November of the Soul

by George Howe Colt

  In 1974, a decade before the “Westchester suicides,” eleven teenagers killed themselves in San Mateo County, a string of bedroom communities south of San Francisco. Today it would be called a cluster. At the time it wasn’t called anything; as was the case elsewhere, schools generally hushed up the deaths. Charlotte Ross, director of the Suicide Prevention and Crisis Center of San Mateo County, found that all eleven teenagers had left clues recognizable to people with training in suicide prevention. Over several days, for example, a sixteen-year-old asked his teacher, “Do you have to be crazy to kill yourself?”, wrote the word death across the back of his hand, and one morning told a friend he was “going to heaven very soon.” That day in class the boy slipped a revolver from a brown paper bag and killed himself.

  Later that year Ross attended a World Health Organization conference that asserted that suicide among youth had reached “epidemic” proportions. Ross returned from that meeting determined to try a new approach to preventing adolescent suicide. Adapting the program she used to train her hotline volunteers, she went into the schools and trained teachers to recognize and respond to signs of depression and suicide. She found that students were crying out for help but not getting it. Teachers were dealing with suicide threats and attempts more and more frequently but had never been told what to do. They were terrified of responding to veiled suicidal messages for fear of putting the idea into a student’s head. “We had cases where an English teacher would receive an essay on suicide and return it to the student corrected for grammar,” said Ross, who taught the teachers not to be afraid to ask specifically about suicide.

  The program worked. Teachers reported increased confidence in dealing with the subject, and there were more calls to the prevention center from adolescents as well as from teachers and administrators asking for advice. But training teachers didn’t reach the heart of the problem. In a survey of 120 high school students asking to whom they would turn in a suicidal crisis, 109 said they would turn first to a friend. Parents were perceived as part of the problem, “unable to understand, but able to interfere,” observed Ross, while guidance counselors were for “getting you into college.” Ross decided to go into the classrooms to teach students themselves about warning signs, depression, and how to help one another.

  Spurred by anxiety over the adolescent suicide “epidemic,” suicide prevention in the schools soon reached epidemic proportions. All across the United States, social workers and counselors went into health classes and assemblies to teach students, teachers, administrators, and parents about suicide. A slew of pamphlets, films, slide shows, seminars, and curricula on adolescent suicide were developed. Public service announcements on radio and television, featuring Bette Midler, Mariette Hartley, and Nancy Reagan, urged teenagers to choose life (“If you have suicide on your mind, wait a minute. I’m Mariette Hartley . . .”). Largely through Ross’s efforts, in 1983, California became the first state to mandate suicide prevention programs in schools. Several other states quickly followed suit. By 1986 there were more than a hundred school-based programs in the United States, reaching an estimated 180,000 students. Mark Fisher, former director of the Suicide and Crisis Center in Dallas, could have been describing most of these programs when he said, “Our goal is to help youngsters, sometime during junior high or high school, learn the warning signs of suicide in the same way they would learn the warning signs of an impending heart attack, and come up with sort of an emotional CPR: that when you know someone who’s suicidal or you recognize suicidal things in yourself, you know exactly what to do—the people to contact and the resources available.”

  The programs ranged from free, one-shot presentations like George Cohen’s to the “comprehensive” curriculum offered by the South Bergen Mental Health Center in New Jersey, in which teachers and school personnel, then parents, and finally the students themselves were trained over several months. While most programs were aimed at high school students, a clinic in Plainville, Connecticut, trained high schoolers to teach and counsel students down to the fifth grade about suicide prevention. The Dayton, Ohio, Suicide Prevention Center performed puppet shows about death and dying for elementary school children. Although the shows did not deal specifically with suicide, the topic often came up in discussion. (“Children with a clearer understanding of the nature of death may be expected to choose suicide as a less attractive behavior during a time of depression or agitation in their lives,” concluded two assistant professors at Wright State University in a monograph on the puppet show.) On Chicago’s North Shore, where twenty-eight suicides in seventeen months beginning in 1978 brought it the title The Suicide Belt, young social workers were dispatched to school and community hangouts—smoking lounges, gymnasiums, hamburger joints—to meet with kids on their own turf. A prevention center in Ithaca, New York, sent its young counselors into local high schools, where they hung out in the gym, cafeteria, and carpentry shop and made themselves available to any students who wanted to talk. Several prevention centers sponsored telephone hotlines on which teenagers counseled teenagers, while others offered group therapy in which suicidal adolescents met weekly with a psychologist or social worker to discuss parents, schools, friends, drugs, sex, and suicide. In Westchester County several teenagers who had attempted suicide performed skits about suicide at area high schools, then led discussions. Another Westchester County prevention organization helped students act out key scenes from Romeo and Juliet, encouraging them to write alternative, nonsuicidal endings. A California group developed suicide-prevention-themed video games.

  The array of options was bewildering. I recall attending a conference sponsored by the American Association of Suicidology at which a table near the registration desk was stacked with brochures hawking dozens of mail-order curricula appealing to a range of budgets. For $6.60, William Steele offered Preventing Teenage Suicide (“A must for every parent and those who work with teenagers”), a workbook that included “rating scales, assessment guides, guided discussions, actual situations, role-playing scripts, methods of communicating and helping, quizzes about suicidal issues, situations and the suicidal person.” For $48.95, a Denver psychologist marketed Youth in Crisis, an “action manual” that “motivates the reader to become a community leader in youth suicide prevention” and was “presented in a durable, attractive three-ring binder allowing for reproduction of various forms and instruments provided.” For $150, Southwest Associates, Inc. Management Resources/Nexus Plans, an affiliate of Netcare Corporation, advised me to “Order Your Copy Today” of its manual, which would help me develop and institute “a comprehensive school-based and community program for preventing the Number Two Killer of our Teenagers today—SUICIDE.” (In its excitement, Southwest Associates, Inc., miscalculated; suicide was—and is—the third leading cause of death for teenagers.) For $395, LexCom Productions of Columbia, South Carolina, offered “a sensitive, insightful two-part video series” with “vivid slice-of-life vignettes.” The company urged me to “use the enclosed order form to act immediately. You could save a life.”

  While no doubt well intentioned, the programs were unsettling. They held out the promise that a recipe existed for preventing suicide and that they knew the ingredients. As a culture, we had gone from a time when no one talked about suicide to a time when virtually any talk about it was considered good. Schools without programs were deemed “neolithic” and “resistant.” Wrote Westchester psychiatrist Samuel Klagsbrun, “Any school administrator that stands in the way of an intelligent adolescent suicide program, which includes a healthy discussion with teenagers, has to be able to live with death on his or her hands.” But what was an intelligent program? In the field of suicide prevention, mere good intentions were often taken as the litmus test of worth, though few of these programs had been evaluated and their effectiveness depended largely on who taught them. And while most programs revolved around teaching the warning signs, a few maverick educators took other approaches—one of which seemed to have more in common with the
tactics used at Miletos in 500 BC than with those used in George Cohen’s classroom.

  Convinced that the rise in adolescent suicide was due in large part to a romanticized conception of death and self-destruction, Victor Victoroff, chief of psychiatry at Huron Road Hospital in Cleveland, decided to show teenagers what he called “the real face of suicide.” In his presentations to high schools, Victoroff showed graphic color slides of young people who had come to emergency rooms following suicide attempts: a girl whose stomach was being pumped; a girl with slit wrists; a boy whose face had been blown away by a gunshot. He displayed the suture kits used to sew up wounds, the tracheotomy kits used to cut new air holes for breathing, the tubes used to pump stomachs. He handed out a “suicide packet” that contained a card bearing the phone number of the local suicide hotline and a cotton pad soaked in ipecac. “I ask them to smell the ipecac—it really stinks—and I tell them, ‘This is what we pour down people’s throats after an overdose,’” Victoroff told me. “I make it clear that being treated for a suicide attempt is likely to be one of the more unpleasant experiences a person may have to endure. I explain how many attempters end up half-blind or paralyzed. I want them to know that playing around with suicide is a dangerous game.” At this point, after offering squeamish audience members a chance to leave—“few do,” he said—Victoroff showed slides of completed suicides on the autopsy table: examples of suicide by strangulation, stabbing, poisoning, electrocution, asphyxiation, and gunshot. He concluded his presentation by asking everyone in the audience to “kill themselves.” “I get out a clock and say, ‘Now we’re all going to commit suicide. I want you to hold your breath for thirty seconds.’ As they hold their breath, I tell them that they are lying in bed. They have taken pills and the poison is beginning to work. Then I tell them they have four minutes left before they lose consciousness and die.” Victoroff paused. “The point is that I’ll use any means I can to cut through the romantic haze that sometimes surrounds suicide. I want the students to know that suicide is not romantic at all. It’s hard and dirty, and it involves a lot of heartache and agony.” By the time I spoke with him, Victoroff estimated that he had made his presentation to ten or fifteen thousand adolescents. “And until somebody tells me what I’m doing is wrong,” he told me, “I’m going to continue.”

  Who could say whether Victoroff’s scare tactics or Cohen’s touchy-feely approach worked better—or whether any of these programs worked at all? Although there was anecdotal evidence of their efficacy—Victoroff, for instance, told me that over the years he had received a stack of letters from would-be suicides thanking him for dissuading them from their plans—there were few objective evaluations. And although a rising tide of opinion suggested that talking about suicide was the best prevention, some people worried that programs promoting openness about suicide might in fact encourage it by making the act seem less forbidden. They pointed to the drug education programs of the early seventies, which did not markedly affect the drug abuse problem. In one of the first rigorous evaluations of suicide prevention efforts, Columbia University psychiatrist David Shaffer studied the effects of three different programs in New Jersey high schools. While there was no evidence that the programs caused wide distress, neither was there widespread attitude change, though a few students who were already suicidal became even more upset after being exposed to the program. Calculating that the number of students who might be saved by such programs was minuscule, Shaffer concluded that their possible benefits were outweighed by their possible harm. “I believe there should be a moratorium on suicide awareness programs directed at students,” he told a stunned audience at the 1988 annual meeting of the American Association of Suicidology.

  Distorted and magnified by the media (“Do-Gooders to Rescue Again, but Are They Killing Your Kids?” was the headline in the Palm Beach Post), Shaffer’s broadside had a dramatic effect. “The negative publicity set us back ten years,” says Diane Ryerson, founder of the South Bergen program and former director of the AAS Prevention Division, who has trained more than two hundred schools and mental health agencies in suicide prevention. “People were suddenly afraid to implement programs, schools didn’t want to get involved, and we couldn’t get money to evaluate the programs that already existed. People began to question whether we should be talking about suicide in the schools at all.” Despite efforts by prevention movement veterans to “deShafferize” schools, as one of them puts it, many smaller, less established programs folded, including George Cohen’s Westchester Interagency Task Force, whose sponsors suddenly began to worry that the program might inspire copycat suicides.

  Emboldened by Shaffer’s outspokenness, other critics surfaced. Some claimed that school programs often used inaccurate or exaggerated data. Others faulted them for being unable to reach certain high-risk populations: runaways, dropouts, the incarcerated. Others fretted that programs placed an unreasonable burden on young people and suggested they train community “gatekeepers”—police, clergy, coaches, physicians—instead. A study of 115 school-based programs found that most consisted of a brief, onetime lecture on the warning signs, in which suicide was portrayed as a response to extreme stress that, given sufficient pressure, could happen to anyone. Only 4 percent of the programs mentioned that suicide is usually linked to a psychiatric disorder. “By deemphasizing or denying that most adolescents who commit suicide are mentally ill, these programs misrepresent the facts,” warned a blistering 1993 report in American Psychologist. “In their attempt to destigmatize suicide in this way they may be, in fact, normalizing the behavior and reducing potentially protective taboos.” A 1994 CDC summary of programs recommended forging closer links between prevention programs and existing community mental health resources, increasing attention on young adults (a group at far higher risk than teenagers), encouraging parents to restrict their children’s access to lethal means, and integrating suicide material into broad-based adolescent health curricula rather than running suicide-specific programs. While admitting that there was no evidence that prevention programs actually contributed to suicidal behavior, a 1998 survey found “no justification” for them.

  It is likely that school suicide prevention programs are neither so harmful as their detractors claim nor as beneficial as their most passionate advocates suggest. In the past few years, however, several studies of comprehensive, carefully considered, second-generation programs have found that they influenced attitudes toward suicide, made troubled students and their friends more likely to seek help, and even contributed to a reduction of suicidal behavior. A 2004 study of twenty-one hundred students in Connecticut and Georgia who had taken the SOS High School Suicide Prevention Program, which combines screening for depression with education about suicide and mental illness, found that those who had gone through the program were 40 percent less likely to have attempted suicide over the following three months than a control group. “Shaffer has perpetrated a myth that programs are harmful—and there’s no basis for that,” says John Kalafat, a psychologist at Rutgers University who studied countywide programs in New Jersey and Florida and found significant reductions in youth suicide rates following the programs that did not occur either nationally or elsewhere in those states. Encouraged by these findings, programs are beginning to return to the classroom. Several states—Colorado, Washington, Maine, and Florida—are developing comprehensive prevention curricula. Shaffer himself, suggesting that programs emphasize “case finding,” has developed TeenScreen, in which high schoolers fill out a brief questionnaire asking them about suicide risk factors; if the responses indicate that he or she may be at risk, the student then fills out a “comprehensive” computerized mental health evaluation. The results are reviewed by a clinician who interviews the student and decides whether he or she should be referred for treatment. TeenScreen is now used by schools and clinics in thirty-four states. Critics of the program point out that the vast majority of students in distress—78 percent according to one study—turn first to peers and are re
luctant to confide in an adult, albeit an adult disguised as a questionnaire. They also suspect that, given the notorious mood swings of adolescence, a onetime test might allow many troubled teens to slip through the cracks. “Teens may be suicidal tomorrow but not today,” as Ryerson puts it.

  Whatever the approach, the tragic nature of adolescent suicide makes it likely that there will always be programs for its prevention. Following the suicide of their seventeen-year-old son, Mike, in 1994, a Colorado couple, Dale and Dar Emme, acknowledging that Mike had been in trouble but hadn’t known how to ask for help, printed up cards with the message It’s OK to Ask4Help! on one side and information on where to find help on the other. Thus began the Yellow Ribbon Suicide Prevention Program, in which the Emmes and other “trainers” talk to schools and communities about depression and suicide, hand out Yellow Ribbon cards, urge parents and kids to wear the yellow ribbon, and (for $10) sell Link, a nine-inch stuffed toy bear sporting a yellow ribbon on his chest and an “Ask-for-Help” card in his backpack, “to let you know you are NEVER alone.” The Emmes estimate that they have trained over two hundred thousand people, and Yellow Ribbon now has chapters in all fifty states and forty-eight other countries. “More than 2,500 LIVES HAVE BEEN SAVED!” proclaims its Web site. “5 MILLION Yellow Ribbon Cards have been distributed. 42,000 letters asking for help & telling of lives saved have been received. . . . Why do prevention programs in schools and communities? Because they work!”

  VII

  BEGINNING TO CLOSE

  THE DOOR

  TWO YEARS AFTER being discharged from Four Winds, Dana Evans was on the dean’s list at a local community college. She hadn’t taken a drink or used drugs during that time. She attended three AA meetings a week and had started a chapter at school. She had told several friends that she was an alcoholic, one or two friends that she was in a psychiatric hospital, and no one about her suicide attempts. She was living at home. She and her mother were getting along better. “We’re not best friends or anything, but it’s okay. We talk about work and school. Sometimes we even share makeup.”