly Japanese way of showing willingness to die for a higher cause (Iga, 1973; Yamamoto and Iga,
1975). The warrior code of the samurai (bushido) holds that the

Until

meaning of life is to find the right time and place to die. Death is beautiful and purifies the body, regardless of how life was lived. Besides seppuku, the Japanese have historically glorified selfdrowning (tosui jisatsu) and jumping from a high place (tooshin
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jisatsu). When a college student (leaving behind a poetic suicide note) jumped to his death from the top of a waterfall in 1903, he was imitated by 200 other young people; and when a young woman lept into the crater of a volcano in 1933, 944 others followed suit (Iga et al, 1978). Novels and plays repeatedly extol the romantic beauty of the double suicide of lovers or of mass suicide as a protest against mistreatment and dishonour when the Japanese have been
defeated in wars. Child rearing has remained traditional and quite uniform in Japan. The Japanese family is close-knit, to an extent that is difficult to comprehend by Westerners according to some Japanese authors (Kimura, 1967; Iga, 1981). Parents inculcate an intense desire for success in their children, not only for the childs sake but because it is their duty towards the parents. The parents are represented as leading a life of self-sacrifice devoted to the children. The mother is supposed to exist only for her family. Typically, she pressures her children (in particular her sons) to constantly strive to improve their performance. The obligation to maintain and enhance the good name of ones family, the ever present gossip, and the ridicule of those who fail, exert strong group pressure on the young. Failure generates intense feelings of shame, guilt, and despair. The stresses resulting from expectations of educational achievement in sons and marital success in daughters are often implicated in the suicidal behaviour of young Japanese. Since entrance into a prestigious school or university is paramount to social success, students are under constant pressure to prepare for entrance examinations. Since leading educational institutions are overcrowded, a high percentage of the candidates face the crushing experience of failing these exams. Their choice is either to reconcile themselves and their parents to lowered social aspirations, or to commit suicide. To a high degree, the outcome will depend on the attitudes of significant others. Girls are expected to do well at school in order to assist with their sons education. Japanese women are expected to marry between the ages of 18 and 23. Marriage is virtually the only source of security for a woman in Japan. Failure to marry or marriage failure results in a sense of hopelessness. Since premarital chastity and parental approval of the marriage are expected, about 10 percent of suicides of young women are motivated by pre-marital pregnancy, and 20 percent by having failed to obtain parental approval for their marriage. Young people in such serious distress would seem to need counselling to prevent self-destructive behaviour, yet Kimura (1967),
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Ishii (1981) and other authors claim that the general attitude of the Japanese towards those in distress is one of indifference or avoidance. Japanese society as a whole, including educational institutions, have few if any helping agencies for youth in crisis. Although nearly two thirds of female and nearly half of male students have at one time or other contemplated suicide (Ohara, 1961; Iga, 1971), very few ever spoke of their intention. Suicide notes often express extreme loneliness, as when one student wrote: &dquo;No one will understand, so I am not going to write the reason for my suicide.&dquo; Comparative studies of German and Japanese adolescents with suicidal behaviour demonstrate that the Japanese youths were more often introverted, shy individuals than the Germans, and more often had few or no friends (Kitamura, 1982, 1983). Taking all the above factors into consideration, it appears plausible that the risk of suicide is high for young Japanese of both sexes. Japanese statistics confirm this. Suicide is the second major cause of death in females aged 15-19 and the principal cause of death in females aged 20-29. For males of the same age groups, the rate was twice as high as for females (Iga, 1971; Iga, et al, 1975, 1978). The suicide rate among students of Kyoto University during the years 1960-1980 averaged 48.5 per 100,000 (Ishii, 1981). Recently a new trend has appeared in the suicide statistics of Japanese youth; an increase in suicide attempts but a reduction in completed suicides. At the same time delinquency, violence at home and at school, dropping out of school, and alcohol and drug abuse have increased significantly (Ohara, 1970). According to Wen (1974) and Kitamura, et al (1983), these phenomena are the result of secularizing and Westernizing trends in modern Japan. However, the recognition that the rigorous school system places unreasonable stresses upon young people, has resulted in attempts at educational reform. It will be interesting to see how these new developments will influence the suicidal behaviour of Japanese youth in the future.
AMERINDIANS AND INUITS

Self-destructive behaviour and suicide are generally thought more prevalent among Amerindians and Inuits than among any other populations in North America. However, there are significant variations between different indigenous cultural groups (Webb, 1975). As the author has worked among these populations for the past 20 years, this paper concerns itself with the indigenous peoples of British
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Columbia and Alaska. Amerindians and Inuits in these areas have for centuries lived in small communities in physical and climatic conditions similar to Norways, sustaining life in a constant struggle against harsh elements. As in Norway, exposure to modern Western life styles has only recently influenced their tradition-oriented existence. Suicide was known to these peoples in pre-contact times but was probably at least as rare as it is in Norway. In contrast to Norway, the suicide rates of these northern peoples have assumed unheard-of dimensions in recent decades; in some communities suicide rates are still on the rise among the young. In Norway it was the Norwegians themselves who took the initiative to acquire modern technology and adapt it to their traditional life style. But in the case of the Amerindians and Inuits it was foreign colonizers who imposed an alien technology and culture. By introducing environmentally damaging industries (such as mining, logging, and commercial fishing), European intruders encroached upon the indigenous populations land and forced them to give up much of their traditional ways of life. While Amerindians and Inuits expected that their children would become respected citizens and wage earners in white society in exchange for giving up their aboriginal culture, religion, and language, the great majority find themselves impoverished and forced to exist on economic supports provided by agencies of white society. The effects of imposed rapid Westernization have been devastating for these native peoples and should serve as a warning to tribal populations in the Third World who are now becoming involved in the rapid transition to a modern industrialized society. Observations on societies undergoing Westernization suggest that when tribal people have lost their traditional cultures, and are unable to achieve a satisfactory status in the new society, their young people often fall victim to what Jilek (1982) has called anomic depression. This term denotes a psychophysiologic and behavioural syndrome, characterized by anomie absence of traditional norms guiding behavand by cultural identity confusion; a chronic dysphoric state iour with lack of interest in life, lack of self-respect and purpose, and no hope for a better future. These young people who have also lost culturally acceptable ways of expressing anger and frustration, are extremely susceptible to the temporary escape provided by alcohol. The disinhibiting effect of alcohol facilitates violence and selfdestructive behaviour, thus creating new misery and the desire for further escape, ultimately leading to suicide.
-

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Recent statistical data on mortality in British Columbia reveal extremely high accident and suicide rates among the Amerindians compared to the total population of the Province. Causes of violent death among young Amerindians in British Columbia (for example, by fire, motor vehicle accidents, drowning, homicide and suicide) are mostly alcohol related. In the age group 15-29, suicide is the leading cause of violent death (1978: 37 percent; 1979: 28 percent). Even more disquieting is the fact that suicide also accounts for a significant percentage of violent deaths in the age group 5-14 (1978: 11 percent; 1979: 20 percent). Although there are variations in suicide rates among different tribal groups, investigations of selected populations reveal that the suicide risk is highest for young Amerindians aged 16-25 (Hochkirchen and Jilek, 1983). In Alaska suicide rates for the native population of Amerindians and Inuits are more than double that for the total United States and, in contrast to the latter, almost entirely accounted for by younger age groups (Kraus and Buffler, 1979; hTadkarni and Deutsch, 1981;

Buffler, 1982; Mala, 1984). Suicide was by no means unknown in traditional Amerindian and Inuit life. Old people might commit suicide when they felt too sick
disabled to be of further use. Those who committed suicide for altruistic reasons (to prevent capture in wartime, or retaliation against their band, or in atonement) were honoured since it was thought that they had thereby secured the best status in the afterlife. The mythological theme of death and rebirth symbolically enacted in ceremonials still invests suicide with an aura of atonement and purification. Traditional mortuary customs continue side by side with Christian funeral services. In some communities today a person who takes his own life is respected as a fallen hero. For days the whole commuity participates in ritual speechmaking in praise of the deceased, believing this will help reunite him with his ancestors. Teenagers have been heard to express the sentiment that only at their funeral will they get the attention and acceptance they long for in life. For the young, violent deaths, accidents, and suicides have become the major excitement in their boring life on the small reservations. Youngsters have been observed playing the game of suicide in the schoolyard (Shore, 1972) and adolescents test the seriousness of each others suicidal threats. They tease those who express suicidal intentions, provoking action lest they be accused of cowardice. Self-destructive behaviour becomes a learned and rewarded
or

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pattern and those who die by suicide become the idols of their peer
group. An examination of the home situations and child rearing practices of contemporary Amerindian and Inuit families reveals a dismal picture. The adult generation, frustrated by rapid culture change, involved in alcohol abuse, and suffering from frequent family disasters, have little time or emotional resources for their children. Traditionally children were taught by example; verbal communication between parents and children was, and still is, quite limited. The youngsters grow up among alcoholized adults and family life is disrupted by sickness, violence, and accidents. The thought of suicide is ever present. As compared to other ethnic groups, Amerindian children in British Columbia are vastly over-represented in hospital admissions for serious injuries and illnesses. The frequent experience of breavement, neglect, hunger, physical abuse, and illness is an important reason for Amerindian children growing up depressed and frightened. These children lack the feeling of basic trust so important for healthy personality development. With the gloomy outlook on life conveyed to them by their parents, they possess few inner resources to deal with stressful situations. These background factors must be considered in any explanation of why so many young Amerindians and Inuits suddenly and seemingly inexplicably commit suicidal acts, with little concern for the distress they cause family members. To them life is worth little and death is the path to peace and reunion with glorified ancestors. As an Amerindian teenage boy expressed in his suicide note, &dquo;One life and one life lone and life so mix-up. I will not die as a coward to face life, but to live in the land of my forefathers. To die as a man. To show no fear.&dquo; In a questionnaire given to Amerindian school children, a typical response to the question &dquo;What does it mean to be brave?&dquo; was, &dquo;To have the courage to kill yourself (Shore, 1972). Young boys in Amerindian and Inuit society today have an even more stressful existence than their female peers. A girl can perceive a purpose in life in her future role as a mother. Young women have a better chance to find a place in the majority society, either through marriage or by working in service jobs not available or not acceptable to men. Amerindian men have lost most of their traditional functions as warriors or hunters, they have great difficulty competing for jobs in the majority society, and they harbour intense but unverbalized resentment against Whites as domineering bosses and privileged sexual rivals. In a study of Alaskan native suicide between
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1950-1974, the male/female ratio was 23/15 for the age group 15-19; and 34/19 for the age group 20-24 (Kraus and Buffler, 1979). The intensity of frustration and anger is reflected in the violent manner young Amerindian suicides kill themselves. Young men use shooting and hanging eight times more often than women who prefer drugs or poison (Hochkirchen and Jilek, 1983). Young people who grow up lacking the feeling of basic trust experience a great need for love and care, which emotionally unstable parents cannot provide. The rage and frustration this provokes among the young is countered by anger and rejection by the adults. Farber (1968), designated a society which consists of many such psychologically disturbed people as a &dquo;suicidal society&dquo; which cannot continue to exist. In many Amerindian and Inuit communities this is now beginning to happen, and epidemics of suicide among young Indians on reserves have been observed and documented (Fox and

Ward, 1977; Ward, et al 1977).

DISCUSSION AND CONCLUSION

religious and cultural attitudes influence suicide people are difficult to verify in a scientific way. It is worthwhile to note, however, that in Norway self-destructive behaviour is abhorred and viewed as cowardly and senseless. Suicide is rare in Norway and epidemic or mass suicide has not been reported. In sharp contrast to this Norwegian attitude, Japanese culture has a tendency to glorify suicide as the ultimate expression of self-control and courage, and it offers several patterns for ritualized suicide. Japan has high suicide rates; epidemic and mass suicide are well known phenomena. In Amerindian and Inuit youth the tendency to react to stress with self-destructive behaviour is prominent. Such behaviour is facilitated by the cultural belief that in death the suicide will be reunited with the ancestors who, in contrast to living generations, are romanticized as the true heroes of their people. In the cultures we have compared, high suicide risk for the young appears to be linked to disturbed family life during childhood. In the case of Norway, young sailors (who as a group show a suicide rate three times as high as the national average for youth) frequently come from a disturbed family background. In Japanese youth, an association between suicide risk and disturbed family life has been pointed out by Wen (1974). There was a significantly higher suicide rate among Japanese youth in the years 1950-1960 than either before
rates in young
98

The way in which

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after this period; young people had experienced an unstable childhood, they grew up while parents were either uprooted because of World War II or had experienced emotional trauma and grief due to the severe losses in the war or in the atomic holocaust of Hiroshima and Nagasaki. Because of the Japanese surrender, the parenor

tal generation emanated feelings of shame, cultural frustration, and a gloomy outlook on the future and on life in general. Wen (1974) and Lin (1969) confirm that the very young are extremely sensitive to insecurity in their social environment, and that the negative experiences of the war and post-war periods in Japan were crucial in creating psychologically vulnerable youth. During young adulthood, under the stresses of competitive education and socio-cultural reorientation, many of these young people chose opting out of life. A graphic picture of student suicides at Kyoto Uiversity between 1930 and 1978 illustrates the dramatic increase of suicides in the years
1950-1960

(Ishii, 1981).

Alcohol and, to a lesser extent, drug abuse are other factors which deserve attention as contributing to high suicide rates. Alcohol abuse in parents creates an unstable family milieu; the material poverty, physical violence, and disturbed interpersonal relationships between parents and children result in physical and mental suffering in children which is difficult to measure and therefore rarely taken into consideration. As soon as the youngster starts to drink, following the example of adults or giving in to pressure from peers, he learns to use alcohol for problem solving and thus embarks on the road to self-destruction. Intoxication may bring preexisting emotional dispositions and latent resentments to the fore. The negative feelings that the children of alcoholic parents often harbour become exacerbated. In the acute withdrawal phase of the &dquo;hangover&dquo; period when dysphoria is prominent, feelings of shame and helpless rage may lead to a suicidal act. Retterstol and Sund (1965) calculated that the suicide rate for patients treated for drug and alcohol abuse in Norway is 60-80 percent higher than for the general population. In a follow-up study, Stang (1980) demonstrated that the recent increase in suicide rates for younger age groups of both sexes parallels an increase in alcohol consumption in these populations. A review of the suicide rates in Denmark is of interest in this connection. There was a marked drop in suicide rates shortly after World War I; this drop in rates coincided with a drastic decrease in alcohol consumption due to the introduction of a high tax on alcoholic beverages which was in force during that period but was later abolished. Liquor
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is virtually unavailable in many districts of western Norway; even tourist hotels cannot obtain a licence to sell alcoholic beverages. In eastern Norway there is no such restriction and it is remarkable that suicide rates in eastern Norway are nearly twice as high as those of western Norway (Retterstl, 1975a). Using annual alcohol related death rates as indicators of alcohol consumption, Kraus and Buffler (1979) were able to show that in the Alaska native population there was a simultaneous, nearly matching increase in the suicide rate for the same population over the same period of time. Widening our cross-cultural comparison to include suicide among youth in Micronesia (Hezel, 1977; Rubinstein, 1983) and Western Samoa (Keith-Reid, 1983), we note that the main factor contributing to the high suicide rate is alcohol abuse by the young people following the example of their fathers and other male family members. A high percentage of the suicides had experienced an unstable or disrupted family life during childhood under Westernizing influences. It is noteworthy that drinking among young men has been increasing steadily since 1960 when the ban on importing alcoholic beverages into Micronesia was lifted (WHO, 1984) and the number of suicides has shown a dramatic increase, especially in men (Rubinstein, 1983). Whether a young person who in distress contemplates ending it all will take the last step to self-destruction will depend, in many cases, upon the availability of a supportive network. In Norway young people grow up with the conviction that in a crisis situation they can ask for help, either from their family or from friends or neighbours. It appears that people in sparsely populated regions are inclined to be helpful to each other since survival depends on cooperation. In contrast, in densely populated countries like Denmark and Japan indifference to the noisy crowd surrounding one becomes part of survival and fierce competition for coveted positions compel the young to compete rather than cooperate. In these countries a youngster in distress who withdraws into depression is easily overlooked by those around and, if there are few helping resources available to young people, the resulting feeling of rejection and loneliness might tip the scale toward suicide. In Amerindian and Eskimo communities, threatened by deculturation and social disintegration, the parental generation is constantly preoccupied with psychosocial stress and traumatic events. Few of them have the resources to help the young in crisis (Resnik and Dizmang, 1971; Dizmang, et al, 1974). The non-indigenous physicians, nurses, police, and social service staff, to whom they have to turn for help, are often ignorant of the
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sociocultural situation and have great difficulty in comprehending the ambivalent feelings and motives of suicidal young people. Turning over responsibility for a young person to professionals and paraprofessionals, especially if they are outsiders who speak a different language, further alienates the young from their own people. Relief from an intolerable situation might be achieved temporarily but the emotional needs of youth can hardly be met by outsiders and the initial suicide attempt may easily be followed by suicide when the vulnerable young person is again left to fend for himself. Another group of youngsters at risk, but not accounted for in Amerindian suicide statistics, are Amerindian children placed in nonAmerindian foster homes. Frequently old enough to suffer the full emotional consequences of displacement, and rarely given an explanation for being taken away from their family and the home environment, these children become fearful and suspicious. Manipulated by outsiders indifferent to their wishes, they experience a sense of helpless rage and degradation and often show acting-out behaviour. They are therefore shifted from one foster home to another during their formative years. Thwarted in their effort to form meaningful interpersonal relationships, and confused in their cultural identity, they respond to stressful situations with feelings of hopelessness and depression and with self-destructive behaviour. A recent film by the National Film Board of Canada (Richard CczrdinaL, A Cry from a Diary of a M6tis Child), documents the life of suffering and eventual suicide at the age of 17 of an Amerindian foster child in Canada. The film heightened awareness of this problem among Amerindian peoples and child protection agencies. It promoted changes in Canadian legislation towards culture-congenial foster care and confronted Amerindian communities with the need to take full responsibility for their own children. Taking issue with the increasing suicide problem among his people, a well known Inuit physician writes: &dquo;I believe that if there is going to be any change in the incidence of suicide, there has to be research done by Native people themselves. And the solutions have to come from each individual community. No one book or theory has all the answers.&dquo; (Mala, 1984:5). Efforts in this direction are already showing results. Amerindian spiritual leaders of the North Pacific coast have have been able to involve hundreds of young people in the revived Spirit Dance ceremonial, where they find a new Indian identity and renewed pride in their cultural heritage (Jilek, 1982). The Spirit Movement of Alaska Eskimos is a fast growing indigenous
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and culture-congenial forum for young people to learn from their elders how to cope with lifes stresses in traditional ways instead of opting out through alcohol abuse and suicide. Some Alaska native peoples have banned alcoholic beverages from their villages and have banded together to help those members of their community who are alcohol abusers. To combat boredom among the young, free-time activities other than drinking and watching TV have been introduced (such as traditional dancing, sports, arts and language courses) where young and old come together. Women play a decisive role in bringing about these positive changes. There are already indications that selfdestructive behaviour among the young is decreasing in such communities (Shore, et al, 1972). At least for a short time, a young persons suicide will arouse feelings of regret and remorse. As long as the number of suicides in a community does not exceed a certain limit, people will readily accept general explanations such as mental derangement, personal tragedy, or some &dquo;inherited&dquo; weakness in the suicide which could not be changed. But where the recent trend of increasing suicide among young people is manifest, community leaders and the older generation will have to ask themselves what has gone wrong with their society; why so many young people are finding it a society in which it is not worthwhile to live. It will certainly be more constructive to devise culture-congenial ways of helping young people to feel accepted, useful and wanted in their community than to excuse community inertia by projecting the blame for lack of services on the authorities and on health professionals.
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