The purpose of this study was to examine the influence of cultural factors on the suicidality in a sparsely populated rural district in Sweden, where I worked as a general medical practitioner, for about 18 months in 1984-1986.

Most previous studies of suicide take as their point of departure the comparison between group of persons who have committed or attempted suicide, and a group of persons who have not. Efforts are made to make the groups as similar as possible in other respects. While this method gives important clues to the differing factors between the groups, it usually does not take sufficient account of the cultural and situational circumstances/1. Nor does this method lead to a deeper understanding or analysis of the cultural forces and motives which can lie behind suicide.   

The method rests on the assumption that there are persons who are likely to commit suicide, and others who are not, and that is the difference between the groups which is of interest. Even if this is accepted, the strict separation of the groups must seriously be questioned with reference to the prevalence of suicidal thoughts in a population and the difficulty in analyzing the statistics for attempted suicides but also for completed suicides. By picking out one person from a population and one act from a broad range of cultural behaviours the analysis tends to focus on individual and psychological factors, while the role of culture and society in shaping suicidal behavior is correspondingly underrepresented.  

The district, where I worked, had a suicide rate, which had, since 1970, been 2-3 times higher than that of the country, the county and the whole commune, of which it was a part. Considering the statistics over a ten-year period, that meant about 50 per 100.000 inhabitants. Four fifths of the suicides were committed by men.

The district had a somewhat different history from the rest of the commune. It was inhabited for the first time in modern history by Finns, who were invited by the Duke Karl, later King Karl IX, in the 16th and 17th centuries, to come and cultivate the large forests in the west of Sweden; while most other people in the region came earlier from the south, following the rivers. One question put was therefore, whether this special culture and history could have some importance for the high rate of suicide.

To analyze that, I chosed to follow an anthropological tradition of studying societies through “participant observation”. All the ways in which I came into contact with suicide, in ordinary conversation, case-histories told, descriptions and comments, medical records and statistics were deemed to be important, and were analyzed in relation to the culture generally.

A special study was made of the men, who died from suicide 1959 – 1984, a total study population of 23 men. For them, a documentary study was made, checking medical records, notes from the social welfare bureau and from the police investigations at their deaths for factors that in other studies have shown a statistical relation with suicide./2 Relatives were also interviewed, when possible.

The suicides of these men, and also some other suicides, which I heard of from relatives of the men, and seven men at risk of suicide, whom I met in my work, were also analyzed according to a model, that views suicide as one of many alternative acts or solutions, chosen by an individual in a situation of crisis (figure 10 in the book). The ways in which all the stages of this model are influenced by culture, was examined.

Most studies of suicide analyze persons, who have been in contact with psychiatric care, or other medical professionals. The aim is preventive, and one central task assigned to health workers is to observe and detect persons at risk in their daily work, and to learn to help them. Special importance is laid on persons with psychiatric diseases, especially depression, and alcoholic dependency/3.

In this study population of 23 men, only five, possible a sixth, had been in contact with psychiatric care. They were taken into a psychiatric hospital 1-4 years before their deaths. Two of them were hospitalized after attempted suicides, another two for alcoholic addiction and the remaining man for sleeping disturbance. None of them had known psychiatric contact during their last year. These cases were diagnosed as follows: “Alcoholic addiction” in two cases, “Neurosis” in one, “Insania praesenilis” in one, “Casus mentales NUD (without more precis specification)” in one and “Endogenous depression” in one, a diagnosis that was later changed and does not seem to have been quite certain. These diagnoses did not give much information about the situation in which the men needed psychiatric care, and where for instance three men were hospitalized after their divorces.

The contacts with somatic care were also few and had often occurred many years before the deaths of the subjects. First, I could only find records for half of the men. Later, when I was able to go through all the papers in the medical archive, including notations for child care and school medical examinations, and by checking up all other possible medical centers around, I found that there were still five men, who did not seem to have had any contact with medical care during their lifetime. Four of them were even not seen by a doctor after death, as the death certificate was given by the police, who investigated their suicides. Despite the fact that the subjects have had so little contact with medical centers for most of their lives, and five subjects had none contact at all, 55% of the men were in contact with a medical doctor in their last six months and 30% in their last month.

In the analysis, 50% of the men were found to have been misusing alcohol. However, in half of them the addiction was not known by the health workers, and in one not even by the family.

It might contribute to these figures, that during the last part of the observation period, where was either no general practitioner in the district or the position was held by a locum. On the other hand, the continuity of staff at the service was quite high, as the same man practised half time during a large part of the period. He also lived in the district, had good contact with people, and helped a few of the men in question. Still, when asked, he answered that he had not found suicide to be a particularly important problem in the area. This opinion was also given by the nearest psychiatric hospital.

Church registers containing the causes of deaths in the district during the period 1910-1983 were gone through, to find the statistical pattern. The statistics are insufficient and unreliable in part till about 1940 because many deaths are recorded as having no known cause, and many cases of drowning are recorded, that can hide some suicides. Suicides at that time required special funeral procedures, which may be a reason for noting them in the church registers, while there might also have been a tendency not to judge a death as a suicide, if it was not obviously such.

From the 1940´s, statistics about death are more reliable. They show, since the end of the 1960´s, a suicide rate 2-3 times higher rate than figures for the whole commune, county and country. While showing an increasing death rate, the number of suicides has been markedly constant, only differing by two for each 10-years-period since 1925, if the war period 1935-1944, when they were lower, is set apart. Therefor the rate can be said to illustrate and correlate with the increasing depopulation because of lack for jobs.

Among the men who died as a result of suicide during the period 1959-1984, most suicides occurred between the ages of 30-54 years, in the age groups where depopulation was most pronounced. In these age groups, the population diminished by two thirds during the twenty years 1960-1980. The statistical sample is small and difficult to judge. Many men were unmarried. Nevertheless, the same rate of suicides was found as for the general population, and it is only among the divorced men that the risk of suicide seems to be higher, compared to the population. The risk of suicide was less among married men. The disappearance of almost 80% of forestry work, which is the principal type of work in the region during the twenty years under consideration had, to a great extent, been compensated by depopulation, and none of the men were quite unemployed when they died, while there might certainly have been instability and worries about jobs at times.

The situation nowadays has been formed by historical factors. When the Finns came at the turn of the 17th century, they brought with them their knowledge of how to swidden the forests to sow rye and how to obtain bog-ore from the lakes to make iron for tools and guns. Guns were at that time everyday equipment for men, that men put on like their coats when they left the house, to use as a defence against foreigners, hiding from justice in the forests, or taking the opportunity to bring home some passing game, for food.

The Finns came, singly or a few together, and set up homesteads at regular distances from each other. There are stories of the quarrels, that could break out, if a neighbor came too close and threatened the sparse resources at the boundaries. Everything needed had to be made in the homestead. The roads were, in this century, too bad to be passable in the summer. In the winter, horse transport was possible on the lakes and hard snow areas and produce were even brought to Västerås and Stockholm for sale.

Things changed a great deal at the end of the 18th, when import taxes in Europe were dropped, and the big forest companies started to buy up forests for exploitation. For some decades people came from other parts of Sweden to work in the forests, some to make a profit, while other became proletarians, sometimes living all year round in badly equipped forest huts. In that way the forest companies took over more and more of the initiative in the region. They even ruled over that third of the forest, that had been set apart to be kept as common land. With the rationalization and technical innovations in forest work that speeded up after 1960, a lot of forestry jobs have disappeared, also taking with them other sorts of jobs.

There are some factors that seem to croup up through history. There is, first of all, the forest and its importance as a resource and a productive sector, but also as a place, which gives plenty of rewards for skill in hunting and fishing. There is personal quality or individuality, or the power and will to be able to solve one´s own problems through one´s own efforts; and there is isolation, that is geographically and historically shaped. In recent years, there is also depopulation, which is felt as a continuous strain, threatening the jobs and the possibilities for staying in the area.

Today, even if the forest, as a productive resource, is no longer in the hands of people living in the area, it is still a place where men like to go to fish and hunt. This is the principal reason why young men struggle to stay in the area, while young women do not seem to have the same sort of reluctance to leave the district. Some men spend whole days alone in the forest hunting with a dog. Most men also work in the forest. In that way, the forest is especially a man´s place, while the women take care of the children and most of the daily domestic duties.

The old culture is in many ways connected with the forest, still living its life in old blast furnaces for bog-ore, church yards and the ruins of early homesteads and especially through the hunting, that runs like a red thread through history up to the present day, most strongly expressed in the yearly elk-hunting in the autumn. Many of the strains in relation to the new society, with other demands that have degraded the district to a depopulated backstage area, can therefore be said to focus on the men.

While the demands on men are set at a high level, the ideal is also set high. There are strong expectations of a man to do a good job in his regular work and to solve different practical problems, that occur in a region with long cold winters and old wooden houses, without complaining or unnecessarily bothering others. It is through this capacity to control and govern an often demanding nature, that he is judged in society. An ideal sometimes mentioned is the Finns, for whom nothing was said to be impossible, and descent from the Finns is still seen as a guarantee for these qualities.

A man also takes pride in his relationship with nature and his power to manipulate and rule it through work. In doing so, he often has a personal relationship with his work and its material. He gains confidence from it and turns to it in times of crisis and unhappiness. Sometimes it might be felt that this relationship is even stronger than his relations with other people, and it is through this that he can make himself useful and valued in society, and give something to the people he loves, his family.  

The families, or groups to which he is connected by kinship, are often big, occupying in some cases a large part of the villages. It is in these that the men can find his principal social network. With respect to other families he is representative of his own family, making these contacts a risky interface of social control, envy and sometimes unpleasant gossip. The outer society, consisting of different public services, like school, medical care, social welfare, police, fire brigade and church is mostly governed by decisions made in other places and in the end by the Swedish government, and is often regarded with suspicion.

According to Firth/4 suicides can be analyzed as social acts, or as one of many possible solutions in a situation of stress or crisis. By analyzing an act of suicide, its normative and communicative side is believed to be more important than its technical, strictly goal-oriented side. The difficulty certainly is, that reliable explanations are hard to get at, even, as Ruth Ettlinger/5 has shown, after a suicide attempt and much of the logic and reason that leads a man to suicide, is not obvious, but gets an implicit meaning in the culture. Any interpretation, therefore, has to be built to a great extent on circumstances or contextual facts.
Nevertheless, many of the men in this study did leave often short and often misunderstood messages during their lifetime and some left suicide-notes behind. From these, the men can be seen to have committed suicide in the frame of mind that they had nothing to live for, that they could not manage a situation or had failed, or that they were afraid they were suffering from some disease. Many of the men expressed the wish not to hurt or burden their families, and this was even given as the reason for suicide.

A divorce from a woman or separation from a family was found to be one of the external situations that created suicidal thoughts. It sometimes led to many weeks of hard alcoholic drinking. Most of the men, who gave as a reason that they had nothing to live for, were unmarried in the age-range of 45-60. About two thirds of the men, who in some way felt they had failed, were alcoholic or a few had other addictions. Four of them had been blamed by some member of the family just before their suicides. One of the men did hide his addiction from his family till his death; one had just been discovered. One of them was critized by a family member, who had earlier played along with him. His relatives were quite consistent about one other man, who did not misuse alcohol, saying that it was his feeling of shame over a, not yet discovered, harm done to a friend, that caused his death.

To have a disease was another situation, that often evoke suicidal thoughts. By studying the medical records, it can however be found, that the men´s despair and resignation was not shared by the doctors in the records, who found their diseases treatable and even expressed confidence in their progress. The reactions of the men that led to suicide, were usually not discovered, and one conclusion drawn from that, is that primary care must find better methods of defining and treating illnesses, or the patients´ reactions and experience of diseases, in order to prevent suicide. Two men did not even ask a doctor about the symptoms, that made them commit suicide.

Most striking is the way in which men kept to their ideals for manly behavior all the time up to their suicides. In some cases, it is also felt, that this ideal could make suicide look like the only acceptable or morally right way of handling a situation. These suicides are judged as “fatalistic”, a type of suicide, that Émile Durkheim/6, who invented the concept, did not feel to be important in a modern society.  His conclusion has, however, later been questioned/7.

One could ask, what makes a man, diverging from or not fulfilling the social ideal, take his life. It is suggested, that a self-experienced difference between the ego and the ideal creates a strain in an individual, that has to be solved. Theoretically, this is possible in three ways. One way would be to change the ideal. A prerequisite for this seems to be that there is another group with differing ideals, of these there are few in a homogeneous society, in which the individual is accepted. This might be a reason why the risk of suicide has been shown to decrease among alcoholics, when they are absorbed into a Skid-Row-group of socially degraded misusers/8. Another and probably the most used method, is to try to shape a compromise between the ego and the ideal, to try to live up to the norms in a better way and to lessen some of the demands on oneself. The third method, however, could be to take one´s life, thereby extinguishing ego and showing conformity to the cultural ideal.

In this region the gun, that was found to be the principal tool used in suicide, was deeply connected with history, man´s work and relation to nature and symbolizing the manly ideal, expressed yearly ritually through the elk-hunt. By using it for a suicide, the act acquires even more a sense of redress/9.

As social integration has been seen since Durkheim (1897)/6 as a first requisite in the prevention of suicide, it was supposed that the men should have tried to get help and support from their families. However, only half of the men were found to have turned to their families, and some of them did so just before the suicide, like an announcement of their decision to kill themselves. This was especially true of the men, who were judged to be most integrated, respected and liked in their families. Men I met often expressed it as shame or weakness to be forced to bother the family with their problems. One man, who did turn to his family, was even criticized by a brother for not being able to solve things for himself, “as I have had to do”. In that way many of the men, who seemed well integrated, did in fact lack support from their families. Not many of them did either turn to a friend or medical care.

Instead, the men quite as often, tried to solve the situation themselves by turning to what I have called, individual alternatives. In that way, some of them sought refuge in nature, by going fishing or hunting, or by taking the car to drive out into the forest. Others tried to find relief in their work or in alcohol. The relation to alcohol was found to be a dual one. It was often a strong alternative, so that some men tried to ride out the crisis by several weeks´ heavy drinking, that sometimes ended in hospital care, while the disappointment and the reproaches from relatives for alcoholic drinking was certainly one of the reasons for suicide.

The engagement of the health authorities in preventive measures against suicide has mostly been taken from a clinical perspective. It has stressed the need for therapeutic contacts and proper (often medical) treatment of depression. While this is important, it has so far not given convincing proof, that we can through these measures reverse an increasing tendency to suicide in a population. There are in the complexity of factors around suicide, also cultural, social and situational factors, which should be analyzed to find complementary methods of a general prevention.

1. To give an example, some suggestions for prevention in the area analyzed, might be:
Socialize the manly ideal. By work through the pedagogical resource persons in pre-school and school a greater openness and acceptance of one´s own reactions could be aimed at and practiced, as a greater capacity to deal with crises situations.
2. Give the families support. The families as primary network sources should be given support and help in this function, while at the same time the men need therapeutic contacts outside the cultural frame of the family.
3. Create alternatives. Different socio-therapeutic measures, that could include local initiative, can be used to counteract the distress shaped by isolation and depopulation.
4. Finally, combat alcoholic addiction, but not by moralistic attitudes, that might increase the suicide risk. Other alternative crisis solutions should stimulated.

These interventions, which would engage also persons outside the medical frame, should currently be evalutated and adapted to a growing understanding of suicide as a cultural fact in the area.