“One kind of person most likely to kill himself is someone experiencing a depressive reaction for the first time,” says psychologist Douglas Powell, who worked at Harvard University Health Services for many years. “Young people who are depressed often think that one thing, one event, will make it all better—a good grade, a boyfriend. It’s important to help them realize that it’s perfectly possible to have a date that isn’t earth-shattering, and that even if it’s not such a great time, you’re still the same person afterward and it’s not the end of the world.” Depressed adolescents are apt to blame themselves for feeling bad and to punish themselves for imagined failures. “Kids who have never experienced failure go into a tailspin when they get a twenty-three on a biochemistry test,” says Chicago psychiatrist Derek Miller. “One of the most important things we can do for our children is build some failure into their lives so they learn that it is possible to fail without being a failure.” San Francisco psychiatrist Jerome Motto drew applause at a conference on adolescent suicide when he suggested, “Early on, we should give children puzzles they can’t solve—and then give them love when they fail.”
While depression and suicide are closely related, depression is not the only answer; for every teenage suicide there are hundreds of depressed teenagers. And depression is twice as common in females as males, yet suicide is four times more common in males. Clinicians have struggled to isolate the factors that separate suicidal depression from depression, but they tend to come up with abstractions such as “loneliness,” “isolation,” “low self-esteem,” and “a profound sense of worthlessness.” Psychiatrist Aaron Beck, the founder of cognitive therapy, cites “hopelessness” as the key factor, and in a series of studies has shown it to be a strong predictor of suicide in depressed patients. (Psychiatrist Calvin Frederick goes two h’s further: “helplessness, hopelessness, and haplessness.”) Comparing twenty-six depressed patients who had completed suicide with twenty-six depressed patients who had not, a group of clinicians found that while hopelessness, rage, self-hatred, and anxiety were more prevalent among those who had completed suicide, “the acute affective state most associated with a suicide crisis was desperation.” Still other clinicians have found a significant relationship between hopelessness and what psychiatrists call “locus of control.” People who believe that the outcomes of events are due to forces outside themselves, and whose sense of self-esteem is based on what others think of them, tend to feel more hopeless than those who feel that events are contingent on their own actions. Adolescents who depend on others for a sense of self-worth may find a reason to live in someone or something else. They put all their eggs in one basket—a sport, a grade, a person—which then becomes all-important. Often that reason may be a boyfriend or girlfriend. “If the adolescent has no other sources of self-esteem, the relationship becomes tremendously overvalued,” says Samuel Klagsbrun, a psychiatrist in Westchester County. “It becomes the foundation of the person’s life. ‘If the other person loves me, I’m okay.’ But if that goes, it’s as if everything goes—because there’s nothing left to bank on.”
As early as 1938, psychiatrist Gregory Zilboorg noted the greater frequency of parental death in the history of suicidal people and suggested that the loss of a family member when the child was at the height of the Oedipus complex or in the transition to puberty led to a morbid identification with the dead person and rendered the child especially susceptible to suicide. “This is probably the most primordial cause of suicide in the human breast,” he concluded. Since then, many studies of suicide have found a high incidence of parental loss. Examining fifty suicidal patients of all ages, psychiatrists Leonard Moss and Donald Hamilton identified what they called a “death trend”—95 percent of the patients had suffered the loss of a close relation. In 75 percent of the cases, the deaths had occurred before the end of adolescence. A University of Washington study of 114 completed and 121 attempted suicides found that the death of a parent had occurred significantly more often in the childhood of the actual suicides than in that of the attempted suicides. They concluded that an inability to come to terms with a parent’s death in childhood leads to an inability to cope with loss in later life. “Loss in all of its manifestations is the touchstone of depression—in the progress of the disease and, most likely, in its origin,” wrote the novelist William Styron in Darkness Visible, a harrowing account of his descent into suicidal depression. Although Styron traces his illness to genetic vulnerability—like him, his father had been hospitalized for severe depression—he ascribes an even more important role to the death of his mother when he was thirteen.
If that early parental loss is by suicide, it may be even more debilitating; people who have had suicide in their family are eight times more likely to complete suicide themselves. Whether that heightened risk is due to the disruption caused by parental psychiatric illness, to inherited vulnerability to depression (or another psychiatric illness associated with suicide), to what psychologists call modeling—the fact that once certain behaviors are introduced into a family, they may become more acceptable, in the same way that the offspring of dentists are more likely to become dentists themselves—or to a combination of these, or to some other factor, is a subject of controversy. It will be discussed further in part two.
Death is not the only way in which adolescents may lose someone close to them. Not surprisingly, suicidal young people are apt to come from families where there have been problems. Comparing 505 children and adolescents who had attempted suicide with a control group, psychiatrist Barry Garfinkel found that the attempters came from families that showed more “disintegration.” Families of attempters had higher rates of medical problems, psychiatric illness, substance abuse, paternal unemployment, and completed or attempted suicide. Both parents were present in fewer than half the families. (Numerous studies of completed suicide have found high rates of parental psychopathology—particularly depression and substance abuse.) In a study of 120 young suicide victims in the New York metropolitan area, Columbia University epidemiologist Madelyn Gould found that certain psychosocial factors increased suicide risk among adolescents even beyond the risk attributable to psychiatric illness. The most notable ingredients: problems at school or at work, a family history of suicidal behavior, poor parent-child communication, stressful life events, nonintact family of origin, a mother with a history of depression, a father with a history of trouble with the police. Child psychiatrist Cynthia Pfeffer of Cornell University Medical College found that parents of suicidal children were subject to intense mood shifts, lacked the ability to delay gratification, and were extremely dependent and incapable of communicating with or guiding their children. In short, they were like children themselves. Given these findings, it is hardly surprising to learn that family cohesion is a protective factor; one study found that students who described their family life as one of mutual involvement, shared interests, and emotional support were five times less likely to be suicidal than were adolescents who had the same levels of depression or life stress but were raised in less tightly knit families.
One of the strongest risk factors for suicide is childhood trauma, which can not only trigger a range of immediate effects, from low self-esteem to substance abuse to delinquent behavior to difficulty forming attachments—all of which are associated with suicide risk—but can also increase the chances of developing depression, substance abuse, and other psychiatric disorders associated with suicide. (Nearly half of all abuse victims develop at least two disorders by age twenty-one.) Over the last decade, neurobiologists have found that childhood trauma can derail the developing brain, causing potentially lifelong alterations in cognitive development and disrupting its stress response system, rendering children more vulnerable to later stressful events as well as to the development of psychopathology. Of the many types of childhood trauma, sexual abuse is the strongest risk factor, implicated in an estimated 9 to 20 percent of adult suicide attempts. A review of twenty studies concluded that adults with a hi
story of physical or sexual abuse in childhood are up to twenty-five times more likely to attempt suicide. The greater the trauma—duration, use of force, relationship of perpetrator to victim, whether or not penetration occurred—the greater the risk of suicide. “Violence is a learned response to frustration and anger,” says Harvard epidemiologist Eva Deykin, whose study of 159 adolescents who had attempted suicide found a frequent incidence of physical or sexual abuse. “An individual who is exposed to child abuse might incorporate that response, turning aggression inward, as a means of coping with outside infringements.”
In much of this research, science merely confirms common sense. A child who grows up in a dysfunctional household is more apt to have problems later on. But these “problems” may erupt in a variety of ways; no one has yet pinpointed which are more likely to lead to suicide and which to drug abuse, alcoholism, or other symptoms of unhappiness. Every risk factor mentioned thus far—depression, parental loss, abuse—causes stress and pain that may be expressed in a variety of self-destructive behaviors, all of which are connected to suicide like stars in a constellation. Studies have found high rates of attempted suicide among juvenile offenders, among homeless and runaway youths, among drug and alcohol users, among teenage mothers, among cigarette smokers. While these studies have led some nonclinicians to the simplistic conclusion that drugs, crime, and teenage pregnancy can cause suicide, they indicate that unhappy adolescents are turning to a variety of self-destructive and risk-taking behaviors to cope with their pain. They are all forms of communication; suicide is merely the most radical. And adolescents who use these other methods are more apt to turn to suicide if their communication goes unanswered. Says counselor John Tiebout, “Today teenagers have to go to more and more extremes to get what they want. And maybe suicide fits into that dynamic. Being depressed or getting high is not a strong enough way to communicate to the world how miserable and fucked-up you are.”
If these problems are accompanied by substance abuse, they are especially likely to end in suicide. Autopsies tell us that one-third to one-half of teenage suicides are under the influence of alcohol or drugs shortly before they kill themselves, while nearly one-third of teenage attempters are drunk or high shortly before they attempt. The Department of Health and Human Services has estimated that three in ten adolescents have drinking problems. While drugs and alcohol don’t cause suicide—after all, millions of teenagers drink or use drugs and do not kill themselves—under their influence, underlying rage is more readily translated into aggression. Alcohol is a depressant, which can make an already depressed person more depressed, and as “liquid courage” it can lower inhibitions and release suicidal impulses. (Those impulses are far more likely to be acted on if guns are available; teenagers who use firearms are five times more likely to have been drinking than those who use other methods.) A Houston study of 153 adolescents who had made “nearly lethal” suicide attempts—attempts that would have ended in death if someone hadn’t intervened—found that drinking within three hours of the attempt was the most important alcohol-related risk factor, more important even than alcoholism or binge drinking. Drugs and alcohol themselves offer a withdrawal, a step away from reality and a step toward suicide. Alcohol abuse is one of many self-destructive behaviors that have been called slow suicide. Sometimes, however, it is not so slow, as in the case of a fifteen-year-old Colorado boy who went to a party and drank nine cans of beer, a quart of bourbon, and half a bottle of whiskey. He died that night.
No matter how self-destructive urges are manifested, the sources of an adolescent’s need to harm himself, directly or indirectly, are often difficult to trace. While many suicides come from broken, disturbed homes, a great many more children from troubled homes turn out fine. And more than a few suicides grow up in intact, loving families. What makes one child grow up liking himself and another child grow up hating himself?
Some psychiatrists believe that the seeds of self-esteem and the ability to cope with stress are planted in mother-infant bonding, the connective tissue of looks, touches, and words that forms between mother and child within the first year of the child’s life. When a crying baby gets a gentle, loving response, he develops what psychoanalyst Erik Erikson calls “basic trust.” He is more apt to grow up feeling loved and lovable, to develop a sense of self-worth and a belief that he is not powerless in the world. The English psychoanalyst John Bowlby, a pioneer in the study of bonding, demonstrated that young children are upset by even brief separations from their mother. If the child’s cries or tantrums are ignored, the child, he says, may adopt a permanent pose of detachment that may render him unable to form meaningful relationships for fear of being abandoned, as he felt he once was by his mother. “A baby repeatedly left to cry alone ultimately learns to give up and tune out the world,” says psychologist Lee Salk. “This is learned helplessness and possibly the beginning of adult depression.”
Orthodox Freudians trace the roots of adolescent suicide back to mother-infant bonding. “Nearly every suicidal child we’ve seen has suffered a break, a problem, in the mother-infant bond,” write the authors of A Cry for Help, a book about adolescent suicide. “. . . We must realize that the suicidal impulse can be engrained within the first few months of life.” But to blame suicide on bonding failure, one would be obliged to trace that failure back to how that mother bonded with her mother, and so on. The seeds of trust planted in infancy merely provide the base on which a sense of self-esteem is built. That sense is constantly reinforced or undermined by subsequent life experiences. In adolescence, however—an especially vulnerable stage in which a young person is beginning the process of breaking away from his parents and searching for his own identity—conflicts over separation and dependence are at their most intense. “The child who feels unloved in infancy or in early life, whether perceived or true, is more likely to grow up feeling unloved and unwanted, and unable to love and be loved,” says psychologist Pamela Cantor. “This may cause difficulty in forming meaningful relationships and lead to frustration, anger, and depression.”
For years, researchers have tried to find a genetic marker for suicide. They haven’t found it, but they have found evidence of a specific biological link to suicidal behavior. By analyzing the cerebrospinal fluid of those who have attempted suicide and studying the brains of those who have died by suicide, neurobiologists have discovered that some suicidal people, regardless of psychiatric diagnosis, have lower than average levels of a brain chemical called serotonin. They have found these abnormalities in suicidal people as well as in impulsive, aggressive individuals, often in association with depression. Researchers have suggested that serotonin dysregulation is a biological trait that predisposes to suicide; a depressed person with low serotonin function is more likely to respond to a stressful experience by acting impulsively or aggressively or both—and that action may include a decision to attempt suicide.
Although the serotonin research, which will be discussed in part two, is extraordinarily promising, much remains to be learned. Only a fraction of suicides are linked to serotonin dysfunction—how large a fraction is not yet known—and serotonin depletion is also found in people who aren’t suicidal, just frustrated or depressed. Furthermore, the research has yet to be replicated in adolescents. Yet these findings may help explain why a large proportion of young male suicides—the highest risk category among adolescents—has been found to have a combination of depression and antisocial or aggressive behaviors, often complicated by drug or alcohol use. Many of them have a history of disciplinary problems at school or with the law. Psychiatrists at the Los Angeles Suicide Prevention Center found that over 40 percent of the suicidal youngsters they studied had had physical fights with family members. In a recent survey of high school students, the CDC found that those who had attempted suicide during the preceding twelve months were nearly four times more likely to have reported fighting than those who hadn’t attempted suicide. Studying suicides age nineteen and under in the New York metropolitan a
rea, psychiatrist David Shaffer found that a minority of suicides—mostly girls—showed a picture of uncomplicated depression, while the largest diagnostic group, about 25 percent—mostly boys—was composed of adolescents with both aggressive and antisocial symptoms and depression.
Such a description certainly fit Jimmy Pellechi, the eighteen-year-old who shot himself in North Tarrytown two days after Justin Spoonhour’s death. A big, awkward adolescent, Jimmy dropped out of high school during senior year, drank heavily, never backed down from a fight, spent evenings racing with friends on his motorcycle, and had what his best friend described as an “I don’t give a fuck” attitude and what older townspeople called “a death wish.” One night, after drinking heavily, Jimmy telephoned the girl he had been seeing and told her that he had a gun and if she didn’t promise to stop going out with other boys, he would kill himself. She refused. Jimmy put his father’s shotgun to his head and pulled the trigger.
For the depressed and suicidal teenager, the breakup of a relationship may be what clinicians call the “precipitating” or “triggering” event. In Madelyn Gould’s study of adolescent suicide, nearly half of the 120 victims had experienced a recent disciplinary crisis or interpersonal loss—a suspension from school, an appearance in court, a breakup with a girlfriend or boyfriend. After such an incident an adolescent may feel he has failed and that his failure is unacceptable to his parents, his peers, or himself. Teenagers arrested for the first time on charges of drunken driving and jailed overnight, for instance, are often overwhelmed by shame. Feeling they cannot face the outside world, they may take their own lives, often during the first few hours of confinement. (One young man, jailed on a minor charge, hanged himself while his parents were in the next room posting his bail.) Adolescents confused about their sexuality may commit suicide rather than admit to themselves or their parents that they might be gay. “In all the teenage suicides we see,” says Judy Pollatsek, a counselor in Washington, D.C., “the kids always have some secret and are terrified that someone is going to find out.” A few hours after learning she was pregnant, a fourteen-year-old girl, fearing her parents’ reaction, killed herself by kneeling in front of a train. Suicide is often an impulsive act; among adolescents, especially so. In the Houston study of nearly lethal suicide attempts, almost 25 percent of the adolescents reported that fewer than five minutes passed between their decision to kill themselves and their actual attempt.
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