Book Reviews

Cynthia R. Pfeffer, The Suicidal Child. New York: Guilford Press, 1986. 318 pages. Jeffrey H. Newcorn, Director, Child Psychiatry Inpatient Unit, Mount Sinai Hospital; Instructor in Psychiatry, Mount Sinai School of Medicine.

Since the first flyers announcing the publication of The Suicidal Child appeared, this book has been eagerly anticipated by many. After all, Dr. Cynthia Pfeffer has been a leading researcher in the area of childhood suicide, and her work has reached a large population through her many publications and presentations. Now the President of the American Association of Suicidology and book review editor for this journal, she is one of the recognized leaders in this young but growing field of study. Finally, after a number of months, the book is now available and is sure to fulfill the expectations of those who have been waiting.

The core of this book is Dr. Pfeffer's own work with suicidal children. To those readers who are familiar with her publications, this will be clearly seen in her presentations of the phenomenology and prevalance of suicidal behavior in psychiatric inpatients, outpatients, and non-patients; concepts of death in children; observations relating to family dynamics in families with suicidal children; and the idea that suicidal behavior forms a continuum ranging from suicidal thoughts to threats, attempts, and committed suicide. In a textbook format, there is more space to elaborate these concepts and rework them into a larger picture. As a result, while certain concepts may be familiar, the viewpoint is fresh. A bonus in this volume is a comprehensive appendix in which the scales Dr. Pfeffer has used in her research can be found.

Dr. Pfeffer illustrates her points by presenting clinical vignettes throughout the text. There are no doubt many cases taken from Dr. Pfeffer's extensive experience with suicidal children in clinical practice, both in inpatient and outpatient settings. In addition, there are vignettes of normal children talking about suicide and death, which presumably were gathered in her studies of normal children in public schools. In all, over 80 clinical vignettes are presented.

However, The Suicidal Child is not simply a book about Dr. Pfeffer's work. In addition, a complete review of the literature can be found here. Representative studies are not simply quoted, but are also presented in summary fashion, and conclusions are explained. Some of these studies are quite up-to-date, a major accomplishment in a textbook. Papers through 1985 are included. This must have involved numerous rewrites and last-minute changes in the text, all of which guarantee that this book is not out of date at the time of its publication.

Dr. Pfeffer's major contribution to the study of suicide in children has been to describe what is actually seen and to organize clinical material in a way that is sensible and useful. If her research has been of a descriptive and phenomenological nature, her basic clinical orientation is drawn from psychoanalytic theory, and she clearly states this in the text. This theoretical framework is worth noting here because it is felt throughout the book. There is a very nice balance between what is postulated in theory and what is known because it has been observed, and this balance contributes to Dr. Pfeffer's ability to assemble a coherent picture of this complicated area of study.

The first section of the book, on clinical description and epidemiology, succeeds in presenting familiar subject matter in a new and interesting manner. The chapter on epidemiology contains references as recent as 1985 (as noted above), in addition to detailed descriptions of more traditionally cited papers. Presentations of epidemiological studies by Dr. Pfeffer and her colleagues give a sense of immediacy to the discussion. Dr. Pfeffer is well known for her view of suicidal behavior as a continuum, described above, and this point is clearly made. It seems particularly relevant to establish this in reviewing studies of suicidal behavior in young children, since the phenomenon of completed suicide occurs so rarely in children that it has been difficult to know how to study it.

In addition, clinicians are frequently asked to decide whether a self-destructive thought or act should be termed “suicidal” in the true sense of this term. This discussion is introduced in the first section (Chapter 1, “Definition and Classification of Suicidal Behavior in Children”), but is followed through in a later chapter in greater detail (Section II, Chapter 7, “Children's Concepts of Death”). This is another outstanding chapter, written from a developmental perspective, which points to the many thoughts and feelings children have about death by presenting direct quotations from 11 different children. The overlap of the normal and the pathological, particularly in children recently exposed to the death of a loved one, brought to mind an issue I have wrestled with in clinical practice. I found myself wanting to offer a clinical vignette from my own experience in support of these points—an experience that many readers are no doubt likely to have as well.

Another concept introduced in Section I and elaborated in Section II relates to ego dysfunction during the suicidal episode. These chapters integrate traditional psychoanalytic concepts based on early parent-child relationships with more recent studies relative to cognitive and social functioning. Dr. Pfeffer's studies of defense mechanisms in suicidal children should attract the attention of many readers in her discussion of fantasy material in suicidal children. It will feel familiar to those who have worked with such children. The discussion builds toward a model presented by the author in an attempt to integrate the various components into a final common pathway leading to suicidal behavior.

The second section, on risk factors, is perhaps the most varied and also the most interesting section in the text. There are two chapters on affective and depressive disorders; while it may seem difficult to understand why they are divided as they are, both are highly informative and well written. The first chapter deals with affective disorders in children and adults from primarily descriptive and biological points of view. A review of Beck's work with depression and helplessness as these variables affect suicidal behavior is presented, and portions of clinical scales used in this work are reproduced. Studies by other authors are also carefully reviewed, showing that helplessness may be a common final affect leading to suicide. Analogous research with children is presented, but the number of studies to date is small. Important studies related to the subject of biological markers in suicide are discussed, (i.e. CSF5-HIAA, GH response, REM latency) and there is a full review of the dexamethasone suppression test in children. The chapter on depressive disorders in children begins with early theories of Freud, Spitz, and Melanie Klein, and proceeds to empirical research of the 1970s and 1980s. An excellent review of depression rating scales and structured interviews can be found here. Following a number of clinical case illustrations, a short review of follow-up studies (there are very few) presents what little information is available at this time.

A similarly interesting and well-written pair of chapters concerns the families of suicidal children (i.e., family histories, children of depressed and suicidal parents) and family interactions in families with suicidal children (i.e., dynamics within the children's immediate families). The latter chapter is based on an earlier paper of Dr. Pfeffer's, published in the American Journal of Psychotherapy. Both family chapters deal with important issues in a sensible way, though I am by nature skeptical of the type of model presented in the family interaction chapter. Even if this model is not the model of interactions within the families of suicidal children, it pushes us to consider what these interactions are often like.

The two chapters comprising the third section, on assessment of suicidal risk, are also both of fine quality. While some parts of the chapter on clinical interviews will be familiar to many readers, a number of important issues are discussed thoughtfully. How to deal with discrepancies in parent and child reports of past behavior and how the clinician himself or herself may respond to a suicidal child are issues that simply must be talked about. Dr. Pfeffer is also successful at spelling out an information base that is required in the evaluation of a suicidal child. This will be extremely useful to trainees and even to established practitioners who are honest enough to realize that a more expansive data base for evaluation of suicidal children may be in order. Moving from talk to play, many readers will enjoy the chapter on observation of the play of suicidal children. For those of us who deal regularly with such children but who have not yet closely observed hundreds of such children, the collected observations of the author are most welcome.

The fourth and final section of the text is entitled “Intervention for Suicidal Behavior.” It describes an approach to treatment planning for suicidal children and presents models for inpatient and outpatient treatment. These chapters are well organized, and the sensible models for treatment will appeal to many readers. I must confess, however, that I am often disappointed when I encounter such models in print. Somehow or other, the complexity and art of clinical treatment is almost impossible to capture in words, and the results seems to me often disappointing. While I basically agree with Dr. Pfeffer's proposals for treatment and feel that anyone who follows them will perform at a very high level, something of the active sense of treatment seems to be missing. In addition, some readers may take issue with relegating a number of important treatment modalities to “adjunctive” status while individual therapy, essential as it is, occupies center stage alone. For some children, educational, pharmacological, or social interventions may be equally important.

In conclusion, The Suicidal Child is a very important book that is scholarly, sensitive, and extremely useful. It is likely to appeal to a wide audience, and this is proper. There is something here for professionals at all levels of experience, medical and nonmedical alike, and there are many useful suggestions regarding potential research projects for those who are seeking to study this area seriously. As Dr. Pfeffer aptly notes in the epilogue, this book can only focus on what is known today. There are many gaps in our knowledge. But there will be more learned and more written in the years to come. Perhaps Dr. Pfeffer will be able to present us with answers to some of the questions she raises in this volume in the not-too-distant future.

Joseph Richman., Family Therapy of Suicidal Individuals, New York: Springfield, 1986. 210 pages.Reviewed by Fady Hajal, Assistant Professor of Psychiatry, Cornell University Medical College.

The recent wave of adolescent suicides suggests a need to reconceptualize suicidal behavior as embedded in a familial-social context, rather than as a strictly individual (intrapsychic) matter. Dr. Richman's book presents such a reformulation of suicidal phenomena, one that integrates contributions from the field of individual psychology (and psychoanalysis) and the field of family therapy. Dr. Richman argues in his book that suicidal behavior pertains not to an individual alone, but to a family and social network. Richman attempts to show precisely how family factors play crucial roles in all the phases leading up to suicidal behavior. Family events and dynamics contribute to all the stages leading up to a suicidal crisis—first as vulnerability factors, later as risk factors, and finally as immediate precipitants of a suicidal action. Dr. Richman draws his evidence from his extensive experience working with hundreds of individuals and families in suicidal situations.

This book is divided into three sections. The first deals with the origins of suicidal crises. At the root of any suicidal crisis, Dr. Richman argues, there are vulnerabilities, which can best be summed up in two concepts at the interface between individual dynamics and family systems: separation and symbiosis. The specters of separation and loss are threatening for suicidal individuals and families. Separation anxiety generally transcends the individual most visibly suffering from it, for the problem of separation pervades the family system as it is experienced by many, if not all, family members. Families that are characterized by a symbiotic quality, with rigidly knit, alienated-alienating relationships, experience the threats of separation and loss more intensely and desperately than other families. Separation and loss in these families are felt not only as threats to the individual, but as threats to the family. A “survival” myth prevails, which postulates that the entire family will be destroyed if any one of its members leaves.

Thus is set the drama that may eventuate in suicide: The developmental push toward separation clashes with the conservative, homeostatic forces in the family, which fears that the loss of one of its members is tantamount to its own annihilation as a family organization. Often one family member has come to symbolize the values, traditions, and myths of the family, and thus the family is unable to release him or her from its fold. Any threatened or actual loss of that member will trigger reactions and processes aimed at maintaining family stability, at the cost of blocking change or individuation, even at the cost of suicidally sacrificing the individual. The individual trapped between his or her own growth imperatives and the homeostatic family pull may despair of finding any way out of the dilemma other than suicide. If the suicide is completed, its repercussions will shake the family to its roots. The “ripple effects” will spread conflict, blaming, and physical and emotional distress throughout the family system, sometimes culminating in a death in the family or even another suicide.

Dr. Richman identifies other conditions as risk factors for suicide. Bereavement, for example, constitutes a risk factor. Richman points out that suicidal ideation and impulses may occur frequently in a state of bereavement, particularly when the dead person is one of the central figures in a family, symbolizing primary attachments as well as family values and history. The ripple effects of such a death are all the more destructive if the family's mourning is interfered with. In such situations, bereaved family members may become the target of blame and scapegoating, and may be left unsupported and disconsolate, thus putting them at risk for self-destructive resolution of the mourning crisis.

Such is the risk in states of bereavement that Richman strongly supports the idea of training funeral directors in the techniques of family interviewing and intervention. Funeral home personnel would thus be able to identify families undergoing disturbed mourning and to refer them for further help, either from mental health professionals or from self-help groups.

In the second part of his book, Dr. Richman elaborates on the mental health assessment of families with suicidal individuals. Since he believes that the family is generally an etiological component of the suicidal situation, as well as being affected by it, it follows that a psychiatric assessment of any suicidal situation (whether actual or potential) must involve the entire family. In Dr. Richman's opinion, an assessment of the individual alone, no matter how thorough, is insufficient. Consequently, family members, including the suicidal one, are seen individually at first and then as a group, in an effort to comprehend family patterns and dynamics, to identify powerful family members, and to look for “suicidal” interchanges. In some families, explicit or covert death wishes are directed at the suicidal member of the family. In addition, assessment of the family allows the clinician to gauge the adequacy of the family and social network to support the suicidal individual in an effort to stave off the suicidal crisis. Formulation of a treatment plan is done with the collaboration of the family as well as the suicidal individual.

Dr. Richman asks all family members to agree to a “no-suicide pledge.” Usually such a no-suicide contract is established with the suicidal individual alone; Dr. Richman advocates the family no-suicide pledge because he believes that the acceptance of suicide as a possibility is a family and social network phenomenon. He also identifies a number of family characteristics that should alert the clinician to suicidal potential in the family. Among these, he lists an inability to accept necessary change; role and interpersonal conflicts; failures and fixations; unbalanced or one-sided intrafamilial relationships; and affective difficulties.

Included in the section on assessment is a chapter describing the application of the Machover Figure Drawing Test to the task of assessment of suicidal potential. Dr. Richman believes that this procedure is particularly sensitive to the expression of suicidal impulses, because the act of drawing (as opposed to talking) helps the individual overcome cultural and linguistic barriers as well as verbal defenses. Thus, the patient may expose in the drawings subterranean impulses that may be otherwise unacknowledged. Problems in impulse control and acting out can be picked up by the test, as well as more formally elaborated suicidal impulses. In a number of suggestive drawings that Dr. Richman includes in this chapter, the expression of suicidal ideation takes the form of slash lines at the level of the neck or the wrists, for instance, or of heavy underlining of certain areas of the body that may later be the sites of suicidal attack on the body (stabbing, etc.). The author recommends that all psychiatric patients be routinely evaluated for suicidal potential with drawings as an important diagnostic tool.

The third section of the book deals with the family treatment of individuals manifesting suicidal behavior. Again, the emphasis is on the need to help the family resolve the stalemate pertaining to issues of separation and individuation. A primary focus of the family work is to disentangle the symbiotic ties that bind the family members together and perpetuate the fear of being disloyal to the family. However, Dr. Richman cautions the too-eager beginning therapist against demanding or expecting an early, and probably premature, loosening of the symbiotic bonds. Accepting the family as it presents itself to the clinician is an important first step for the therapist in order to establish a rapport with the family. The capacity to empathize with all family members, no matter how rageful or destructive they seem to be, is an important ingredient in work with these families. Using clinical vignettes as illustrations, Dr. Richman describes several of the types of patterns—double binds, scapegoating, role failures, emotional isolation within the family, and social isolation without—that characterize suicidal families. He also describes patterns of communication within these families that convey suicidal messages to the suicidal member.

Dr. Richman's book is highly informative and provocative. His perspective on the family determinants of suicide is original and enriching. His formulation of suicide as a crisis of the family and social network makes eminent sense. Clinicians and all those who are in a position to help people tormented by suicidal impulses should be familiar with this conceptualization of suicidal behavior so as to include the families of their suicidal patients in their assessment and intervention. As a first step, they should read this interesting and helpful book.

Eric E. Rofes “I Thought People Like That Killed Themselves”Lesbians, Gay Men and Suicide. San Francisco: Grey Fox Press, 1983.Reviewed by Sharon Valente, Adjunct Assistant Professor of Nursing, University of Southern California.

One of the most critical contributions an author can make is to present a problem that fascinates the mind and captures the emotions of the reader, and that stimulates interest in further research and investigation. Eric Rofes does this effectively as he explores the problem of suicide and homosexuality. The provocative questions and data in this book must be considered by anyone who is involved in suicide work, prevention, or research. This book challenges the reader to reconsider personal values and attitudes toward homosexuality, to evaluate the needs of suicidal clients who are gay men or lesbians, and to look again at the taboos that have kept both suicide and homosexuality hidden and shrouded in stigma. Rofes's thesis is that suicide and self-destructive tendencies among gay men and women are rooted in social oppression. It is these same forces that have kept the suicides of gay men and women from adequate research and investigation.

In Chapter 1, “Myth and Fact of Gay Suicide,” Rofes first states that although gay studies reports of the 1970s have shown that suicide attempts and serious suicidal thoughts are three times higher among gays than heterosexuals, it is premature to conclude whether the gay suicide rate is increasing or decreasing. Nonetheless, these findings do highlight a serious problem; they indicate the need for more representative sampling and research data on completed suicide in gay and lesbian subjects of various age and ethnic groups.

The chapter continues with a discussion of the historical context of homosexuality and suicide. Before the 19th century, both suicide and homosexuality were considered as isolated actions of individuals who had fallen victim to sin and crime, and society imposed severe punishments on such individuals. If suicide was discovered, then the corpse could be degraded and the family stripped of possessions and left in shame. Unless homosexuals managed to avoid exposure and live in secrecy, they too faced severe penalties: The accused could stand trial and accept a punishment that might include burning at the stake, castration, flogging, or hanging in the public square. Escape into exile was a possibility for those with money; for others, agony preceded the third option—suicide. After the 19th century, many literary and scientific writings perpetuated the myths that connected homosexuality with illness and violence.

Once homosexuality was considered an illness, the medical profession “energetically analyzed the ‘cause’ and searched for the ‘cure’(p. 7). The most dangerous fable that accompanied this medical investigation was the notion that the homosexual act itself already represented a ”suicidal tendency, an inner fury against prolonging the race or an unconscious need to merge with the stronger person of the same sex“ (p. 9). The attitude of condemnation was clear in the literature, which continued to link homosexuality to suicide and publicized the idea that gay men and women were responsible for murder, suicide, and ruin. Another myth proclaimed that homosexuals were depressed, dejected ”people frequently on the brink of suicide after a life of hopeless despondency” (p. 11). Rofes demonstrates that even though these myths were far from the truth, they had a tremendous impact on the gay men and women who were forming their identities at a time when these images prevailed and other, more realistic role models were either invisible or unavailable.

In Chapter 2, “Scandal, Blackmail and Public Exposure,” vignettes illustrate how many men and women have been forced to choose between what they perceive as a life of ruin and disgrace or the only escape they see, suicide. Schoolteachers have given up careers and moved rather than face exposure. Gay men and women in the armed forces or government service have chosen suicide rather than face morals charges for lewd conduct. In one instance, an accused man who was verbally abused in jail later slashed his wrists and hanged himself. The president of Washington, D.C.,'s Gay Activist Alliance told the press, “Some say this man committed suicide. We know he was killed by the society which made him an outcast.”

Suicide as an escape from blackmail or scandal is not only a phenomenon of the past. Today, gay men and lesbians are perhaps even more vulnerable to public exposure than they were in past years. As more people become aware of gay life-styles, gay couples have less chance of remaining unnoticed. Antihomosexual attitudes change slowly, and the price of being visible may be greater for some than the costs of suicide. This vulnerability will continue as long as laws specifically target or are primarily enforced against lesbians and gay men. Some gay men and women will continue to choose suicide rattier than face trial. As Stuart Kellogg, interviewed by Rofes, says in an eloquent discussion of his suicide attempts, “Who wants to live if living means a charade at best and exile at the least?”

In Chapter 3, “Lesbian and Gay Youth and Suicide,” Rofes states that sexuality is a critical but ignored motif in suicide and that youths who struggle with gender, sexuality, and homosexuality issues consistently report that health professionals and others turn a deaf ear to these concerns. These teens are estranged not only from the medical profession, but from other sources of understanding and support as well. Case excerpts show how adults have ignored the themes of homosexuality and remained blind to obvious clues to gender and gay issues. Unfortunately, the teens struggle with these problems in silence and feel unable to surmount the barriers of taboo and suppression. Communication for any suicidal teen is always difficult. The teen who has questions about whether he or she is gay or lesbian must overcome additional barriers to talking about inner turmoil and questions about life, death, and identity.

“Suicide and Activists,” the fourth chapter, concerns the myth that “coming out” as a gay person may offer the antidote to the suffering of a stigmatized life-style. The illusion for some is that activism and visibility have the potential to change homophobic attitudes, stereotypes, and oppression, and possibly to protect the self-image by directing anger toward an outside target. While coming out can make resources more available and can increase self-esteem, the reality is that any change is slow. The dreams of great change and the slow process of realistic change may conflict, leaving despair and depression.

Claudia Scott and Michael Silverstein were two activists interviewed by Rofes whose suicides demonstrate that self-destructive tendencies may continue when the benefits of coming out and activism are not enough. The cases of Michael and Claudia show that life for a gay person remains difficult, painful, and sometimes overwhelming. Despite their political achievements, they were struggling with deeper conflicts and pressures that pushed them toward self-destruction. Rofes emphasizes that although this conflict may be misinterpreted as a link between the self-concepts of gay men and women and suicide, it is obvious that homosexuality “itself is not the problem but rather it is the way in which society at large perceives and reacts to homosexuality” (p. 54).

Finally, Rofes indicates that medical examiners and police authorities are likely to consider the deaths of lesbian and gay male activists as suicide, regardless of the circumstances surrounding the deaths. This is the opposite of the tendency to consider most other suicidal deaths as accidents unless there is specific evidence pointing to suicide; in some cases, suicide is denied unless a note is visible.

In Chapter 5, “Substance Abuse and Gay Suicide,” there is little disagreement not only that the rate of alcoholism among gay men and lesbians is high, but also that their alcoholism is a response to feelings of depression. Alcoholism also clearly connects with thoughts of suicide and higher rates of suicide. Reasons for the high rate of drinking in the lesbian and gay community include the role bars play as centers of socialization, the common use of alcohol and drugs as one way to cope with societal oppression, and the importance of alcohol in the social network. Often drinking in a bar is equated with identifying with the gay community. In case vignettes, Bill and Michael describe their experiences with alcohol and illustrate how their addiction grew. Rofes points out that alcoholism and drug use are problems that face both gay and straight communities. He focuses on the need for programs to prevent continued patterns of depression, alcohol and drug abuse, and suicide attempts. Programs are needed for substance-abusing gay men and women that help these people find other ways besides the substance abuse to deal with pain and anger at societal attitudes. Rofes also notes that substance abuse programs that do not cater to gay or lesbian communities probably have a large percentage of gay male and lesbian clients; yet these programs are hampered because they ignore the special problems of the lesbian and gay male substance-abusing population. Rofes suggests that substance abuse will continue as long as using alcohol or drugs is accepted as a part of gay or straight sexual identity. Rather than being accepted as a status symbol, substance abuse should be recognized clearly as a problem of self-destructive proportions.

In Chapter 6, “Areas for Continued Research,” Rofes suggests a number of aspects of suicide and homosexuality that deserve investigation: suicide among elderly lesbians and gay men; sexual practices or fantasies and suicide; gay youth and suicide; suicide among closeted homosexuals; the role of suicide among lesbians and gay men of color; and the loss of a lover as a risk factor in suicide.

In the final chapter, “Ending Gay Suicide,” Rofes focuses on intervention at all stages. He begins by emphasizing the importance of suicide counselors who evaluate their own homophobic attitudes and who become knowledgeable about gay and lesbian issues as well as suicide; he also encourages the gay community to become more aware of the signs of suicide and the ways of providing support, resources, and referral to individuals who are suicidal. The issues of postvention, discussed next, include all aspects of coping with death and bereavement. There is particular emphasis on the difficulties that survivors such as “gay widows” face in legal issues of inheritance and questions of ownership rights; also described is the community grief that results when a member of the gay or lesbian community dies, especially when the person is a well-known activist.

The section of the chapter on prevention stresses the danger of separating mental health issues from sociopolitical issues. Rofes maintains it is important to acknowledge that the root cause of suicide among gay men and lesbians lies in the persecution they experience. Rofes explores Durkheim's premise that the status lesbians and gay men are granted as social outcasts forms one pathway to suicide: “Until societal attitudes change significantly and being gay or lesbian does not conflict with other status as a parent, worker, teenager, or professional, suicide will continue to plague gay men and lesbians” (p. 118). Rofes also advocates continuing resistance as the major work of suicide prevention. He challenges politicians, educators, and church officials, as well as health professionals, to address and change the social oppression and antigay attitudes that forge the forces of suicide.

Ending gay suicide requires an end to discrimination, hatred, violence, and trivialization directed against lesbians and gay men. Nonetheless, the present challenge for health professionals and suicidologists is to investigate the idea that homosexuality may be a critical risk factor in suicide; to understand the problem through adequate research; to prevent suicide through well-developed, sensitive intervention programs sensitive to the needs of the gay and lesbian community; and to advocate community-based prevention and education. This book is “must” reading that will provoke thought and discussion among all people committed to understanding and decreasing suicide.