DEPARTMENT OF PSYCHOLOGY UNIVERSITY OF GHANA ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT BUERNORKIE MANYEYO PUPLAMPU (10225576) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPhil PSYCHOLOGY DEGREE JULY 2015 University of Ghana http://ugspace.ug.edu.gh i DECLARATION This is to certify that this thesis is the result of research undertaken by Buernorkie Manyeyo Puplampu under supervision towards the award of Master of Philosophy in Social Psychology Degree in the University of Ghana. ………………………………………… Buernorkie Manyeyo Puplampu (Student) Date…………………………………. ………………………………………… Dr Joseph Osafo (Principal Supervisor) Date…………………………………. ………………………………………… Professor Charity Sylvia Akotia (Co-Supervisor) Date…………………………………. University of Ghana http://ugspace.ug.edu.gh ii ABSTRACT Reducing the loss of life due to suicide has become a critical international mental health goal. Several researches in the field of suicide prevention have focused on the role of medical facilities, schools and other local or state organizations and the role of religious leaders as gatekeepers has been overlooked. Using a qualitative approach, the study explored the attitudes of Christian, Islamic and Traditional religious leaders within the Ga East Municipal District of Ghana towards suicide, examined their treatment regimens and also assessed how they perceive their role in suicide prevention. Thematic analysis of transcribed data revealed that participants perceived suicide as abhorrent because life is sacrosanct and must be preserved. The motivations for attempting or committing suicide were also perceived by participants to be caused by both psychological and diabolical factors. Furthermore, participants detached their attitudes towards the suicidal person (someone who needs care) from suicide as an act (an act contradictory to their faith) and showed them care. The assessment of treatment regimens when they interact with suicidal persons showed that they create healing communities and also counsel and refer them for clinical and professional care. Besides the use of spiritual healing such as prayer and deliverance, participants also encourage social support and induce hope into suicidal persons to allay their fears through the use of religious or doctrinal teachings. Additional findings showed that the Ghanaian cultural setting abhors or perceives suicide as unacceptable hence the treatment regimens identified were more intervention based (i.e. employed only after suicidal persons have been identified) than prevention focused. Based on these findings, recommendations are made for possible improvement. University of Ghana http://ugspace.ug.edu.gh iii DEDICATION To my late younger Sister Buernorkuor Siadeyo Puplampu. Kuor, you will forever remain in my heart. University of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENT Foremost, my immense gratitude and appreciation goes to the God of my life, for being my Help in ages past, my Hope for the years to come, my Shelter from the stormy blast and my Eternal hope. Furthermore, I want to thank my family (Rev. Gideon Buernor Puplampu, Mrs Joyce Korantenma Puplampu, Buermle Suomi Puplampu and Maku Mawulerde Puplampu) for standing by me through thick and thin especially for their support and prayers during the write-up of this project when I almost gave up. Additionally, I want to thank Professor and Mrs Cephas Omenyo and Professor C. Charles Mate-Kole for their immense support in helping me to get back onto the MPhil program and spurring me on till completion. I am eternally grateful. I also want to use this very rare opportunity to recognize and acknowledge my wonderful blessing of supervisors, Dr Joseph Osafo and Professor Charity Sylvia Akotia. They have been very supportive and patient with me throughout this research period and did not get tired of my endless questions. May the Good Lord remember you for this. I also want to express my sincere gratitude to all who supported me in diverse ways especially Mr Emmanue Nii Boye Quarshie, Mr Anakwah Nkansah and Mr Edem Adjei. May the Good Lord God richly bless you all. Finally, I want to remember the exceptional members of staff of the Department of Psychology. Thank you all. University of Ghana http://ugspace.ug.edu.gh v TABLE OF CONTENTS DECLARATION………………………………………………………………………………i ABSTRACT…………………………………………………………………………………...ii DEDICATION………………………………………………………………………………..iii ACKNOWLEDGEMENT……………………………………………………………………iv TABLE OF CONTENTS…………………………...…………………………………………v LIST OF TABLES………..…………………………………………………………………..ix CHAPTER ONE…………………...…………………………………………………………1 1.0 INTRODUCTION………………………………………………………………………....1 1.1 Background to the Study ………………………………………………………………….1 1.2 Attitude towards suicide…………………………………………………………………...3 1.3 Problem Statement ………………………..………………………………………………5 1.4 Aim………………………………………………………………………………………...8 1.5 Specific Objectives of the study……………...……………………………………………8 1.6 Significance of the Study………………………………………………………………… 8 1.7 Research Questions…………………………………………………………………….… 9 CHAPTER TWO……..……………………………………………………………………..10 2.0 LITERATURE REVIEW…………………………………………………………….…..10 2.1 Introduction………………………………………………………………………………10 University of Ghana http://ugspace.ug.edu.gh vi 2.2 Theoretical Framework…………………………………………………………………10 The Sociocultural Theory …………………………………………………………..10 Role Theory: Religious Leaders as Suicide Gatekeepers …………………………..13 2.3 Review of Related Studies………………………………………………………………15 Cultural factors that influence attitudes toward suicide ……………………………15 Factors that influence suicide prevention……………………………………..…… 22 The role of religion and religious leaders in suicide prevention ………………… 26 2.4 Rationale..………….…………………………………………………………………..30 CHAPTER THREE………………..………………………………………………………33 3.0 METHODOLOGY………………………………………………………………………33 3.1Introduction………………………………………………………………………………33 3.2 GHANA: THE RESEARCH SETTING...…………………………………………….…33 3.3 Population……………………………………………………………………………….34 Participants/sampling technique ……………………………………………………35 3.4 Criteria for selection………………………………………………………………….…36 3.5 Research Design ……………………………………………………………………..…36 3.6 Measuring Instrument…………………………………………………………….…… 37 3.7 Procedure……………………………………………………………………………… 38 3.8 Analysis of data ………………………………………………………………………..38 University of Ghana http://ugspace.ug.edu.gh vii 3.9 Ethical considerations …………………………………………………………………40 CHAPTER 4…………………………………...………………………………………….. 41 4.0 FINDINGS………………………………………………………………………………41 4.1 Introduction…………………………………………………………………………….41 4.2 The Context: Cultural Abhorrence …………………………………………………….41 4.3 Diverge to Converge: Life Preservation ………………………………………………43 4.4 Motivations: Psychological and Diabolism ………………………………………….. 46 4.5 Care or condemnation? ………………………………………………………………. 50 4.6 Caring to Treat ………………………………………………………………………….55 CHAPTER 5…………………………………………………...……………………………67 5.0 DISCUSSION……………………………………………………………………………67 5.1 Introduction……………………………………………………………………………..67 5.2 Attitude towards suicide: Cultural Artifact……………………………………………67 5.3 Suicide as Pathology…………………………………………………………………. 69 5.4 Suicide Intervention ……………………………………………………………….….70 5.5 Trustworthiness of the Study…………….……………………………………………...75 5.6 Implications……………………………………………………………………………76 5.7 Methodological Limitations …………………………………………………………..78 5.8 Recommendations for future Research………………………………………………78 University of Ghana http://ugspace.ug.edu.gh viii 5.9 Conclusion……………………………………………………………………………..78 REFERENCES…………………………………………………………………………… 81 APPENDICES……….…………………………………………………………………….95 APPENDIX A: ETHICAL CLEARANCE ……………………………………..…………98 APPENDIX B: INTERVIEW GUIDE…………………………………….……………… 99 APPENDIX C: LETTER OF INTRODUCTION …………………………………………102 University of Ghana http://ugspace.ug.edu.gh ix LIST OF TABLES Table 3.1: Demographic Characteristics of Participants University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 1 CHAPTER ONE 1.0 INTRODUCTION 1.1 Backgrou n d to the Study Suicidal behavior has been the focus of a growing body of research internationally, cross- nationally as well as comparatively (Adinkrah, 2011). Durkheim (1896) identifies suicide as any death that is the immediate or eventual result of a negative (e.g. refusing to eat) or positive (e.g. shooting oneself) act accomplished by the victim himself or herself. Similarly, Silverman (2006) also assumes that µVuicide is, by definition, not a disease, but a death that is caused by a self- inIOicted intentionDO Dction or EeKDvior¶ p. . The phenomenon has become a continuous public health challenge around the world and, in countries where information on suicide is available, it is among the ten leading causes of death for all ages, while in some countries it is among the top three causes of death for people aged 15 to 34 years for both males and females (World Health Organization (WHO), 2011). The World Health Organization estimates that about one million people kill themselves every year (WHO, 2011). Specifically, the global rates of suicide are estimated at 14 suicides per 100,000 inhabitants, including 18 suicides per 100,000 for males and 11 suicides per 100,000 for females (Bertolote & Fleischmann, 2009). The highest suicide rates for males and females are found predominantly in Eastern Europe, in countries such as Lithuania and Belarus (Bertolote & Fleischmann, 2009). The lack of systematic data collection and good quality research due to sociopolitical and cultural reasons makes the statistics on suicide in Africa unreliable (Meel, 2006; Schlebusch, Burrows & Vawda, 2009). Reports however, indicate that suicide seems higher in the Eastern University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 2 and Southern parts of Africa compared to countries in the West and North of the continent (Kinyanda, Hjelmeland, Musisi, Kigosi, & Walugembe, 2005). Similar to what is found in the Western world, suicide is more common among males than females with a varying ratio between 1.75 in Egypt to 9.00 in the Seychelles (Schlebusch, 2005). Particularly, South Africa has been described as one of the suicide capitals of the world where it is estimated that 10,000 people engage in suicide yearly, and one person takes his or her life every hour. This represents 10% of all non-natural deaths present in South Africa (Meel, 2006 ; South Africa National Injury Mortality Surveillance System, 2004) and Schlebusch (2005), suggests psychopathology, substance abuse, family dynamics and HIV AIDS as some of the factors responsible for these high suicide statistics. In India also, where the completion rates of suicide attempts may be higher than other Asian countries, Pillai, Andrews, and Patel (2009) report that violence and psychological distress are independently associated with suicidal behavior. Domino (2005) suggests that attitudes toward suicide are quite complex and intertwined with the values and religious perspectives of a person. Religion therefore seems to be a major dimension of attitudes towards suicide as suggested by Domino, Niles and Raj (1993) because during suicidal crises, the religious beliefs and values held by an individual can act as a buffer against stress and provide an element of comfort to such distressed persons. It is therefore predictable that the religious beliefs and values held by an individual for whom these are important will affect how and who help is sought from (Bhugra, 2010). Specifically, Early (1992) mentioned the responsibility of the church in the African American coPPXnit\ Dnd VDid µ,I tKe cKXrcK iV to provide VociDO inteJrDtion Dnd PorDO vDOXeV tKDt ZiOO University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 3 pervade the African American community, then its role must go beyond the reOiJioXVO\ Dctive¶ (p. 26). In this regard, outreach programs spearheaded by religious institutions might benefit non-religious survivors and hence, lead to social change. To capitalize on the role of religious leaders in suicide prevention therefore, it is necessary to develop an understanding of religious differences within and among religious communities. 1.2 Attitu d e tow ard s su icid e Attitudes toward suicide have varied broadly throughout history. Tang and Yang (2003) describe suicide attitudes as a consistent and persistent tendency towards suicidal behavior that individuals hold. Presently, in Ghana, suicidal behavior is proscribed socio-culturally (e.g. Hjelmeland et al., 2008) fuelling negative attitudes toward the act, perpetuating secrecy and non- reporting. Hence, there are currently no reliable statistics to estimate the prevalence of suicide in the country (Adinkrah, 2010). Besides this socio-cultural position against the act, it is also prohibited legally. Explicitly, the 1960 Criminal Code, (Act 29) Section 57 (2) states cDteJoricDOO\ tKDt µZKoever DttePptV to coPPit VXicide VKDOO Ee JXiOt\ oI D PiVdePeDnor¶ ZKicK could attract a jail term of about three years. Thus, the legal instrument criminalizing the act, coupled with the widespread sociocultural prohibition against suicide discourages accurate reporting of data and thus underestimates the size of the problem. Also, based on 5oVenEerJ Dnd +ovODnd¶V 10 three-component model of attitude (attitude as a predisposition to some class of stimuli with cognitive, affective and behavioral responses), Wang et al. (2008) conceptualize suicide as approach-avoidance behavior and relentless positive or negative emotions towards suicidal behavior and people who commit suicide. McCormick (1964), for instance, reported that people in ancient Egypt considered suicide a humane way of University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 4 escaping from an intolerable condition. Japanese Kamikaze pilots for example, also considered it honorable to perform suicidal missions by crashing their airplanes into an enemy target and for centuries in Japan, indigenes respected shamed individuals who make amends for desertion of their duties or failure by dying through the hara-kiri (ritual suicide with a dagger). Historically, ,ndiDn ZoPen Zere expected to perIorP tKe µVXttee¶. 7KXV tKe\ EXrned tKePVeOveV to deDtK on D funeral pyre after their husband died. In several other societies, suicide has been made illegal. For example, Plato, the ancient Greek Philosopher vehemently disapproved of suicide (Carrick, 2001). Generally, ancient Roman Governments countered suicide because the nation tends to lose assets such as slaves and soldiers. Moreover, Judaism clearly prohibited suicide except when one faced capture by an enemy, as in the mass suicides of Masada (Witztum & Stein, 2012; Zerubavel, 1994). For instance, Christianity has generally condemned suicide as a failure to uphold the sacredness of human life and Witztum and Stein (2012) also report that Saint Augustine, in the 4th Century AD decreed suicide as a sin. Similarly, the Roman Catholic Church by the middle Ages forbade the burial of suicide victims on consecrated ground. Furthermore, unless the suicide resulted due to illness or madness, English Law, considered suicide to be a crime punishable by the forfeiture of property and goods to the government. These criminal views of suicide immigrated to colonial America where it was adopted by individual states. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 5 1.3 Proble m State men t Suicide is a major public health problem as recognized by the World Health Organization. Completed and attempted suicides result in serious and enormous medical, economic and social costs. The phenomenon is also very disturbing to the quality of life of survivors and their families and friends. $VViPenJ 1 KDV deVcriEed *KDnD¶V reOiJioXV VpKere DV D ]oo iPpO\inJ tKDt VeverDO reOiJioXV sects coexist. Therefore, the religious attitudes towards suicidal behavior and the meaning uncovered cannot be generalized as representing the entire view of all the religious groups in Ghana. For instance, Osafo, Knizek, Akotia, and Hjelmeland (2013c) in a study on attitudes toZDrdV VXicidDO EeKDvior IoXnd tKDt pDrticipDntV¶ reOiJioXV orientDtion Dnd coPPitPent to observing fundamental religious beliefs affect their interpretation of suicidal behavior as unacceptable. Their religious practices and beliefs provided alternative avenues for dealing with such crises. Religion is therefore seen as life preserving and counteracting the decision for self- destructive behaviors such as suicide. Religion was a source of coping and thus could be protective oI VXicidDO EeKDviorV. ,t DOVo provided tKe PotivDtion Ior tKe pDrticipDntV¶ ZiOOinJneVV to provide help to suicidal persons. Religion in this cultural context thus influences attitudes towards suicide and becomes an important variable to be considered when planning future research and intervention programs on suicide in Ghana. The authors recommended tKDt µIXtXre studies could therefore consider the opinions of people of other religious affiliations and their unique conceptualizations of suicide in order to further our understanding of the relationship EetZeen reOiJioXV IDctorV Dnd DttitXdeV toZDrdV VXicidDO EeKDvior in *KDnD¶. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 6 Correspondingly, the researcher after perusing the literature on suicide discovered that common to all the three main religions in Ghana (Christianity, Islam and African Traditional Religion) is the certainty in the judgment of the soul by God in the afterlife (e.g. Mbiti, 2006). Hence suicide is perceived as a religious contravention connected with the eternal damnation of the soul of the person who has killed him or herself as a consequence in the afterlife. This present study therefore aims to explore the critical issues of the attitudes of religious leaders of these three main religions in Ghana toward suicide, their treatment regimens and their role in suicide prevention. Many people agree that suicide prevention is an emergent concern, yet they fail to notice the role of religious leaders in the suicide prevention process (Hirono, 2010). Particularly, several researches in the field of suicide prevention have focused on the role of medical facilities, schools and other local or state organizations (e.g. Brunero, Smith, Bates & Fairbrother, 2008; Carmona-Navarro & Pichardo-Martinez, 2012; Neville & Roan, 2008; Norheim, Grimholt & Ekerberg, 2013; Osafo, Knizek, Akotia & Hjelmeland, 2012). The role of religious leaders in the literature has however had little attention; yet the researcher presumes that religious leaders can stop people from committing suicide through counseling and preaching. Several people who commit or attempt suicide are religious and in several instances, are suicide survivors, that is, they have family members, relatives or friends who have committed suicide (Sakinofsky, 2007). During funerals or memorial services, these survivors may have had the chance to speak with their religious leaders about the meaning and morality of suicide. If religious leaders speak negatively about suicide, then suicide survivors (persons who have lost relatives, friends or family members by suicide) might become vulnerable to suicide. On the other hand, if religious leaders express empathy and understanding towards the survivors, the pain of losing their loved one will lessen. For example, many suicide survivors struggling with University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 7 the moral principles of suicide might be concerned whether suicide is a sin (e.g. if they are Christians). This therefore makes the role of religious leaders in suicide prevention very key (Hirono, 2010; Osafo et al., 2013c). Concisely, the key role of religious leaders in suicide prevention PD\ Ee in tKe coXnVeOinJ Dnd prevention oI µinter-generational VXicide¶, which includes a sequence of suicides within the same family, among relatives and friends. Additionally, there might be differences between the views and treatment regimens of Christian, Islamic and Traditional leaders in suicide prevention. Generally, suicidal behavior is condemned by major religions such as Christianity, Islam, Hinduism and Judaism (Gearing & Lizardi, 2009; Sisask et al., 2010); however, compared to Christianity and African Traditional Religion, there is an Islamic view that actions committed in tKe coXrVe oI MiKDd reVXOtinJ in one¶V oZn deDtK Dre not conVidered VXicide even iI E\ tKe nDtXre of the act, death is assured (e.g. suicide bombing). Instead, such acts are considered a form of martyrdom. Divergently, there is Quranic evidence stating that those involved in the killing of the innocent are transgressors and wrongdoers. Nonetheless, some argue that Islam does permit the use of suicide against oppressors and the unjust if one feels there is no other option available and life otherwise would end in death (Muslim Public Affairs Council, 2015). Moreover, previous studies on attitudes towards suicide in Ghana have concentrated mainly on students, are largely quantitative, and have not examined and compared more specifically, the attitudes and treatment regimens of religious leaders in the three main religions within the country and how they perceive the crucial role they play in the suicide prevention process. How these religious leaders respond at points of contact with suicidal persons or attempters and survivors will influence how they respond to the support offered. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 8 It is against this background and observation that this exploratory research is being embarked on to examine the attitudes and treatment regimens of Christian, Islamic and Traditional leaders and how they perceive the role they play in the prevention of suicide in Ghana. 1.4 Aim The general aim of this study is to explore the attitudes of Christian, Islamic and Traditional religious leaders in the Ga East Municipal District towards suicide, examine their treatment regimens and how they perceive their role in suicide prevention in Ghana and its implication for the development of a suicide prevention strategy in Ghana. 1.5 Specif ic Objectives of the stud y  To explore the attitudes of religious leaders towards suicide and suicidal persons.  To explore the treatment regimens employed by religious leaders in suicide prevention.  To compare the attitudes of Christian, Islamic and Traditional leaders towards supplicants who attempt suicide. 1.6 Signif icance of the Study  Demonstrate the need to understand the role of religious leaders in suicide prevention.  Contribute to knowledge on the relationship between religion, attitudes and suicide.  The findings of this current study will contribute to the suicidology literature in general Dnd reVeDrcK on $IricD¶V VXicidDO EeKDvior in pDrticXODr. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 9 1.7 Resear ch Qu estion s  How do religious leaders in Ghana perceive suicide?  What are the treatment regimens of these leaders?  Are there any differences in the treatment regimens offered by Christian, Islamic and Traditional religious leaders?  How do religious leaders perceive their role of suicide prevention in Ghana? University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 10 CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Introd u ction This chapter consists of the theoretical framework and review of relevant literature. Two theories significant to this study have been considered. The review of related studies aims to critically review previous research on suicide and their important contributions to the literature. In the light of the research objectives, the areas to be explored in the review of relevant literature include- attitudes of religious leaders towards suicide and suicidal persons, treatment regimens employed by religious leaders in suicide prevention and a comparison of the attitudes of Christian, Islamic and Traditional leaders towards supplicants who attempt suicide. 2.2 Theoretical Framew ork A number of theoretical perspectives have been offered to explain suicidal behavior. For the purposes of this present research, two key theoretical frameworks are used to explain attitudes towards suicide and to a larger extent, suicidal behavior and ideation. These are 9\JotVN\¶V (1978) sociocultural theory and Role Theory (Biddle, 1986; Katz & Kahn, 1978). The Sociocul tural Theory This theory focuses on the significant contributions which society makes to individual development. It emphasizes the interaction between developing societies and the culture in which they live. Summarily, sociocultural theory postulates that our individual behaviors and thoughts are products of our culture and the interaction we have with society at large. Sociocultural theory realizes the role co-operation, negotiation and social interaction play in the University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 11 course of learning and development. Inherently, the norms, practices and discourse of a particular society must be taken into cognizance as a function of attitude formation. According to Lantolf (2000), one of the most basic concepts of sociocultural theory is the assertion that the human mind is mediated. Lantolf reports that just as humans do not straightforwardly act on the physical world but instead, rely on tools which allow them to change the world, and with it the circumstances under which they live in the world, they also use symbolic tools and signs to regulate and mediate their relationships and interactions with their fellow humans and thus change the nature of these interactions. According to Vygotsky, whether these artifacts created by humans are physical, tools, symbols or signs, they are made under cultural specific and historical conditions and are made available to successive generations, which they can then further modify before passing onto the next generation. These conditions therefore point out that as a child grows up in a society where suicide is perceived as a taboo, an abominable, unacceptable and despicable act, this child will then internalize this custom and that will become a part of him or her until it is modified. Specifically, a child who grows up within a society that holds negative attitudes toward suicide will grow to hold the same attitude and further transfer it to his or her children. Contrarily, a child who grows up in a society that holds positive or liberal attitudes towards suicide will also learn this and pass it on to his or her off-springs. In sum, the sociocultural theory pioneered by Vygotsky (1978) suggests that society is responsible for inculcating societal values, customs and norms into a child right from birth with the parents of the child serving as the primary representatives of their culture. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 12 5eODtinJ 9\JotVN\¶V VociocXOtXrDO tKeor\ to tKe *KDnDiDn VettinJ 2VDIo +MeOPeODnd $NotiD, and Knizek (2011a) for example, report that there is a widespread stigma against suicide and suicidal persons. Furthermore, Osafo et al. (2011b, 2013c) report that people refuse to name a child after an attempter or individual who has died through suicide. In addition to these, the attempter is also criminally prosecuted (Adinkrah, 2010; Hjelmeland, Osafo, Akotia, & Knizek, 2013). These harmful reactions may expose the suicidal attempter to further traumatic experiences, which could aggravate their perturbation and gradual lethality. In such a cultural setting that has harsh reactions and social attitudes towards suicide and suicidal persons, these reactions might further agitate or perturb the suicidal individual. A major aftermath of a suicide attempt that makes the experience more distressing than reparative for victims is the negative reactions from significant people in the society (Pompili, Girardi, Ruberto, Kotzalidis, & Tatarelli, 2005). Attention has also been drawn to the cost effectiveness of harnessing important local resources in this regard since the country presently has a huge shortfall in mental health professionals (Fournier, 2011; Prince et al. 2007; Read, Adiibokah, & Nyame, 2009; Saraceno et al., 2007). Hence the best situation would be the provision of support services following a suicide attempt from important people in the society such as religious leaders. Additionally, religious groups have been found to be one of the means of bridging this gap (Ae-Ngibise et al. 2010; WHO, 2002) and evidence continues to reveal that religious groups in Ghana are engaged in some form of mental healthcare delivery and a large number of Ghanaians access such services (Ae-Ngibise et al., 2010; Read et al., 2009). University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 13 It is therefore especially important to examine how religious leaders perceive suicide in such a proscriptive moral and cultural context which stigmatizes suicide to ascertain how they perceive their role of suicide prevention in Ghana and what treatment regimens they employ in helping to modify the behavior of suicide attempters. Role Theory : Religiou s Leaders as Suicid e Gatekeep ers Role theory posits that most of everyday activity tends to be an acting out of socially defined categories (e.g. father, teacher, priest, manager). Therefore specific social roles are accompanied by sets of rights, duties, expectations, norms and behaviors that a person has to fulfill and face. This model is based on the observation that people behave in predictable ways, that is, an individXDO¶V EeKDvior iV context-specific and based on social position and other factors. The focus of this study is therefore on reOiJioXV OeDderV¶ role in suicide prevention. In this current stud\ tKe reVeDrcKer conceptXDOi]ed reOiJioXV OeDderV DV µVXicide JDteNeeperV¶ D terPinoOoJ\ ZKicK ZDV IirVt XVed in tKe µ5eDdinJ (DJOe¶ D newspaper in Reading, Bergs County, PA) on the 30th of June in 1968. Regarding the role of religious leaders in the prevention of suicide, their unique role is that of counselor as part of their profession- specifically pastoral or religious counseling. Particularly, suicide prevention is an extension of pastoral counseling. Turner (1996) puts forward the argument that although pastoral counseling may be a regular job for religious OeDderV VoPe oI tKeP PiJKt Ee conIronted ZitK VitXDtionV oI µroOe DPEiJXit\¶ Dnd µroOe conIXVion¶ in tKe diVcKDrJe oI tKeir dXtieV VpeciIicDOO\ EecDXVe tKeir proIeVVionDO roOeV Dre restricted to religious activities. In other words, non-religious counseling might be beyond the obligations of religious leaders. Therefore, the perception of religious leaders as to whether counseling is part of their obligations might be largely dependent on the individual religious leader¶s decision or their philosophy. If suicidal and depressed believers ask a religious leader University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 14 for pastoral or religious counseling, religious leaders have a responsibility to refer them to other mental health professionals. Nonetheless, religious leaders are in a position to advocate for a suicide prevention strategy through their advocacy efforts when they deal directly with the suicidal person or their community. Consequently, religious leaders have the potential to be advocates of policy change. Role theory is also explained in public and social contexts. More specifically, individuals have public and social roles in addition to family roles such as mother, daughter, son or father. Public and social roles are imperative because the roles are not delineated by individual aspiration, but by public consensus and social norms. In the pastoral or religious counseling scenario, the religious leader ought to provide religious or pastoral counseling based on normative reasons. Hence, if religious leaders think that suicide prevention is part of the obligations of their role, they might then include suicide prevention as a part of their religious or pastoral counseling. Contrarily, if religious leaders do not see suicide prevention as part of their role responsibilities, then that individual religious leader might not incorporate suicide prevention as part of their religious or pastoral counseling. This scenario might create a role conflict, which might occur when there is a fissure in the expectations of role obligations between religious leaders and supplicants. Consequently, Durkheim advocates that only comparative analysis affords the elucidation of suicide scientifically. +ence Ke pXtV IorZDrd tKDt µD VcientiIic inveVtiJDtion cDn Ee DcKieved onO\ iI it deDOV ZitK coPpDrDEOe IDctV¶ 'XrNKeiP 18 p.41 . 7KiV VtXd\ tKereIore VeeNV to explore the role of religious leaders in suicide prevention by comparing Christian, Islamic and 7rDditionDO reOiJioXV OeDderV¶ perceptionV oI their role obligations and the treatment regimens they employ toward suicide prevention in the Ga East Municipal District of Ghana. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 15 2.3 Review of Related Studies This section below reviews studies conducted on attitudes toward suicide and suicidal persons for the past three decades. Cultural factors that inf lu en ce attitud es tow ard suicid e Lester (2008) asserts that culture provides a set of standards and rules that are shared by members of a society that shape and determine the range of appropriate behavior. Hence, culture impacts the behavior of nationalities, ethnic groups and subgroups within a nation. Consequently, different continents and nationalities present different ways of living. For this reason, different societies or countries are likely to present differing cultural explanations of behavior or attitudes toward suicide. Some laid down cultural traditions either by convention or law may be antagonistic towards suicidal individuals and surviving family members which reflect in their attitudes towards suicide. In the attempt to address the impact of culture on suicidal behavior and to understand the variations in the meaning of suicide across cultures, Colucci (2008) for example, examined the social representations, values, beliefs, attitudes and meanings that 700 young Italian, Indian, and Australian University students aged between 18-24 years express in relation to suicide. Analysis of structured and open-ended questionnaire items and focus group verbatim transcripts revealed differences and similarities across cultures in meanings and social representations of suicide. First, there were differences on prevalence: more than half of the total sample reported suicide ideation but this was higher among Italian and Australian students, compared to Indians. In contrast, the latter reported more suicide attempts, followed by Australians, then Italians. Secondly, there were statistically significant differences on almost all suicide attempt reasons University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 16 between cultures. For instance, Indians agreed more that some youth attempt suicide to force others to do what they want. Compared with the other two samples, Italian students disagreed more that youth who attempt suicide are mentally ill. Thirdly Indians, followed by Australians had more negative attitudes towards youth suicide compared to Italians. But there were also differences, in that, Indian participants more frequently mentioned God as a deterrent against suicide compared to participants in Italy and Australia. Italians rarely expressed negative judgments towards suicide (e.g. suicide is selfish) to justify the choice not to commit suicide whereas this was quite frequent in Indians, followed by Australians. Additionally, Australians more often expressed that they would get some help and support compared with the other groups. In relation to help-seeking, overall, the majority of students reported that, if they are thinking about killing themselves, they would talk to no one or friends, followed by someone in the family. In another cross-cultural study, Hjelemeland et al. (2010) also compared the level of suicide intent among 460 male and 752 female parasuicide patients from various European regions. Although some statistical significant differences in level of suicide intent between the regions in level of suicide between the regions and genders were found, the effect sizes of these relationships were so small that the differences have neither practical nor theoretical significance. As far as level of suicide intent is concerned however, the WHO/EURO Multicentre study has succeeded in recruiting a relatively homogeneous group of self-harming patients across borders of region, culture and country. Furthermore, Mugisha, Hjelmeland, Kinyanda, and Knizek (2011) in a qualitative study, used both focus group discussions and key-informant interviews to examine the attitudes and cultural University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 17 responses to suicide among the Baganda in Uganda. Findings from interviews revealed that suicide is perceived as dangerous to the whole family and the entire community. Specifically, communities and family members adopt various ritual practices to distance themselves both socially and symbolically from the suicide. These rituals are characterized by broad themes: the regulation of affect and the attempt to secure future generations. Additionally, Hjelmeland et al. (2008) studied the self-reported suicidal behavior and attitudes toward suicide in psychology students by comparing Ghana, Uganda and Norway. Minute differences only were found in own suicidal behavior. Nonetheless, knowledge of suicidal behavior in the surroundings was more common in Uganda, than in Norway and Ghana. Even though differences were found between the three countries in attitudes toward suicide, which stress the need for culture-sensitive research and prevention, many of the differences were marginal. The most profound difference discovered was that the Norwegian students were more reluctant to take a stand on these questions asked compared to their African counterparts. Osafo, Hjelmeland, Akotia, and Knizek (2011b) in a qualitative study, also sought to understand how laypersons from rural and urban settings in Ghana conceived the impact of suicide on others and how that influences their attitudes towards suicide. Interpretative phenomenological analysis of data revealed that the perceived breach of interrelatedness between people due to suicidal EeKDvior inIOXenced reVpondentV¶ vieZ oI VXicide. They viewed suicide as representing a social injury. Such perception of suicide influenced the negative attitudes the respondents expressed towards the act. The authors assert that these negative attitudes are cast in consequential terms. Hence, suicide is an immoral act because it socially affects others negatively. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 18 Correspondingly, Eshun (2003) also examined the role of family cohesion, religiosity, gender and negative suicide attitudes as potential determinants of cultural differences in suicide ideation among 375 students from the United States and Ghana. Findings revealed significant cultural differences for suicide ideation, family closeness, religiosity, and negative suicide attitudes. Also, negative attitudes and family cohesion were the significant predictors for both cultural groups while gender was a significant determinant for suicide ideation among Ghanaians, but not Americans. Religiosity was a significant determinant for either group. In another study, Osafo, Knizek, Akotia and Hjelmeland (2013c) examined the influence of religious factors on the attitudes towards suicidal behavior in Ghana. They discovered that largely, respondents were religiously committed individuals who greatly endorsed religious practices and beliefs as coping and survival norms. Inherently, the participants viewed suicide as the consequence of failure to make use of these coping and survival norms during crisis. Based on such a religious perception and conformity to such core religious beliefs, the participants perceived suicide as unacceptable. Thus as a religious country by behavior, and as people become more committed to such core religious beliefs and values, they condemn suicide. Notwithstanding, religion provides them with the motivation to help individuals experiencing suicidal crisis. Lester (2008) also mentions that gender, as influenced by culture, can impact on suicide. Specifically, within European nations and the United States of America, non-fatal suicidal behavior appears to be less common among men than in women. Hence, suicidal behavior is perceived DV D µIePinine¶ EeKDvior E\ tKe JenerDO pXEOic (Linehan, 1973) and by suicidologists as well. Nevertheless, other cultures provide examples where non-fatal suicidal behavior, often carried out in front of others, is more common in men rather than women. The Yukon and the University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 19 Kaska (or Nahane), a Native Canadian tribe located in British Columbia provides a good example of this. Additionally, Segal, Mincic, Coolidge, and 2¶5iOe\ 004 coPpDred tKe DttitXdeV oI oOder Dnd younger adults towards suicide and suicidal risk. They found that older adults had significantly more acceptable attitudes toward suicide than younger adults, which was largely related to a lack of religious conviction. Evans and Farberow (2003) have also given a comprehensive account of some prehistoric cultural factors that precipitated suicidal behavior. They reported that Japanese may commit suicide to prove their sincerity or avoid disgrace. Also, widows among prehistoric Indians, used to coPPit VXicide on tKeir KXVEDnd¶V IXnerDO p\re DV inVtitXtionDOi]ed Dnd VDnctioned E\ tKeir cXOtXre¶V doctrine in +indXiVP cDlled Suttee. These indicate that attitudes toward suicide are imbibed in specific cultural doctrines. Largely, collectivism and individualism have also been tagged as cultural factors that influence attitudes toward suicide. For example, Goldston et al. (2008) have discussed collectivism as a central value of many cultures, although there may be within-group differences in the degree to which groups indicate a collectivist versus an individualistic orientation. Interdependence or collectivism among people may provide a sense of belonging for individuals at risk for attempting suicide and this may mitigate risk for suicidal behaviors. Some studies have compared these cultural factors and have mostly found more negative attitudes toward suicide in collectivistic than individualistic cultures. For example, Etzersdorfer, Vijayakumar, Schony, Grausbruger, and Sonneck (1998) found in a study on attitudes toward suicide among respondents in Austria (Individualistic culture) and India (collectivistic culture) that respondents University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 20 in the collectivistic culture had more negative attitudes toward suicide than their counterparts in the individualistic culture. Correspondingly, Peltzer, Cherian, and Cherian (2000) compared Blacks, Whites and Asians in South Africa and discovered that plans to commit suicide and suicidal ideation are highest among Asians and Whites as compared to blacks. In another study, Carmona-Navarro and Pichardo-Martinez (2012) evaluated the attitudes and impact of emotional intelligence among mental and emergency health nurses via a questionnaire. Generally, data analysis showed an adverse attitude towards suicidal behavior. Moreover, the findings on the moral dimension of the questionnaire differentiated between mental health and emergency professionals. Additionally, possessing a high level of emotional intelligence and a higher degree of mental health training is connected with a more positive attitude towards patients with suicidal behavior. Using the Suicide Opinion Questionnaire, Kim, Lee, Lee, Yu, and Hong (2009) also evaluated the awareness and attitude toward suicide in 264 community mental health professionals and 228 hospital workers in Korea from July to September 2007. Findings revealed significant differences in attitudes in terms of religion, age, marital status, educational background, the economic position, and different professional licenses. Specifically, the hospital workers were of the view that suicide was due to mental illness, and suicide was high for the people in a special environment and who lacked motivation, which caused them to fall in a dangerous situation. Additionally, respondents with lower educational levels attributed suicide to mental illness. The awareness for suicide was also significantly higher in the group with postgraduate education, unmarried people, mental health professionals and the individuals who had concern and experience with suicide. Items such as mental illness, religion, risk and motivation were the factors that had an influence on the awareness of suicide. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 21 Likewise, Anderson and Standen (2007) investigated the attitudes of one hundred and seventy- nine nurses and doctors who work with children and young people who self-harm. Using the Suicide Opinion Questionnaire (SOQ), they explored the effect of basic demographic factors on attitudes towards suicide in the staff group. They found no significant differences between staff working in the accident and emergency area, pediatric medicine or adolescent inpatient mental health services in relation to gender, age, clinical specialty and length of experience in current post. Both doctors and nurses indicated agreement on the Mental Illness, Cry for Help, Right to Die, Impulsivity, Normality and Aggression Scales. They however had less agreement on the religion and moral evil scale. Only the scores for mental illness were statistically different in relation to professional group. There were no other significant differences on the other clinical scales in relation to age, length of experience in current post, gender and clinical specialty. It is argued that complex attitudes need to be considered in the training for healthcare professionals and in the development of current suicide prevention policy. Correspondingly, Lee, Tsang, Li, Phillips, and Kleinman (2007) conducted a study which evaluated the attitudes toward suicide, suicidal inclination under 12 hypothetical scenarios and prior suicidal experience using a convenience sample of 1,226 people who completed the self- report Chinese Attitude toward Suicide Questionnaire (CASQ-HK). Respondents revealed, in keeping with Chinese tradition, both tolerant and condemning attitudes, which varied with their socio-demographic characteristics. Largely, they were not strongly persuaded to consider the presence of complex situations. Female gender, the presence of suicidal ideation and older age were associated with more contemplation of suicide. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 22 Factors that inf lu en ce suicid e preven tion Some factors have generally been identified to impact both the content and intervention of programs aimed at helping people in a suicidal crisis or those who deliberately self-harm. For instance, Adinkrah (2010) investigated the current patterns and meanings of male suicidal behavior in Ghana by examining official police data spanning 2006-2008 and found that reported cases of fatal and non-fatal suicidal behavior tremendously involved males. Additionally, the investigation discovered that majority of males who engaged in suicidal acts did so to deal with dishonor of variable sources and feelings of shame. The author stresses the need to change the rigid dichotomization connected with male-female gender roles and socialization that accentuate masculinity ideals in Ghana and the need for increased research and the support for counseling for males facing emotional stress. Similarly, Sefa-Dedeh and Canetto (1992) report that among other things, suicidal behavior among women in Ghana comprised insubordination to the domineering expectations in the family and society. Akotia, Knizek, Kinyanda, and Hjelmeland (2013) also indicate that religion played a double-edged role in suicidality: on one hand suicide attempters found religion helpful during life crisis, but on the other hand, their religious belief augmented self-condemnation and feelings of guilt. The attitudes that clinicians hold towards suicide and suicide prevention initiatives may also impact their management skills and suicide risk assessment. Brunero, Smith, Bates and Fairbrother (2008) conducted a study that assessed the attitudes of a group of non-mental health professionals toward suicide prevention initiatives. They discovered that health professionals who had suicide prevention education demonstrated considerably more affirmative attitudes toward suicide prevention initiatives. This therefore demonstrates the need to educate non-mental health professionals in suicide risk management and awareness. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 23 Barriers to accessing health care are other factors that influence suicide prevention. Specifically, Cho et al. (2013) suggest that suicide risk increases significantly with comorbidity; so effective and timely access to health care is essential to reducing the risk of suicide. However, health systems in many countries are not only complex but limited in resources as well; navigating these systems is a huge challenge for persons with low health literacy and low mental health literacy in particular (WHO, 2013). Additionally, the stigma related with seeking help for mental health disorders and suicide attempts further aggravates the difficulty, leading to inappropriate access to care and to higher suicide risk. Furthermore, the World Health Organization (2014) asserts that the stigma against seeking help for suicidal behaviors, problems of substance abuse or mental health, or other emotional stressors continues to exist in many societies and can be a substantial barrier to individuals receiving the aid that they need. Moreover, stigma can discourage the families and friends of vulnerable people from providing them with the support they might need or even from acknowledging their situation. Stigma therefore plays a major role in the resistance to change and implementation of suicide prevention responses (Matsubayash, Sawada, & Ueda, 2014; Reynders, Kerkhof, Molenberghs, & Audenhove, 2014). For example, a multicomponent mental health awareness program for young people was developed and tested in the Saving and Empowering Young Lives in Europe (SEYLE) project. SEYLE is a preventive program which was tested in 11 European countries and which seeks to promote mental health among school-based adolescents In European schools (Carli et al., 2013). Every country performed a randomized controlled trial consisting of three active interventions and one minimal intervention that served as a control. The active interventions comprised professional screening for at-risk adolescents, gatekeeper training and a mental health awareness program (Wasserman et al., 2012). Compared to those in University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 24 the minimal intervention, adolescents who took part in the mental health awareness program had significantly lower rates of both severe suicidal ideation or plans and suicide attempts at 12- month follow-up. Wasserman et al. (2014) recommends that for optimal implementation of awareness programs, it is necessary to consider the help and support of local schools, teacher, politicians and other stakeholders. The lack of adequate mental health training is another factor that influences suicide prevention initiatives. For instance, Osafo, Knizek, Akotia, and Hjelmeland (2012) analyzed the interviews of 9 clinical psychologists and 8 emergency ward nurses to examine their attitudes toward suicidal behavior and its prevention in Ghana. They discovered that the attitudes of these health workers seemed to be transiting between morality and mental health. Specifically, the psychologists generally viewed suicide as a mental health issue, stressing an empathic and caring view of suicidal individuals and approaching suicide prevention from a health-service viewpoint. In contrast, the nurses to a certain extent held a moralistic attitude toward suicide. They viewed suicide as a crime and saw suicidal persons as blameworthy and hence approached suicide prevention from a proscriptive standpoint. The authors argued that clinical experience with suicidal persons, religious values and educational level were the factors influencing the differences in attitudes toward suicide and suicide prevention between nurses and psychologists. The authors therefore recommended that pragmatic suicide prevention efforts should be based on mental health education and improvements in primary health care. Informal approaches such as strengthening the legal code against suicide, threatening suicidal persons with the religious consequences of the act and talking to people were also recommended by the authors as realistic approaches to suicide prevention. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 25 Furthermore, Norheim, Grimholt, and Ekeberg (2013) examined the attitudes of 229 professionals working in mental healthcare outpatient clinics in Child Adolescent Psychiatry (CAP) and District Psychiatric Centers (DPC). Findings revealed that all respondents had positive attitudes and endorsed that suicide was preventable. However, professionals who were specialists or who had received supervision were more positive. CAP professionals were less pleased with available treatment. Psychotherapy was considered the most suitable form of treatment whereas psychiatric disorders were considered the most common cause of suicidal behavior. Goldston et al. (2008) have also discussed that collectivist orientation may also augment acculturative stress and discrimination as well as the awareness of racial oppression, which usually affects bigger communities. Therefore, rather than serving as a protective factor, collectivist orientation may serve as a risk factor for suicidal behaviors. For example, attitudes toward substance abuse, antisocial behavior and degree of cohesion as well as attitudes toward death have also been discovered as factors influencing suicide prevention (WHO, 2014). Psychologists therefore, need to be conscious of the degree to which the history of racism and or societal pressures as well as the process of acculturation has eroded a sense of community and interdependence amongst some people. Notably, the WHO (2014) points out that there are multiple causes and pathways for suicide. Interventions that contain more than one prevention strategy might therefore be principally useful for preventing suicide. Particularly, research suggests that multicomponent program strategies are associated with successful treatment regimen aimed at reducing suicide rates. For example, the United States Air Force program consisting of 11 community and health-care components with accountability and protocols was shown to be very effective in preventing University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 26 suicides in the Air Force (Knox et al., 2010). Similarly, another multicomponent program targeting depressive disorders in Nuremberg, Germany, significantly reduced suicide and attempted suicide rates (Hegerl, Rummel-Kluge, Varnik, Arensman, & Koburger, 2013). Specifically, the program consisted of four different interventions: a public relations campaign targeting the general public; training of community facilitators such as journalists, teachers and police; training of general practitioners; and supporting patients and their families. This multifaceted intervention has now been applied by the European Alliance against Depression, which comprises partners from 17 countries (Hegerl & Network EAAD, 2009). Multicomponent interventions for high-risk individuals also appear to be effective. For instance, a study by While et al. (2012) investigated the effect of nine components of health-service reform on suicide outcomes in the UK. The study revealed that health trusts that implemented more service reforms showed larger reductions in suicide. Specifically, a 24-hour crisis response, dual diagnosis policies, and a multidisciplinary review after a suicide death were the three programs associated with suicide reduction. These studies collectively demonstrate that there may be additive and synergistic effects of integrating multiple interventions. The role of reli gion and reli giou s lead ers in suicid e preven tion Africans have been noted as disreputably religious. Specifically, Mbiti (2006) asserts that religion pervades all their aspects of life so fully that it is not always possible or easy to segregate or detach it. Osafo, Knizek, Akotia, and Hjelmeland (2011b) have confirmed this assertion. They discovered that Ghanaian laypersons are dedicated to the normative and core religious values, belief and practices of preserving life. Consequently, suicidal behavior was unacceptable. Nonetheless, religion aided their willingness to help people during suicidal crisis. Moreover, Knizek, Akotia, and Hjelmeland (2010) examined the attitudes of Ghanaian University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 27 Psychology students towards suicide using a qualitative analysis of open-ended questions to investigate what they perceived to be the causes of suicide and how suicide could best be prevented. The study revealed that there was a huge impact of religion on the attitudes toward suicide as well as some difficulty in distinguishing between their religious and professional roles and responsibilities. Likewise, Akotia, Knizek, Kinyanda, and Hjelmeland (2013) in a qualitative study investigated the role of religion in the experiences of persons who attempted suicide in Ghana. They interviewed 12 men and 18 women on admission at various hospitals and clinics in Accra. Findings showed that religion provided an extenVive context ZitKin ZKicK inIorPDntV¶ experiences could be understood. All interviewees acknowledged God as the owner of life and death. A few informants reacted to the suicidal act in opposition to their religious system and expressed anger and disappointment in God while the majority reacted in a way that resonates with the system and sought for forgiveness from God. Neville and Roan (2013) in another study, conveniently sampled 45 nurses in a different study, which was aimed at examining their attitudes toward suicide and to achieve a better understanding of factors impacting the identification and management of suicide risk and XOtiPDteO\ iPprove pDtient VDIet\. )indinJV DIter DnDO\ViV oI dDtD VKoZed tKDt nXrVeV¶ edXcDtionDO level and age considerably correlated with affirmative attitudes toward suicide and that religion was also a significant predictor of positive attitudes toward suicide. Gielen, van den Branden, and Broeckaert (2009) also used PubMed to search and review articles published before August 2008 with the aim of evaluating the impact of religion and worldview on the attitudes of nurses toward euthanasia and physician assisted suicide. Majority of the University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 28 studies that were identified demonstrated a clear relationship between religion or worldview and nXrVeV¶ DttitXdeV toZDrd eXtKDnDViD or pK\ViciDn DVViVted VXicide. )XrtKerPore ideoOoJicDO affiliation or religion, observance of religious practices, religious doctrines, and personal importance attributed to religion or worldview influenced disparities in attitudes. Nonetheless, a logical relative interpretation of the results of the identified studies was difficult. The authors therefore concluded that no study had so far explored the relationship between worldview or reOiJion Dnd nXrVeV¶ attitudes toward physician-assisted suicide or euthanasia and that more research is required. +irono 013 in D VXrve\ DOVo exDPined $PericDn &KriVtiDn Dnd -DpDneVe %XddKiVt cOerJ\¶V perception of their role in the prevention of suicide. Analysis of responses using both quantitative and qualitative methods revealed that many Japanese Buddhist clergy think that the issue of how one dies is not the most important issue. Many American Christian clergy conVidered VXicide to Ee D Vin EXt tKDt µ*odV Oove iV Dvailable for people who committed VXicide¶. Correspondingly, Agilkaya (n.d.) interviewed and compared the religious dispositions among Turkish-Muslims who attempted to commit suicide. Interviews were analyzed under headings like religious beliefs and behaviors, God images and relations and the meaning of life. Content analysis of interviews showed that with the exception of one atheist, the rest of the sample had religious beliefs. Additional analysis showed that differentiation had to be made concerning religious beliefs, since the sample demonstrated that 29% had individual religiosity while the remaining 67% had formal religiosity. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 29 To comprehend the experiences of suicidal persons in Ghana, Osafo, Akotia, Andoh-Arthur, and Quarshie (2015) interviewed 10 persons after they had attempted suicide. Thematic analysis of dDtD reveDOed tKDt PotivDtion Ior VXicidDO EeKDvior incOXded pDrtner¶V inIideOit\ VociDO tDXntinJ and hopelessness. Suicidal persons reported stigma expressed through social ostracism and physical molestation that left them traumatized. They however coped through religious faith, social support from relations and use of avoidance. In a different study, Yapici (cited in Agilkaya, n.d) in his comprehensive study on Mental Healt h and Reli gion discovered that hopelessness, depression, self-esteem and suicide risks which are predictors for suicidal behavior differ among Turkish students regarding their level of experiencing Gods existence in their inner world. Consequently, students who develop an inner relation with God, take refuge with and rely on God and remember God regularly are in better mental health. Students who pray for the help and support of God, that means who turn to God in the awareness of their weakness, helplessness and desperation, cope much better with daily stress, depression, hopelessness and thereby suicide risks. Remarkably, apart from this particular research by Osafo, Agyapong, and Asamoah (2015) which aimed at carefully outlining and bringing to the fore the role of religious groups in mental health, the review of literature did not reveal much on the attitudes of religious leaders towards suicide and the specific treatment regimens they employ in preventing suicide. Specifically, the study by Osafo et al. (2015) explored the nature of treatment regimen for mentally ill persons by interviewing 12 clergy from a particular Christian strand called the neo-prophetic Christian ministries or churches. Analysis of data using interpretative phenomenological analysis (IPA) showed that these clergy perceived mental illness as a spiritual rather than a biomedical problem. Also, the treatments they prescribed for mental illness advance toward two key approaches University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 30 namely the hope induction approach and the prophetic deliverance approach. Assessment of cure for illness also involved self-care and community participation, perceived complete exorcism and observation of restored orientation. 2.4 Ration ale As efforts accumulate towards the vital need to improve mental healthcare services in low and middle-income nations, attention has been drawn to the cost effectiveness of harnessing vital local resources in this regard (Prince et al. 2007). Ae-Ngibise et al. (2010) and WHO (2014) have discovered religious groups as one of the means of bridging this gap. Furthermore, there is increasing evidence that religious groups in Ghana are engaged in some form of mental healthcare delivery (e.g. Ae-Ngibise et al., 2010; Laugharne & Burns, 1999; Read, Adiibokah & Nyame, 2009). Accordingly, the Ghana Ministry of Health (2005) also indicates that there are about 45,000 traditional healers registered in Ghana, with many churches providing a syncretic spiritual healing to about 70-80% of persons using them as forefront service workers. Furthermore, Roberts, Asare, Mogan, Adjase, and 2Vei 013 in D recent report on *KDnD¶V PentDO KeDOtK system also indicate that a huge proportion of traditional practitioners and faith healers offer treatments such as medications, refer mental illness cases to psychiatric services for attention and also use mechanical shackles to restrain about 41-57% of patients. This present study therefore explores the critical issues of the attitudes of religious leaders toward suicide, their treatment regimens and their role in suicide prevention in Ghana. Many people agree that suicide prevention is an emergent issue, yet they overlook the role of religious leaders in the suicide prevention process (Hirono, 2010). Additionally, several researchers in the University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 31 field of suicide prevention have focused on the role of medical facilities, schools and other local or state organizations. The role of religious leaders in the literature has however had little attention yet the researcher believes religious can stop people from committing suicide through doctrinal teachings, counseling and preaching. Several suicide attempters are religious people who ascribe to one religion or the other. Still, others are suicide survivors, that is, they have family members, relatives or friends who have committed suicide. During funerals or memorial services, these survivors may have had the chance to speak with their religious leaders about the meaning and morality of suicide. If religious leaders speak negatively about suicide, then suicide survivors might become vulnerable to suicide. On the other hand, if empathy and understanding is expressed towards the survivors, the pain of losing their loved one will alleviate. For example, many suicide survivors struggling with the moral principles of suicide might be concerned whether suicide is a sin (e.g. if they are Christians). This therefore makes the role of religious leaders in suicide prevention very key (Hirono, 2013). Concisely, the key role of religious leaders in suicide prevention may Ee in tKe coXnVeOinJ Dnd prevention oI µinter-generational VXicide¶ ZKicK includes a sequence of suicides in the same family, among relatives and friends (Hirono, 2010). Additionally, there might be differences between the views and treatment regimens of Christian, Islamic and traditional leaders in suicide prevention. Furthermore, the 1960 Criminal Code of Ghana criminalizes suicide (Adinkrah, 2010), and there are no official public figures on suicide in the country. Additionally, Osafo et al. (2011a), in a study among psychology students in Ghana also found that almost half (47%) of the students knew someone who had attempted suicide. Similarly, Hjelmeland et al. (2008) discovered that although there are no reliable official statistics on the act, one in five knew someone who had University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 32 killed him or herself. Based on these findings, the researchers specified that suicidal behavior could be an extensive public health crisis in Ghana. Additionally, previous studies on attitudes towards suicide in Ghana have concentrated mainly on students, are largely quantitative, and have not examined more specifically, the attitudes, role and treatment regimens of religious leaders in the suicide prevention process. How these religious leaders respond at points of contact will influence how suicidal persons as well as survivors respond to the support offered. It is against this background and observation that this exploratory research is being embarked on to examine the attitudes and treatment regimens of Christian, Islamic and Traditional leaders and their role in the prevention of suicide in Ghana. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 33 CHAPTER THREE 3.0 METHODOLOGY 3. 1 Introd u ction This chapter outlines the methodological approaches adopted in this study. It also presents the population and setting for the study and the techniques used for the design of the study and data gathering. The populations chosen for the study were Christian, Islamic and Traditional leaders in the Ga East Municipal District located in the Greater Accra Region of the Republic of Ghana. The choice of the population was informed by the nature of the research topic, which aims to expOore 5eOiJioXV /eDderV¶ roOe in addressing the problem of suicide. 3.2 GHANA: THE RESEARCH SETTING Ghana is a culturally heterogeneous (Adinkrah, 2011) and sovereign state situated just north of the Equator on the West Coast of Africa and shares borders with the Ivory Coast to the West, Togo to the East, Burkina Faso to the North, and the Atlantic Ocean to the south. It is a developing country occupied by diverse groups of approximately twenty-three million people distinguished mainly by language. The Akan-speaking ethnic groups (e.g., Ashante, Fante, Kwahu, etc) are numerically dominant, collectively constituting 49.1% of the entire Ghanaian population. The Mole-Dagbani, Ewe and Ga-Dangme are some of the other ethnic groups and constitute 16.5%, 12.7% and 8% respectively. Religious heterogeneity in Ghana is reflected in the various institutionalized and traditional religious faiths with which Ghanaians identify. According to the 2000 census, 68.8% of the University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 34 population indicated an affiliation with one of several Christian denominational churches, followed by Islamic adherents (15.9%) and subscribers of traditional faiths such as ancestor veneration (8.5%). Another 6.1% of Ghanaians reported no affiliation with any religion (Care International, 2009; Ghana Statistical Service, 2002). 3.3 Population Christian, Islamic and Traditional Religious Leaders within the Ga East Municipal District of the Greater Accra Region served as the population for the study out of which 14 males and 14 females between the ages of 20 to 60 years took part in the study. The Ga East Municipal District was chosen because of the inability of nationwide study due to time and financial constraints. Also, it is a heterogeneous setting made up of urban and rural dwellers. Branches of all the three major religious denominations in Ghana are found within the District. Participants are easily accessible and this therefore provided a clearer picture on the attitudes and treatment regimens utilized by these religious leaders in suicide prevention. Particip an ts/samp li n g tech n iq u e Informants for this study were 28 adults made up of 16 Christian (Ordained Reverend Ministers / Pastors), 8 Muslim (Imams) and 4 Traditional (Chief/ Elder/Priest) religious leaders. The major factors guiding the choice of this sample size was the concept of f saturation. Qualitative studies are cautious of saturation where the data being collected or cases being examined may not throw any further light on the issue under investigation hence the researcher stops conducting further interviews (Mason, 2010). Other factors included the heterogeneity of the population under study, the selection criteria, the multiple samples within one study as well as the budget and resources available to the researcher (Ritchie, Lewis and Elam, 2003). Fourteen of the informants University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 35 were females while fourteen were males. Two participants were unmarried and the rest were married. The ages of the informants ranged between 20 to 60 years whereas their tenure in their roles as religious leaders was ten years and more. Majority of the informants (12) were Ga- 'DnJPe¶V 3 Zere (Ze¶V 11 Zere $NDn Dnd tKe rePDininJ  Zere IroP tKe 1ortKern *KDnD ethnic groups. (Refer to Table 3.1). Table 3.1 Demograp h ic Charac te ristics of Particip an ts Variable Frequency (n) Percentage (%) Age Range 20-30 31-40 41-50 51-60 1 5 11 11 3.6 17.8 39.3 39.3 Gender Female Male 14 14 50.0 50.0 Marital Status Single Married 2 26 9.1 90.90 Religiou s Leader Categ ory Christian Muslim Traditional Religion 16 8 4 59.09 31.82 9.09 Ethnicity Ga-Dangme Ewe Akan Dagomba 12 3 11 2 42.9 10.7 39.3 7.1 Purposive and snowballing sampling techniques were used in the selection of informants. These techniques were chosen because of the conviction that the rigidity of sample selection involves thoughtful and precise picking of cases, which are in line with the purpose of the research (Patton, 1999) and additionally based on the willingness and availability of informants to University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 36 participate in the research. Furthermore, some informants, due to their longer tenures as religious leaders might have richer knowledge hence, they could provide more insight into the issue of interest than others (Marshall, 1996). Led by this understanding, some informants recommended other helpful persons for the study, whose consents were sought and interviewed. 3.4 Criteria for sele ctio n The participants for the research were eligible for selection based on the following conditions:  Participants must either be Christian (Ordained Reverend Ministers / Pastors), Muslim (Imams) or Traditional (Chief/ Elder/Priest) religious leaders.  Participants should have been in leadership positions for ten years and more. 3.5 Resear ch Design A comparative design, using a qualitative approach was employed by the researcher to explore the attitudes of religious leaders and the treatment regimens they use in suicide prevention. According to Silverman (2006), suicide is a complex issue and Hjelmeland (2010) and Colucci (2006, 2008) assert that in a cultural environment, a qualitative approach is required in order to understand the meaning people make out of the phenomenon. Qualitative research design is based on the stance that people understand and relate to things cognitively- from within the mind. This design seeks to provide contexts, like one-on-one interviewing, that allow a participant to express their beliefs, assumptions, desires and understandings (Willig, 2001). Qualitative research is valuable for the in-depth study of complex phenomena (Hjelmeland & Knizek, 2010). Additionally, it provides understanding and deVcription oI peopOe¶V perVonDO experiences of phenomena and can therefore generate detailed University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 37 and rich information on a phenomenon as they are embedded and situated in local contexts. The qualitative researcher is highly sensitive to modifications that occur during the conduct of the research, which broadens its knowledge base. Hence, the qualitative approach would be used to explore the phenomenon under study, which iV µVXicide¶. 3.6 Measurin g Instru men t A semi-VtrXctXred intervieZ JXide ZDV XVed to DVVeVV tKe inIorPDntV¶ DttitXdeV toZDrdV suicide and suicide prevention. The investigator¶V IocXV ZDV to exDPine in detDiO KoZ inIorPDntV perceive Dnd PDNe VenVe oI tKe pKenoPenon µVXicide¶ Dnd tKe treDtPent reJiPenV tKe\ XVe in suicide prevention. This therefore necessitated the use of a flexible data collection tool to serve as a guide and which would also allowed an in-depth examination of the personal and social worlds of the informants (Smith & Osborne, 2003). This form of interviewing allows the researcher and participant to engage in a dialogue and the interviewer is freer to probe interesting areas that arise. Additionally tKe intervieZ cDn IoOOoZ tKe reVpondent¶V intereVtV or concernV (Smith & Osborne, 2003). Some of the items on the guide are:  Please explain how religious leaders treat persons with suicidal crisis (explore all the treatment regimens that informant provide or list- e.g., prayers, fasting, counseling, deliverance etc.)  How do you use counseling (and other treatment regimens listed above) to help someone in suicidal crisis?  Have you counseled with any individual/s who reported thinking about committing suicide in this your profession? (Refer to Appendix C for the Interview Guide) University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 38 3.7 Proced u re Ethical clearance was attained from the Ethics Committee for the Humanities at the Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, Legon. Consent forms were designed and presented to every informant who agreed to participate in the research. Introductory letters signed by the Head of the Department of Psychology, University of Ghana reveDOinJ tKe reVeDrcKer¶V identit\ tKe rDtionDOe Dnd tKe ViJniIicDnce oI tKe VtXd\ in tKe prevention of suicide were given to the religious denominations involved. Interviews were conducted predominantly in English between January 2015 and February 2015 by the researcher using the interview guide prepared. However, where participants felt more comfortable using any local dialect, they were granted the opportunity to do so especially in Dangme, Ga and Twi since the researcher is familiar and fluent in such local dialects. Appointments were booked with informants who consented to participate after permission was granted. Interviews were conducted mainly in their offices and in their homes on a few occasions. Whittemore, Chase, and Mandle, (2001) argues that the validity of interpretation is a key issue in qualitative studies. Therefore to ensure validity, the investigator checked and summarized during the interview process whether the views of informants have been rightly recorded (Whittemore et al., 2001). With permission from the participants, the interviews were audio-recorded and later transcribed accurately. 3.8 Analysis of data Thematic analysis was used to analyze the audio-recorded and accurately transcribed data. The transcribed data was read over and over again which assisted in the easy identification of words, concepts, ideas and themes that appeared recurrently. Themes, words, ideas and concepts that University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 39 appeared repeatedly in the interviews were compared and cross-checked with other interviews and found to be consistent and saturated by the end of the twenty-eighth interview. Thematic analysis is a method for identifying, analyzing and reporting patterns (themes) within data (Braun & Clark, 2006). This method minimally organizes and describes data set in (rich) detail. It however goes further than this to interpret various aspects of the research topic (Boyatzis, 1998). Thematic analysis differs from other analytic methods that seek to describe patterns across qualitative data and does not require the detailed theoretical and technological NnoZOedJe oI DpproDcKeV VXcK DV µtKePDtic '$ JroXnded tKeor\ interpretive pKenoPenological analysis and thematic decomposition analysis. Thematic analysis is flexible. Through its theoretical freedom, it can provide a rich and detailed yet complex account of data (Braun & Clarke, 2006). The analysis involved the preparation of data to be examined by transcribing the interview into text and reading the text to note items of interest in order to gain a sense of the various issues entrenched in the data. Further microanalysis of the data was done by thoroughly reading and examining the text closely, line by line. After close examination of the text, items of interest were grouped into proto-themes, where themes begin to emerge by organizing comparable items into categories as well as investigating the proto-themes and efforts were made to define these proto-themes. The text was re-examined cautiously for significant incidents of data for each proto-theme by taking each theme individually and re-examining the original data for information relating to that theme. Additionally, the final form of each theme was restructured and the meanings of the themes were examined closely using all the materials connecting to each theme. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 40 The name, definition and supporting information were re-assessed for the final conclusion of each theme, using all the data relating to it. Finally, each theme was reported with its description in addition to exemplifying it with some quotations from the original text to help convey its meaning to readers. 3.9 Ethical consi d eration s Ethical clearance was attained from the Ethics Committee for the Humanities at the Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, Legon. Approval was sought from the head pastors, imams and chiefs of the various religions from which participants were chosen. The religious leaders were informed about the nature of the study through their Heads following from the issuance of an introductory letter from the Department of Psychology, University of Ghana. Religious leaders who consented to participate in the study were given forms to formalize their participation. Moreover, participants were notified that participation was completely voluntary and that they could opt out at any time during the interview sessions. Furthermore, they were also guaranteed of confidentiality by way of withholding their names due to the highly sensitive nature of suicide. Arrangements were made for participants who may need attention from a clinical psychologist or competent counselor following the interview session. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 41 CHAPTER 4 4.0 FINDINGS 4.1 Introd u ction This chapter presents the findings based on the data obtained from the field. Essentially, the chapter covers the themes that originated from the responses of participants. These themes were then structured into meaningful units using the sub-themes derived from them. After analysis of the transcribed data, findings were organized around six five major thematic areas: The Context: Cultural Abhorrence, Diverge to Converge: Life Preservation, Motivations: Psychological and Diabolism, Care or condemnation? Sub-themes were recognized under each key thematic area to capture the pertinent voices reflecting the treatment regimens and the attitudes of the respondents toward suicide and suicidal persons. For ease of reference and to see whether there are differences due to gender and religious affiliation, codes were used to identify respondents as such: CRL Man/Woman refers to a male or female Christian religious leader, IRL Man/ Woman refers to a male or female Islamic religious leader and TRL Man or Woman refers to a male or female Traditional religious leader. 4. 2 The Context: Cultural Abhorren ce In the effort to discover the attitudes of religious persons toward suicide and suicidal persons, it iV neceVVDr\ to XneDrtK reOiJioXV OeDderV¶ eVtiPDtion oI tKe cultural context within which suicidal behavior occurs and how it is viewed. Generally, the participants provided a cultural context that abhors suicidal behavior, with strong stigma practices towards the suicidal person. University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 42 A Moslem respondent clearly put it thus: µ…it is no t acceptable. To the Ghanaian, nobody should commit suicide.’ (IRL Man, 59 years). The implication here from this Moslem respondent is that, although suicide occurs, it is not considered an acceptable cause of death because the Ghanaian society prohibits such actions. A Christian respondent also goes further to indicate a similar view of suicide that is widespread in Ghana. Specifically, she said: ‘….they have a very hard attitude towards it. They feel it’s a disgrace to the family and people are very unsympathetic…G enerall y, people consider it a taboo....a shame… a disgrace’ (CRL Woman, 58 years). 7KiV pDrticipDnt¶V XtterDnce indicates that within the Ghanaian culture, there is a perceived interrelatedness of people and the consciousness that suicidal behavior affects tKe IDPiO\¶V VociDO iPDJe 2VDIo et DO., 2011a). Hence the act is considered as shameful and disgraceful. This view appears to facilitate the general attitude of abhorrence towards the phenomenon of suicide in Ghana (Osafo, Akotia, Andoh-Arthur, & Quarshie, 2015). A Traditional leader also observes how people dissociate themselves from the corpse of a person who has died through suicide. ‘There’s an elderly soldier in this town. He died suddenly. It was said that he shot himself…The whole town saw it as an abominable act. He was not originally from University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 43 thi s tow n. He was t aken to his own hometown and even there, they didn’t bury him in the publi c cemete ry. They went to search for somew here, dug a hole and brought a past or from Accra to come and bury him because the tow n past or said he wouldn’t bury him because he committed suicide (TRL , Wo man, 60 years ). 7Ke VenVe tKDt tKe deDd VoOdierV¶ Dct oI VKootinJ KiPVeOI DIIectV tKe toZn¶s social image is demonstrated in how they relate to the corpse by sending it back to its hometown. In its hometown, the digging of a pit for burial rather than the public cemetery shows how the corpse of suicide deaths are treated and buried. Also, the refusal of the town pastor to bury the corpse resulting in a pastor being brought from Accra to carry out the burial are all measures which these two towns have employed to distance themselves from the corpse and to endorse their social disavowal of the act (Mugisha et al., 2011). 4. 3 Diverge to Converg e : Life Preserva tion This theme examines the dynamic nature of the attitudes of these religious leaders toward suicide. It shows that the religious leaders did not appear to have a personal attitude towards suicide, but rather relied on either one or multiple views to adduce their perspective on suicide (religious, or traditional). However, the end result of this divergent perspective was to affirm that suicide was not acceptable and thus life-preservation should be the supreme action during distress. Illustrative of these are voices below: µIn Islam, Allah did not say we should kill ourselves. If you intentionally kill yourself…on judgment day, All ah w ould punish you’ (IRL, Woman, 51 years). 7KiV ,VODPic reVpondent¶V VtDndpoint iV KinJed on tKe VinJOe reOiJioXV EeOieI tKDt VXicide iV forbidden in Islam as stated in stated in PDn\ verVeV oI tKe 4Xr¶Dn. )or exDPpOe µ$nd Vpend in University of Ghana http://ugspace.ug.edu.gh ATTITUDES AND TREATMENT REGIMENS IN SUICIDE PREVENTION: THE ROLE OF RELIGIOUS LEADERS IN THE GA EAST MUNICIPAL DISTRICT’ 44 the way of Allah and do not throw [yourselves] with your [own] hands into destruction. And do Jood indeed $OODK OoveV tKe doerV oI Jood.¶ $O-Baqara 2: 195). Therefore this participant perceives that committing suicide is destructive and makes the dead person liable to punishment from Allah on the day of Judgment (e.g. Mbiti, 2006). However, a Christian respondent draws from multiple (cultural and Christian) perspectives to expatiate her attitude towards suicide. She states: ‘Ehhhm not really, it is my Christian view that has affected my thinking. Ehhm, because I think if you commit your life to Christ, you would depend on Him and wouldn’t have to go thi s far. So the fact that our culture doesn’t accept it… Well, I know it isn’t a good thing to do, but it isn’t that which has affected my thinking. It is my Christian background that is affecting my thinking’ (CRL, Man, 43 years). This participant accedes that generally the Ghanaian cultural context is abhorrent to suicide. Nonetheless, her attitude towards the act stems mainly from her Christian beliefs as stated in many verses in the Holy Bible. For example, µ