November of the Soul

by George Howe Colt

  Even more distressing was the growing evidence that suicide prevention centers were not preventing suicide. While centers often publicized their efforts by claiming their work “saved lives”—the National Save-A-Life League, for example, asserted that since 1906 they had saved one thousand lives per year—they offered no real proof. Few centers evaluated their services, and their assumption that the application of care and support prevented suicide was based on letters and calls from grateful clients. When a 1968 study found that the suicide rate in fifteen English towns with a Samaritan branch had fallen, the declining English suicide rate was credited to the Samaritans. But a subsequent, more carefully controlled study found no difference in the rates of comparable communities that had a Samaritan branch and those that did not. In the United States, psychologist David Lester compared eight cities that had prevention centers in 1967, eight with centers in 1969 (but not in 1967), and eight without centers during those years and found that the centers made no significant difference in the suicide rate. While centers provided a “needed and useful service” in counseling the distressed, Lester concluded that suicide was “relatively immune” to prevention programs. Other statistics seemed to support this. Between 1960 and 1970 the number of centers in California grew from one to nearly thirty; the suicide rate grew from 15.9 to 18.8. In Los Angeles, site of the movement’s flagship prevention center, the rate jumped from 17.5 to 21.3. And in the United States as a whole it rose from 10.6 to 11.6.

  The exaggerated hopes kindled by prevention programs underscored their apparent failure. The centers were discredited as quickly as they had been embraced. By 1969, Shneidman had left the CSSP for academia. Citing surveys that claimed only 12 to 15 percent of the calls to centers dealt with suicide, his successor, psychiatrist Harvey Resnik, advised centers to change their names to “Suicide Prevention and Crisis Intervention Center” to reach a broader base. The shift at CSSP reflected not only disappointment with the centers’ failure to subdue the suicide rate but also the changing agenda of the federal government. During the late 1960s there was increasing pressure to do something about runaways, teenage pregnancy, and “the drug epidemic.” When Bertram Brown became NIMH director in 1970, he designated child mental health as the institute’s top priority. Child mental health was in, drug abuse was in, minority groups were in. Suicide was on its way out. The government, which in ten years had spent more than $10 million on suicide research, decided it was a bad investment. In 1972 the CSSP was disbanded, and the concept that had launched the Los Angeles Suicide Prevention Center more than a decade earlier—that suicide was a proper and necessary research topic, that suicidal people could and should be helped—had been diluted. Fifteen years after Shneidman, Farberow, and Litman insisted that the word suicide be a part of their new center’s title, a sign on the bulletin board at the UCLA meditation center printed the LASPC’s telephone number above this all-purpose encomium: “Need a place for a good rap? Call the Los Angeles Suicide Prevention Center.”

  Why didn’t all this time, money, and sheer good intentions have a measurable effect? Research shows that most calls to prevention centers are not from the severely suicidal. In a study of ten centers, 33 percent of their callers had been considering suicide, and the percentage of seriously suicidal callers was far smaller. More than half of the four thousand calls received monthly at the Suicide Prevention and Crisis Center in Buffalo, for example, were from crank callers, pranksters, or people who hung up immediately. The majority of suicides are older white males; the majority of prevention center callers are young white females. Although some suggest that most people are simply not aware that prevention centers exist, a study by San Francisco psychiatrist Jerome Motto found that while 80 percent of a group of depressed and suicidal persons had heard of the local prevention center, only 11 percent had used it. Suicidal people, reasons sociologist Ronald Maris, are simply too isolated to call a stranger.

  Yet prevention centers clearly get many high-risk callers. At the LASPC, several follow-up studies showed that about 1 percent of callers killed themselves within two years. Although these figures may be interpreted several ways, they indicate that prevention centers work with a high-risk group: callers represent about one hundred times as great a risk of suicide as the general population.

  Some say prevention centers do not offer enough. “They don’t take responsibility for the patients,” says psychiatrist Douglas Jacobs. “People call up and get referred, but research shows that follow-through is at best fifty percent. Many patients may never make it—they may feel they’ve already made a connection.” Centers may be better suited to helping the “situational suicide,” a caller whose stability has been upset by specific events, than the chronic suicidal caller. In his follow-up studies of LASPC clients, Litman found that most subsequent suicides were by high-risk callers who were suicidal over a long period; they need more than just a patient ear and a referral. However, when the LASPC experimented with an eighteen-month follow-up program of callbacks and home visits to high-risk cases, there were seven suicides in the group that got extra care and only two in the control group. The specially trained volunteers felt “overwhelmed” by the demands of continued contact and wanted to turn over more difficult cases to the professional staff. The continuing relationship offered by the volunteers was “too little too late,” concluded Litman.

  Concerned by the unsupervised growth of centers in the late sixties and early seventies, the American Association of Suicidology has tried to impose minimum standards for prevention centers. But whether because of cost, excessive criteria, or simply because it’s not necessary, only 172 of the 626 suicide prevention and crisis intervention centers currently listed in the AAS handbook have been certified. This reinforces the skepticism felt by some mental health professionals about the centers’ efficacy. Although attitudes have come a long way since 1965, when the San Francisco coroner referred to the staff of the local center as “a bunch of clowns,” some psychiatrists disparage the “amateurism” of the volunteers and dismiss their work as “hand-holding.” Others worry about the danger to callers who get busy signals or an answering machine, or who are put on hold. (While such annoyances may further depress a caller, one suicidal woman who called a center and got an answering machine burst out laughing at the absurdity of the situation. The tension of her despair was pricked, and she survived the night.) A few analyze the motives of the volunteers; several studies have suggested that suicide prevention work may attract emotionally troubled people seeking to work out their own problems while attempting to help others. Nevertheless, therapists often refer their patients to prevention centers when they don’t want to be disturbed. Centers report a boom of calls in August from people whose therapist has gone on vacation, leaving the local prevention center’s number.

  At the same time, while admitting that they are no substitute for professional help, some prevention center volunteers harbor distrust and resentment of mental health professionals. (At one point, in fact, the rift between professionals and volunteers threatened to split the AAS in two.) “It’s nothing but doctors figuring out how to protect themselves from suicidal patients,” scoffs the head of one center, walking out of an AAS seminar. Hearing that a suicidal patient shows “strong cathexis of the self with superego aggressive energy and inadequate cathexis with narcissistic libido,” a volunteer wants to know how to use that “on the firing line.” As a result of such mutual antipathy the possible benefits of therapist-volunteer cooperation have not been fully explored.

  Meanwhile, prevention centers continue to refine their services. In an attempt to reach a greater number of high-risk callers, centers have developed programs for specific target groups. Some operate special lines for AIDS, child abuse, rape, the homeless, gays and lesbians. Some offer group therapy for the suicidal or support groups for bereaved family and friends left behind after a suicide. Others run training and education programs for the police, the military, or high school and college students. San Franc
isco Suicide Prevention spawned the Friendship Line, a twenty-four-hour suicide hotline for the elderly, including regular callbacks and home visits. For many years, the Samaritans of Boston organized a suicide prevention program at a local jail, in which inmates befriended other inmates. Perhaps the most important innovation was the establishment, in 1999, of the National Hopeline Network, a single, easy-to-remember, toll-free number (1-800-SUICIDE), through which calls are routed to the nearest AAS-certified crisis line. By 2005, the Hopeline had received more than 1 million calls.

  In the past several years, government attention has returned to suicide, with a fanfare of federal activity that brings to mind the heyday of the CSSP. In 1999, Surgeon General David Satcher issued a “Call to Action to Prevent Suicide,” which outlined the need for broader public awareness of the problem, increased research and development into treatment and prevention strategies, and reduction of stigma associated with mental illness and suicidal behavior. This, in turn, led to the National Strategy for Suicide Prevention, in which a coalition of clinicians, researchers, and survivors designed a comprehensive blueprint for reducing suicide and self-destructive behaviors. Its eleven goals and sixty-eight objectives range from standardizing protocols for death-scene investigations to improving firearm safety design to increasing the number of TV programs, movies, and news reports that follow recommended guidelines for depicting mental illness and suicide. The NSSP initiative is ambitious. But without sufficient funding at the federal, state, and local level, it won’t get far. Indeed, an Institute of Medicine Report, published by the Academy of Sciences as part of the NSSP initiative, pointed out that suicide, which is responsible for more than thirty thousand deaths a year, receives one-tenth the federal funds given to the prevention and treatment of breast cancer, which takes the lives of some forty thousand women each year. “The committee finds that this is disproportionately low, given the magnitude of the problem of suicide,” they concluded. “A substantial investment of funds is needed to make meaningful progress.” Whether that investment will ever be made—or whether federal attention to suicide will last any longer than it did during the glory days of the CSSP—remains to be seen.

  How these initiatives will affect suicide prevention centers also remains to be seen. They will likely continue with business as usual. Although they no longer make exaggerated claims of efficacy, evidence suggests that suicide prevention centers do, in fact, save lives. A University of Alabama study, comparing suicide rates in Alabama counties that had a center with those that did not, found that the centers were associated with a reduction of suicides by young white females—the demographic group to which most callers belong. Extrapolating their calculations to include the entire nation, they estimate that suicide prevention centers save the lives of 637 young white females each year.

  With or without statistical reinforcement, the value of prevention centers should not be assessed solely by the suicide rate. While the word suicide is prominent in their advertising and an estimated one-third of their callers are suicidal, suicidality is not a prerequisite for calling the SPC or any other suicide prevention center. But if what keeps people alive is connection, centers may provide a small dose of caring that may prevent someone’s sadness from spiraling into suicide months or years down the line. “Most callers are lonely, frightened, desperate people who don’t know where to turn, and when they call the center, at least they get some sort of answering voice,” says Robert Litman. “That’s not necessarily suicide prevention, but it does play a part in stabilizing society. It is a little bit of society’s answer to the chaos that society creates.” Just as Nietzsche said the thought of suicide “helps one through many a dreadful night,” the thought of a suicide prevention center has gotten many thousands of people through their own dreadful nights. David Klugman remembers one of the first calls he handled at the LASPC. When he picked up the phone and said “Hello, may I help you?” there was a silence. Then a timid voice on the other end said, “I can’t talk now . . . I just needed to know someone’s there.”

  III

  TREATMENT

  THE VAST MAJORITY of people who attempt or complete suicide never come in contact with a prevention center. Even for those who do, the prevention center is only a first step. There are two parts to suicide prevention—identifying the person at risk and deciding how to help him. Most of the work of the prevention movement has focused on finding the suicidal person. Shneidman is one of many suicidologists who believe that suicidal people communicate their intentions through the kinds of “clues” described earlier—giving away prized possessions, making statements like “You’ll be sorry when I’m gone”—but that most people don’t know how to listen. “Education is the single most important item in lowering the suicide rate,” he says. “I don’t mean suicide prevention classes. I mean a general heightening of awareness, so that if I give you my watch, you won’t simply take it and thank me. You ought to say, ‘Ed, sit down, tell me what’s happening.’” Shneidman advocates mass media campaigns like the one that helped 46 million Americans give up smoking in the past several decades.

  Even to suicidologists, however, clues are often recognizable only in retrospect—and in hindsight almost anything can look like a clue. “I’m sure if you or I went out the window right now, somebody might say, ‘I knew that was going to happen someday,’” psychologist Douglas Powell told me. While working at Harvard University Health Services, Powell counseled the friends of a student who had run through a dormitory window to his death shortly before final exams. For weeks afterward the boy’s friends wondered why, agreeing there had been no apparent cause, no clue. Then his roommate recalled a singular detail: Nick had always set ashtrays, mugs, and postcards on his windowsill. For several weeks before his death, each time Nick sat in front of that window, he had removed another item. “People say, ‘Well, how can these things happen to your children and you not notice them?’” the father of a sixteen-year-old boy who attempted suicide told a reporter. “Well, all I can say is you can sit in a house and the sun goes down and you never see it go down, and the next thing you know it’s dark.”

  Even when people recognize clues they may fail to respond, through ignorance, denial, indifference, or even hostility. Psychiatrist Leon Eisenberg told me about a college student who was having a turbulent affair with a classmate. “He said, ‘If you don’t go steady with me, I’ll jump off this building.’ She said, ‘You don’t have the guts.’ He did. He ran right up the steps to the eighth floor, out on the roof, and jumped off,” says Eisenberg. “And I might add that the young lady showed no remorse at all.” It is not known what proportion of people who leave clues go on to kill themselves. “All the students come in at some point and talk about suicide,” a high school social worker says. “I can’t put them all in the hospital.”

  How should one respond to a cry for help? The most important thing is to listen, to show empathy, and to take the problem seriously. Too often, because of uneasiness or fear, a friend may laugh off a plea or ignore a clue. “Anybody who talks about suicide is serious,” says psychiatrist Michael Peck. “It’s not up to us to make a judgment about whether he or she will do it or not.” Although you may suspect the person is talking of suicide just to get attention, it is vital to take the person at his or her word. One of the biggest myths about suicide, as the LASPC learned, is that people who talk about it won’t do it. While there are no statistics on how many of those who threaten suicide go on to attempt it, it’s far better to overreact than to underreact. Avoid being judgmental. Telling the person to “snap out of it” is like telling someone with two broken legs to get up and walk. And the common response “But you have everything to live for” may only deepen the person’s feelings of guilt and inadequacy. Questions like “Are you very unhappy?” and “How long have you felt this way?” give a person the chance to vent his feelings and perhaps reduce his anxiety. Although people often worry that asking about suicide will plant the idea in the distressed person’s head,
this is not true. Asking about suicide demonstrates concern and shows a willingness to discuss anything he or she might be feeling. Experts suggest being direct: “Are you thinking of suicide?” If the answer is yes, ask if he has planned how he might do it. If he has a plan, this indicates imminent danger and the need for immediate professional help.

  But even when the signs are recognized and the person is brought into treatment, it is only the beginning. Every day in hospitals, emergency rooms, outpatient clinics, private offices, and suicide prevention centers, clinicians must make quick decisions about the risk of suicide, sifting the highly suicidal from the suicidal from the nonsuicidal. These decisions are usually made by observing the patient’s appearance, body language, and discernible mood—and by asking about self-destructive thoughts, sleep disturbance, alcohol use, access to lethal means, sources of stress, and other factors associated with suicide. Clinicians have long wished for a more “objective” assessment tool—test chestnuts like the Rorschach, TAT, and MMPI have proved to be of little help—and over the years they have devised dozens of scales and questionnaires that purport to quantify suicide risk. Perhaps the most widely used is the Beck Scale for Suicide Ideation (SSI), which measures the intentions of people who are thinking of suicide with nineteen questions, beginning with “Wish to Live” (scored “moderate to strong,” “weak,” or “none”) and “Wish to Die” (same options). Developed by University of Pennsylvania psychiatrist Aaron Beck, the founder of cognitive behavior therapy (and of the Beck Hopelessness Scale, the Beck Depression Inventory, and the Beck Anxiety Scale), the SSI is one of the few tests shown to have some predictive value. A twenty-year follow-up study of seven thousand depressed patients who had taken the SSI identified forty-nine suicides; those who had scored above 3 on the SSI were nearly seven times more likely to have completed suicide.