Why do some people kill themselves? What causes the problem?
Suicide is not confined to humans alone.
It is said that when lemmings breed to a state of overpopulation they commit collective suicide by pouring over cliffs into the ocean, while dolphins and whales have been known to end their lives by deliberately stranding themselves in the shallows. It is as if Nature controls ecological balance by an invisible pair of hands.
"Maintaining ecological balance" does not, however, account for the phenomenon of human suicide. Instead, there are cultural, social and psychological factors that need to be examined.
Fate, or psychiatric illness?
Last October a talented 9th grade school pupil died by jumping from a high window. In his suicide note the boy wrote that after coming under suspicion of cheating at school, "the idea of suicide, which I had already contemplated, suddenly took hold." What shocked many was that the boy's parents said his suicide had nothing to do with school, and was a "personality" problem.
Why do some people commit suicide and others not?
In psychiatric medicine the causes of suicide are attributed to differences in people's "constitutions." Chiang Han-kuang of Tri Service General Hospital's Department of Psychiatry says that people prone to suicide tend to share certain character traits: they are easily upset, unstable, anxious, depressive and poor at adjusting.
People with these characteristics do not inevitably commit suicide, but are more likely than others to resort to suicide under particular kinds of external pressure.
In addition to the existence of suicidal character types, it is true in Taiwan as elsewhere in the world that a high percentage of people who kill themselves are suffering from psychiatric illness, with depression being the major factor.
According to Hu Wei-heng, President of the Taipei City Psychiatric Center, studies in the West have found that 45-70% of those who commit suicide are suffering clinical depression, while 15% of clinically depressed people die by suicide.
"A suicide attempt is one of the symptoms of a psychiatric condition," says Chiang Han-kuang. Psychiatrically ill people often make repeated attempts on their own life, with virtually no advance warning.
Lin Hsien, psychiatrist formerly at NTU Hospital, gives a disturbing description of the suicide of one psychiatric patient in his book The Mind and Mental Illness. When a nurse dropped a milk bottle the patient picked up a fragment of glass unnoticed, and calmly used it to slit his own belly under the covers. By the time that the nurses saw him turning pale he was already beyond saving.
The age of depression
The increased incidence of depression in society is closely related to changes in society itself, and according to some sociologists, it is society's "inhumanity" which causes people to lose the will to go on living.
The renowned sociologist Emile Durkheim believed that there is a direct link between suicide and the condition of society. Whenever the social order is disrupted by a major upheaval, whether that upheaval is for the better or worse, people become increasingly prone to suicide.
When the established order is being overhauled, society loses its own sense of identity, and pressure mounts up. Under these circumstances some people become "acute-ly" suicidal, and many others "chronically" suicidal. According to Hsu Wen-yao, associate professor in psychology at National Chengchi University, many behavioral habits actually equate to suicide, including smoking, drinking, drunk-driving and speeding.
"Taiwan is currently in a 're-ordering' phase," says Hsu. "Tradition has been smashed but a new order has yet to take its place. During this process of transition society is manifesting serious signs of 'disorder.'"
Taiwan has experienced similar periods of adjustment in the past. The rate of suicide began creeping up during the political turmoil and economic instability that followed the Second World War, climbing from 10 per 100,000 of the population to a peak of 19.1 per 100,000 in 1964. For the last ten years, however, the rate has consistently been below 10.
A mirror on society
"One can get a more accurate picture of a country's welfare system, the mental well-being of ethnic groups, and the overall health of society by looking at the suicide rate rather than life expectancy," remarks Hu Yu-hui, professor at Yangming University's Institute of Health and Welfare.
Suicide can be said to hold a mirror up to society. Who do we see in that mirror in Taiwan, as the people most likely to kill themselves?
Surprisingly, the answer is neither teenagers nor police-groups about which there are strong suicide-related concerns-but old people, whose deaths rarely make the news.
Elderly people have the highest rate of suicide among all age groups in Taiwan. In 1996, the suicide rate among those aged 65 and over in Taiwan was around six times the rate for those in the 15-24 age bracket-an unusually high ratio. In Britain, there is virtually no difference between the two rates, while in Australia the rate is actually slightly lower among the elderly than the young (see Table 1).
Researchers note that the high rate of suicide among the old has to be viewed in connection with the problems of poverty, illness and low self-esteem.
According to a government survey in 1989, 57% of old people in Taiwan live in poverty. The lower down the social ladder old people are, the greater their economic dependence on their offspring. In the case of women who are old and illiterate, 78.6% of living expenses are provided by their offspring.
The low status of the old in today's families can be read from the space they are given to occupy. Traditionally, an old member of the family would have one of the principal rooms in the house. Today, however, old folk are more likely to be crammed into the most out-of-the-way corner in the apartment.
In addition to poverty, loneliness and lack of self-respect, the old also have to cope with illness and physical decline. For many this is when life loses its luster, and thoughts turn to ending it all.
Western countries have longer experience dealing with the problems of an aging population, and have developed systems of social welfare to provide for the economic, medical and other needs of the old.
In Taiwan, where the welfare system is still being developed, looking after the old is basically a matter for the family. Changes in society, however, mean that the traditional functions of the family have begun to drop away. When neither the family nor society is equipped to take care of the old, they fall between the cracks, and perhaps it is not surprising then that so many turn to suicide.
"Looking after the old is a major responsibility of society. Leaving it as an internal matter for the family results in old people being a 'burden' on the family," says Hu Yu-hui. While studying women's issues, Hu found that "in those Asian societies which emphasize 'three generations living under the same roof,' and expect the family to be welfare-provider to the aged, elderly women are at higher risk of committing suicide than their counterparts in Western countries."
Hu explains that it is easier to compare suicide rates among different countries by looking at the relative rates for different age groups, because of the varying levels of accuracy among each country's suicide statistics. In Taiwan, the rate of suicide among elderly women is 3.2 times higher than the rate for women in general, while the corresponding ratio is 4.2 in Singapore and 2.4 in Japan. In contrast, the ratio is only 1.2 in the US and 1.5 in the UK, Sweden and Australia-countries with a developed system of welfare provision for the elderly.
Of course, the traditional values of a society are a significant factor. Among the Chinese it is considered a virtue to take care of one's family elders, and there is more reliance on relatives, whereas privacy and independence are emphasized in the West, where old people are more likely to want to live alone and thereby to preserve their own dignity.
Teenagers don't know real depression?
In terms of age brackets, the suicide rate in Taiwan peaks twice: among the old and among teenagers.
Old people commit suicide faced with "the bleak years of decline." It's distressing, but not incomprehensible. When teenagers-who should have their best years ahead of them-kill themselves, however, it is both saddening and inexplicable. It was in July 1994 that Taiwan was stunned when two high-achieving pupils from the elite Taipei First Girls High School killed themselves in a hotel in a suicide pact.
Hsu Wen-yao points out that rising suicide rates among teenagers is a feature common to many societies, and research suggests this is related to various factors including a rapidly changing environment, family break-up and declining levels of family support.
Another factor is that as schools get ever larger, it becomes increasingly difficult to give students adequate counselling. Faced with problems, today's teenagers often have no-one to turn to for support or help.
According to a survey conducted by the John Tung Foundation in the Greater Taipei area, some 36% of school pupils at the upper-elementary and middle-school level are "unhappy."
For teenagers, the main pressures come from family and from relations with their peers. Hu Yu-hui has found that teenagers are more likely to become depressed and consider suicide when they encounter the divorce or separation of their parents, or illness, or relationship problems.
Teenagers contemplating suicide very rarely make use of the organizations that can help them at such a time. According to Chu Kai-yu, general secretary of the Taipei City Lifeline, teenagers account for less than 6% of calls for help that the lifeline receives, and when teenagers do attempt suicide they often succeed first time around. NTU Hospital psychiatrist Wang Hao-wei explains that teenagers have a limited choice of tools for the job, and little sense of moderation, with the result that they are more likely than other groups to die in their suicide attempts.
Communication, and seeking help
Suicide also reflects gender inequality in society. Research shows that females in Taiwan are more likely than males to contemplate or attempt suicide.
Statistics from the Lifeline, which primarily aims to prevent suicide, show that nearly 70% of calls are from women seeking help or needing someone to talk to about their troubles, which testifies to the pressures and burden of being a women in this society.
Hu Yu-hui explains: "The high rate of suicidal feelings among females is due to the fact that with the limited resources and power at their disposal, women only have suicide to resort to as a means of crying for help, or retaliating." On the other hand, the actual suicide rate for women is lower than for men, because women adopt milder methods, primarily overdoses.
During Taiwan's early period of modern development, however, young women between the ages of 20 and 24 had a higher suicide rate than their male peers, running counter to the established pattern around the world in which suicide rates are higher among males. Citing 1905 as an example, Hu reports: "In that year the suicide rate among young women in Taiwan was eight times the rate in the US, and 20 times the rate in Sweden and Spain."
According to research by the American anthropologist Margery Wolf, Taiwan at that time was a traditional patriarchal society in which there were great pressures on a new daughter-in-law joining the family, and this was reflected in the high rate of suicide among young women. As the biography of Shih Chen Hsiu-lien, the mother of Acer Group founder Stan Shih records, in those days it was considered more daring for a young woman to run away from the family than to kill herself.
With the spread of the "nuclear family" as well as the concept of gender equality, there has been a gradual decline in the rate of suicide among young women. Among old people, however, the rate of female suicide is gradually climbing. It used to be that young women committed suicide to escape the trials of life as a daughter-in-law. Women of that generation who survived to become today's mothers-in-law find that the situation is now reversed, and once again they are in the age bracket with the higher rate of suicide (see Table 2).
It is worth noting that marriage has a very different effect on the suicide rates of men and women. Research by Hu Yu-hui reveals that men who are unmarried, divorced or bereaved of their spouse, are more likely to commit suicide than married men, whereas the suicide rate for women is more or less the same whether or not they are married.
"Men rely on women to prop up their psychological well-being," says Hu, and marriage clearly has a "protective function" for men.
Higher rates of suicide in the hills?
Another result of the unequal distribution of resources in society is the high rate of suicide in Taiwan's mountain areas.
From the teenage years upwards, the rate of suicide among Taiwan's aboriginals far exceeds the national average, particularly among males in their prime years. According to work by Chang Li-yun, a researcher at Academia Sinica's Institute of Ethnology, the rate of death by human causes (including suicide and alcoholism-related liver cirrhosis) in this category is six times the national average.
In spite of living conditions which are a great improvement on the past, Taiwan's mountain districts are still poor compared to the rest of the island. Under pressure from Han Chinese acculturation and the flow of young people away to the cities, communities in these areas have been left facing declining populations and social disintegration. The stress shows up in the high suicide rate.
Associate researcher Cheng Tai-an of the Academia Sinica Institute of Biomedical Science conducted a four-year study into suicide in the east coast region of Taiwan, where he found an alarming suicide rate of 24 per 100,000; 97% of those who killed themselves were suffering psychiatric illness, most commonly depression and alcoholism.
The final way out
Although suicide rates vary according to sex, ethnicity and age group, it is relationship problems that form the most common single factor.
Some people attempt suicide in an effort to regain lost affection. But "crying wolf" too often ends in disaster, as in the case of pop singer Yu Feng, whose boyfriend declared after her death that Yu hadn't really intended to kill herself. A young woman whose relationship is in trouble may take an overdose, from which she is saved, in order to reclaim the attentions of her boyfriend. Six months later, however, the relationship is back in trouble and the couple eventually break up.
There are also instances where one person, knowing that the relationship cannot be rescued, commits suicide in order to punish their partner with a lifetime of guilt. In one case, a bright and talented financial analyst at a securities firm, despairing over the collapse of her marriage, killed herself and her two little children with doses of hydrochloric acid. Her husband was having an affair and wanted a divorce, and she had reportedly told a friend: "I want to make him regret it for the rest of his life!"
Suicide is also frequently the final option for people who feel they are in an unendurable position. "Face" and personal reputation have always been big concerns among the Chinese, and Chinese history is littered with tales of those who committed suicide rather than live with the shame of their failures. It still happens today, as in the recent case of the company boss who fled to Canada with huge debts after his business collapsed, but couldn't escape his guilt, and finally killed himself along with his wife and children.
The silent protest
The extinction of any life is a loss to society. According to a study by Wang Jung-teh and Tsao Chao-yi of National Taiwan University's Institute of Public Health, during 1989 alone Taiwan lost total income of over NT$7.7 billion through suicide. The figure would be far higher if the accumulated cost of medical treatment, and of the time and cost to the relatives of those who killed themselves could be factored into the equation.
Can suicide be prevented?
Among different trades and professions, it is suicide in the police force that has drawn most attention in recent years. People tend to ascribe this to dangerous work, long hours and heavy pressure. Statistically, however, the suicide rate among members of the police force is not particularly high, and the causes usually concern relationships or family problems, just as in other sectors of society. The only distinguishing factor is that with easy access to guns, police tend to commit suicide by shooting themselves.
For this reason, making it harder to obtain lethal weapons could affect suicide rates. Wang Hao-wei describes how the introduction of stricter gun controls in a certain US state, stipulating a wait of six weeks between registering to purchase a gun and actually obtaining the weapon, immediately cut the incidence of impulse suicides and led to a fall in the overall suicide rate. Similarly, it is said that there was a marked drop in suicides in Britain after that country began using non-toxic domestic gas.
According to Hsu Hsi-hsiang, who has worked as a volunteer on the Taipei City Lifeline for 11 years, the first thing when dealing with someone who wants to commit suicide is to avoid giving any advice, because they "won't hear it." The best approach is to be with them through the anguish, and later slowly help them to tackle their problems and find a way forward.
Chu Kai-yu, secretary-general of the Taipei City Lifeline Association, stresses that someone who has just attempted suicide should never be left staying on their own, because people in this condition have not yet recovered from their problems and may well try again.
Aside from these technical preventatives, the most fundamental point is that suicide is a warning sign and cannot be ignored. The wide disparities that exist between the suicide rates of different age brackets and different ethnic groups form a silent protest-a protest that must be heard as we consider the future distribution of resources in society.
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Death is the worst suffering of all-why should anyone voluntarily end their own life?
p.114
Neglected by family and society alike, Taiwan's old people have the highest rate of suicide of any age group.
(facing page) Women shoulder all manner of burdens in the family, and tend to rely more on religion for strength. During the early part of this century female suicide was more pronounced among the younger generation. Today, however, it peaks among old women-the most disadvantaged of the disadvantaged.
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Table 1. Rates of Death by Suicide-An International Comparison
Source: WHO (World Health Statistics Annual,1994)
graphics by Liao Tzu-Wen
p.117
Drag racing and drug abuse can also be viewed as self-destructive, suicidal behaviors.
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Table 2. Women's suicide rates in Taiwan, 1905 and 1984
graphics by Liao Tzu-Wen
Suicide rate per 100,000
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High suicide rates among specific sectors of the population provides a warning, which must be heeded, about the "inhumanity" of society.
For some people, attempting suicide seems the only way left to communicate or cry for help. Timely and genuine concern from those around them is of prime importance.
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