In some ways the United States as a whole is in the same dilemma as the US Air Force but with one important caveat. As a nation, we have never reduced suicide rates by design, as the Air Force has. And since 2007, with suicide rates up by 35 percent overall and by more than 57 percent in some groups, any illusion of control or impact on suicide rates we might have had is surely gone. You probably don’t know that the United States has a national suicide policy created by a distinguished organization called the National Action Alliance for Suicide Prevention. The policy came out in 2012. But no expert I spoke with even mentioned it, and until I looked it up, I’d never read a word of it. A recent report by SAMHSA about the national policy contained these words:
This report concludes that despite this increasing level of activity, efforts to implement all that we know about suicide prevention as part of a comprehensive approach that seeks to prevent suicide across the lifespan (including adults as well as youth) have been rare.
“Rare” is putting it mildly. The truth is our government has not attempted a systemwide approach to suicide prevention. There have never been more federal, state, and local initiatives to stop suicide, at great cost, but they’ve operated outside any unified national plan. And remarkably, virtually no data is available about the success or failure of most of these efforts. Meanwhile, suicides have only risen. What are we to conclude except that these efforts are failing? Ten years later, one is right to wonder if there is any difference between a national policy and none at all. About the Action Alliance strategy, Eric Caine wrote, “The National Strategy is not a true strategy that is implemented nationally. It is an encouraging document, meant to provide grist for states and to use in some fashion with Congress. But the bits and pieces that have been created in no way constitute the implementation of an integrated ‘strategy.’ ”
SAMHSA’s 988 Suicide and Crisis Lifeline is an example of an important part of the plan that came into existence and has already created positive change. Certified Community Behavioral Health Clinics are another encouraging part, but there are presently too few of them to make a substantial difference in suicide rates.
It’s not as if the United States doesn’t know how to create a systems approach to suicide prevention. The USAF provided a blueprint of a community-based network of overlapping systems of care. Another US-based initiative bears exploring even though its benefits apply only to members of private health care organizations, not the general public. The Zero Suicide program, developed by the Henry Ford Health System in Michigan, aims to prevent all suicides among its patients. The program was created almost twenty years ago by a group of Henry Ford mental health practitioners who wanted to improve support for patients suffering from depression. Under the Zero Suicide program, patients are assessed for suicide risk at every visit and assigned to one of four risk categories. Each risk level comes with a specific treatment plan and timeline for care, ranging from immediate inpatient treatment for those at high risk to referrals for outpatient therapy for those at moderate risk. The program also includes the development of a safety plan for at-risk patients, which can include removing access to firearms or other lethal means from the home. Staff members also follow up with patients during transitions in care, particularly after psychiatric hospitalization, when the risk of suicide is highest.
The impact of the Zero Suicide program has been impressive. Before its implementation, the suicide rate among Henry Ford’s mental health patients was approximately 100 per 100,000, similar to rates in other mental health populations. However, in the program’s first nine years, the rate dropped to an average of 22 per 100,000, according to a 2015 report published in JAMA Psychiatry. That’s a huge success. The program will be expanded to primary care, since 83 percent of those who attempt suicide visit a doctor in the year preceding their death. Henry Ford aims to provide all its one million patients with at least one annual suicide evaluation during a visit to their general practitioner.
The success of the Zero Suicide program, combined with its relatively low cost for training staff and updating electronic health records, has led to its adoption by at least 500 other US health care systems, as well as hospitals in the United Kingdom, Australia, and other countries. The Zero Suicide Institute provides guidelines for implementing the program. The director of the institute, Julie Goldstein Grumet, PhD, is optimistic about the program’s potential to be successful in a variety of settings. “It just makes sense,” she said. “And that’s what’s inspiring people to try it.”
Its downside? It’s available only to members of participating health care networks.
Applying a systems approach to an entire nation is far from impossible. Some nations have faced a suicide crisis as harrowing as the United States’ and enacted public policies that reduced suicides in the entire country—broad, community-based approaches that catch a great number of suicidal individuals in a big net. Denmark, once plagued by an astronomical number of suicides, is one such place.
“My name is Troels Torp. Most mornings I get up and turn on the TV, put on the news. Then I make a pot of coffee and just open my work PC to start working.”
Troels Torp, over six feet tall, is a boyish, red-haired man of thirty-four. And since his condominium is at the top of his building and the roof intrudes with oblique angles and windows, he frequently ducks and minds his head. Yet his apartment is spacious for one occupant, with a quirky, cozy feeling in the bedroom, kitchen, living room, and music room, where he plays guitar. He goes to work at the kitchen table, which he keeps spotless like the rest of his quarters. The space is airy and spare, which seems to be the Scandinavian way.
Troels says, “I write a lot of articles so there is a lot of research and I do that in the morning. I enjoy it because I am a very curious person, and I love to embrace new knowledge. I love to study different things and kind of be a nerd about it. I’m never satisfied, I want to know it all.” Troels’s smile contains a hint of frustration, as if I’m standing between him and his research, which I am. “In the afternoons I write.”
Research, writing, then well before sunset each day Troels shuts down his computer and goes for a walk in the parks of Aarhus, Denmark’s second-largest city. It’s located on the eastern coast of the Jutland peninsula, which borders the Kattegat Sea, gateway to the North Sea. Aarhus has a rich history dating back to the Vikings. Several universities call it home and it enjoys waves of invasions by students from all around Denmark and the world.
Troels walks on beaches and in the woods to escape the crowds. “What nature does for me is give me tranquility.” Troels laughs ironically as he claims, “It’s my safe place. It’s where I can clear my head and put on music and walk and I don’t have a direction or a goal in mind. I just follow the path wherever it takes me.
“I have a rule to walk at least once every day, and not just for ten minutes. It has to be thirty or forty minutes but usually an hour. That way when I come home, my head is clear and I’m feeling calm, and not feeling stressed about the workday. And that gives me time to prepare for the day tomorrow.”
In short pants over long legs, Troels strides across black coral rocks on a white sand beach. In dark woods he feeds apples to fearless deer. His life was not always so orderly.
“I had always been this very easy to talk to, happy-go-lucky guy, never having a bad day. But when I was in my last year of high school I was a runner on an elite track and cross-country team. And I got a lot of back injuries. The doctor took an MRI and they told me I have to stop running; otherwise I will have three disks extrude in my back.
“So I just lost my entire identity at that point. I was an elite runner, then suddenly I wasn’t. At the same time, my best friend stopped talking to me. I never knew why but he just stopped.”
His best friend turned his back on Troels and, worse, encouraged others to do so too. Fifteen years later the memory still creases Troels’s brow. But his high school growing pains were just a warm-up for the calamities of college. Troels studied medicine, intending to become a physician. His fellow students seemed overly competitive and harsh. In the words of neuroscientist John Mann, the world seemed excessively cruel.
Troels said, “The students were very hard on each other. Always trying to put each other down, always trying to be the best. I got trampled on a lot. Not physically but mentally.”
The academics and hostile atmosphere stressed Troels so much he began drinking alcohol to get to sleep. Soon he drank alcohol to get himself up. He stumbled through two semesters but had to repeat one. An accidental injury introduced Troels to self-cutting. Cutting provides short-term relief to some people in deep psychological pain, but it’s a losing proposition. The relief quickly diminishes, and the self-harm can lead to suicide. Anyone self-cutting should immediately seek care.
Troels spent a few weeks in a psychiatric hospital. Then, instead of relief, visions and voices haunted him. He said, “I suddenly started to hear voices, and I started having visions. The scariest one was when I was watching television. One of the actors’ shadows went out of the screen and into the room and just ran around me and out the door. I knew it wasn’t real. But I still saw it.”
The voices were persistent and cruel. “I had two different voices, a woman’s voice on my left side, and a man’s voice on my right. And both of them were just talking negatively about me and saying, ‘You’re no good. You can’t do anything right. You should just kill yourself. You should cut yourself. Nobody loves you. You don’t even love yourself.’ ”
Troels took a leave of absence from college. The voices pushed him to the edge. To keep them at bay, he spent days drinking and cutting. Finally he’d had enough. He attempted to kill himself three times.
“I don’t think that I actually wanted to die,” Troels told me in a quiet voice. “It was more a feeling of just getting relief. Kind of just, make it all stop. Just stop.”
Troels failed his first two suicide attempts, and his father interrupted the third. Troels grabbed the lifeline he extended. He let his father take him to a psychiatric hospital. There, psychiatrists added personality disorders to his prior diagnoses of depression and anxiety.
There is a cultural perception that college provides some of the most memorably upbeat years of the lives of those lucky enough to attend. It’s a period of physical and intellectual maturing, a time to learn exuberantly, to gain freedom from parental supervision and family dynamics. Many students get their first thrilling glimpse of their careers. Many make lifelong friends. Some meet their husbands or wives. College is transformative. It expands the world a hundredfold.
But college and university students have the deck stacked against them. Suicide is the second-biggest killer in their age group, from ten to thirty-five, and suicide is one of the most common causes of student deaths. Each year, some 24,000 college students attempt suicide, while about 1,100 die trying. About 12 percent of students report suicidal ideation during their college years. In 2019, according to reports, 36 percent of undergraduate college students tested positive for depression, and 31 percent for anxiety. The majority of students are exposed to the suicide or suicidal attempt of someone they know.
There are reasons for these suicides. Young adulthood, the college years, are when serious mental health issues, such as schizophrenia and bipolar disorder, typically first appear. College years come with a raft of risk factors. It is many students’ first time away from home; many face stiff competition for grades, and students worry about their academic performance in a way they never did before. Drugs and alcohol are easy to obtain and abuse. Students have to build a new support network and come to rely on their families less and less. Many face financial strain. Some become homeless.
In the United States, there are about 1.3 million homeless students enrolled in college. About one-fifth of them have disabilities. Imagine the academic and social challenges of college while you’re sleeping in a shelter, in a tent under a bridge, or in a car, or are perpetually couch surfing at the homes of friends.
Men in their college years are four to six times more likely than college women to kill themselves. Women in college are two to three times more likely to attempt suicide. For students of color and LGBTQIA+ students, overall mental health impacts are even more severe. Fortunately, there are organizations that can prevent higher education from becoming a mental health minefield. Interestingly, some of them, such as the Jed Foundation (JED), were influenced by the Air Force’s successful eleven-year suicide prevention campaign.
In 2000, Donna and Phil Satow founded JED, naming it for their youngest son, who died by suicide. Today the foundation is a leading nonprofit dedicated to promoting emotional health and preventing suicide among young adults. One of the key resources JED offers is its educational program for schools and colleges. The foundation provides training and support for school administrators and educators to help them create safe and supportive environments for students and catch mental health issues upstream of crisis events. This includes training on how to recognize signs of mental distress, how to provide appropriate support, and how to connect students to mental health resources. JED’s efforts don’t end on campus; the foundation provides resources for families and individuals not affiliated with a school. Its website offers a range of resources on topics related to common mental health conditions, self-care strategies, and ways to support someone in need.
Effective campus programs including JED emphasize social connectedness and life skills. To stay mentally healthy, students must pursue a healthy lifestyle, which incorporates nutrition, exercise, sleep, and general work-life balance. And many enter college without must-have practical knowledge, such as how to balance a budget and pay bills on time. Staying organized and protected from many sources of stress is a big part of college success.
Some students enter college with long-standing mental health disorders; caregivers must be alerted to their needs, and their treatment must continue through their transition. Some centers of higher learning train staff members and students to be “gatekeepers.” They learn the warning signs of people at risk of suicide, and how to assist them in getting care. Professional services such as crisis management, substance abuse therapy, and mental health assistance are crucial components of on-campus treatment. Campuses must fight the stigma attached to mental health conditions and normalize help-seeking.
And finally, campuses must attend to means restriction. As way too many school shootings have shown us, student gatherings are no place for firearms. Restricting the availability of poisons and dangerous lab chemicals, and erecting barriers on bridges, parking garages, and residence towers are all proven means of reducing suicides at school.
The suicide rate in Troels Torp’s native Denmark has historically been among the world’s highest. In 1980 it was 38 per 100,000 people over the age of fifteen. By comparison, that same year the United States’ suicide rate was 12.3 per 100,000 people of all ages. By 2007, however, the Danish rate dropped to 11.4 per 100,000, or approximately where it is right now. That’s more than a 30 percent drop in suicides, and among high-income countries, Denmark has one of the lowest rates.
In 2007 the US suicide rate was just 11.4 per 100,000; today it’s about 13.9. Between 1999 and 2006, the US rate increased by less than 2 percent per year; however, after that, it increased at twice that rate.
How did Demark achieve a 30 percent reduction? Over decades the country took action against their suicide emergency with a multipronged systems approach. Like the US Air Force program and Zero Suicide, Denmark did not implement one approach but many overlapping approaches, and this seems to be key to the success of any systems approach. One substantial prong is that Denmark provides all its citizens with free health care, including mental health care. This includes access to psychiatric emergency rooms, early intervention services for young individuals experiencing psychosis, and specialized treatment for anxiety and depression.
The jewels in the crown of the Danish approach to suicide reduction are nineteen specialized medical centers dedicated to treating suicidal patients. These clinics, called suicide prevention clinics, are open twenty-four hours a day, seven days a week, and are available to provide vital support and treatment to individuals who have attempted suicide or are struggling with thoughts of suicide, including young people and children. They offer counseling, therapy, and medication, and long- and short-term treatment as needed.
I can’t help but contrast this immediate access to care with stories I’ve repeatedly heard across America of individuals, especially the young, who are in suicidal crisis but do not receive meaningful treatment for days or weeks after seeking it. From 2007 to 2016, emergency department visits for pediatric mental health conditions increased by 70 percent, but hospitals and state and local governments have done little to address this sea change. A shortage of beds in psychiatric units results in “boarding” the patient in featureless rooms with no phone or television for days, even weeks at a time. Often the doors to the rooms are left open day and night so staff can keep an eye on the patients. Anyone who’s tried to sleep in a busy, noisy hospital understands that this can be torture. And as we know, adequate sleep is fundamental to mental health.
In the worst cases, these environments exacerbate the young patient’s condition, and the long-term impacts can be catastrophic. “We have a national crisis,” says JoAnna Leyenaar, MD, PhD, MPH, a pediatrician at Dartmouth-Hitchcock Medical Center who led a study on pediatric boarding in emergency departments. Dr. Leyenaar estimates that between one thousand and five thousand young people board each night in the some four thousand US emergency departments.
It is excruciating to imagine as many as five thousand young people in crisis each night boarded in noisy, prison-like holding rooms until psychiatric beds and basic psychiatric care become available. But that’s the disgraceful reality in one of the world’s wealthiest nations.
Denmark has a population of about 5.9 million, about the same as the state of Minnesota. While the United States, with a population of about 331 million, has no suicide-specific hospitals or clinics, Denmark has nineteen. One of them, Amager Psychiatric Center in Copenhagen, is an elegant, modern building composed of stainless steel, floor-to-ceiling windows, and bright, welcoming interiors. It breathes a mood of calm. Troels Torp spent seven weeks in a hospital much like this one near his home in Aarhus. He underwent intensive psychoanalysis and was painfully weaned off psychotropic medications and alcohol. He credits the hospital with saving his life.
At Amager Psychiatric Center, therapists like psychologist Titia Lahoz explore patients’ dangerous thoughts. Lahoz, originally from Spain, told me how it felt to lose a patient to those thoughts.
“When a patient dies in our center, of course it affects us very much. I have colleagues who stopped working in the field afterwards. It takes time to recover. We have an expression in Denmark, ‘to have ice in the stomach.’ It means that you keep cool or calm in crisis situations. You lose the ice in your stomach when a patient dies, but it’s good to know that after a while it returns. And then you evaluate what you might have done differently with that patient.”
The core of Lahoz’s approach, which combines elements of different therapeutic styles, is to establish a strong personal connection with her patients. David Jobes, whose Collaborative Assessment and Management of Suicidality (CAMS) approach is widely used in suicide prevention clinics throughout Denmark, would simply call this empathy. Lahoz says, “When you are suicidal, it’s difficult to find solutions by yourself. I think you need to talk to other people to get some other perspectives and to share your emotional pain. It gives some relief.”
In fact, it gives proven relief. According to research led by the Johns Hopkins Bloomberg School of Public Health, a group of Danish men and women who underwent voluntary short-term psychosocial counseling after a suicide attempt experienced a 25 percent reduced rate of subsequent suicide attempts and suicide deaths.
Lahoz proposes ten therapeutic sessions for each patient. “While they are having those ten sessions, we find out if they have any psychiatric disease that needs to be treated. Because people can come in from the street to the suicide prevention clinics and have no prior psychiatric record. We can diagnose them.”
Patient Thea Pedersen is twenty years old and dropped out of university because of her suicidal ideation. Lahoz and Thea are both petite women with brown hair; they could be mistaken for mother and daughter. The two sit facing each other in a bright wood-paneled space lit by ceiling-high windows. It looks more like an upscale boardroom than a room for therapy. At first, Thea rarely makes eye contact. Lahoz slowly gets her to open up as she learns the broad strokes of her circumstances.
“When you have suicidal thoughts, what are they really about? If you weren’t here anymore, what would you really like to get rid of?”
Thea gently cries. One of her thumbs vigorously rubs the top of the other. “The thoughts that are going on in my head. All the time.”
“What kind of thoughts?”
“I do not know what I am going to do with my life. My mother wants me to settle down and give her grandchildren. And my boyfriend just broke up with me because I’m so sad.”
“Wow, that’s a lot. You feel your mother’s expectations. And you just had a breakup. How long have you had thoughts about killing yourself?”
Thea considers. “Six months. I was still in college and I couldn’t focus on my work. We studied in groups. The others got mad at me because I was always distracted.”
“School too. What else sets off these thoughts about ending your life?”
“Many of my friends got married and have children and things like that. And careers. I can’t see any of it. I want it all to stop. I want it to just be over.”
I want it all to stop. Thea’s words echo Troels Torp’s. Generally speaking, suicidal people aren’t planning to go to a better world but to escape the pain of this one. Put another way, they’re ambivalent about dying, but they will often do what it takes to stop immeasurable pain.
Lahoz says to Thea, “So there’s your mother’s expectations, your studies, your boyfriend breaking up with you. And life seems to be passing you by while your friends get on with theirs. All together in your head and you want it to stop. It’s quite heavy to think such thoughts, Thea. I am so glad you made the decision to come here. That is a great first step.”
From the Safety Plan Intervention to CAMS to Titia Lahoz’s hybrid approach, therapists quickly cover the basics with people in crisis. It gives them an understanding of the source and severity of their suicidal ideas and tells them if the patient needs inpatient care and supervision. Often the therapist moves on to the safety plan, created by Drs. Barbara Stanley and Gregory Brown, in use in Denmark and around the world. They help the patient create a list of distracting activities that can hold off a suicidal impulse. To that they add people who can help the patient, friends first and then professionals. They urge limiting dangerous means, such as medications, the use of trains, crossing bridges and highways, and other activities that could inspire an impulsive act. And invariably the therapist assures the person in crisis that her condition is temporary, and with sessions of therapy and perhaps medication, the persistent thoughts assailing her can be tamed, perhaps even eliminated.
In 2016, the Johns Hopkins Bloomberg School of Public Health examined the long-term impact of Danish suicide clinics. The researchers scrutinized health data from over 65,000 Danish people who attempted suicide between 1992 and 2010. Of those people, 5,678 received psychosocial therapy at one of Denmark’s suicide crisis centers. Their outcomes were compared with 17,304 people who had attempted suicide but hadn’t sought treatment afterward. Both groups were followed for about twenty years. According to the study, individuals who got therapy had a 38 percent lower risk of dying from any cause and a 27 percent lower risk of making another suicide attempt over the first year. After five years, the number of suicides in the group that had received treatment after an attempt was 26 percent lower. In the group receiving therapy, the ten-year suicide rate was 229 per 100,000, compared to 314 per 100,000 in the group not receiving therapy.
Lahoz knows the treatment isn’t wholly effective for every patient for the rest of their lives. No inpatient or outpatient treatment appears to be. “It seems like the effect is tapering off after three, four years,” she told me. “But of course, when we finish with people here, we always tell them that now we know you. So you’re very welcome at another time. If you need to, you just call us again and we can start a new session.”
Thea Pedersen is just starting out. A veteran of intensive suicide therapy, Troels Torp is doing exceptionally well. It’s been six years since he left a hospital and he no longer feels the need for medicine or talk therapy.
But the fact that Troels wound up in a hospital is not what the Danish systems approach to suicide prevention intends at all. It is designed to keep as few people as possible from ever having to go into inpatient care. Denmark’s suicide reduction system begins well upstream of suicidal ideation to nip mental health issues in the bud.
Rows of colorful children’s bikes line the front entrance to Ny Hollænderskolen, a Danish elementary school in Frederiksberg Municipality, Copenhagen. Inside, student artwork papers the walls, and the familiar scent of industrial cleaner, which must have been agreed upon by an international treaty of school janitors, gently accosts your nose. Ann Eskildsen’s third-grade class of twenty students is, with a couple of exceptions, a sea of blond hair, blue eyes, and pale skin. Like third graders everywhere, her kids are allergic to calm and addicted to bouncing out of their seats. But while they bubble with intelligence and mischief, they closely listen to their teacher and rarely misbehave. Her secret? A classroom contest called the Good Behavior Game.
First, Ms. Eskildsen divides the class into two teams and writes I and II on the chalkboard. Throughout the morning lessons, whenever a student speaks out of turn, leaves their seat, or causes any kind of disruption, Ms. Eskildsen rewards the other team with a point. By recess time two hours later, Team I has won 3–2. Victorious, and with whoops and high fives, Team I celebrates. Then both teams pile into coats and head outside.
In Kansas in 1969, a group of teachers and academics created the Good Behavior Game to help teachers keep control of classrooms without having to correct every little instance of disruptive or aggressive behavior. At the same time, the intervention promotes self-regulation, group regulation, and social behavior. The game treats the classroom as a community. To get along in the community, students must identify their desire to act up, and curb it. Behaving earns your team a victory shared by every member. Misbehaving, and earning points for the other team, earns derision and self-reproach. But these effects are short-lived; the game is played many times a week, and everyone gets a chance to shine.
For such a mild intervention, the Good Behavior Game is disproportionately impactful. Annette Erlangsen, PhD, the head of program at the Danish Research Institute for Suicide Prevention, is a big fan of the Good Behavior Game. She told me, “The Good Behavior Game is a way of trying to make young people have a more reflective knowledge of their own emotions and how they deal with extreme emotions. One can see it as a kind of suicide prevention initiative in the sense that it helps young people get onto a healthy pathway for mental health.”
One study of the Good Behavior Game in first- and second-grade classrooms in the 1985–86 academic year yielded remarkable long-term results. The study followed up with students at the ages of nineteen and twenty-one. Researchers discovered that relative to a control group, they had significantly lower rates of antisocial personality disorder, drug and alcohol use disorders, regular smoking, delinquency and incarceration for violent crimes, and suicidal ideation. Earlier studies with shorter follow-up times showed similar results.
Dr. Erlangsen reports that Denmark’s suicide reduction program has a host of additional components, some of them carefully planned and others that arose from social norms. They fall into three categories. Universal interventions impact the entire population; selective interventions are aimed at those who are at greater risk for suicidal behavior; and indicated preventions focus on individuals who have already engaged in harming themselves. Patients like Troels Torp, hospitalized for suicide attempts, come under the third category. Thea Pedersen, who had not yet attempted suicide, belongs in the second.
Erlangsen acknowledges the huge role of universal health care, including free mental health care, but she says restriction of means—a universal intervention—has had the biggest impact.
“Medical doctors became much more aware of prescribing medications in smaller amounts to make sure people with severe mental disorders didn’t have large quantities of dangerous medications at home. Other means restriction were weapons. We have an abundance of international evidence that shows if one makes restrictions on the number of firearms, then the suicide rate goes down. So it’s very evident that this is really a low-hanging fruit in terms of suicide prevention. In a Danish context, weapons are for hunting. Handguns are practically absent in Denmark.
“Catalytic converters on cars were introduced in the 1980s and ’90s. So carbon monoxide poisoning from car exhaust became practically nonexistent.”
Restricting household gases that contained carbon monoxide was another universal component of means restriction, a strategy that had stunning success in reducing suicides in Great Britain beginning in the 1950s. Others included restricting barbiturates and opioid painkillers. Ibuprofen and acetaminophen come in blister packs of just ten pills. Train stations and platforms throughout Denmark use barriers to prevent pedestrians from stepping onto train tracks and jumping from bridges onto tracks.
At the selective level, there are many significant risk groups who are in danger of suicide, including those who are addicted to alcohol or drugs, have recently been diagnosed with a serious physical illness, have previously attempted suicide, and people who are homeless, institutionalized, or imprisoned. A psychiatrist and an ambulance are always available as part of a psychiatric emergency outreach team to help patients who are experiencing a serious crisis. Home visits and family assistance are provided to patients who have been released from a mental hospital. Additionally, the Danish charitable group Lifeline has a suicide hotline that provides trained volunteers to those in need.
Hospitals and clinics in Denmark aim to bridge the gap between treatment and social support services, such as housing assistance and vocational training. In the United States, psychiatric care and social services are often strangers. When individuals are released from inpatient psychiatric care in the US, many fall back into the conditions of unemployment, homelessness, and substance abuse that added to their suicidal inclinations to begin with. This partly accounts for why US patients’ chances of killing themselves are highest in the first few weeks after discharge, and remain elevated for several months afterward (though, to be fair, to some degree this is true almost everywhere). When Troels Torp was discharged after seven weeks in a hospital, he was provided with a place to live. Like every Dane, he received funds to finish college. He graduated and soon became financially independent, as he is today. Troels’s story is one of hope.
In the music room of his condo, Troels skillfully picks at his Washburn acoustic guitar. The room’s bare wooden walls make a natural amplifier—the tuneful melody carries through the apartment. Troels schedules his music too. For him it doesn’t pay to be too busy, but neither is it good to have too much unstructured time.
He says, “Today I live a modest life, I will say, a simple life. And that’s how it should be for me. I always say to myself that I have to be as content when I go to bed in the evening as I am when I get up in the morning. I have my strategies for when I’m kind of starting to feel bad, kind of feeling stressed out or feeling the need to do self-harm. I have my different strategies. And I’m sticking to ’em.” Troels smiles bashfully.
Two hours later, something completely unexpected is happening. Applause breaks out as Troels Torp confidently strides onto a stage in an auditorium at Odder Højskole, a Danish Folk High School. Folk high schools in Scandinavian countries are boarding schools where mostly young people can study whatever they like before embarking on college or careers. There are no grades, no pressure. A faculty member has introduced Troels and the subject of his talk—surviving suicide—to about a hundred young adults in folding chairs. Commenting on his introduction, Troels jokes, “That was a little depressing, wasn’t it? How ’bout we change gears?”
Gone is the modest, simple-living Troels, and in his place a charismatic orator in a flowered T-shirt. He has a harrowing but hopeful story to tell. With humor he disarms the students, hooking them from the start. I learn this is Troels’s 150th talk for an organization called One of Us. Since 2017 he’s given talks, sat on roundtables, even met with the United Kingdom’s Prince Harry to discuss mental health issues among young Britons.
In the back of the auditorium, a blond woman whose black-framed glasses make her look teacherly is here to support Troels. Anja Kare Vedelsby is a One of Us program manager and soldier in the battle against mental health stigma. She tells me about One of Us. “We fight stigma by promoting inclusion and combating discrimination related to mental illness. We do that with a big core of ambassadors. And ambassadors in One of Us are all people with lived experience of mental illness. Like Troels.” One of Us is one more tool in Denmark’s systems approach to suicide prevention. After the initiative achieved impressive results in the nonprofit sector, the Danish government decided to fund it indefinitely. Vedelsby says, “People with mental illness risk being excluded from many different areas of life, from society in general, from social life and even within the family. And in the labor market you risk not getting a job, or being excluded from the labor market once you get ill. We’re trying to change all that.”
They change that by putting people with behavioral health issues, and sometimes their relatives, in the public eye, in talks, media interviews, and on television. They promote the idea that you can recover from mental health problems, or you can struggle with them your whole life. Either way, you are still a valuable human, still “one of us.” The organization’s motto: No more silence, doubt and taboo about mental illness!
At the front of the room, Troels talks about social exclusion, being ostracized by friends, and badly fumbling college his first time out. He has set the stage for his years of struggle and wants to brace the young audience for it. “So, are you ready for a heavy load?” he asks. “Because here comes my diagnosis.” As he starts describing his horrifying visions and voices, you want to reach out and tell this earnest young man it’s okay now, but of course he knows it. It’s okay now. The Troels you really want to comfort is eighteen years old, and lost.
Vedelsby continues, “Troels is a really excellent ambassador in One of Us, because he worked through so many of his very serious mental health problems in a way that he is able to share today. And he shares them in a very reflective, engaging manner.”
Troels concludes his talk under a rain of applause. He blinks in the spotlight, returning to his humble core, a modest man bewildered by resounding approval. It’s like payback for many years in the wilderness. You find yourself cheering too.