Book Reviews

David C. Clark (Ed.), Clergy Response to Suicidal Persons and Their Family Members. Chicago: Exploration Press (Chicago Theological Seminary, 5757 S. University Avenue, Chicago, IL 60637), 1993. 219 pages.

Reviewed by The Reverend Richard Liew, PhD, Director, Pastoral Care and Education, The New York Hospital-Cornell Medical Center, Westchester Division, White Plains, New York.

As Dr. Clark, the editor of the book, states so succinctly: “Suicide, is an equal-opportunity tragedy — it touches every age group, ethnic group, race, and level of income or education (p. 170). Suicide is the eighth leading cause of death in the United States. The ensuing devastation and suffering from suicide “profoundly alter the lives of more than 3,800,000 Americans each year” (p. 171). Given the magnitude of this problem and the fact that most people (when faced with a crisis like this) turn to their clergy, it is fitting that the clergy is the natural target of this book.

This book grew out of the series of conferences held at the Rush-Presbyterian-St. Luke's Medical Center in Chicago, where the editor is associate professor in the Departments of Psychiatry and Psychology, and where he is also the director of the Center for Suicide Research and Prevention. The conferences were designed to impart current research findings on suicide and their practical implications for clergy with congregations.

Among the contributors to the book are psychiatrists, theologians, psychologists, pastoral counselors, rabbis, pastors, ethicists, and chaplains. Many of the contributors (e.g., Rev. Laurel Arthur Burton, ThD, Rev. Homer U. Ashby, PhD, Rev. George Fitchett, DMin, Paul C. Holinger, MD, — to name just a few) are well known and respected in the pastoral care and counseling circles.

The book provides guidelines for recognizing and responding to individuals with suicidal behavior and communication, and to ministering to these individuals, their families, and others who have to cope with the aftermath of suicide. The 15 chapters of the book (excluding the introduction and the three appendices) are organized into six sections. Each section addresses one of the following subject areas: “Suicide in Theological Traditions,'’“Fundamental Knowledge and Skills for Clergy,” “Physical Illness and Suicide,” “Grief After Suicide,” and “Spirituality and Mental Health.” Significant emphasis is placed on the recognition, detection, and assessment of suicidal risk. But equal emphasis is also given to the circumstances and situations where referral is advisable — perhaps necessary — and how to go about it. Other important issues covered in the book include the moral and ethical dilemmas related to “rational suicide” (p. 101) and “the right-to-die” (p. 102), and the legal dilemmas related to “confidentially” (p. 83) and the legal “duty to warn” (p. 83). The book is rounded off with three appendices. Appendix A provides a thorough overview of the scope of the problem and the demographic patterns of suicide. Appendix B and Appendix C are two public reports: Appendix B is the “CDC (Centers for Disease Control) Recommendations for Community Plan for the Prevention and Containment of Suicide Clusters” (p. 187), and Appendix C is the “Recommendations from a Workshop on Suicide Contagion and the Reporting of Suicide” (p. 207), which includes guidelines for public officials and media to use when working with a suicide story.

With its practical suggestions, advice, and cautionary notes, this book takes a pragmatic approach in assisting clergy to deal with suicide. The liberal use of case materials along with generous doses of clinical vignettes, throughout the book, helps bring home the point, breathes life into the subject matter, and vividly portrays the issues. A non-Christian cleric, unfortunately, will need to overlook the rather consistent association and reference to the clergy with the Christian term “pastor,” in order to discover the value of this book.

This easy-to-read book is a welcome addition to the sparse body of pastoral care literature on the subject of suicide. All pastoral and spiritual caregivers, regardless of whether they are novices or veterans, or whether they are clergy with congregations, chaplains, pastoral care educators and students, or hospice caregivers, or nurses will garner much from the book. Recommendation? A definite read — better yet, own the book!

Raymond Jack, Women and Attempted Suicide. Hillsdale, NJ: Erlbaum, 1992. 279 pages.

Reviewed by Silvia Sara Canetto, PhD, Department of Psychology, Colorado State University, Fort Collins.

In many industrialized countries, nonfatal suicidal behavior — commonly referred to as “attempted suicide”—is, in Showalter's (1985) words, a “female malady.” Yet the meaning and implications of women's preponderance among suicide attempters has been virtually ignored in the theoretical and empirical literature. Jack's book Women and Attempted Suicide does just that; it addresses what the author considers the main questions of nonfatal suicidal behavior in Western industrialized countries: Why women? Why self-poisoning?

Jack describes the epidemiology of nonfatal suicidal behavior and finds that traditional theories have misinterpreted or neglected several of its distinctive features. For example, he notes that most theories do not deal with the fact that nonfatal suicidal behavior is most common among working-class individuals. His conclusion is that available theories have overemphasized individual variables, such as psychopathology, while neglecting contextual variables, such as gender and social class. Finally, he proposes to increase both our understanding of nonfatal suicidal behavior and the efficacy of intervention practices via attributional theory.

One limitation of Jack's analysis is that he recognizes age as an important predictor of risk for nonfatal suicidal behavior but does not integrate age into his theory (“Why is nonfatal suicidal behavior most prevalent among young women?”). Similarly, questions of race/ethnicity/immigration status are not addressed, neither as theory nor as treatment concerns. There is a larger body of literature on the suicidal behavior of women of color than one is led to believe by the coverage in his book. Finally, the author does not question the common assumption that women's suicidal behavior is “motivated most frequently by events in the ‘private’ or relational domain, whereas that of men more often is related to events occurring in the ‘public’ realm of work, financial and legal problems” (p. xiii). Although he acknowledges that social expectations influence women and men toward different kinds of “nonconformity or deviance” (p. xiv), he does go on to examine how social expectations may also affect what are considered gender-appropriate contexts and reasons for suicidal behavior. As long as interpersonal rejection is viewed as the most legitimate and gender-appropriate precipitant for women's suicidal behavior, women may be reluctant to recognize and report motives other than relational loss for their suicidal acts. Similarly, as long as researchers view relationships as the primary source of well-being for women, they may be reluctant and/or unable to recognize impersonal stressors (such as unemployment) as factors in women's suicidal behavior (see Canetto, 1991, 1992–1993, for reviews of the recent literature; and Kushner, 1985, 1993, for historical evidence).

In my opinion, this book's strength lies in its integration of historical and sociocultural sources and perspectives. Overall, it is a fine example of thought-provoking, sophisticated, and yet accessible scholarship. In more ways than one, it deserves the recognition due to pioneer contributions.

David Lester and Margot Tallmer (Eds.), Now I Lay Me Down: Suicide in the Elderly. Philadelphia: The Charles Press (PO Box 15715, Philadelphia, PA 19103, USA), 1994. 239 pages.

Reviewed by Yoshitomo Takahashi, MD, Vice-Councilor of Research, Tokyo Institute of Psychiatry, Tokyo, Japan.

First of all, I would like to thank the editors, David Lester and Margot Tallmer, and all of the contributors, for publishing this comprehensive book that provides understanding about suicide among the elderly.

Much attention has been paid to suicide among young people in many countries, but, in fact, suicide among the elderly has become a serious problem in mental health. For example, in the United States in 1992, elderly people over the age of 65 years accounted for 12% of all the population but suicides of the same age group consisted of 20% of all suicides (13% and 27%, respectively, in Japan). This tendency is also observed in many other countries. It is also expected that the elderly population will grow further in most of the developed countries in the 21st century. Therefore, the prevention of suicide among the elderly has been and will continue to be a priority issue in mental health in the future.

However, it is no exaggeration to say that this issue has been almost entirely ignored. As Joseph Richman mentioned in this book, “Elderly suicide is preventable and treatable, but few people are aware of it.” Proper recognition of the risk and adequate intervention can prevent elderly suicide. Defeatism, from which many people erroneously believe that it is not worthwhile helping suicidal elderly, itself is the biggest obstacle we have to overcome.

In Now I Lay Me Down: Suicide in the Elderly many top suicidologists have addressed various substantial topics: epidemiology of elderly suicide, physical and psychiatric disorders relating to suicide, demographic characteristics of elderly suicide, clues for earlier detection of suicide risk, versatile treatment methods (physical and/or psychiatric treatments, group and individual psychotherapy), suicidal elders in long-term care facilities, and assisted suicide and the elderly.

It goes without saying that this book has enriched the literature of suicidology, but I would have liked several aspects of elderly suicide to have been discussed in more detail. As a clinician, I have found that the elderly patient sometimes develops different symptoms from the younger one. For example, some patients do not develop overt depressive symptoms — such as depressed mood or psychomotor retardation — but rather somatization. They do not look very suicidal superficially, but the potential risk is high. Alternatively, it is sometimes very difficult to differentiate the death of a patient who develops delirious symptoms from physical illnesses or side effects of medication as being suicidal or accidental. I wish that these topics and their countermeasures could have been discussed in more detail.

These comments do not decrease the value of this book, which is highly recommended reading not only for mental health professionals but also for those who are concerned with this contemporary problem of elderly suicide.