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.
Psychologists at the University of Washington decided to focus on why people don’t kill themselves; their Reasons for Living scale scores forty-eight factors connected to a patient’s coping skills, fear of social disapproval, moral objections to the act, and concern for family. And while most scales are intended for those who may be thinking about suicide, the Risk-Rescue Rating, devised by Boston-area therapists Avery Weisman and William Worden, computes the lethality of an actual attempt by assigning points to five risk factors (which include actual damage inflicted, and method—pills get one point, jumping and shooting, three) and five rescue factors (which revolve around the chances of being found in time to survive). The rating is tabulated by dividing risk score by risk plus rescue scores and multiplying by one hundred. Thus, it is demonstrated that a thirty-eight-year-old unmarried waitress who ingested sedatives, then went to a movie theater, where she was found in a coma and subsequently died, received an eighty-three, the highest possible score.
While these scales provide useful checklists for clinicians, playing “the numbers game,” says psychiatrist Douglas Jacobs, can be dangerous. “You have to be careful. On a percentage basis, young people are less likely to kill themselves, but if one of them does, for that person it’s one hundred percent.” Jacobs points out that the risk factors used in most scales may change. The dramatic increase in adolescent suicide has subsided; the rate for the elderly has gone down. (It has been suggested that different scales be developed for specific populations: for young females, for Native Americans, for middle-aged alcoholics, for patients in psychiatric hospitals.) Suicidal feelings fluctuate over time, and a rating that may be valid one day may be invalid the next; like the weather, points out psychiatrist Robert Simon, suicide risk must continuously be monitored. And no matter how specific the scale, no matter how frequently applied, there will be exceptions to the rule. University of Alabama researchers, declaring that most assessment tests are “too complex or cumbersome for practical and routine use,” devised the SAD PERSONS scale, an acronym for ten risk factors. Scoring one point for each, the patient’s probability of making an attempt is rated from one to ten. Suggested treatment is based on score, ranging from “send home with follow-up” (0–2) to “hospitalize or commit” (7–10). The researchers concede that some people may slip through the statistical net. “For example, a fourteen-year-old girl who attempted to hang herself ‘because the devil came and told me to’ might score only three points on the scale.”
Some believe the patient may be the best judge. In their 1973 paper “Patient Monitoring of Suicidal Risk,” a group of California therapists suggested that clinicians simply ask the depressed patient how long and under what circumstances he will stay alive. The patient is then asked to make a pledge: “No matter what happens, I will not kill myself accidentally or on purpose at any time.” The authors wrote, “If the patient reports a feeling of confidence in this statement, with no direct or indirect qualifications and with no incongruous voice tones or body motions, the evaluator may dismiss suicide as a management problem.” Claiming that in five years none of the six hundred patients who had made “no suicide” decisions had broken their pledge, the authors declared that their technique was “suitable for use by inexperienced nonprofessionals as well as by experienced professionals.”
“Patient Monitoring of Suicidal Risk” may smack of a certain inmates-running-the-asylum naïveté, but over the decades it has evolved into the widespread and controversial practice of “no-suicide contracts,” in which a patient promises, verbally or in writing, not to kill himself, and to keep his therapist informed of any self-destructive impulses. Although studies have shown that under the temporal and financial pressures of managed care, clinicians increasingly rely on no-suicide contracts as a form of risk management, no studies have shown whether they actually work. A survey at Harvard Medical School found that 86 percent of psychiatrists and 71 percent of psychologists worked in settings where no-suicide contracts were regularly invoked, yet fewer than 40 percent had been trained in their use. Many clinicians find them helpful; others point out that signing a contract may make the therapist feel safer but is no guarantee the patient won’t kill himself. “Indeed, the use of such contracts flies in the face of clinical common sense and may in fact increase danger by providing psychiatrists with a false sense of security, thus decreasing their clinical vigilance,” wrote Marcia Goin, president of the American Psychiatric Association, in 2003. “. . . We can make contracts with builders, insurers, and car dealers, but not with patients.” Arguing that no-suicide pacts cannot substitute for comprehensive risk assessment, psychiatrist Robert Simon concludes, “The contract against self-harm is only as good as the soundness of the therapeutic alliance.”
What assessment scales and no-suicide contracts prove most convincingly, it seems, is that our ability to predict suicide is negligible. “Although we may reconstruct causal chains and motives after the fact, we do not possess the tools to predict particular suicides before the fact,” concluded psychiatrist Alex Pokorny after his scale for suicide risk proved unsuccessful in a prospective study of forty-eight hundred inpatients at a Texas VA hospital. Says Robert Litman, “Even for someone in a high-risk category, the chances of suicide within a year are much less than the chance that he will not have committed suicide within that time. In twenty-five years, I can remember perhaps three cases where I felt the chance of a certain person committing suicide within the next year was more than ten percent.”
Even the most effective scales are intended to be a supplement to clinical judgment, not a substitute for it. “You can know all the statistics and scales and still not have any ability to assess a patient,” says one psychiatrist. But if the scales haven’t proved their worth, neither has clinical intuition. In one study a computer was shown to be more accurate than experienced clinicians in predicting suicide attempters. Adding insult to injury, half the patients preferred the computer to the therapist as interviewer.
For some of these reasons, a number of mental health professionals scoff at the “clues” approach to suicide prevention. “We’ve reached the point of no return in defining vulnerable populations,” says psychiatrist Herbert Hendin. “It amounts to looking for the proverbial needle in a haystack.” Hendin knocks Shneidman’s proposed educational blitz. “I don’t follow the logic of putting millions into educating the lay public in something that psychiatrists haven’t proven they can identify. It makes more sense to do something for the people you do find. A lot of seriously suicidal people present themselves to us in ways nobody can miss—they jump from five-story buildings—and nobody does anything for them.” The highest predictor of suicide risk is a previous attempt; between 25 and 40 percent of completed suicides have tried before, and 2 percent of those who attempt will complete within one year, 10 percent within ten years. Yet most attempters are returned to the community after being stitched up or pumped out, without provision for further treatment. (In one study, half of all adolescents brought to emergency rooms after a suicide attempt did not receive follow-up care—surprising until one learns that 70 percent of emergency-department physician training programs offer no instruction in the management of psychiatric problems.) “If you could identify twenty percent of the seriously suicidal from those who make attempts and cure ten percent,” declares Hendin, “you could literally change the suicide rate.”
Can clinicians “cure” suicidal people? The question is rarely asked. The bottom line at most prevention centers and in most prevention literature is to get the suicidal person to professional help. Although getting the person to that help can be difficult—reluctance by the person or his family to admit there is a problem, the stigma of being in treatment, and the high cost of quality care are a few of the obstacles—it is often assumed that once we do, the problem is solved. Yet professional help is no guarantee against suicide. Clinicians often point out with alarm that slightly more than half of people who kill themselves have never seen a mental health professional; the flip side—that nearly half of people who kill themselves have seen a mental health professional—should be considered nearly as disturbing. Indeed, people who have made attempts and entered treatment have the highest suicide rate of any patient group. Yet the focus of suicide prevention has been on assessment and prediction of suicide risk; treatment has largely been ignored.
How do clinicians treat suicidal people? A therapist’s first task, of course, is to address the crisis and decrease the risk of suicide, just as counselors are trained to do on the SPC phone lines. “The immediate goal of a therapist, counselor, or anyone else dealing with highly suicidal people should be to reduce the pain in every way possible,” writes Shneidman. “Help them by intervening with whoever or whatever is causing their distress—lovers, parents, college deans, employers, or social service agencies. I have found that if you reduce these pressures and lower the level of suffering, even just a little, suicidal people will choose to live.” In his book Definition of Suicide, Shneidman described a counseling session with a distraught college student. Pregnant, single, profoundly religious, and overwhelmed by shame and guilt, the girl had decided to kill herself. Shneidman’s initial task was to help her to realize that alternatives existed.
I did several things. For one, I took out a single sheet of paper and began to “widen her blinders.” Our conversation went something on these general lines: “Now, let’s see: You could have an abortion here locally.” (“I couldn’t do that.”) . . . “You could go away and have an abortion.” (“I couldn’t do that.”) “You could bring the baby to term and keep the baby.” (“I couldn’t do that.”) “You could have the baby and adopt it out.” (“I couldn’t do that.”) “We could get in touch with the young man involved.” (“I couldn’t do that.”) “We could involve the help of your parents.” (“I couldn’t do that.”) “You can always commit suicide, but there’s obviously no need to do that today.” (No response.) “Now, let’s look at this list and rank them in order of your preference, keeping in mind that none of them is perfect.”
The very making of this list, my non-hortatory and non-judgmental approach, had already had a calming influence on her. Within a few minutes her lethality had begun to de-escalate. She actually ranked the list, commenting negatively on each item. What was of critical importance was that suicide was now no longer first or second. We were then simply “haggling” about life—a perfectly viable solution.
Once the immediate danger has passed, how does a therapist treat a suicidal patient? Ask almost any therapist and he or she is likely to answer, “Suicide is a symptom, not a diagnosis.” (Although “suicidality” is included as one of nine symptoms of a depressive episode in the Diagnostic and Statistical Manual of Mental Disorders, suicide itself is not listed as an illness.) Nor is suicide dependent on a specific disorder. “Suicidal behaviors may be generated in the presence of practically any diagnostic entity, and at times in the absence of pathological states,” says psychiatrist Jerome Motto. Because a clinician can’t treat suicide as directly as he might treat, for example, strep throat—there is no antibiotic for suicide—he must treat the patient’s closest diagnosable ailment, which is, more often than not, some form of depression. Many clinicians believe that if they successfully do so, they’ve treated the suicidal patient, as if suicidality were simply a nasty side effect of the underlying illness. Yet some suicidal patients, albeit a minority, have no diagnosable underlying illness, and patients often kill themselves shortly after coming out of a depression—or long after a depression has lifted. “Suicide proneness is primarily a psychodynamic matter; the formal elements of mental illness only secondarily intensify it, release it, or immobilize it,” psychiatrists Dan Buie and John Maltsberger have written. “The urge to suicide is largely independent of the observable mental state, and it can be intense despite the clearing of symptoms of mental illness.”
How is the “underlying illness” of the suicidal patient treated? Although there is no pill for suicide, there are scores for depression and other psychiatric conditions. Over the past several decades, growing emphasis on the role of mental illness in suicide has combined with extraordinary advances in the development of psychotropic medications to effect a sea change in the treatment of suicidal people. Twenty or thirty years ago, depressed and possibly self-destructive people were likely to be treated with psychotherapy, supported, where indicated, by medication. By the new millennium, drugs were the treatment of choice—in most cases the only treatment—for depression as well as nearly every other psychiatric condition, with psychotherapy occasionally playing a supportive role. As journalist Daphne Merkin wrote in the New York Times, “In our age the triumph of the pharmaceutic has overtaken the triumph of the therapeutic; for all but a select few the cost-effective discussion of dosages has replaced the expensive discussions of dreams.”
What is now referred to as the “drug revolution” had its roots in the late 1940s, when French naval surgeon Henri Laborit was looking for something to calm his patients before administering anesthesia. He found that chlorpromazine, a sedating antihistamine, induced a “euphoric quietude.” He recommended the drug to his psychiatrist colleagues, who tested it on a variety of mentally ill patients and found it effective in the treatment of manic depression and schizophrenia. In 1954 it was introduced to the United States. Thorazine, the brand name by which chlorpromazine would be known, achieved remarkable results. Patients who had been unruly and assaultive were suddenly docile. In some hospitals the use of straitjackets, wet packs, and seclusion was virtually abandoned. Many patients were able to return to the community. Described—admiringly—by some as a “chemical lobotomy,” Thorazine became the drug of choice in American mental hospitals. Although many therapists believed Thorazine would be a panacea for suicidal patients, the drug offered control, not cure. In 1954, the year tranquilizers were introduced at Metropolitan State Hospital in Norwalk, California, the inpatient suicide rate more than doubled. Investigators suspected that the staff might have relaxed their vigilance because of the drugs’ efficacy in controlling symptoms. (Indeed, Thorazine rendered patients “immobile” and “waxlike,” as described by the lead investigator for the pharmaceutical company that manufactured it. He meant this as high praise.)
Over the following decades, Thorazine was followed by a succession of seemingly ever more miraculous medications: lithium, a naturally occurring salt, proved effective in moderating the roller-coaster mood swings of manic depression; clozapine helped quiet the nattering voices of schizophrenia; monoamine oxidase inhibitors and their successors, the tricyclic antidepressants, such as Tofranil, had a leavening effect on severe depression. Perhaps the biggest change came in 1988, when fluoxetine (better known by its brand name Prozac) was introduced in the United States, the first in a new class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs), which, as their name suggests, act by blocking the removal of serotonin at the synapses, thus increasing the availability of serotonin in the brain while leaving other neurotransmitter levels unaffected. Prozac and its cousins—Zoloft, Paxil, and so on—were so successful in providing relief to depressed men and women, as well as in giving a lift to millions more mildly unhappy people, that by 2000, one in ten Americans was taking antidepressants. An increasing number of citizens of Prozac Nation, as it has been dubbed by the writer Elizabeth Wurtzel, are young; in 2002, nearly 11 million children and teenagers were prescribed antidepressants, accounting for 7 percent of all antidepressant prescriptions, more than triple the number ten years earlier.
Despite their success in relieving the symptoms of psychiatric illness in millions of people (and, in the process, doubtless keeping many of them from killing themselves), these medications have had a more complicated relationship to suicide than might be expected. Among all the psychopharmacological treatments, the only one clinically proven to reduce suicide risk is lithium. In 2001, Harvard Medical School psychiatrists Leonardo Tondo and Ross Baldessarini analyzed thirty-three studies conducted over the previous thirty years and found that patients with major depression or bipolar disorder who hadn’t taken lithium were thirteen times more likely to have completed or attempted suicide than those who had taken it. (The suicide rate of those who had taken lithium was, nevertheless, nearly three times higher than that of the general population.) In a German study, 378 psychiatric inpatients, half with bipolar disorder, half with major depression, were randomly assigned to lithium, an anticonvulsant, or an antidepressant on their release from the hospital. Over the following two and a half years, four killed themselves and five made serious attempts; none were in the group taking lithium. The study’s author suggested that lithium may have a direct effect on suicidal behavior, independent from its effect on depression, perhaps by reducing aggression and impulsivity. Unfortunately, not all patients respond well to lithium, either because their systems won’t tolerate it, or because of its possible side effects—blurry thinking, weight gain, tremors, lethargy. Others may balk because of the hassle: lithium treatment requires monitoring of blood levels every few months. Or, like Brian Hart, they may consider lithium stigmatizing and stop taking it, either periodically or permanently. (Nearly one-half of all patients with bipolar disorder fail to adhere to their medication regimens at some point.) If there is anything more dangerous than a bipolar patient not being on lithium, it is a bipolar patient going off lithium; Tondo and Baldessarini found that suicidal acts rose sixteenfold in the first year after discontinuing treatment.
The tricyclic antidepressants, on the other hand, while enormously helpful in relieving depression, are also potentially lethal; many people have ended up killing themselves with the very medication prescribed to keep them from killing themselves. Knowing that a mere six or seven pills might mean the difference between an effective dose and a fatal one, clinicians faced a catch-22—they couldn’t prescribe antidepressants without the risk of the patient using them to kill himself, but it was difficult to treat clinical depression without prescribing antidepressants. Patients near the beginning of treatment may experience what has been called rollback, in which the antidepressant gives them sufficient energy to act on their suicidal feelings—as well as supplying them with the means to do it—before their depression lifts completely.
The introduction of the SSRIs seemed to resolve these issues. Although they are about as effective as the tricyclics, the SSRIs are less expensive, have fewer side effects (lowered libido being the most prominent), and are easier to administer. They are also far less toxic; used in intentional overdoses, they are rarely fatal. Indeed, many researchers suggest that the only problem with SSRIs is that not enough people take them and those who do don’t take enough. Studies of completed suicides reveal that only 8–17 percent were being treated with antidepressants or other prescription psychiatric medications, and only 6–14 percent of depressed suicide victims had dosage levels sufficient to be of any help. (Some of these low dosages, of course, can be attributed to patient noncompliance: one in four victims of suicide fail to adhere to their medication schedule in the month before death.)
Given that they reduce depressive symptoms and decrease aggressive, impulsive behavior, it would seem to follow that the SSRIs might have a measurable effect on suicide. Indeed, the massive increase in the number of prescriptions written for SSRIs in the United States and several other countries over the 1990s correlated with a decline in suicide rates in those countries. At the same time, most controlled studies have failed to find that SSRI treatment has made statistically significant differences in suicidal behavior on an individual level. (It is difficult to gauge accurately the effect of medications on self-destructive behavior, because suicidal people are systematically excluded from clinical trials by drug companies hoping to demonstrate the superiority of their products and because it would be unethical to withhold treatment from them during a controlled prospective study.) Indeed, evidence of their efficacy in treating depression has also proved elusive; in half of all adult studies, SSRIs have proved no better than placebos.
Nevertheless, the SSRIs were so popular that when reports began surfacing in the early 1990s suggesting that Prozac itself seemed to make some people suicidal, they were dismissed by pharmaceutical companies and federal regulators as vigorously as if someone had tried to discredit motherhood and apple pie. Those concerns resurfaced in 2003, however, when an FDA drug safety analyst reviewed the results of fifteen clinical trials evaluating the effect of various antidepressants on pediatric depression. Few of the trials showed that drugs relieved depression any better than placebos. (Indeed, of all the SSRIs, only Prozac has been shown to be effective in treating depressed pediatric patients.) Far more troubling, however, he found that children and teenagers given antidepressants were almost twice as likely as those given placebos to become suicidal. The risk was small—of one hundred pediatric patients given antidepressants, two or three might be expected to think about or attempt suicide who would otherwise not have—yet statistically significant. (None of the children in the trials completed suicide.) Perhaps most troubling of all, the results of many of these trials had been kept secret for years by the drug companies that had sponsored them.
The news was so shocking that, seemingly in denial, the FDA initially disputed their own analyst’s findings and hired a team of researchers from Columbia University to reassess the data. The Columbia researchers, however, agreed with the FDA analyst. In October 2004, following hearings in which dozens of devastated parents blamed their children’s suicides on the drugs, the FDA required the makers of ten antidepressants (including Prozac, Zoloft, and Paxil) to include “black box” warnings on the labels attesting that they “increase the risk of suicidal thinking and behavior” in children and adolescents. (No one is yet certain whether SSRIs trigger suicidal behavior or whether, like the tricyclic antidepressants, they may supply patients with sufficient energy to act on their suicidal feelings before their depression lifts completely.)
Given that both lives and money were at stake—$12 billion of antidepressants were sold worldwide in 2002—it was a difficult and contentious decision. Some therapists suggested that the efficacy of SSRIs and the ease of prescribing them had allowed physicians to become cavalier about dispensing them and expressed hope that the warnings would discourage indiscriminate and inappropriate use. Others worried that the warnings would scare therapists off from prescribing potentially lifesaving drugs for children in need. As it is, said psychiatrist John Mann of the New York State Psychiatric Institute, only 20 percent of the four thousand adolescents who kill themselves each year have ever taken antidepressants, and NIMH estimates that 15 percent of teenagers with untreated depression will eventually kill themselves. “It is probably the case that antidepressants both cause and prevent deaths,” wrote Andrew Solomon, author of The Noonday Demon, a study of depression, in the New York Times. “But it is also clearly the case that they prevent more deaths than they cause. The danger is that in seeking to prevent antidepressant-related suicide, we will increase depression-related suicide.”
The ascendancy of the SSRIs has tipped the scales in the long, bitter turf war between biologically oriented and psychodynamically oriented therapists. These days, few clinicians would suggest that psychotherapy alone, without medication to address the underlying illness, is enough to prevent profoundly suicidal individuals from killing themselves. Yet many would maintain that medication alone is enough to deal with depressed and possibly suicidal individuals. Indeed, in most so-called therapy, the only contact the doctor may have with a patient following an initial assessment and prescription are brief follow-up visits to discuss side effects and to ascertain whether the dosage needs adjustment—a procedure quicker and, in many cases, no more personal, than an automobile’s three-thousand-mile oil change. Discussions of treatment issues in the literature revolve around medication, monitoring, and compliance; psychotherapy, if mentioned at all, is usually described only as an aid in encouraging adherence to the pharmaceutical schedule.
The recent controversy over SSRIs and suicidal behavior suggests, however, that while psychopharmacology has changed the way we treat suicidal people, it may not, by itself, be enough. Despite their extraordinary success, medications have proved to be something of a red herring in the treatment of suicidal patients. They may relieve the symptoms of psychiatric illness, but they do little to alleviate the stresses—family problems, loss, trauma—that may have triggered or exacerbated the illness. And, says psychiatrist John Maltsberger, “While they are no doubt important in preventing a great many suicides, they do not necessarily alter the underlying vulnerability to suicide.” Indeed, the excitement over antidepressants has obscured the fact that depressed and suicidal patients are best served by a combination of medication and psychotherapy. When a recent NIMH study of 439 depressed teenagers concluded that Prozac was far more effective than talk therapy in treating depression, it was hailed as a triumph of medication over psychotherapy; all but ignored was the finding that the most effective treatment of all was Prozac and talk therapy. Numerous other studies have demonstrated better outcomes in depressed, bipolar, or schizophrenic patients who receive both medication and psychotherapy rather than drugs alone. Yet most insurance companies cover the costs of brief medication visits but not of more than a few sessions of psychotherapy, which is often dismissed as expensive, complicated, time-consuming, and even irrelevant. “Medicine alone is not sufficient for treatment of suicidality,” concluded a comprehensive report on suicide by the Academy of Sciences in 2001. “. . . Psychotherapy provides a necessary therapeutic relationship that reduces the risk of suicide.”
What kind of psychotherapy? Because the field is itself fragmented by turf battles, there is little agreement on how to treat any mental illness. A person suffering from depression may be treated with yoga, Reiki, massage, hypnosis, sleep-deprivation therapy, homeopathy, magnets, Saint-John’s-wort, Qigong, acupuncture, or any of the more than 250 types of psychotherapy practiced today. (Of them, only psychoanalysis is agreed to be inappropriate for suicidal patients: “Most are too anxious, too depressed, or just not well enough put together to stand it,” says Herbert Hendin, himself a psychoanalyst.) Although suicidal patients come with different diagnoses with different needs, they are likely to get whatever the therapist practices. “One would hope that clinicians had a number of strings to their therapeutic bow and would change depending on the nature of the problem,” says psychiatrist Leon Eisenberg. “Unfortunately, this field is characterized by people who do the same type of treatment for every customer that comes along.” A therapy that may work with suicidal patients will be ignored by most clinicians if it is not their modus operandi.
Although evaluations of long-term therapeutic interventions on suicidality are rare—too difficult, too expensive, too risky, too ethically iffy—a few approaches appear to be helpful in reducing suicide risk. Beck’s cognitive behavior therapy, a short-term treatment that helps depressed patients to reinterpret their negative, distorted thoughts in a more realistic, positive light, seems to reduce the feelings of hopelessness that lie at the core of many suicides. Studies have shown it may reduce suicidal ideation and attempts more effectively than nondirective psychotherapy. Dialectical behavioral therapy, developed by University of Washington psychologist Marsha Linehan specifically for use with chronically suicidal people, helps the patient to develop alternatives to self-destructive behavior, and to find ways to handle the intense surges of emotion that characterize borderline and bipolar patients. In weekly psychotherapy sessions, a problematic behavior or event from the past week is discussed in detail; in weekly group therapy sessions, coping skills and mindfulness techniques adapted from Buddhist meditation are taught. Between sessions, therapist-client telephone contact is encouraged. “The emphasis is on teaching patients how to manage emotional trauma rather than on reducing them or taking them out of crises,” Linehan has written.
Group therapy with suicide attempters has been valuable in reducing stigma and isolation. “The person realizes she’s not alone—that everyone else in the room has had suicidal thoughts, so there’s no need to maintain secrecy,” Chrisula Asimos, a San Francisco psychologist who worked with groups of suicidal people for many years, told me. The group, in fact, tends to reduce the focus on suicide. “The issue of suicide loses its impact,” says Asimos. “We talk openly about suicide, but we focus on other options. In a group, people can see how other people who have been there longer have moved away from suicidal behavior and explored healthier alternatives.” Bonding among group members (who are encouraged to be in individual therapy as well) extends beyond meetings; they organize group dinners and birthday parties, and like members of Alcoholics Anonymous who call each other when they have the urge to take a drink, they share home telephone numbers to be available to each other in times of crisis. When one group member who was acutely suicidal worried about jumping from her apartment window, the entire group helped her move from her lonely twentieth-floor rooms to a cheerful residence club on the ground floor.
But while group therapy seems to make suicidal patients more comfortable, the thought of working with a roomful of high-risk patients can be daunting. “Group therapy for suicidal patients hasn’t caught on because therapists are afraid of it, and I can well understand why,” says Norman Farberow, who pioneered therapy groups for suicidal people at the Los Angeles Suicide Prevention Center. “Most suicidal people are insatiable in their need for care and support, and when you get a half dozen depressed and severely suicidal people together, it’s very draining.” There has been no conclusive research on the efficacy of groups for the suicidal, but of hundreds of high-risk patients who were in Farberow’s groups, none completed suicide while in the group, although two former members took their lives after they had left the group against staff advice. When I met Chrisula Asimos, she had been running groups for sixteen years; during that time, no member had completed suicide. At one meeting, however, an older member suffered a fatal heart attack while in the bathroom. It was a traumatic experience for the group, but, said Asimos, “I’m convinced he came there to die—that we were his family.”
In some therapeutic approaches the therapist himself seems to serve as a substitute family. In their work with suicidal patients over several decades, Boston psychiatrists John Maltsberger and Dan Buie have evolved what they call the “psychodynamic formulation” of suicide. “This approach looks at suicide in terms of developmental failures that make it impossible to maintain a sense of self-worth,” says Maltsberger. “Many people who grow up suicide-vulnerable have failed to get the love they ought to have had from their mothers. Others have received good mothering but for little-understood reasons cannot make use of it.” In normal development, he explains, capacity for autonomy increases with age, enabling one to endure degrees of loneliness, depression, and anxiety. Suicide-vulnerable people fail to develop sustaining inner resources; they must depend on external supports. When those supports fail, suicide is a danger.
Though Maltsberger’s theoretical approach to suicide is heavily influenced by Freud, in practice the psychodynamic formulation is quite practical. “It boils down to finding out what a person has to live for,” says Maltsberger. “Most people live for all sorts of things—friends, a special person, work—and if they lose something on one front, they pick it up on another. But suicidal people are quite deficient in any capacity to keep themselves afloat on the basis of inner resources. Once somebody threatens suicide, you start looking at what resources the person has.”
Maltsberger and Buie specify three areas people live for: other people, work, and their body. “Obviously, when someone who is dependent and depressive loses a girlfriend or a husband, it can precipitate a suicidal crisis,” says Maltsberger. “Then there are people who never have relationships, who lock themselves in the library and devote themselves to scholarship. But when they retire or can’t work anymore, they may kill themselves. A surgeon may live only to operate; if he loses the use of his hands, he may do away with himself. And there are people who are very dependent and depressive, but as long as they can jog and look in the mirror and say ‘Gee, I’m in great shape,’ they can go on.
“So if someone has relied all his life on some capacity to work at Sanskrit, and he goes blind, the task becomes to find what this person can substitute as a lifesaving activity.” Just as Shneidman worked to “widen the blinders” of the pregnant young woman on a short-term basis, Maltsberger, in the psychodynamic formulation, tries to help the patient expand his long-term reasons for living. “It isn’t always possible. Many people are quite indifferent to the love of others, for instance. Others may be indifferent to success at work. Suicidal people are very specialized in what they will accept as a reason for living.” At first, says Maltsberger, the therapist himself may have to constitute that reason “until the patient can regain his balance and stand up again.”
The psychodynamic formulation offers therapists a practical way to help decide when someone is suicidal, what to do for treatment—which, in many cases, may involve medication—and whether hospitalization is indicated. It also requires a therapist to know a patient’s history thoroughly and to spot events in a patient’s daily calendar that might heighten suicide risk. “Treating suicidal people means being available—intensively—from time to time when they’re between supporting figures or research projects,” says Maltsberger. “I might call them on the telephone every day. You have to be waiting there like a net, hoping that as time goes on the person can widen his repertoire and make room for other sustaining influences.”
Even the psychodynamic formulation, however, offers only temporary relief. Can vulnerability to suicide be altered? Maltsberger sighs, like the Wizard of Oz after giving out heart, brains, and courage only to find that Dorothy still needs to find her way back to Kansas. “That’s most ambitious,” he says slowly. “That means helping the patient restructure his mind, which is very, very difficult and, in some cases, impossible.” He pauses. “Often psychiatrists don’t want to try.”
In part because they are the only mental health professionals allowed to prescribe medication, psychiatrists have long been regarded as the last word for suicidal patients. “We all use psychiatrists as backups for these cases,” a Boston social worker told me. “The psychiatrist is the bottom line.” One would therefore expect psychiatrists to know a good deal about suicide. They don’t. In fact, they score no better then radiologists on tests determining their knowledge of suicide risk factors; other mental health professionals score only slightly higher than college students and the clergy. A 1983 survey of more than three hundred training institutions found, on average, no more than a half day’s formal education devoted to suicidology by any of the mental health disciplines. Fifteen years later, a survey of 166 psychiatry residency programs found that while most now offered training in the treatment of suicidal patients, such training was often “relatively superficial in nature” and was usually delivered in the context of supervised clinical work. Only one-quarter offered workshops devoted specifically to suicide. (Forty percent of graduate programs in clinical psychology offer formal training in treating suicidal patients.) What suicide training there is is increasingly devoted to pharmacology; discussions of family dynamics, interviewing techniques, and unconscious forces have given way to discussions of dosages and blood levels. Indeed, many clinicians feel that no specific training for suicide is needed. “Experience is the best teacher,” insists one psychiatrist. (Residents are likely to acquire experience; a majority of patients on training wards are there because of a suicide attempt or severe ideation.)
Others disagree. “Residents are trained as they get cases, by supervisors who were treated in the same haphazard way,” sociologist Donald Light told me. Light spent two years in the 1970s studying psychiatric residency training at the Massachusetts Mental Health Center in Boston, one of the most highly regarded psychiatric training programs in the country at the time. “So a lot of homemade ideas about suicide care are perpetuated from one generation of psychiatrists to the next.” Light recommended a specific training module to the American Psychiatric Association, in which each residency would have an in-house expert through which all suicide cases would be routed. Residents would be required to work at a crisis phone service and to attend regular seminars in suicide care, stressing availability, the need to relax confidentiality, the necessity of involving friends and family, and the importance of working in clinical teams. The APA’s response, according to Light, was “polite.”
Alan Stone has been another advocate of specific training in suicide care. Years ago, after a rash of suicides at McLean Hospital, an elite, private psychiatric institution near Boston, where he was director of residency training, Stone concluded, “During the course of that epidemic, it became painfully apparent that many psychiatrists possess no systematic or comprehensive approach for dealing with suicidal patients.” In a series of papers, Stone and the late Harvey Shein, his successor and former student, proposed that “suicidal risk must be monitored in a way that is analogous to the current hospital management of acute coronary artery disease.” They suggested that suicidality be made an explicit focus of treatment and that the patient’s family be brought in and told. “Once the patient’s suicidal thoughts are shared, the therapist must take pains to make clear to the patient that he, the therapist, considers suicide to be a maladaptive action irreversibly counter to the patient’s sane interests and goals; that he, the therapist, will do everything he can to prevent it.” (Ironically, Shein, who campaigned for openness about suicide, couldn’t follow his own prescription; several years after the last of those papers was published, he took a fatal overdose of sleeping pills at the age of forty-one. The embarrassed hospital was hardly forthcoming itself; it reported that its promising young psychiatrist had “died suddenly” and persuaded the local newspapers to call the death a heart attack. At the next staff meeting, the hospital director didn’t mention Shein’s suicide until a grieving employee insisted on broaching the subject.)
It is clear that some training is needed. There are therapists who still share with laymen simple misconceptions about suicide—for instance, that if you ask a person about suicide, you’ll plant the seed in his mind, or, conversely, that if he talks about suicide, he won’t do it. Or that if a patient really wants to kill himself, you can’t stop him. The most common fallacy may be the supposed distinction between serious and nonserious attempters. While it is tempting to assume, for example, that wrist-cutters are manipulators who don’t intend to die, they should always be taken seriously. Writes Maltsberger, “Some patients almost ready for suicide but as yet undecided may betray their ambivalence through a minor attempt. . . . We know of one young schizophrenic woman who ingested six Stelazine tablets, an event misunderstood at the time as a negativistic gesture of little significance. A few days later, her indecision resolved, the patient fired her father’s pistol through her head.”
Sometimes, specific types of therapy may be harmful. One such approach involves what children call reverse psychology; while most therapy concentrates on the part of the patient that wants to live, “paradoxical technique” plays the flip side. The patient says life isn’t worth living; the therapist agrees. Light remembers a psychiatrist who claimed never to have lost a patient with this risky technique. He came close. “One girl had a blade at her wrist and he kept saying, ‘Go ahead, go ahead.’ He was pushing her down the hallway and she went screaming out of the hospital.” She made a small cut but recovered. Such brinkmanship requires an experienced therapist. Impressed with the jocular, Jewish-mother approach his supervisor used, a young resident tried it himself. “So already you should die” came out sounding like “you should die.” Two months into treatment his twenty-two-year-old patient put the plastic slip of a record jacket over his head and suffocated.
Another therapist took the opposite tack. On learning that one of his patients, a businessman, had slashed his wrists, he rushed to the emergency room where the patient was being sewn up and gave him a right hook to the jaw. “How dare you do anything so stupid?” he yelled. “If you ever do anything like that again, I’ll kill you!” Perhaps encouraged by his therapist’s concern—or stunned by his Sunday punch—the patient did in fact get better.
When Maltsberger was a resident, he had a patient who repeatedly slashed her wrists. “I was getting fed up,” he recalls, “and one day I said, ‘If you’re not interested in changing, we can arrange for you to be someplace else.’ I think that remark was motivated by hate. My basic message was ‘We’re tired of you; get off your ass or get out of here.’” On the next attempt the patient nearly killed herself. It was the first time Maltsberger had confronted countertransference hate—an emotional response therapists may have to certain patients. Such reactions can be particularly intense with suicidal patients. Extraordinarily demanding, they may attack the therapist, verbally or physically; they may shadow him or make anonymous phone calls. (Maltsberger knows of two instances in which patients telephoned suicide threats at the moment they correctly guessed their doctor was eating Christmas dinner.) The mere passivity—“almost a sucking quality,” says Alan Stone—of some suicidal patients is likely to inspire boredom, malice, even hatred, in a therapist. “When you deal with suicidal people day after day after day, you just get plain tired,” says James Chu, a psychiatrist at McLean Hospital. “You get to the point of feeling, ‘All right, get it over with.’”
In one of the few papers on the subject, Maltsberger and Buie describe how therapists may repress such feelings. A therapist may glance at his watch, feel drowsy, daydream—or rationalize referral, premature termination, or hospitalization just to be rid of the patient. Sometimes a frustrated therapist will issue an ultimatum. Maltsberger recalls one therapist who, treating a chronic wrist-cutter, “just couldn’t stand it, and finally she said, ‘If you don’t stop that, I’ll stop treatment.’ The patient did it again. She stopped treatment, and the patient killed herself.” Reviewing the treatment of thirty men and women who killed themselves as inpatients or within six months of discharge, William Wheat isolated several patterns that he believes contributed to the suicide: the therapist’s refusal to tolerate a patient’s immature, dependent behavior; the therapist’s pessimism about treatment progress; and the therapist’s inability to recognize an event or crisis of overwhelming importance to the patient. “All of these processes,” wrote Wheat, “can lead to a breakdown in the therapeutic communication resulting in the patient’s feeling abandoned or helpless, thus setting the stage for the disastrous result of suicide.”
Light contends that only certain therapists are able to withstand the demands of suicidal patients. “We should be candid about the fact that most psychiatrists are not built for suicide care. Let’s select about ten percent who have the stomach for it, who can handle the high anxiety, who might even like it, who have a kind of Green Beret outlook, and give them special training and then make it clear to other psychiatrists that when they get a suicidal case, they refer it to this person.” The late Bruce Danto, a psychiatrist who founded the Suicide Prevention and Crisis Intervention Center in Detroit, liked to talk about what he called the “psychiatric suicidologist,” which, in his description, seemed to be part social worker, part psychologist, and part cop. (With degrees in sociology, social work, and medicine, and a deputy sheriff’s badge, Danto was all of the above.) “The psychiatric suicidologist must have skills over and above those of psychiatrists in general,” he told me. “With these problems you can’t simply sit back in your chair, stroke your beard, and say, ‘All the work is done right here in my office with my magical ears and tongue.’ There has to be a time when you shift gears and become an activist.” Support might involve helping a patient get a job, attending a graduation, visiting the hospital, even making house calls. “I would never send somebody to a therapist who has an unlisted phone number,” said Danto. “If therapists feel that being available for telephone contact is an imposition, then they’re in the wrong field, or they’re treating the wrong patient. They should treat only well people.” The psychiatric suicidologist must also pay attention to “the tools of self-destruction.” Danto kept a collection of guns and knives belonging to suicidal patients, who held receipts. “Once you decide to help somebody, you have to take responsibility down the line.”
While many psychiatrists find such suggestions too gung ho, they admit that not all psychiatrists are equally fit to deal with suicidal cases. “There are many psychiatrists who don’t necessarily have great experience in treating people who have made suicide attempts,” Ari Kiev, a Manhattan psychiatrist, has said. “I would much rather have my social worker or even the receptionist deal with some suicide-prone patients than just any psychiatrist.” Herbert Hendin gets many referrals from uncomfortable colleagues. “A lot of people who do reasonably well with other patients cannot deal with suicidal patients,” he says. “The bigger tragedy is if somebody is not comfortable, you shouldn’t spend ten years trying to analyze his discomfort—let him treat someone else.” Robert Litman interviewed more than two hundred therapists shortly after the suicide of a patient. They expressed fears of being vilified in the press, of being sued, of being investigated, of losing professional standing, and of inadequacy. (Suicide is, in fact, the most common cause of malpractice litigation against mental health professionals.) Litman points out that therapists must understand that no treatment—psychopharmacology, psychotherapy, electroshock, hospitalization—can guarantee that suicide will not occur. When he lectures residents about suicide, he tells them that it is important to realize that they will undoubtedly have a suicide at some point in their practice. Indeed, it is part of psychiatry’s folklore that one is not a full-fledged therapist until one has had a patient who completed suicide.
“These doctors who get so anxious when a patient threatens suicide haven’t settled in their own lives the question of who’s responsible,” says Maltsberger. “If there’s any blame to be assigned, it would be on the person who brought the patient into that plight in the first place. That might be the patient, the patient’s parents, or it might be God. Who knows? But it isn’t the poor therapist!” In forty-five years of practice Maltsberger has never had a suicide. Doesn’t that make him nervous? “All the time,” he says quickly. “But at this stage of the game if a patient of mine did away with himself, I would be very sad, but any self-reproach would have to do with how well I applied my art. It’s like surgery. If you operate on somebody and you don’t make any mistakes, and you tie off all the bleeders and the patient doesn’t make it, it’s sad, but that’s probably the way the ball bounces.”
“I had a patient a couple of years ago who dropped out of treatment to go back to school, but he continued to come in periodically,” says Ari Kiev. “One night I got a message that he’d called at nine. I called back at ten, and whoever answered said he was asleep.” Kiev speaks slowly. “Next day his girlfriend called me and said she hadn’t been able to locate him. She’d tried at home and nobody had answered. I put two and two together and called 911. They went up there and he was dead. He’d gotten drunk and taken an overdose. So I was having second thoughts—since it wasn’t like him to call me, maybe I should have acted on the call and insisted that whoever answered the phone wake him up, which is when I would have found he couldn’t be wakened and called the police.” He riffles through the appointment calendar on his desk. “I don’t think I’m responsible, but you feel responsible. . . . I can answer these things from the point of view of the psychiatrist’s way of BS-ing the world and BS-ing himself—‘It’s the patient’s responsibility’—but you’re caught up with people, and it’s not as easy as all that.”
Certainly, some suicides may be resistant to any intervention. In a study of schizophrenic hospital patients, Shneidman and Farberow describe a man who received psychotherapy but remained acutely suicidal. He was given a steady barrage of electroshock treatments for several years, but he repeatedly tried to hang himself. He was given a lobotomy. He was calmer, but remained suicidal. One day, despite the vigilance of hospital staff, he finally succeeded in hanging himself.
Amid a glossary of possible techniques, clinicians sometimes overlook simpler approaches. “I had a slasher my first year in the hospital,” recalls one psychiatrist. “She kept cutting herself to ribbons—with glass, wire, anything she could get her hands on. Nobody could stop her. The nurses were very angry. They hate these patients, and they get very angry at the resident whose patient it is. I didn’t know what to do, but I was getting very upset. So I went to the director and in my best Harvard Medical School manner began in a very intellectual way to describe the case. To my horror I couldn’t go on but began to weep. I couldn’t stop. He said, ‘If you showed the patient what you showed me, I think she’d know you cared.’ So I did. I told her that I cared, that it was distressing to me. She stopped. It was a very important lesson.”
Psychiatrists may be the bottom line for suicide care, but the ascendancy of HMOs and the proliferation of SSRIs have made it likely that most depressed and suicidal patients will never see a psychiatrist—or any other mental health professional. Between 50 and 75 percent of those seeking help for a psychiatric disorder are treated in a primary care setting; up to 10 percent of primary care patients suffer from major depression. Yet general practitioners, who are thus best positioned to help suicidal patients, are perhaps least prepared. Medical education is dominated by illnesses of the body, and the mind is relegated to a few lectures in psychology plus a four-to-six-week psychiatric rotation. Commenting on his 1997 survey, which found that fewer than half of primary-care-physician-training programs collaborated with departments of psychiatry—and that those that did, didn’t collaborate much—former APA president Jerry Wiener suggested that the current position of GPs as the frontline providers of psychiatric care “leaves them in the role of the emperor who rides naked through the streets while managed-care and cost-cutting health-policy gurus ask that we admire the emperor’s new clothes.” In another survey, 3,375 primary care physicians reported widespread lack of knowledge about the diagnosis and treatment of depression—which may help explain why more than half of patients with depression seen by primary care physicians are misdiagnosed. (NIMH data suggest that as many as 30 percent of people who walk into a general practitioner’s office use physical complaints as a smoke screen for depression and other mental health problems and that GPs miss 90 percent of those cases.) Even when depression is accurately diagnosed, the majority of patients are undermedicated, receive inadequate follow-up, and often fail to be given appropriate medication adjustment. Depressed children may be most at risk; a survey of pediatricians and family physicians found that 72 percent had prescribed SSRIs for a child or adolescent, yet only 8 percent felt they had received sufficient training in treating youthful depression.
If few GPs are equipped to diagnose and treat depression, fewer still are equipped to assess and treat suicidal patients. The knowledge base has no doubt improved since 1967, when a survey of Philadelphia medical schools found that half the students believed that if a person talks about suicide, he will not commit it. (Half also believed that masturbation frequently causes mental illness; it is not clear whether this was the same half.) Yet in a recent poll reported in the Journal of the American Medical Association, 91 percent of physicians felt their knowledge of suicide assessment and treatment techniques was inadequate. One-third of people who kill themselves see a primary care provider in the week before their suicide; more than half in the month before, and nearly 75 percent in the previous year. “Many people go to physicians hoping to be asked about suicide,” says psychiatrist Alan Stone. They’re not likely to be. A 2000 study found that many physicians still believe the old canard—that if they ask a patient about suicide, it will plant the idea in his head. This may be why only slightly more than half of primary care physicians directly question patients about suicide during routine depression evaluation. Although the 2001 Academy of Sciences Report recommended that medical and nursing schools incorporate the study of suicidal behavior into their curricula, there is institutional reluctance. “We don’t pay enough attention to psychiatric aspects of medical education, so I welcome anything in that direction,” says psychiatrist Leon Eisenberg. “But specifically for suicide?” He shrugs. “We don’t even teach our medical students how to deal with stress in themselves.” Even if GPs had the training to assess suicidality, few have the time; the average visit to a primary care physician lasts 16.3 minutes, during which patients bring an average of six problems to discuss. “The worst thing about HMOs is that there’s no longer any time to spend with the patient,” says a GP with thirty years’ experience. “The drugs came along and really worked, but they’re so easy to abuse—a patient comes in depressed, and when you look out and see fifteen or twenty people in the waiting room, you don’t have time to do anything other than toss prescriptions at the fellow.”
Among the most difficult decisions for any medical professional, whether psychiatrist or family physician, is whether to hospitalize when a patient is, as Ari Kiev puts it, “hot.” Increasing attention to patients’ civil rights has barbwired the issue; a clinician may be sued for putting a patient into the hospital or for keeping him out. “People often send people to hospitals not because they think they’ll do better there but because they’re afraid there will be a suicide for which they’ll be held responsible,” says Hendin. Such buck-passing is based on the belief that the hospital, where access to potential tools of self-destruction is limited, is the safest place for suicidal patients. “We tend to think we’ve solved the problem by getting the person into the hospital,” says Norman Farberow, “but psychiatric hospitals have a suicide rate more than five times greater than in the community.” (They are, admittedly, working with a high-risk group; the majority of inpatients are admitted because they have threatened or attempted suicide.) While acknowledging that hospitalization may be the only answer to a severe suicidal crisis, Farberow calls it “an expensive, frequently crippling, stultifying experience.” In the opinion of some psychiatrists, the hospital may literally be the last resort. “I rarely put suicidal patients in the hospital anymore,” says Maltsberger. “People need the hospital when they have nothing else to sustain them. If they can get a good therapist without going in, they’re better off. The hospital is the absolute end of the line.”
Certainly, even at the finest hospitals and despite the most stringent controls, patients find ways to kill themselves. Some 5 percent of all suicides take place in mental hospitals, nearly half of them within a week of admission. David Reynolds, an anthropologist who entered a California VA hospital under an assumed name and condition found “hundreds of ways”—nails; windows; razors; plastic bags; broken glass; high places; coat hangers; tonguing and accumulating pills; stuffing toilet paper down one’s throat; even clogging a sink, filling it with water, then banging one’s head against a faucet until, unconscious, one drowns. In a study of hospitalized patients who had completed suicide, more than 40 percent had been on fifteen-minute “checks” at the time of their death. Paradoxically, some in-hospital suicides may be a sign of a healthy environment; an exceedingly low rate of suicide in a hospital may mean restrictive measures are excessive. “Very often hospitals are dominated by the same mentality that may have brought the patient there in the first place,” says Hendin. “They don’t want to be blamed for a suicide, so they devote their efforts to monitoring the patient—preventing and controlling.” There is little evidence that seclusion rooms, surveillance cameras, twenty-four-hour observation, or removal of “sharps” and other ingredients of “suicide watch” are effective. Half of all suicides at Metropolitan State Hospital in Norwalk, California, over forty-two years took place in seclusion rooms. In fact, a study attributing a decline in suicides at Baltimore’s Sheppard Pratt Hospital to a decrease in such measures concluded that protective restrictions may increase suicide by calling attention to it. Susanna Kaysen, whose memoir, Girl, Interrupted, describes her stay at McLean Hospital, told me that after months of unshaven legs and plastic spoons, “people started thinking about committing suicide because the hospital makes such a big deal about keeping people from committing suicide.” Hendin shakes his head: “That’s what the problem is! Suicidal people are into control, the hospitals are into control, and it becomes a power struggle in which no therapy can take place.”
Therapy may not be the most important service a hospital can offer a suicidal patient. When William Styron, suffering from depression and beset by suicidal thoughts that seemed only to be exacerbated by the medication his psychiatrist prescribed, inquired “rather hesitantly” about hospitalization, his psychiatrist said he should avoid it “at all costs,” because of the stigma. When his condition worsened, however, Styron was admitted. Although he scorned the therapeutic agenda—group therapy was “a way to occupy the hours”; art therapy was “organized infantilism”—Styron believes that the hospital saved his life.
. . . it is something of a paradox that in this austere place with its locked and wired doors and desolate green hallways—ambulances screeching night and day ten floors below—I found the repose, the assuagement of the tempest in my brain, that I was unable to find in my quiet farmhouse.
This is partly the result of sequestration, of safety, of being removed to a world in which the urge to pick up a knife and plunge it into one’s own breast disappears in the newfound knowledge, quickly apparent even to the depressive’s fuzzy brain, that the knife with which he is attempting to cut his dreadful Swiss steak is bendable plastic. But the hospital also offers the mild, oddly gratifying trauma of sudden stabilization—a transfer out of the too familar surroundings of home, where all is anxiety and discord, into an orderly and benign detention where one’s only duty is to try to get well. For me the real healers were seclusion and time.
Time, however, is a luxury that few patients can afford. Styron was fortunate in being able to finance a seven-week stay in one of the best psychiatric facilities in the country. Most insurance policies cover only five days of inpatient care—down from thirty in the late eighties, ninety in the late sixties—hardly long enough to get started on a course of medication, let alone in-depth psychotherapy. (Medications are the primary—and, often, only—form of treatment in psychiatric hospitals today.) Hospitals across the country are under increasing pressure from insurance companies to make patient stays shorter, and under pressure from all sides to get patients “cured,” or at least functioning, before their coverage runs out. (The American Psychiatric Association boasts that most hospitals “begin planning for discharge on the first day of admission.”) Over the last several decades, with growing reliance on drug therapy and increased pressure to cut costs, the average psychiatric hospital stay has dwindled to twelve days. At private hospitals like Styron’s—of which there are not many left—inpatient treatment can run more than $1,000 a day, a rate at which extended care is available only to a select group. The alternative is a state hospital, where levels of staffing, training, funding, and treatment are far lower, making it “extremely difficult for state hospital staff to provide a true rehabilitative program to their patients,” according to psychiatrist Robert Okin. “Moreover, these conditions lead staff to conclude that they are neither expected nor required to do much more than provide a safe place for patients to spend their time.”
Today, even a “safe place” for patients to spend their time is difficult to obtain. When advances in psychopharmacology, press exposés of state hospital “snake pits,” and the Community Mental Health Centers Act of 1963 led to deinstitutionalization in the late sixties, the move was applauded as a reform in the tradition of Pinel striking off the chains at Bicêtre two centuries earlier. Beyond the great expectations, however, there was little planning. Thousands of patients were discharged annually to community facilities that were inadequate or nonexistent. The state hospital population plummeted from 558,600 in 1955 to 54,000 in 2000, setting adrift a flood of mentally ill people to fend for themselves amid a patchwork quilt of services that had neither the time, training, nor funds to cope with them. Many of the deinstitutionalized ended up wandering the city streets. Experts estimate the number of America’s homeless to be as high as 3.5 million—as many as 35 percent of whom suffer from untreated psychiatric illness. Many others ended up in prison, having committed petty crimes, acted threateningly, or just caused trouble once too often. Some 250,000 mentally ill Americans live behind bars—78 percent more than a decade ago and nearly five times the number in state psychiatric hospitals.
There has been no research on the effect of deinstitutionalization on suicide, but while state hospitals are crying out for qualified therapists (who can make three times more money in private practice), patients are crying to get in. “These days it’s easier to get admitted to Harvard than into the state hospital,” observes one psychiatrist. In most states, a person must be judged to be at risk of doing “serious harm to himself or to others”—homicidal or suicidal. But admission is often decided on the basis of bed availability rather than need. “They take only the most violent, the most psychotic,” fumes a community mental health center director in New York City who admits he has coached suicidal patients on how to act sufficiently disturbed when they present at a hospital. Suicide ideation no longer guarantees admission; people commonly attempt suicide to get in. Even then they may be refused. Investigating the suicide of a Los Angeles woman, a social worker learned that on the last day of her life she had tried to commit herself into three large hospitals with psychiatric units. She was turned away at all three. That night she killed herself.
Even if a person manages to get into a public psychiatric hospital, stringent admission standards have changed the hospital milieu. “You used to be able to send a depressed patient to the hospital for R and R,” says an Oakland therapist. “Now people in the hospital are very crazy, and if you are able to get hospitalized, you’re surrounded by psychotic patients. It can be very scary.” If a patient isn’t “crazy” enough, the hospital isn’t apt to let him remain. “You get into unfortunate situations because the state hospitals often don’t keep people who are suicidal unless they are incredibly suicidal,” says Stanford University psychiatrist Alan Schatzberg, who worked at McLean Hospital for nearly twenty years. “It becomes a kind of dangerous game of chicken.”
The patient is usually the loser. Repeated studies have shown that the suicide rate jumps in the weeks immediately after patients leave the relative safety of the hospital and return to the stressed environment they’d left, frequently without provision for follow-up care, and with the increased likelihood that they will stop taking their medications. “Often caught in the dilemma of being too well to be in the hospital but not well enough to deal with the realities and stresses of life outside, as well as having to contend with the personal and economic consequences of having a serious mental illness, patients sometimes feel utterly hopeless and overwhelmed, and kill themselves,” writes Kay Jamison in Night Falls Fast. Yet something as seemingly trivial as a piece of mail may help. A study by San Francisco psychiatrist Jerome Motto and epidemiologist Alan Bostrom of 843 suicidal people who refused follow-up treatment after discharge found that sending them regular letters expressing concern—as simple as “we hope things are going well for you”—resulted in a lower rate of completed suicide.
With treatment decisions increasingly based on legal or financial considerations rather than on patient need, the suicidal person is caught in the middle. At a time when the percentage of mentally ill people in this country has swollen, according to NIMH estimates, it is increasingly difficult for them to get care. The inability of the mental health system to cope with the demand has led to a practice that seems an unsettling symptom, as it were, of an underlying illness in the system. In the past several decades, more than a few overcrowded clinics and hospitals, frustrated by a particularly troublesome patient, have bought him a ticket and put him on a bus bound for a distant city, where he arrived homeless, friendless, and alone. “Greyhound therapy,” as it has been dubbed, seems a chilling end point to the humanism that, in part, inspired deinstitutionalization. It makes one wonder how far, despite our 250 different psychotherapies and our armamentarium of wonder drugs, we have come since the medieval days when townspeople loaded irksome madmen onto a boat and shipped them downriver in what became known as a ship of fools.
Because so much emphasis has been put on psychotherapists and dispensers of medications, it is easy to forget that suicide prevention has long had another genre of gatekeeper: the clergy. Modern suicide prevention programs were originated by religious groups, but despite strong evidence that religion plays a protective factor, with the medicalization of mental illness suicide has been secularized and the clergy’s role consequently underestimated and ambiguous. Studies say that 50 to 80 percent of people with mental health problems come first to the clergy. “Often the clergy are not aware of the problem and pass it off,” says Monsignor James Cassidy. “Most clergymen don’t realize their limitations and the importance of getting professional help.” Earl Grollman, a rabbi in Belmont, Massachusetts, and the author of numerous books on death and suicide, says, “I have to laugh when I read Ann Landers telling suicidal people to ‘speak to your clergyperson.’ There might be three people in all of greater Boston that I consider to be knowledgeable in this field. Clergypeople feel they have to give a religious orientation, not understanding that prevention consists of listening, caring, and touching.” Grollman pauses. “There’s a story told about Martin Buber. He is praying when someone knocks at the door and says, ‘Can I see you?’ Martin Buber says, ‘I’m busy. Come back later.’ The person never comes back—he commits suicide. And Martin Buber says, ‘Here I had a chance to be with God, but I lost God in prayer.’”
“I don’t think doctors appreciate the role of the pastor in counseling,” the Reverend Robert Utter of the Church of the Nazarene in Cambridge told me. “But that may be changing. They’ve come to realize we’re available every hour of the night or day, and we don’t charge a fee.” For the parishioner in crisis Utter prescribes a list of scriptures, extra prayer, perhaps an outing with the church singles group, and in emergencies the counseling center at nearby Eastern Nazarene College. “We believe in hell, so our people would think twice before taking their life,” says Utter. “There is an expression I use when counseling people who talk about suicide. I tell them, ‘You think you have problems now; wait until you end up in hell. You’ll just be out of the frying pan and into the fire.’” Prescribing the Bible rather than antidepressants can be a risky therapeutic approach. In 1980, a California church and its pastor were sued by the parents of a twenty-four-year-old man, in the first prominent clergy-malpractice lawsuit. After a previous suicide attempt, Kenneth Nally had been in pastoral counseling with the Reverend John MacArthur Jr. of Grace Community Church of the Valley, who referred to suicide as “one of the ways that the Lord takes home a disobedient believer.” Nally shot himself. Although Nally had been seen by several physicians and a psychiatrist, his parents claimed that MacArthur had tried to dissuade their son from seeking secular help and had made his condition worse by telling him that his depression was the result of his sinning.
Although the $1 million suit was eventually dismissed by the California Supreme Court in 1988, which ruled that as “non-therapist counselors,” the clergy had no legal duty to save lives, it underlined that in their response to suicide, clergy are often torn between viewing the person as a patient and viewing him as a parishioner. Religion and psychiatry work in an uneasy truce, as if psychological and spiritual dimensions inhabited different halves of the person. While counseling in the emergency room of the Cambridge Hospital, psychologist Nancy Kehoe, who is also a nun, realized that religion never came up in patient assessments. Kehoe sent a questionnaire to local clinics and found that of fourteen hundred suicidal cases, religion was broached in fewer than three hundred, more often than not by the patient. “In the face of suicide, which is a person’s ultimate statement about life and death, why do we separate mental health and belief?” asks Kehoe. Clinicians have found numerous reasons to do so. “Many of them were taught that science and psychology should be separate from religion,” says Kehoe. “Some are very uncomfortable with the subject. Others don’t know what to ask beyond ‘Are you Protestant, Jewish, or Catholic?’” Kehoe’s definition goes beyond what she calls “God talk”; it means thinking about a person’s spiritual life as part of the total picture. “Then when a person is talking about suicide, it’s natural to say, ‘What do you think you’re going toward? What kind of spiritual things keep you going?’” Clinicians in Kehoe’s study who did bring up religion found it useful. Says Kehoe, “Some even felt that if a person had lost faith, it was an indicator of suicidal risk.” (One wrote, “Highly religious people do not commit suicide.”) She sighs. “All I’m asking is whether we’d learn something about a person if we brought up his spiritual beliefs, without judging whether or not it’s going to save lives.”
Kehoe’s findings are troubling. If suicide is purely a biological and psychological problem, then treatment is clearly the undisputed province of the physicians and mental health professionals. But the strands that combine to prevent a suicide are as numerous as those that combine to push someone to suicide. In the twenty-first-century perspective of suicide from the medical model, we risk excluding not only the religious or spiritual dimension of self-destruction, as Kehoe points out, but the social and existential dimensions as well. “Suicide can best be understood in terms of concepts from several points of view,” wrote Edwin Shneidman in Definition of Suicide. “It follows that treatment of a suicidal individual should reflect the learnings from these same several disciplines.” Shneidman suggested that optimum treatment might be effected by a “Therapeutic Council.” “Such a council would be concerned with the biological, sociological, developmental, philosophical, and cognitive aspects of its patients. It might include a biologically oriented psychiatrist, a psychoanalytically oriented therapist, a sociologist, a logician-philosopher, a marriage and family counselor, and an existential social worker.” While Shneidman’s proposal is, of course, impractical, the concept is sound. If suicide is caused by a variety of factors, suicide prevention should address each of those elements.
Even further, true suicide prevention might address the problem before people reach the point of crisis, before they call the hotline or appear in the emergency room. While not thought of primarily as suicide prevention measures, there are many steps that might help reduce the suicide rate: further developing our understanding of alcoholism, depression, and schizophrenia; routine screening for problem drinking in all patients; tackling such societal ills as unemployment, divorce, homelessness, violence, inadequate education, unwanted children, and neglect of the elderly; improving medical and social services and making them accessible and affordable to all; finding ways to promote ethical and spiritual values; and reducing the threat of terrorism. In short, one might lower the suicide rate by giving people more reasons to stay alive. Years ago psychologist Pam Cantor appeared on the television news show Nightline to discuss the causes of suicide. At the end of the program, host Ted Koppel said, “All right, we have half a minute left. You’ve described the litany of ills that exist. Is there anything that can be done short of changing our society inside out?” “Well, I don’t think you should say ‘short of,’” answered Cantor. “I think that’s what’s necessary.”