For many years suicide had been a subject no one talked about. On the fourth floor of the old TB building, people talked of little else. “People used to ask us wasn’t it depressing, but it was very lively,” says Sam Heilig. “We had a great camaraderie, and we had a lot of laughs.” And because no one had ever before made this kind of intensive effort to study suicide, there was a feeling among the staff that they might solve the enigma. “I really thought that within a few years we would unravel some of the mysteries of why a person takes his life,” says David Klugman, a psychiatric social worker who joined the staff in 1960. “I believed that by analyzing each event in depth as it happened, we’d find some key or clue that would explain it. Maybe I was a little naive, but I thought we were going to find the answer.”
While they did not find the answer, they developed many of the concepts and techniques that are now standard in the field. (And published them. Between 1956 and 1966, Shneidman, Farberow, and Litman alone authored, coauthored, or edited four books and more than eighty papers on suicide, ranging from “Suicide Among General Medical and Surgical Hospital Patients with Malignant Neoplasms” to “Sex and Suicide.”) They developed the concept of clues. They developed the concept of lethality, described by Shneidman as “the probability of an individual killing himself in the immediate future.” Previously, a person was thought to be suicidal, or he wasn’t. The LASPC proposed that some suicidal people are at higher risk than others, and for each person the degree of risk or “lethality” fluctuates over time. They devised a Suicide Potential Rating Scale, a fifteen-item questionnaire based on demographic and psychological factors, to measure that risk. They developed the idea of “the suicidal crisis”—that most people are acutely suicidal for a relatively short time and, if helped through that time, will survive. During that crisis the LASPC stressed the importance of active intervention, constant contact with the patient, calling in the family, and breaking confidentiality if necessary. They described suicide as a “dyadic” event and suggested involving a person’s “significant other” in treatment whenever possible. And for those who work with suicidal people, they stressed the importance of frequent consultations, sharing the burden, and working as a team.
In 1958, after giving a speech at the VA hospital, Shneidman and Farberow were approached by Theodore Curphey, chief medical examiner–coroner for Los Angeles County, whose office was responsible for determining the cause (heart attack, gunshot, and so forth) and mode (natural, accident, homicide, or suicide) of all deaths in the county. Each year some one hundred deaths were regarded as equivocal—the coroner was unable to determine whether the death was an accident or a suicide. Curphey suggested that the LASPC might be able to help. Just as pathologists and toxicologists ascertained the cause of death by examining physical evidence, the LASPC staff might collect psychological evidence, interviewing relatives and friends of the victim to reconstruct his state of mind preceding his death. LASPC staff members were made deputy coroners, and the Death Investigation Team annually performed more than one hundred “psychological autopsies,” as Shneidman named them. Their most celebrated case was number 435: Marilyn Monroe. When she died of an overdose of barbiturates on August 4, 1962, Curphey asked Farberow and Litman to investigate. By interviewing Monroe’s friends and associates they learned that she had attempted suicide twice before and that she had been deeply depressed before her death. Their recommendation was for “probable suicide.” (Psychological autopsies are now commonly used to help determine cause of death as well as in suicide research.)
In the media glare following Monroe’s death the “professional suicide workers” of the center’s “suicide team” received nationwide attention, and the LASPC caseload grew exponentially. “By this time we knew that we needed to expand our services,” says Farberow. “We had been conducting ourselves like a clinic, with regular office hours, eight to five. But people were calling us after hours. We knew that because the lines continued to ring whenever one of us was working late. It was usually somebody looking for help.” Before long, they were in what Litman calls “the telephone business.” They started by hiring a telephone exchange to transfer calls to staff members’ homes. But the staff was small, and after a few weeks they realized that they were losing too much sleep. So they trained professionals—psychiatric interns, graduate students in psychology or social work—and paid them $10 a night to take the calls at home. With the Night Watch program, help was now available twenty-four hours a day.
But the volume of calls continued to mount, and in 1964 the center decided to use trained nonprofessionals on the telephone. Although at the time the National Save-A-Life League and England’s Samaritans used lay volunteers, the LASPC prided itself on its professional approach. “I had a lot of reservations,” admits Klugman. “By 1960 I had a master’s in social work and seven years of field experience, yet I felt ill-prepared and inadequate to handle some of the situations I was dealing with on the phone. So how were we going to train middle-aged housewives to do this?” Once they started, however, the LASPC learned the lesson the Samaritans had learned—that trained laypersons can do as well as professionals, even better in some ways. “They didn’t let their professional guard get in the way,” says Farberow. “They were able to interact on a very direct, personal basis with the suicidal person.” The volunteers even began to see an occasional patient in the office and to provide counseling in selected cases. The LASPC caseload continued to grow. In 1966 the center was contacted by nearly seven thousand people.
Not only was the center’s caseload expanding, but their single-minded devotion to suicide lured other professionals out of the woodwork. In 1963, having received a major increase and extension of its NIMH grant, the center moved out of the old TB ward and into a two-story building near downtown Los Angeles. Their new home on Pico Boulevard became a hub for the study of suicide and its prevention. Requests for advice, consultations, reprints, and speeches poured in from around the country and eventually from around the world. Staff members traveled the nation, teaching evaluation and treatment techniques to physicians, nurses, police, clergy, and mental health professionals. The center produced films for police and for physicians on how to handle suicidal people. Twice a year the center offered three-to-five-day training institutes for people from all over the country interested in starting a suicide prevention center in their own community.
The center’s diversity gave it the atmosphere of a small university. Clergy, sociologists, and psychologists visited the center to study suicide or to study how the LASPC studied suicide. Graduate students and interns spent semesters training at the center. Visiting professors gave speeches on suicide and self-destruction. Friday-morning “case of the week” seminars were renowned for their spirited intellectual discourse. Shneidman organized a program in which distinguished scholars, including sociologist Erving Goffman, philosopher Stephen Pepper, and psychologist Elsa Whalley, spent several months at the center “to contemplate suicide and to think about death.” Farberow, who spent 1964 abroad studying prevention organizations in London, Berlin, Paris, and Vienna, became active in the fledgling International Association for Suicide Prevention, and the LASPC’s stream of visitors gained a global flavor. Ten years earlier no one had talked about suicide in the professional community; now the LASPC had become a sort of international think tank devoted solely to the study of suicide and its prevention.
Although their work had begun as a research effort and had only by serendipity come to include clinical work and the use of trained volunteers, Shneidman and Farberow now felt that their most important task was to disseminate the knowledge they had gathered. Comparing the suicide prevention center to “a lifeguard station on a dangerous beach,” they believed that every city of any size across the country should have its own center. “Shneidman had no doubt in his mind that suicide prevention should be a movement,” says a colleague. “When we talked about a suicide prevention center in every community, he carried it to the extreme—that
every person should be a one-man suicide prevention center, should know the signs and be able to help in a suicidal crisis.”
In 1965, Stanley Yolles, the director of NIMH, announced the establishment of a national center for research and dissemination of information on suicide. He asked Shneidman to head the project. Shneidman was ready to move on. He had become restless at the LASPC. For more than a decade he and Farberow had been partners and coauthors; one name was rarely seen in print without the other. In the public mind they were linked together as Shneidman and Farberow, suicide’s Siamese twins. Shneidman was anxious to be on his own. The Center for Studies of Suicide Prevention, as it would be called, was an opportunity to advance both his own career and the growing suicide prevention movement. The following year he moved to Washington.
If suicide was still a taboo subject, suicide prevention had taken a giant step forward with the formation of the CSSP. The fifties and early sixties were a time of government largesse toward mental health, and in their 1966 reorganization NIMH designated five high-priority areas: alcoholism, drug abuse, child and family mental health, crime and delinquency, and suicide. For suicide, which only ten years before could not even be mentioned as a problem, it was an achievement of sorts. Now it had official recognition as a federal target, a social ill to be attacked, like poverty and crime, with good old American know-how and money. The CSSP could dispense grants for research, training, and demonstration projects, but the bottom line was clear. As Shneidman wrote not long after his arrival in Washington, “The goal of the NIMH Center for Studies of Suicide Prevention is to effect a reduction in the suicide rate in this country.”
Suicidology—a word coined by Shneidman to describe the study of suicide and its prevention—had been born, and the movement’s peripatetic ringmaster was everywhere, preaching prevention, inventing concepts, and fizzing with ideas. Identifying the dissemination of clues as “the most important single item for effective suicide prevention,” Shneidman, who became known as Mr. Suicide, called for a program in “massive public education”—and carried it out almost single-handedly by writing pamphlets, organizing symposia, and giving hundreds of interviews. “The ‘early signs’ of suicide must be made known to each physician, clergyman, policeman, and educator in the land—and to each spouse, parent, neighbor, and friend,” he declared. Toward this end the CSSP funded the First Training Record in Suicidology, in which actors dramatized calls to a prevention center; it commissioned Quiet Cries, a play highlighting the ambivalence shown by people experiencing suicidal crises; it assembled a “basic library on suicidology” of ten books and twelve pamphlets, available for $40 a set; it published a journal, the Bulletin of Suicidology, that kept people abreast of developments in the field. It promoted the First National Conference on Suicidology, at which Shneidman was voted founding president of the American Association of Suicidology, an alliance of mental health professionals, sociologists, clergy, and prevention center volunteers. It sponsored a postgraduate fellowship program in suicidology at Johns Hopkins University, in which social workers, sociologists, and psychologists took courses in crisis intervention, the psychology of suicide, biostatistics, suicide and the law, and the epidemiology of mental illness; worked in acute treatment clinics; performed psychological autopsies; did fieldwork in prevention centers; and acted as an expert witness in moot trials involving suicide. Suicide prevention now had not only federal sanction but academic credentials as well.
The most visible evidence of the CSSP’s work was the proliferation of prevention centers. “Just as there are fire stations throughout our country, there ought to be suicide prevention centers in every part of the land,” wrote Shneidman. There were fifteen when he arrived in Washington. A year later there were forty-seven, and by the time he left the CSSP in 1969 there were more than one hundred, with names like We Care, Dial A Friend, Learn Baby Learn, Life Line, Help, and Rescue, Inc. The suicide prevention movement coincided with the spirit of altruism and activism that marked the sixties, and saving lives seemed like the ultimate in caring. Magazines offered histrionic accounts of tearful calls and heroic rescues; movies like The Slender Thread, starring Sidney Poitier and Anne Bancroft, and Dial Hotline, with Vince Edwards and Kim Hunter, dramatized the risks and rewards of volunteering at a prevention center. Would-be lifesavers learned the ropes in articles that promised to teach them “How to Set Up a Suicide Prevention Center.”
While the LASPC served as the prototype—many center directors trained there or used its manual—there were wide variations. Some centers were autonomous, others were affiliated with hospitals or community mental health centers. Some were organized by the clergy, others by physicians, social workers, psychologists, or nurses. While the common denominator was a twenty-four-hour phone line staffed by nonprofessional, trained volunteers, some centers offered face-to-face contact as well. A few offered group therapy. Some had outreach teams for emergencies; at one center volunteers accompanied policemen to the homes of attempters. San Francisco Suicide Prevention placed an ad in the newspaper inviting those too shy to call to write; a Gainesville, Florida, center encouraged suicidal pen pals. A prevention center in Buffalo hosted a weekly television and radio show on which the agency director interviewed people who had once attempted suicide and were now leading productive lives. One center served as an alternative service placement for conscientious objectors.
The CSSP did not fund centers for direct service, and most programs were dependent on community support. Budgets ranged from $500,000 yearly at the Buffalo center to $26.25 per month (the cost of a telephone and a listing) reported by a center in Bismarck, North Dakota. Centers raised funds with walkathons, dances, plays, dinners, rock concerts, house tours, and bingo. When donations fell short, volunteers often passed the hat among themselves. They publicized their services through interviews, telephone directories, brochures, bumper stickers, bookmarks, and newspaper, radio, and television ads. They posted flyers in banks, bars, barber shops, beauty parlors, bus stations, airports, motels, libraries, schools, factories, emergency rooms, police stations, and trailer parks. Some centers enclosed brochures with bank statements, industry paychecks, phone bills. The message was clear: suicide prevention was everyone’s business. Shneidman even pointed out that suicide prevention was cost-effective; he calculated that every averted suicide saved as much as $1 million in lost wages and taxes as well as ambulance and coroner’s costs.
But the growth of knowledge about suicide wasn’t keeping pace with the zeal to prevent it. The movement’s accomplishments were measured in quantity: the proliferation of centers, the number of articles written. In a bibliography covering 1897 to 1970, Farberow noted that more papers and books on suicide had been published in the last thirteen years (2,542) than in the previous sixty-one. But a review of these publications reveals few rigorous studies, more groping than exploration, and little of practical use. A sample of journal articles includes “Lunar Association with Suicide,” in which the authors found a slight increase during the new moon, which they were at a loss to explain, and “Suicide in the Subway,” which discovered “important differences” between those who lay in the train’s path (“traumatic death”) and those who touched the third rail (“nontraumatic death”). “One of the problems in the study of those who kill themselves is that the subject of the study is deceased and hence not available for study,” began the article “Spiritualism and Suicide,” which therefore suggested that mediums be used to contact suicides for research purposes. “If communication is established with a deceased suicide, it seems mundane to administer an MMPI or a Rorschach,” observed the author, referring to two common psychological tests. “However, a psychoanalyst, for example, might well be able to conduct an interview that would illuminate the psychodynamics behind the act. Occasionally, though, spirits have their own agenda for communicating and object to questions.”
The author had a point: research in suicide is limited by the fact that studies are ex post facto. “Individuals corr
ectly determined to be suicides are not available for study,” notes one psychologist. “They are at the morgue.” Other methodological problems have frustrated suicidologists. Because suicide is a statistically rare event, it can take many years to accumulate a significant sample. There have been few long-term studies using sizable control groups. Some of the research is based on as few as two or three subjects, and the same case studies are trotted out again and again like prize pupils, often to illustrate different points. A 1972 summary of research findings since 1882 concluded that the vast majority of suicide research was monotonous, uninspired, and scientifically inept.
Meanwhile, there were mounting concerns about suicide prevention centers. By 1972 there were more than three hundred, but the feverish growth had been haphazard, and there were no accepted standards for service or training. The authors of a survey of 253 centers were “struck by the wide variability in training, efficiency, and effectiveness of the services.” Callers to some centers had problems just getting through. When psychologist Richard McGee placed seventy-six calls to nineteen agencies in the Southeast, he was confronted by eight different types of answering and referral services—message machines, patch systems, callbacks, and so forth—and often experienced long delays before reaching a human being. A 1970 CSSP-sponsored task force, calling for the establishment of minimum standards for centers, admitted, “The establishment of suicide prevention programs was entered into by many who were serious and dedicated but, also, by others who were capricious and ill-advised. The result is a mixture of services which as a whole lack purpose, direction, commitment, and involvement.”
November of the Soul Page 45