November of the Soul

by George Howe Colt

  For many years the National Save-A-Life League was the only prevention group in the United States. Other organized efforts to help the suicidal disappeared almost as quickly as they began. In 1936, for example, Robert Rehkugel, a sixty-four-year-old Methodist pastor in Oakland, announced plans for the Suicide Prevention Society of America, in which retired pastors would counsel potential suicides. Rehkugel planned a Suicide Prevention Sunday, a Suicide Prevention Week, and a Suicide Prevention Patrol of men and women to intercept would-be suicides and restore them to their families. The society’s motto, he said, was Prevent, Seek, and Save; its goal, a 50 percent decrease in suicide by 1940. Beyond the fact that this goal wasn’t met, it is not known what became of the project. Fifteen years later Julia Shelhamer, a seventy-year-old minister’s widow, distressed by reading of the suicide of a prominent Washington, D.C., man, placed a classified ad in the newspaper: “Discouraged? Call DI0614.” Her phone rang steadily—one Sunday she received 110 calls. Her remedy was to listen to callers’ problems, then ask them to pray with her. In 1935, department store tycoon Marshall Field financed the Committee for the Study of Suicide. Under the direction of prominent psychiatrist Gregory Zilboorg, it collected in-depth data on more than fifteen hundred suicides, but work was suspended shortly after the United States entered World War II.

  Beyond these isolated examples, the field of suicide and suicide prevention was primitive and taboo in the first half of this century. Indeed, there was no “field.” “Prior to the 1950s, except for the efforts of a few courageous practitioners, suicide went untreated as a mental health problem and was hardly ever discussed,” psychiatrist Calvin Frederick has written. “It was rarely a point of focus in the media, or in professional literature.” Although an occasional sociologist flung a statistical net at suicide, the subject was not considered a respectable research topic. The word itself seemed distasteful to professionals. (As late as 1955 a Veterans Administration project on suicide was tactfully named the Central Research Unit for the Study of Unpredicted Deaths.) The few papers to be found in the professional literature consisted of a handful of case histories or brief vignettes. No one had attempted to systematically examine the psychological characteristics of suicide and to use that research in prevention. Then, in November 1949, a thirty-one-year-old psychologist found himself alone in a room with hundreds of suicide notes.

  Edwin Shneidman was a precocious young man who entered the University of California at Los Angeles at the age of sixteen. He earned his master’s degree in psychology before serving as a captain in the U.S. Army Air Force. After the war he received his Ph.D. from the University of Southern California and began work at the Veterans Administration Neuropsychiatric Hospital in Brentwood. In November 1949, he was asked to draft letters of condolence to the widows of two former VA patients who had committed suicide. To find out more about the men, he visited the Los Angeles County coroner’s office one rainy afternoon. In a basement vault lined with dusty folders, Shneidman found the folder for one of the men, which contained copies of the man’s suicide note. He looked in another folder and another and realized that the coroner’s office had been filing suicide notes in this room for decades. Shneidman spent the afternoon rummaging through the folders. Though Shneidman’s interest in suicide until then had been tangential, he realized that the study of suicide was “a virgin field.” “I felt,” he says, “like a Texas millionaire coming home and stumbling into a pool of oil.”

  Shneidman called Norman Farberow, a VA psychologist who had written his doctoral dissertation on attempted suicide, and told him about the notes. Like Shneidman, Farberow was thirty-one, had attended UCLA, and had been a captain in the army air force. Following the war he and Shneidman were fellow trainees in the new VA clinical training program, where they became friends. While their backgrounds were similar, the two men were vastly different in appearance and temperament. Shneidman, a short, compact man, sizzled with energy like water on a frying pan; Farberow was a slim, neat, almost elegant man with the manners and bearing of a diplomat. Shneidman’s feisty, restless drive could be grating; the word used most often to describe Farberow is gentleman. For many years the two of them would make ideal collaborators.

  With their cache of 721 notes, Shneidman and Farberow believed they might discover the key to suicidal motivation in the last words of people who kill themselves. They decided to compare the notes with a control group of simulated suicide notes—“pseudocide notes,” as Shneidman dubbed them—composed by nonsuicidal people. Visiting labor unions and fraternities, they asked members to write the note they would write if they were about to take their own life. While some of the longshoremen were skeptical—“You could see them smirking, thinking to themselves, ‘What are these crazy people doing?’” Farberow remembers—they complied. The genuine and simulated notes were typed on index cards, numbered, and shuffled. Then Shneidman and Farberow analyzed them blindly. When they broke the key, they found that the pseudocide notes showed no particular personality patterns; the real notes betrayed various but recognizable characteristics. Fifteen percent, for instance, were written by what they called surcease suicides—older people seeking a release from pain. Many notes reflected a marked ambivalence—it seemed that part of the writer wanted to live, part to die. One note succinctly illustrated this: “Dear Mary: I hate you. Love, George.”

  The suicide-note study was just the beginning. Working out of a cramped basement room in the VA hospital, Shneidman and Farberow began a massive examination of attempted, threatened, and completed suicide. From the coroner’s office they collected the names of eight thousand people who had killed themselves over a ten-year period. Then they combed through two hundred thousand files at hospitals and clinics for the names, collecting the suicide notes, case histories, psychological test results, diaries, and therapy records of these suicides. From physicians they gathered data on 501 attempted suicides. They wandered the wards of Los Angeles County General Hospital interviewing people who had attempted or threatened suicide. And from the local VA hospital they assembled a sample of nonsuicidal patients.

  Their findings contradicted several widely held beliefs. Though it had long been assumed that people who threatened suicide never committed it, they found that three-fourths of suicides followed previous threats or attempts. Though it had long been assumed that “you have to be insane to commit suicide,” they found that only 15 percent of suicides were psychotic. The vast majority were depressed. They discovered that almost half of those who killed themselves did so within ninety days after an emotional crisis, and at a time when they seemed to be recovering; one-third had seen a physician within six months of their death; most suicides were neither crazy people hell-bent on death nor people whose suicide came “out of the blue.” These depressed people didn’t really want to die; they left clues to their plans, and if family and friends had been alert to those clues, they might have been able to prevent the suicide. As Shneidman put it, it was possible for a person “to cut his throat and cry for help at the same time.”

  Shneidman and Farberow intended to confine their efforts to research, but as they prowled hospital wards gathering data, they developed a reputation among the staff as suicide experts. Nurses began asking them to speak with patients who had been admitted following an attempt. The two psychologists politely refused; they were doing research, not therapy. “They’d say, ‘This man came in last night; he drank some cleaning fluid. Would you talk to him?’ or ‘This man cut his throat. Would you speak with him?’ But we said, ‘We can’t talk to him, we’re here on research,’” recalls Shneidman. “Our access to patients dried up. Then someone advised us to buy candy for the nurse, and when she asked us to see a patient, say yes. ‘But we know nothing about suicide,’ I told him. He said, ‘You know more than she does.’” Shneidman chuckles. “And willy-nilly we were in the treatment business.”

  That Shneidman and Farberow were accepted as clinical experts on suicide merely because of their interest in the top
ic is not surprising. If the subject of suicide was ignored by researchers, it was anathema to clinicians. “There wasn’t much known or written about the suicidal patient—treatment was very hit-or-miss,” recalls a social worker. “Most professionals did not want to deal with them. They were afraid of the responsibility. Social workers and psychologists referred—or deferred—to psychiatrists because they were able to hospitalize.” Psychiatrists were no better equipped. “I was taught nothing about suicide in medical school and virtually nothing in my residencies,” says one psychiatrist. “It was just something that you prayed wouldn’t happen, and if you had a suicidal patient, you put him in the hospital.” The hospital was equally unenlightened. “There was very little specific treatment of the suicide problem and very little understanding of why a person might be suicidal,” says a social worker. “The standard procedure was to put all suicidal patients on one ward and just watch them a little more closely.” Fear and ignorance were compounded by the anger many physicians felt at the suicidal patient, especially at those who were rushed to the hospital after an attempt. “Medical staffs were overworked, and many doctors resented spending their time and talents on the suicidal,” says a social worker. “Some doctors while sewing up someone’s wrists would say, ‘You didn’t do that right—next time you have to cut this way to do the job.’” Follow-up care was rare. “The idea was to pump them out, patch them up, and get them home as soon as possible,” says Shneidman. “Nobody wanted the responsibility.”

  Eventually, Shneidman and Farberow began to discuss combining clinical and research activities in a service for suicide attempters. “We thought of it as a suicide prevention referral service,” says Farberow. “The idea was to evaluate and help suicidal people while they were in the hospital, then make sure they got to some kind of resource in the community.” They called Robert Litman, director of the psychiatric unit at Cedars-Sinai Hospital, a bright young clinician who had written a paper on how to deal with suicide on a hospital ward. “They had been working with notes and charts, and now they wanted to work with people,” recalls Litman, whose interest in the subject of suicide had been sparked when his former college classmate Thomas Heggen, author of Mr. Roberts, had taken an overdose and drowned in a bathtub. “They took me to a restaurant in Beverly Hills and literally plied me with liquor. Then they said, ‘What do you think about the idea of a suicide prevention center?’ I said, ‘You’re kidding.’ They said, ‘We’ll put an ad in the telephone book saying suicide prevention, and suicidal people will get in touch with us. You’ll take care of them, and we’ll study them.’” Litman chuckles, remembering. “I thought it was crazy,” he says. “I thought we would attract all the crazy people in town, and we wouldn’t be able to handle them.”

  With the help of Harold Hildreth, a psychologist at the National Institute of Mental Health who believed that NIMH should be exploring taboo areas, Shneidman and Farberow were awarded a five-year, $377,000 demonstration grant, an extraordinary sum considering the time and the subject matter. Meanwhile, Shneidman, Farberow, and Litman discussed names for their service. They agreed that the title should include the word suicide. “It was time for the taboo problem and its attendant stigma to be brought out into the open where it could be acknowledged and dealt with openly and constructively,” they wrote. “We were also aware that what we were planning to do was not prevention, it was intervention,” recalls Litman. “But Suicide Intervention Center?” He shrugs. “Didn’t have a ring to it. Sounded lofty. So we decided to call it Suicide Prevention Center as a challenge rather than hide behind a less provocative title.” On September 1, 1958, the Los Angeles Suicide Prevention Center opened with one phone line and a staff of five.

  From its earliest days the LASPC had an improvised, informal quality. The center was located in an abandoned and condemned tuberculosis ward on the grounds of the Los Angeles County General Hospital. The dilapidated, eightstory redbrick building, ringed with creaky wooden porches where TB patients had taken the sun, had a rococo appeal; television crews filming a story on the center would inevitably drift off to examine the architecture. The center was on the fourth floor, accessible by a clanging, wheezing, often out-of-order elevator. The rooms were high-ceilinged and dimly lit; some were tiled and held bathtubs twice the size of humans. Although a fresh coat of paint and shipments of secondhand desks and chairs from the VA made their corner of the building livable, the setting was bleak. Even as they moved in, the structure was being vandalized by community agencies for plumbing and electricity. One morning a Hollywood film crew arrived; the LASPC’s home, it seemed, made an ideal bombed-out building for their latest World War II movie. “We were concerned that the building would make our clients even more depressed,” says Sam Heilig, a social worker who joined the center in 1960, “but when we’d ask patients if it depressed them, they said no, it sort of fit their mood.” The hospital used a system of colored lines painted on the floor to guide patients to various departments from the guard station at the street. It seemed fitting that the line leading to the LASPC offices was painted blue.

  In its first year the LASPC worked with fifty patients. Each Monday morning Litman would walk over to the county hospital and scout the wards for people who had been admitted over the weekend for a suicide attempt. Usually, there would be at least a half dozen, from which one would be selected as the center’s “case of the week.” Litman conducted a full psychiatric interview, a psychologist gathered test information, and a social worker interviewed the patient’s family and friends. At Friday-morning staff meetings the case was discussed in detail, and treatment recommendations and referrals to appropriate agencies were made. The goal was to examine each case intensively, to learn as much as possible about why that person had tried to kill himself. “None of us knew anything at that time, so we went very slowly,” recalls Farberow.

  “That was our intention,” says Litman. “But what happened was that these people told their friends and their friends told their friends, and pretty soon people were calling us and literally saying, ‘I’m just about to make a suicide attempt—do I have to take these pills or jump off a building before I can talk to you? Or could I shortcut it and come in directly?’” The LASPC became a magnet for suicidal people. Calls came from distressed people, concerned friends and relatives, and therapists happy to refer their difficult cases. One early call came from a teacher who walked into her classroom during recess and found a student hiding behind the blackboard with a plastic bag over his head. When she yanked the bag off and brought the boy around, his first words were “That’s all right. I have a knife at home.” The boy was seven. He was referred to a psychiatric service. Another call came from a frantic psychiatrist. His patient was in the next room behind a locked door with a gun. What should he do? The staff member on duty calmed the psychiatrist, then talked him through the crisis, telling him not to call the police but to take his time, talk to the man, and bring in his friends and family. The psychiatrist followed the advice. Eventually the door opened, and his patient emerged and surrendered the gun.

  Because no rules or guidelines existed for dealing with suicidal people, the LASPC improvised techniques as they went along. Though most of the staff had been trained in Rogerian or Freudian models, these strategies seemed impotent in a suicidal crisis. When a person was out on a ledge, metaphorically or otherwise, it seemed feckless merely to repeat back to him what he was saying and too time-consuming to take five years on the couch to find out why he was up there. “Both of those have given way to better clinical common sense,” Shneidman wrote. “That is, we became directive, assertive, straightforward, even authoritarian—anything that it takes to keep a person from becoming a case in the coroner’s office.” To fulfill its mission the LASPC went to lengths unheard of in traditional therapeutic circles: the staff made house calls, met clients in restaurants, escorted suicidal people to the hospital, brought in family and friends, phoned across country to get one man’s estranged wife to come and see him, dis
patched ambulances or police, and traced calls. One day a client ran out of the offices onto the roof with several LASPC staff members in hot pursuit; they grabbed her and wrestled her back inside before she could jump. Another time a suicidal young woman was brought in by her family; halfway through the consultation she ran out of the building. An LASPC staffer tackled her, put her in a car, and told her brother to sit on her while he drove her to the hospital.

  Like polar explorers, the LASPC staff probed the boundaries of the vast, uncharted territory of suicide and its prevention. Shneidman skittered out on the edge, mapping and naming the new field, inventing its vocabulary, sparking ideas, giving speeches, and writing papers. His wild, often abrasive brilliance was complemented by Farberow’s meticulous organization, dependable scholarship, and attention to detail. As clinical director, Litman was the glue that held the center together, as he saw his own patients, oversaw everyone else’s caseload, and assumed the responsibility for medication and hospitalization. On the rare occasions when a client committed suicide (of the center’s first three hundred patients, there were two), Litman led the painful meeting at which the case was discussed; the staff tried to comprehend what had led to the person’s decision and what else might have been done to prevent it. Litman had some of the imagination of Shneidman and the affability of Farberow and worked well with both of them. His genial, quirky manner and enthusiasm helped give the staff the feeling of a team. Suicide prevention, in fact, tended to scramble the mental health pecking order that placed psychiatrists at the top, followed by psychologists and then social workers. At the LASPC everyone was involved, and there were few rules about who did what. One of the most adept at handling desperate callers, in fact, was the receptionist, Alice Arnold, an outgoing woman who had never worked in the mental health field before. “She was supposed to take business calls, but when none of us was available, she had to take a lot of suicide calls,” remembers Litman. “And she was great on the telephone. . . . When all else fails, you can fall back on being motherly and probably be right.”