Suicide awareness of japanese family descendants

This study aimed to comprehend the meaning of suicide for Japanese descendants. This was a qualitative study, based on Grounded Theory, using a structured interview with sixteen questions, digitally recorded. Subjects were ten descendants who were interviewed in 2011. The opinions of the interviewed showed factors of psychological, social and cultural origin involved in suicide, such as: heredity, religion, mental health, personality characteristics and interpersonal relationships, pleasure and pain at work, stigma and consequences of the act on the family. Family without case of suicide showed attitudes of prejudice and judgment, while those with case displayed feelings of pain in their reports. It was concluded that the Japanese rigid culture, personality, interpersonal communication and the way family and work have effects on their behavior are predisposing factors to suicide, as well as the identification of these factors contributes to a better performance of the nurse.


Introduction
Suicidal behavior is an expressive movement experience of displeasure that has variable intensity and duration.This behavior can be classified into three dimensions: suicidal ideation, which is the desire, thought of endingthe life; attempted suicide, or act of aggression that causes injury to the individual, not necessarily with the aim of death; and the suicide itself, in which the action is consummated, and the outcome is death.It is a phenomenon influenced by several triggering factors, including biological, genetic, psychological, social, cultural and environmental factors (WERLANG;BOTEGA, 2004).
According to data from the World Health Organization (WHO, 2010), about 1 million people committed suicide in 2000, which translates into a rate of global mortality rate of 16 deaths per 100,000 inhabitants, or one death every forty seconds.In addition, ten to twenty times more people attempted suicide worldwide, which means on average one attempt every three seconds.
The World Health Organization estimates that by 2020 more than 1.5 million people will commit suicide per year.High rates are observed in Hungary, Finland, Japan and Australia, where the rate for males exceeds 20 per 100,000 inhabitants.In 2008 the number of suicides in Japan was 30,000, and remained stable since 1998 (BERTOLOTE;FLEISCHMANN, 2002;WHO, 2010).
The meaning of death and suicide in Japanese society Since ancient times suicide is accepted in Japanese society, where the hara-kiri was part of the code of honor of the samurai who practiced it as punishment for a criminal or unworthy acts, to avoid capture on the battle field, as it was considered shameful fall into enemy hands, or in order to reprove his master (YAMASHIRO, 1984).It was and still is considered a way to express courage and self-control, being considered a common practice in order to take responsibility for something, a form of compensation and a kind of excuse for becoming an emotional burden for people who the individual had left (NAKAGAWA, 1995).
For them a dignified death is painless and peacefully, respecting the identity, autonomy and individuality (decision) of whom is dying.This concept represents a model of relationship between society and culture, which has been formed between the interaction of education, lifestyles and social practices (KATSUMATA et al., 2008;NAKAGAWA, 1995).Added to this is the fact that Buddhism, one of the main Japanese religions, does not see death as the end of life, but as a transition to Nirvana; does not condemn suicide and believes that the state of mind is what determines if the act is right or not (KATSUMATA et al., 2010;PERRETT, 1996).
Japan presents a social environment increasingly complex created by a traditional and competitive society, where the group's role and obligations of cooperation and collective responsibility at the expense of individual initiative are essential (KATSUMATA et al., 2008).
In Brazil, and especially in the Paraná State, this issue becomes important because the State houses many Japanese descents, resulting in more health professionals such as nurses, for example, which also have Japanese ancestry.Therefore, this study aimed to understand the meaning of suicide for Japanese descent in Brazil.

Material and methods
The study was qualitative and based on the Grounded Theory (GT).This method allows identifying and organizing the phenomena focused by nursing and generating theories relevant to healthcare practice and research, from comprehending the context in which the client is inserted (CHARMAZ, 2009;DANTAS et al., 2009).
GT analyzes data information of the reality experienced by the social actors, its focus is to present new perspectives and hypotheses that may elucidate the investigated object, rather than theories and concepts predetermined.In this case, it seeks to know the meaning of suicide and suicidal behavior that Japanese descendants possess (CHARMAZ, 2009;DANTAS et al., 2009).
The process begins with the collection and analysis of data to guide the researcher in conducting the literature review, besides directing the possible hypotheses identified during the investigation (DANTAS et al., 2009).
Through the analysis of the first data the research is directed to other data sources in order to acquire new incidents and deepen the knowledge.Therefore, the method is circular to enable the researcher to move the focus of attention according to the data that are being displayed.
There is a theoretical advance during each step of the collection, and the interpretive process is fundamental to the organization of the data into conceptual categories to be analyzed, systematized and interconnected, in which the researcher will find the central phenomenon, in this case the grounded theory.
The use of the comparative method is constant, involving all stages of research, so the researcher needs to have the ability to perceive and understand the meaning of the data findings to distinguish what is relevant or not to the study (CHARMAZ, 2009).
Data collection is considered satisfactory when the data become repetitive and do not provide new concepts, thus verifying theoretical saturation of information.
The interviews were performed from June to July 2011, after approval by the Human Research Ethics, ensuring the preservation of ethical principles in research (n CAAE.0051.0.268.000-11).Subjects were verbally invited by the researcher, in secret and individually in their living environment, consisting of 10 Japanese descents, whose profile is shown in Table 1.The inclusion criteria was to be Japanese descendant Exclusion criteria included: if the individual belonged to one generation higher than the third generation, were mixed-race or had refused to participate in the research.There were refuses by 4 people, which were respected.The interviews were recorded on digital media and in own recorder.We took as initial reference the academic community of the State University of Londrina, represented by students, teachers and employees.
The questions raised by researchers to be answered aimed to know the significance of suicide for families of Japanese descent.From the first interview, each new reflection drove the performance of new interviews, seeking those who had cases in the family, different levels of education, religion, age and profession.

Data analysis
The interview was structured by a set of generic questions (socio-demographic characteristics such as: sex, age, generation of descendants and suicide case in the family) and specific questions that have the objective of seeking the reflection of subjects about the theme.The structured interview has the advantage of obtaining data comparable between several subjects with the guiding questions, aiming to stimulate the subject to talk about the topic.In this theory, data analysis occurs through three distinct but interdependent steps, namely: open coding, axial coding and selective coding.The encoding process aims at reducing the data, which permeated by the encoding process, is essential to reach the theory (CHARMAZ, 2009;DANTAS et al., 2009).
The open coding was done by reading the interviews and subjecting them to the encoding process, line by line.In this phase, the following preliminary codes were developed: 'Identity, Labor and Suicide,' 'Suicide, Depression and Heredity' and 'Religion'.The axial coding aimed to reorganize the code into higher level of abstraction, by establishing the codes 'Perspective on suicide from people without cases in the family' and 'Perspective on suicide from people with case in the family.'The selective coding aimed to refine and integrate all categories, revealing a central category represented by the 'The family in the context of suicide episode.'

Results
The interviews were not integrally transcribed herein in order to respect the conciseness of the study, allowing only the presentation of personal characteristics.Significant portions of the interviews will be discussed in the next item.The identity, in a sociological concept according to Hall (2005, p. 11), is consisted socially and historically over time, andis formed "[…] from our exterior, by the ways in which we imagine to be seen by others".Therefore, it changes constantly and permanently, being something unfinished, constantly in formation.Our identity is formed by the acquisition of meanings and values of cultures, providing stability and space in the social world.
In Western culture, the identity was transferred over time to the national culture, because, in agreement with Hall (2005, p. 14), "[…] national cultures by producing meanings about nation, senses with which we can identify, construct identities".Through the statements it is possible to identify that Japanese descendants are adding cultural characteristics understood as Brazilian to their own cultures and also identify certain traits as being Japanese, believing in the relationship between these psycho-socio-cultural characteristics as a risk factor for suicide when asked about why Japanese commit suicide: [...] People are more sensitive because they are very closed-off, very extreme.The Brazilians know how to be happier, is not like Japanese people who have to be like this, like that.In life we don't need to be so methodical, systematic.The speech below illustrates what Bando et al. (2009, p. 104) reported."Suicide in Japan is the result of a complex system of honor, and responsibility as fundamental principle, failure is considered an irremediable fault." [...] the Japanese did not support lose, to them is all at that time, when they have a frustration they have to end this soon .[...] it is past consequences, customs, the Japanese person overcharges himself, he thinks that just killing himself can end with the problem.My father never admitted that he depended on a child to do things, change clothes, go to the doctor.He did not accept our care.(E7) The speech below corroborates Naito (2007) who investigated this issue, and concluded that Japanese culture does not accept private interests to be disclosed to others, therefore, there is a stigma about mental health so people do not seek help.Naito ( 2007) believes that the suicide of a Japanese worker, who has failed or troubled the company, should not be seen only as an inability to endure social pressures, but rather because he feels guilty for making sad family and employees.In this way, Japanese people see death as an act that demonstrates social responsibility: Nowadays, the company requires the employee to be flexible, autonomous and dynamic.He is charged to quickly adapt to changes, so that the limits are extrapolated, generating thus a difficulty to withstand the pressure exerted.In this way, the work that was once seen as something that ennobles man through the transformation of nature becomes an exercise of competitive and displeasure (GRAY, 1992).
It is noticed in the speech of subjects, the notion of pursuit of productivity, found both in the speech of those who had or had not a case in the family, when asked their view on suicide: Be fired or not getting a job is unacceptable, shameful to the Japanese culture [...] basically it is social, cultural, productivity issue, of being useful to society and when it is not possible they commit suicide.(E2).
The study of Gray (1992, p. 242) describes that: "Japanese office workers often work 3,000 hours per year, an average of more than 8 hours a day, every day of the year [...]", evidencing the high workload, which was also reported by interviewees.
[...] they worked too much, it's a very heavy load.(E4) And when he/she no longer feels productive, the person suffers emotionally: When she has been retired she became very idle, she no longer had that courage, and the depression got worse.(E5) The work as an exercise of competitiveness and displeasure is also noticeable in the speeches of other subjects when asked about their view on suicide: I think is the pressure of having [...], a good job.(E6), Japanese gives society a high value, [...] does not accept if the company breaks, become is ashamed of society.(E9) And in Japan, high rates of suicides are related to pressure at work, charging, Brazil is going through the same line; the cultural issue is that Japanese is worker, which leads to cultural pressure and depression, leading to suicide.(E10)

Suicide, depression and heredity
Depression is a mental disorder that is gaining more space in Japan and Western countries.A study conducted in Japan by Takeuchi and Nakao (2006) estimates that about 90% of people who committed suicide had a mental disorder and that 60% were depressed.During life, one in 20 people end up having a depressive episode, and among 15% with severe depression put an end to their own life (BOTEGA, 2006;TAKEUCHI;NAKAO, 2006).
Heredity is also an important feature for depression, implying a greater risk of depression and suicide in families (BOTEGA, 2006;WERLANG;BOTEGA, 2004;WHO, 2006).It is noticed the recognition of such knowledge by subjects and families of suicidal people, which seems to be well established, but that does not result in rapid detection and treatment:

Religion
What we can observed is that religion has helped the family cope with the suicide death of a relative, also corroborating Botega (2005) and Camon (1990) A study developed in Brazil by Botega (2005) who investigated 538 residents of the city of Campinas, São Paulo State, Brazil, found that in relation to religion, belonging to the spiritualism was more strongly related to the chance of having suicidal ideation compared with Catholics and Protestants.Reactions to voluntary death vary from culture to culture and religion to religion, since it is an action that varies between being seen as a means of liberation or as a very serious sin.

Perspective of the family without cases
In general, the reports showed the suicide as an act of desperation and hopelessness, and it is also incomprehensible in the eyes of the family, allowing them to have moral and religious interpretations.According to Leão and Martins (2010, p. 130): "Death comes as configuration of no alternatives; it is the verification of the desperation inherent to a life full of hopelessness".
I think people commit suicide because they lost hope of achieving dreams.[…] the person doesn't find other way out, because he can't endure living this life.(E1) I am sure that this is a desperate act of not having any hope of any improvement, is the last act.It's an absurd suffering, much larger than she could handle.I think if we rationalize, we cannot understand and measure.(E3) The reports corroborate the statements of a study performed by Leão and Martins (2010), in which the suicide is considered a cowardly act, related to mental illness, featuring a judgment on the act.
It gives a great sadness, because I think it's the last thing a person can get is suicide […] I think suicide is the extreme depression, I think it's even a cowardly act, but considering the psychic aspect, depression, we have to understand.(E6) Cowardice, because we do not have to kill for something that happened that you did not want to happen, God gave life to us, why take it away?Thank God I had no case in my family.I've heard on TV in Japan when I was living there.(E9)

Perspective for people with suicide case in the family
The discourses of the subjects point to the idea of a painful, unexpected and unbelievable act, where the family is helpless before the event occurred, as well the fixation in memory of the death scene by family, also confirming the results of Leão and Martins (2010) on 14 relatives of suicide victims, who reported their experiences in the death of a loved one.I think anyone who comes to this extreme has not any perspective.Whatever he stays here or not, nobody will miss him, and for him there is no other alternative.This is an extreme attitude, a way to end suffering, pressure.(E10) A person commits suicide when it is totally hopeless, you cannot really measure the person's feeling,it is an extreme act.(E2) It comes much sorrow, an unfortunate thing, why that person did this?Why that person did get treatment, why did not seek help.Fatality.(E4) And when it happened, you know when you don't believe?I was very sad, my mother doesn't know, for a year I was pretty bad.I think it leaves a big scar, it was something that I saw and will never get out of my head.(E5) The family in the context of suicide episode Suicide afflicts family, friends and people involved in the act, making them suffer the pain of death and the ethical and moral judgment that society makes upon these people (CAMON, 1990;WERLANG;BOTEGA, 2004).Goffman (1988) a famous sociologist, describes the concept of stigma, which is due to the concealment of the case from society, as a strategy to protect the family from something considered stigmatizing or awful, so that every family faces the event in different ways: Fortunately I had the support from friends, colleagues, family […] My mother's family still has very ancient custom, tied up to the rational, then she didn't allow me to say that my son had committed suicide.It was like a dishonor, so you also have to work this well.We have the professional support […]. (E2) Some families show more unity and cohesion and changes take place in family dynamics after the event: Then the family began to be more careful, keeping an eye, here at home we began to be more careful with my father because he is very anti social, needy and wants all the attention.I think we shall be less selfish, to pay more attention to the other.(E4) Suicide is treated as a taboo; some families hide the facts and realize that suicide brings problems to mental health of the whole family, also revealing the social isolation that precedes suicidal behavior displayed by the person: Here there is the mention of a desire to understand why the individual had performed the act: The family wonders why did he try?[…] Thus we see that suicide is not far from our reality.(E8) A study by Leão and Martins (2010) to analyze the impact on daily life of families of adolescents who committed suicide, the most important issue in the research was the family's struggle to find a reason for the suicide.In the speeches below it is mentioned the word 'charging', indicating the posture and family education, present in Japanese culture.
[…] too much charge from parents, parents determined everything to children, and sometimes they couldn't meet their expectations or rather die than having to obey their parents.(E1) Japanese parents are strict about the study and education of their children, because later these efforts will be reflected in the commitment to work which in turn reflect performance to society.
The issue of charges, the relationship between family and studies[...] I had a son who committed suicide, he failed the entrance exam, I think as a mother, I think if I havehad overcharged him, if he was overcharging himself.It was not over-charging.It does not depend on the other; no one induces another to commit suicide if he didn't have this tendency, the desire to end life.He had already made other attempts, he had been in a nursing home, had made admissions and discharges, he had reached the emergency room due to intoxication by drugs, but in a day he fell, we don't know whether out of curiosity, I say that he fell, but do not know if he fell or jumped.(E2) Reading this speech above, we observed that the mother disclaims any liability for the act of the son and assigns the responsibility for the act to her own son.Even the mother being a nurse, it does not seem to have contributed to what she could accept the existence of the problem and seek professional help, and as a background, perhaps the stigma of suicide as an inhibiting factor.
A study that examined the perception of a Japanese woman about hospitalization, for treatment of cervical cancer, found the importance of speaking and being heard, in order to be understood as a woman experiencing illness and hospitalization.In this case here, we can also understood that because it is a family of Japanese descents, they also have the same needs to be heard and valued (CHUBACI et al., 2005).

Conclusion
The majority described the closed-off and perfectionist personality, the rigid culture that does not value community and interpersonal relationships of them, as the main factors predisposing to suicide.Some reported how the family and work environment interfere in the behavior of the descendants, owing the way to deal with pressure and charging that these have on social and moral life of the individual.
Therefore, it allows the understanding of how descendants react and think about this and also how is the interpersonal relationship between them.Thus, nursing actions like therapeutic communication skills, and psychotherapeutic groups may be more effective.
(E1) I think Japanese is also more difficult to express because they are more closed-off, hold back the emotions, I think it is cultural, not showing too much their emotions […].(E3) [...] The Japanese are very closed-off, my sister was very closed-off (E5) I think Japanese descent are more prone to, most are perfectionist andat any defeat they get too shaken.I think they are much more sensitive.(E6) Suicide is because they are more closed-off, have difficulty in showing feelings [...].(E8) Japanese gives much value to society [...], Japanese wants everything just right [...].(E9)It is noticed in the next speech, the relationship between the current family dynamics and national cultural values, such as those historically reported at the time of the samurai (YAMASHIRO, 1984):I believe my family comes with a tumultuous past, comes from ancient times, the family name comes from the ancient samurai.(E7)

I
had the experience of my father, with more than 82 years who committed suicide, left a very terrible result for us, you cannot figure out why […] I have a son aged 22 who lives cloistered.It might be the same disease as my father?My family was completely dysfunctional, […] all this happened after he committed suicide.The feeling I have is that it is something we inherit.(E7) I think it's adepression issue,the personhas lostselfloveto commitsuch an act.A few generations ago weheard about it in my family.They knew theyhad,but do not knowwhom andwhat timewas.(E6) […] I had a very strong depression.(E7) […] A part of the family is prone to depression.(E10) […] if she had had any family support, or any friend, perhaps it would not had happened.[…] Part of the family has a tendency to depression.[…].(E10) The case of my uncle was depression, he was depressed and no one noticed.He was healthy, had no illness […] I think he was depressed and no one realized it.(E4) […] My sister after retirement became very idle […] and depression worsened.(E5) My wound is still open, very open.(E7) Feelings of powerlessness, how can I help?[...] Thus we see that suicide is not far from our reality.(E8)
, in which religion is seen as emotional support at times of crisis by giving social and Acta Scientiarum.Health Sciences Maringá, v. 36, n. 2, p. 217-223, July-Dec., 2014 If she had had any family support, any friend, perhaps it would not had happened.[…] They had little contact with people […] At the time no one commented […].(E10) It is a very obscure thing that my grandmother had died in childbirth.I think these things happened in the past, but they don't tell us.[…].By reading her diary, it seemed she wanted to return to Japan and had committed suicide […].(E1)