November of the Soul

by George Howe Colt

  Bridge barriers, nets on observation decks, signs and emergency telephones on bridges, windows that don’t open wide—these are only some of the ways in which “environmental risk reduction,” as Seiden calls it, might help prevent suicide. “There is more than one approach to suicide prevention,” says Seiden. “You can try to get inside people’s heads and work with their self-esteem. You can work with parenting and with early recognition of depression, but you can also try to do something about the lethal agents of suicide—the guns, the pills, the bridges. It’s the same as automobile safety. You can do driver training and you can make the car safer. You can change the environment as well as change the individual.” With suicide seen almost exclusively from the medical model, however, the possibilities of environmental and social change have been neglected. Critics say that these are superficial measures, that Seiden is treating symptoms, not causes. “Sometimes that’s all you can treat,” says Seiden. “Frankly, we haven’t had a good record in treating suicidal patients from the inside out.”

  For many years the most popular method of suicide in Great Britain was asphyxiation—sticking one’s head in the oven and turning on the gas. After the discovery of oil and natural gas deposits in the North Sea in the fifties and sixties, most English homes converted from coke gas, whose high carbon monoxide content made it highly lethal, to less toxic natural gas. From 1963 to 1978 the number of English suicides by gas dropped from 2,368 to 11, and the country’s overall suicide rate decreased by one-third. By the mideighties, however, the suicide rate had rebounded to its previous level, suggesting that potential suicides were substituting other methods. But the evidence indicated that taking away one method can have a remarkable effect. Indeed, British and Australian studies show that restrictions on prescribing barbiturates have reduced the number of attempted or completed barbiturate suicides without increasing the number of suicides by other means. Suicidologists have called for tighter regulation of potentially lethal medications and for training physicians and pharmacists in clues to depression and suicide. They propose the universal use of blister packaging, which requires single capsules to be punched out individually, allowing more time for emotions to cool or rescuers to intervene.

  “Much could be gained if we tried to make suicide more difficult for the potential candidate. . . . Opportunity makes the suicide as well as the thief,” observed David Oppenheim at the 1910 meeting of the Vienna Psychoanalytic Society devoted to suicide. “An opportunity for self-destruction is offered to anyone who is in the position to bring about his death by some swift and easy action that is painless and avoids revolting mutilations and disfigurement. A loaded pistol complies so well with all these conditions that its possession positively urges the idea of suicide on its owner.” Far more urging takes place now than in Oppenheim’s day. There are 200 million civilian-owned guns in the United States (more than twice the number thirty-five years ago), including 65 million handguns. During that time, numerous studies have linked increased gun ownership not only to increased rates of crime, armed robbery, and homicide, but also, unarguably, to suicide.

  Only in the United States, among all the countries in the world, are guns the primary means of suicide. They are the most frequently used method in every age group, except ages ten to fourteen, in which they have recently been eclipsed by hangings. In a landmark 1983 study, NIMH researcher Jeffrey Boyd scrutinized suicide rates for 1953 to 1978 and found that the firearm suicide rate had steadily risen while the rate by all other methods had declined. In 1953, firearm suicides accounted for 46 percent of all suicides; in 1978 they constituted 56 percent. (Today, they account for 57 percent.) The jump in the firearm suicide rate accounted for an overall increase in the suicide rate from 12.4 in 1953 to 13.3 in 1978. Suggesting that the rise in suicide by firearms was related to the rise in gun sales and noting that handguns were used in 83 percent of all suicides by firearms, Boyd concluded, “It is conceivable that the rise in the suicide rate might be controlled by restricting the sale of handguns.”

  Subsequent research has supported this hypothesis. One study found that the strictness of state gun-control laws was significantly correlated with suicide rates; states with the toughest gun control laws had the lowest suicide rates. The rates in the ten states with the weakest handgun laws were more than twice as high as rates in the ten states with the strongest laws. A study of suicides in Los Angeles, as well as throughout California, during a three-year period found that citywide, countywide, and statewide the suicide rate by firearms rose and fell in near perfect harmony with the volume of gun sales. A Harvard School of Public Health study found that access to firearms has a much higher correlation to suicide than does suicidal ideation or major depression. Areas of the country in which there are more handguns—the South and the mountain states—had higher rates, even after controlling for depression and suicidal thoughts. “Where there are more guns, there are more suicides,” observed David Hemenway, the study’s coauthor.

  “If guns are outlawed, only outlaws will have guns,” a favorite National Rifle Association homily, implies that ordinary citizens need guns to protect themselves. Yet a gun in the house is eleven times more likely to be used to attempt or complete suicide than to be used in self-defense; only 2 percent of gun-related deaths in the home are the result of a homeowner shooting an intruder, while 83 percent are the result of a suicide—often by someone other than the gun owner. In a study of eighty-two consecutive suicides in Cuyahoga County, Ohio, thirty-five were by gunshot. Only three of the guns had been purchased for the purpose of self-destruction; the majority had been acquired to protect the family. In a King County, Washington, firearms study, there were thirty-seven suicides for every self-protection homicide. Some 35 percent of American households have guns, making them five times more likely to experience a suicide than homes in which there are no guns present. “Guns don’t kill—people do,” another pro-gun-lobby mantra, is technically correct, yet guns make a suicide attempt five times more likely to be fatal; 90 percent of suicide attempts by firearm result in death, compared with 2 to 3 percent of attempts using drugs. “If some persons would use slower methods of self-destruction, some lives might be saved,” concluded a National Violence Commission report. “The possibility that the presence [of firearms] is in some instances part of the causal chain that leads to an attempted suicide cannot be dismissed. With a depressed person, the knowledge of having a quick and effective way of ending his life might precipitate a suicide attempt on impulse.”

  Despite these studies, and while therapists commonly advise families of suicidal patients to “get the guns out of the house,” little has been done on a broad scale to reduce firearm suicides. At the least, suicidologists recommend an enforced waiting period between purchase of a gun and the right to possess it, since the suicidal impulse might fade during that time. Although few of the guns used for suicide (according to one study, about 10 percent) are specifically purchased for that purpose, a study of 238,000 people who legally acquired handguns in California found that suicide was the leading cause of death among recent buyers. In the week following a handgun purchase, gun buyers are fifty-seven times more likely to kill themselves—and they remain at risk for years afterward. (The impact of the Brady Bill has yet to be fully determined. Although one study found a significant reduction in suicide rates following its enactment, the study’s methodology has been questioned.) Suicidologists further suggest that the guns we do have should be fully childproofed. In any case, while many more Americans kill themselves with guns than are murdered with them every year, suicide is rarely mentioned by either side in the gun control debate. In an editorial accompanying Jeffrey Boyd’s research in the New England Journal of Medicine, Richard Hudgens admitted, “It is unlikely that the suicidal use of guns will be an important factor in any eventual decision to limit their availability, for suicide is not high on the list of America’s political concerns.” When approached with the idea that a soaring firearms suicide rate might justify
a call for tighter gun control, a National Rifle Association spokesman responded, “The NRA is not for gearing laws to the weakest element of society.”

  This Darwinian reflection speaks to the heart of the question of how far we should go to prevent suicide. Clearly, we cannot and should not make the world “suicide proof” nor our lives a twenty-four-hour suicide watch. Even if we could, suicides would of course still occur. But even if bridge barriers and gun control legislation were to have no effect on the suicide rate, there may be compelling reasons why such measures should nevertheless be taken. To put up or not put up a barrier says something about the way we feel about suicide and suicidal people.

  I remember discussing the proposed Golden Gate Bridge barrier with a San Francisco friend. “Ninety-nine percent of us don’t need it,” she said. “Is it fair to ruin the view for the sake of a few? If they want to die so much, why not let them?” I found this attitude shared by many people. Their view often seemed based less on respect for individual freedom than on ignorance of the psychodynamics of self-destruction and discomfort with the subject of suicide in general. Whatever their reasons, it troubled me that so many otherwise kindhearted people should object to preventive measures. For how far is it from this passive condoning to the voices one sometimes hears when a crowd has gathered at the base of a tall building, to watch the weeping man on the ledge high above, shouting, “Jump, jump, jump”?

  Fortunately, in answer to the voices who cry “Jump,” many other voices cry “Live”—not just the voices of family, friends, therapists, and prevention center volunteers but the voices of strangers. When the twenty-year-old manager of a Brooklyn clothing store began receiving telephone calls for a now defunct suicide prevention hotline, he took time to listen to their problems. “They just start talking,” he said. “I tell them they have the wrong number, but I ask them if I can help. . . . I believe in helping people out.” When a twenty-six-year-old Austrian threatened to jump from the 446-foot steeple of St. Stephen’s in Vienna, a thirty-four-year-old priest whose hobby is mountain climbing scaled the steeple and persuaded the man to descend. When an eighteen-year-old girl stood on the ledge of a seven-story building in Mexico City, Ignacio Canedo, an eighteen-year-old Red Cross male nurse, inched out toward her. Canedo was tied to a long rope, held on the other end by a squad of firemen. “Don’t come any nearer!” shouted the girl. “Don’t, or I’ll jump!” Canedo grabbed for her and missed. The girl screamed and jumped. Canedo jumped after her, caught her in midair, and locked his arms around her waist. They fell four floors before the rope snapped taut. Canedo’s grip held, and he and the girl were hauled back to the roof. “I knew the rope would save me,” said Canedo. “I prayed that it would be strong enough to support both of us.” There are hundreds of similar stories of potential suicides saved by strangers who instinctively reached out.

  As a term project for “The Psychology of Death,” a course taught by Edwin Shneidman at Harvard, one student placed an ad in the personals section of a local alternative newspaper: “M 21 student gives self 3 weeks before popping pills for suicide. If you know any good reasons why I shouldn’t, please write Box D-673.” Within a month he had received 169 letters. While the majority were from the Boston area, others came from as far away as New York, Wisconsin, Kentucky, even Rio de Janeiro. They offered many reasons why he should stay alive. Some wrote of music, smiles, movies, sunny days, sandy beaches. Some quoted Rod McKuen, e. e. cummings, or Dylan Thomas. They suggested he spend time with others less fortunate than he; implored him to think of those he would leave behind; called him a coward and dared him to struggle and survive. Some referred him to a therapist. Others offered friendship, enclosing their phone number or their address. A few enclosed gifts: two joints of marijuana; an advanced calculus equation; a Linus doll; magazine clippings on the subject of kindness; a photo of apple blossoms with the message “We’re celebrating Apple Blossom Time.” Some simply broke down in the middle of their letters and pleaded “Don’t” or “You just can’t.”

  The student was not actually contemplating suicide, but the answers he received were real. Whether they might have persuaded someone truly suicidal to stay alive is impossible to say. But if the forces that lead someone to suicide are numerous, those forces that combine to prevent someone from killing himself may be equally complex, whether they be SSRIs, a prevention center volunteer, a barrier on a bridge, a Linus doll, or the voice of a stranger saying “I care.” “There is no magic bullet that goes right to the heart of suicidality,” says Robert Litman. “Many, many things together bring a person to suicide, and many, many things together prevent a suicide. But if you have, say, twenty suicidal things and you can relieve just one, leaving only nineteen, you’re probably going to get a sense of improvement and a little more hopefulness. And if you can maybe relieve parts of two or three others and get it down to seventeen, to sixteen, you’re going to get another little increment of hopefulness, and you’re on your way.”

  It was the last day of the fifteenth annual meeting of the American Association of Suicidology. More than five hundred suicidologists from dozens of states and countries had gathered at the Vista International Hotel in New York City for a four-day smorgasbord of workshops on “Suicide: Problems in the Big City,” “Demographic Factors in Suicidal Behavior,” “Fundraising: Effective Strategies and Methods for Suicide and Crisis Centers,” and fifty-five other topics.

  A who’s who of suicide had assembled. Norman Farberow was there. So were Herbert Hendin, Ari Kiev, Bruce Danto, and Nancy Allen, the public health worker who was instrumental in organizing the first National Suicide Prevention Week in 1974. And everywhere you looked there was Edwin Shneidman, speechifying, kibitzing, or just standing in the back of the room watching the proceedings like a proud father. Heady company; at one point twelve past presidents of the AAS sat at the dais. Their combined efforts represented more than a hundred books, a thousand articles, and two hundred years of experience in the study of suicide and its prevention.

  Now, while volunteers took down posters in the lobby (a photograph of a blank brick wall—SUICIDE IS A DEAD END), and the silver-haired proprietor of the Thanatology Book Club closed up shop, the day’s first meeting was getting under way downstairs in the Nieuw Amsterdam Ballroom. It was nine o’clock. Fewer than a third of the registrants were in attendance. Some were recovering from a “Backstage on Broadway” tour arranged by the entertainment committee, while others opted for last-minute sightseeing or for confirming flights home, rather than this session on “Borderline Personality Disorders and Suicidal Behavior.”

  Grisly fare for a Sunday morning. Several people in back slept through presentations by mildly eminent psychiatrists. (My notes are hieroglyphs: “central organizing fantasy of narcissistic union” and “objective scrutiny of object relations.”) As Otto Kernberg, who pioneered the study of the borderline patient, read a dense theoretical paper, a group of psychiatrists in front gazed up with adoration and a prevention-center volunteer in back joked about marketing the speech as a sedative.

  When Kernberg finished, the moderator, a young psychiatrist who had been alternating pensive nods with glances at his watch—it was his job to herd everyone upstairs in time for “Is There Room for Self-Help in Suicide Prevention?”—invited questions. Hands shot up in front, and their owners raised progressively complex issues. But a hand in back, belonging to a shabby fellow in a ponytail, persisted. And the moderator finally gave in.

  The man stood. His jeans and flannel shirt were worn but not dirty. His ruddy face couldn’t decide on a beard or a shave, and his eyes were as cloudy as his question, a stammering ramble proposing meditation as a panacea for suicide. Eyes started to roll in the audience, and there were tolerant chuckles. The moderator flashed the panel an embarrassed collegial smile. When the ponytailed man slowed for a moment, the moderator broke in, “That’s an interesting question, but let’s move on. We have time for one more.” He looked for another hand; the man remained standing.
The moderator began his thank-you-very-much-I’m-sure-we-all-learned-a-lot speech, and the man was beginning to sit, bewildered, when Kernberg reached for the microphone and said, “I’d like to answer that question,” and in his textbook Viennese accent began responding with care and respect.

  V

  LIFE OR LIBERTY

  MOST SUICIDOLOGISTS are governed by a simple rule: when a life is in danger, one does whatever one can to save it. Some disagree. “Suicide is a fundamental human right,” Thomas Szasz has written. “This does not mean that it is morally desirable. It only means that society does not have the moral right to interfere, by force, with a person’s decision to commit this act.” In numerous books, articles, and speeches, Szasz, a professor of psychiatry at the State University of New York in Syracuse, has articulated his belief that mental illness is a fiction invented by psychiatrists to justify coercive interventions and, in the process, trample on the rights of individuals. Not surprisingly he is vehemently opposed to such staples of suicide prevention as third-party intervention, physical restraint, call tracing, and, above all, involuntary commitment. The relationship between suicide preventer and suicidal person, which suicidologists liken to that of parent and child, Szasz views as something far less benign: “If the psychiatrist is to prevent a person intent on killing himself from doing so, he clearly cannot, and cannot be expected to, accomplish that task unless he can exercise complete control over the capacity of the suicidal person to act. But it is either impossible to do this or it may require reducing the patient to a social state beneath that of a slave; for the slave is compelled only to labor against his will, whereas the suicidal person is compelled to live against his will.”