Psychache

June 3, 2001

By Thomas Curwen

Every 17 Minutes, Someone in This Country Commits Suicide. But Opinions on Why there's an Epidemic of Self-Inflicted Death – and how to stop it – Often Conflict.

"Man is the only animal who has to be encouraged to live." Friedrich Nietzsche

1. WHO KILLED HILDA?
Sometimes when I'm in a dark mood, I wonder: If I were to kill myself, would I fall into the flames of hell? Or should someone else burn for this crime against life: the friends who failed me, the society that offered no solace, the God who erred in designing my brain, or DNA?

Like hundreds of thousands of people who have confronted suicide, I wrestle with damnation. But only to avoid a question that is at once more haunting, more difficult and more practical: What could have been done? In my case, what could have been done to stop my friend Hilda Sheryll Barrett as she, at age 36, walked into the garage and sat on an old sofa with a gun in her hands?

We were close – Hilda, her husband, Jim, my wife and I. Jim was at work when Hilda raised the only unlocked gun in their home and pulled the trigger. He found her that night. My wife went over to help clean up. There was a memorial and a yard sale, and for months I believed that her death was none of my business, that I had no right to judge so personal an act. I mourned her and respected her choice without realizing that in the world of suicide, the mere use of a word such as "choice" sets off fierce debate. In the 15 years since Hilda killed herself, I've become a student of the subject. I've learned that someone in the United States kills him- or herself every 17 minutes, for a total of 85 a day, almost 31,000 a year. I've learned that you who are reading this story are more likely to kill yourself than be killed by someone else, that the suicide rate for young people has tripled in the past four decades, that the relentless suicide toll of young men alone dwarfs the number of deaths from the Vietnam War and AIDS combined. I've also discovered an invisible city of doctors, scientists, researchers and families who've lost someone to suicide, all obsessed with why people kill themselves and what can be done to stop them. They believe they have answers and that their answers can save lives. But distinguished opinions about suicide rarely converge, and recommended interventions often conflict – stemming, as they do, from opposing views of human nature.

Take Hilda. Did she die because her brain malfunctioned, twisting some internal knob that dimmed her will to live? Or did her actions that spring day have more to do with a dark turn in her life?

I've never seriously considered killing myself. Yet when the details of Hilda's story finally came to light, they jolted me with such force that people who don't know me – who don't understand the complex subject at hand – might well have wondered whether I, too, would become suicidal.

2. THE DEAN OF SELF-INFLICTED DEATH

Suicidology, the study of suicide, began 43 years ago in the land of sunshine and second chances. Edwin Shneidman, who coined the term, is 83 now. He remains the dean of the discipline, as committed as ever to saving lives, though his approach is being overwhelmed by newer, if less personal, ways of looking at suicide.

When he greeted me at the door of his small West Los Angeles home early last year, Hilda had been dead for more than a decade, and I had stopped pretending that her death was none of my business. Round-faced and bald but for a hint of curly hair at his collar, Shneidman has a confident and gentle demeanor. His mind is quick and playful. He is an easy man to like and to trust.

His wife, Jeanne, was at the market when I arrived. He and I sat on the patio with cookies and coffee. As a Mozart piano concerto played in the background, I asked him how he could live his whole life with questions of suicide so close at hand. His answer was his story.

The son of Russian Jewish immigrants, he had grown up in Lincoln Heights, earned a master's in psychology from UCLA, served as a classification officer for the Army during World War II and received his doctorate from USC. By 1949 he was a 31-year-old clinical psychologist, on staff at the VA Hospital in Brentwood.

One day the director of the hospital approached him. He needed two letters written. Two patients had killed themselves, and he wanted to extend his sympathy to their wives. Shneidman didn't know James Caldwell and Timothy Jones, yet he knew they deserved more than a form letter. He took the next morning off. A light rain was falling as he turned east on Wilshire Boulevard, heading downtown to the coroner's office. The end of the 1940s might as well have been the start of the dark ages when it came to the study of suicide.

The records were kept in a basement beneath a parking garage. Shneidman still remembers the smell of oil and gasoline. And the dust. It was everywhere.

"Caldwell" and "Jones" were two files among thousands in the bunker-like room. The victims were young, married and had served their country during the war. They had little else in common, other than that something, somehow had stopped making sense in their lives. And one other detail: One file contained a suicide note, the other didn't.

As Shneidman gazed up at the thousands of files surrounding him, a half-century of the city's dead, he felt his cheeks flush. There had to be more suicides here, some with notes, some without. If you were to study the notes, what would you learn, he wondered? Shneidman gave me a smile. "I felt like a cowpoke who, wandering home drunk on a dark night, stumbles into a pool of oil and is just sober enough to realize he has found his fortune," he said.

Shneidman recruited a young psychologist, Norman Farberow, and within a few months these two men in white shirts and narrow black ties had more than 700 notes, copied from the coroner's files. But they didn't read the notes. Instead, for the purposes of the study, they commissioned an equal number of fake notes written by volunteers from unions and fraternal organizations. When they put the two sets side by side, the contrast was stunning.

The fake notes were rife with drama and melancholy; the real notes were remarkably banal. Here were attempts to settle the most ordinary aspects of life – a car washed, the laundry picked up – as if there was regret, however tacit, in leaving. "Dear Mary," read one note, "I hate you. Love, George." The discovery of this ambivalence toward dying was revolutionary. It suggested that suicide is less a decision than a reaction. Learn what is being reacted to, then suggest an alternative, and you may have an opportunity to interrupt the suicidal impulse. This became the basis of Shneidman's approach to saving lives.

Suicidology became Shneidman's passion, and he has pursued it as a psychologist, professor and author. In 1974, his "Deaths of Man" was nominated for the National Book Award in science. His latest book, "Comprehending Suicide: Landmarks in Twentieth Century Suicidology," has just been released. It is likely he knows more about the mystery of self-destruction than anyone – which is why I, like most people curious about the phenomenon, turned to him.

A few years after Hilda's death, years before I met Shneidman, I had called the coroner's office asking for documents, thinking I might find some clues about what she had been feeling that morning. A few days later I received the death certificate. It read: "Avulsion of brain. Gunshot wound, head, through mouth." To read the suicide note she had left on the dining room table, I would need the family's permission. By then I knew that wasn't going to happen.

*

3. TO BE OR NOT?
"There is but one truly serious philosophical problem," wrote Camus, "and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy." If the goal of music, literature and art is to help us live, then suicide is a quick end run, eluding all considerations.

*

. . . I took my time, I hurried up
The choice was mine, I didn't think enough
I am too depressed to go on
You'll all be sorry when I'm gone . . .

Greg Barnes cued this song, sung by the band Blink 182, on his CD player and set it up to play over and over again in his garage. He was 17, a student from Columbine High School in Colorado. It was a year after the infamous rampage. While the song played, he fashioned a noose and hanged himself. Listen to the lyrics, read about the dead boy, slip more deeply into the mystery of why suicide happens.

Western civilization has a long tradition of viewing self-destruction as a moral and mental failing. "No man may inflict death upon himself at will, merely to escape from temporal difficulties," St. Augustine wrote in "The City of God." Soon civil and ecclesiastical authorities branded it a sin and a crime. Corpses of suicides were publicly displayed, property confiscated, exorcisms performed. Sermons promised eternal damnation. Some clerics recommended hanging those who attempted suicide. Back then, the devil caused suicide.

One hundred years ago, it was society. More recently, it was the unconscious mind. Today it is mental illness.

Few people I have encountered talk about suicide with the intelligence and compassion of Kay Redfield Jamison. Perhaps this is because she has manic depression and tried to commit suicide herself. In her book, "Night Falls Fast: Understanding Suicide," the professor of psychiatry at the Johns Hopkins University School of Medicine wants to shift the way we think about suicide toward a biochemical consideration of the behavior. "Most people who suffer from depression, manic-depressive illness, alcoholism, or schizophrenia do not kill themselves," she writes, "but a vastly disproportionate number of them do."

I first met Jamison at a suicide prevention conference in Reno. Beyond the din of slot machines and screaming dice players, in the state with the country's highest suicide rate, she and other experts had gathered to consider the societal implications of self-destruction. Most of the sessions focused on numbers and demographics, but Jamison's was filled with easy references to Robert Lowell, Lord Byron and the late Victorian poet Gerald Manley Hopkins.

"The absolute agony of what leads up to the decision to kill yourself is incomprehensible for most people," she says. "Even people who have terminal cancer don't commit suicide." Yet, while acknowledging that the causes of suicide are complex, Jamison has less faith in talking cures than in genetics, neurobiology and psychopharmacology.

When I mentioned the reason for my interest, she warned: "We can't be caught in the romanticization of the individual when it comes to saving lives." The particulars of someone's death may be more interesting than "statistical findings obtained from coroner's reports or DNA gels," but stats and hard science are more effective weapons against the epidemic.

Physicians have long searched for the magical elixir that might ease the suicidal impulse. In the 19th century, treatments included bloodletting, cold-water plunges and drafts of mercury, quinine and opium. In the 20th century, these interventions went out of favor as psychoanalysis came in. In the 1970s, researchers began to identify a link between behavior and the activity of neurotransmitters in the brain. By the early 1980s, researchers discovered that serotonin, a chemical that helps conduct nerve impulses in the brain, occurs in lower than normal levels in the depressed and the aggressive. In December 1986, Eli Lilly and Co. began marketing Prozac, a drug that allows for more serotonin to be available to the brain. Other companies followed with their own Selective Serotonin Reuptake Inhibitors, which have proven effective in treating depression, the most common illness leading to suicide. By the mid-1990s, America was a nation defined by a white and green capsule.

The world of suicide prevention has become a numbers game – 31,000 suicides a year – so it is quite promising to find a single cause, mental illness, lying behind each death. It means that suicide might be more simple than anyone might have imagined – philosophers and poets be damned. So, perhaps this was it. Hilda, as we all well knew, had suffered from manic depression. Could a pill have saved her?

*

4. PSYCHACHE
To swallow a mood-altering pill is to confront a fundamental question: Where does the physical brain stop and the conscious mind begin? Not knowing will forever entangle psychopharmacology and philosophy – medical progress be damned. Studying the dead brain may be easier than peering into the living soul, but how can you pursue one without considering the other?

Poet Anne Sexton's "Wanting to Die" offers a glimpse of the suicidal mind:
Since you ask, most days I cannot remember.
I walk in my clothing, unmarked by that voyage.
Then the almost unnameable lust returns.

*

Even then I have nothing against life.
I know well the grass blades you mention,
the furniture you have placed under the sun.

*

But suicides have a special language.
Like carpenters they want to know which tools.
They never ask why build . . . .

*

Sexton, who suffered from depression most of her life, attempted suicide several times and died of self-administered carbon monoxide poisoning in 1974. Her tenacity, perhaps the grimmest characteristic of many suicides, points to a historic tension: Individual rights versus compassionate intervention. "Dying voluntarily is a choice intrinsic to human existence," writes psychiatrist-libertarian Thomas Szasz. "It is our ultimate, fatal freedom." To which Shneidman responds: "I want to prevent those people who are preventable, and I want to reserve the right to commit suicide for myself. But it is just decency, civilized decency, to throw one's efforts and one's yearning on the side of life."

And so it was that one morning in 1958 a black telephone with a rotary dial started to ring on the fourth floor of an abandoned tuberculosis hospital on the grounds of the Los Angeles County General Hospital.

The phone, a suicide crisis line, was Shneidman and Farberow's idea and the culmination of nearly 10 years of studying suicide. It was the first of its kind in the country. Within six years of researching the deaths of Caldwell and Jones, Shneidman and the fledging L.A. Suicide Prevention Center received the first of three grants from the National Institute of Mental Health that would last almost 15 years. The work of Shneidman, Farberow and their colleagues gained national attention when the center performed a "psychological autopsy" on Marilyn Monroe and determined that her death was a suicide. Farberow continued on to a distinguished career and remains active in suicide prevention. Shneidman founded the American Assn. of Suicidology. He became a professor at UCLA. He wrote the "suicide" entry for the Encyclopedia Britannica. His tenacity has never waned.

"Suicide is a complex malaise," he says. "Sociologists have shown that suicide rates vary with factors like war and unemployment; psychoanalysts argue that it is rage toward a loved one that is directed inward; psychiatrists see it as a biochemical imbalance. No one approach holds the answer: It's all that and much more."

Early on, Shneidman came to see pain, not mental illness, as the most common denominator for all preventable suicide. He even coined a term for the shame, guilt, fear, anxiety, loneliness, dread of growing old or of dying badly that a suicidal person might feel: "Psychache." Treat the psychache, Shneidman says, and you'll treat the suicidal impulse. "For me, today, the central data to elicit from a potentially suicidal person are not a family history, a spinal tap assay, a demographic accounting or a psychoanalytical session," he says. Rather, his approach is to listen closely while asking a patient two basic questions: "Where do you hurt?" and "How may I help you?"

While not opposed to drug therapies, Shneidman thinks the so-called biologicalization of suicide is simplistic. It treats the symptoms, not the disorder. It's fine to look inward at arcing synapses, but don't ignore the external connections: religion, family, work. If a healthy person is hurt when these connections fray, is this unraveling any less devastating for someone with a mental illness? And how does biology explain that suicide hits hardest those whom society shows the least respect: young black men, teenagers, gays and lesbians, Native Americans, elderly white men?

"Suicide is not a disease," Shneidman says. "It is not like a stomachache or a headache or some special physiological state. Each suicide is sui generis. Its reasons, like the mind itself, cannot be categorized. Clinical labels are specious, and to build a profession on them is to put a skyscraper on sandy soil."

After our conversation that afternoon on his patio, Shneidman invited me inside. Slowed by a slipped disc, he shuffled along, his mind happily outracing his stride, and led me into a small bedroom where he works and reads, surrounded by his twin devotions: suicide and Herman Melville.

The two, he said, are more compatible than most might think. He read aloud the first paragraph of "Moby Dick": "Whenever I find myself growing grim about the mouth; whenever it is a damp, drizzly November in my soul . . . I account it high time to get to sea as soon as I can. This is my substitute for pistol and ball. . . ."

This great American novel, he said, is all about suicide.

Maybe all stories have suicide lurking beneath the surface.

Four months after Hilda's death, my wife announced that she was leaving me. The room grew quiet. It took her a minute or two to say that she was moving in with our friend, Jim, Hilda's husband. They had fallen in love months before Hilda killed herself.

5. Of Hotlines and Hell
It is said the eyes are the windows of the soul. At a suicide prevention center, it is the voice. Twelve years after Hilda's death, I started volunteering at a center and listening to the voices, the most pained, hysterical, lost voices I have ever heard: the bereaved mother, the broken-hearted teenager, the shut-in slowly dying of AIDS.

The average call takes about 30 minutes, and the process is like loosening a tight knot. First you establish rapport. Then you gather information, determining the cause of the crisis, assessing its severity and asking questions: "Are you going to kill yourself?" "Do you have a plan for killing yourself?"

Then you listen. You listen and try to explore an alternative to dying that will work, if not for the month or the week ahead, then for the next minute or two. And no matter how slow or frustrating the process, you follow each story wherever it leads, and you work your way back to the sources of the pain, sometimes more than once. The work is no less urgent than that done in an emergency room, only here the bleeding is emotional, the pain psychic. This is where the desperate come to stop, if only temporarily, their dying.

Struck by the success of the Los Angeles Suicide Prevention Center (now called the Suicide Prevention Center of Didi Hirsch Community Mental Health Center), the National Institute of Mental Health invited Shneidman in 1965 to develop a national suicide prevention strategy. When he arrived at institute headquarters in Bethesda, Md., there were 15 crisis centers in the country. In 1966 there were 47, and by the time he left three years later, there were more than 100. But his success was short-lived. In 1969, he accepted an invitation to teach at Harvard, and within two years, the federal government was reallocating the funds he had worked so hard to secure. Some blame his successor at the institute, others blame the nation's changing social climate. Either way, after spending more than $10 million on suicide prevention over 10 years, the government pulled the plug, and local clinics were left to find alternative funding.

The good news is that official interest in suicide prevention is cyclical, and after nearly 20 years of barely being noticed, the death count is again capturing national attention. Three years ago, the U.S. Senate and the House passed resolutions recognizing suicide as a national problem. The Centers for Disease Control is in the midst of funding a three-year study in the Western United States, where suicide rates are the highest in the country, and in California, the Legislature is considering a $3-million bill (SB 620) that would inaugurate a suicide prevention strategy with a special focus on young people. And last month, U.S. Surgeon General David Satcher announced a national campaign that would enlist doctors, the clergy, teachers and insurance companies in the fight.

That's all encouraging. As Jamison, author of "Night Falls Fast," says: "What we do about suicide and mental illness tells us about who we are as a country. . . . "

The bad news is that America is still as queasy about suicide as it is about abortion, euthanasia and other issues where life, death and choice intersect. We put it in a box and we bury it with shame. And as long as we do, experts say, we will likely have an epidemic.

Last year, 43 years after Shneidman and Farberow started answering that black phone with the rotary dial, counselors at the Suicide Prevention Center answered more than 17,000 calls from suicidal people. Yet in recent years researchers have questioned whether the truly suicidal will pick up a phone at their moment of reckoning, and they have offered studies dating back to the 1970s that suggest hotlines don't really work. "Critics of crisis lines miss the point," says Shneidman. "They have limited the notion of effectiveness to the statistical reduction of suicide. I say there is more to it than that. Crisis lines facilitate communication between mental health agencies in an area, and they improve the mental health of the community. And, philosophically, they represent something very important: They represent a fight against nihilism and despair."

Today, even as some therapists acknowledge the wisdom of Shneidman's approach, his legacy is being eroded by a new faith in brain scans and pharmaceuticals.

The phones still ring, though, and I have come to believe the ensuing conversations are as necessary as prescribing drugs or, in the most severe cases, institutionalization.

On late summer afternoons the sun strikes the ficus trees along a Culver City street and fills the Suicide Prevention Center with a lambent green glow. Everything here seems unremarkable: the files stacked on a desk, the cubicles where the counselors take their calls, the table covered with fruit, cookies and the coffee maker. Outside a man waters his lawn, a couple steps into a church, teenagers study the catalog at an auto parts store. When the phone rings, the air grows charged. Idle conversations stop as the coordinator says, "I'll get you a counselor."

Sometimes, when I picked up the phone, I experienced a moment of confusion and I'd think I was listening to Hilda – so clearly did the sound and timbre of her voice continue to resonate in my mind. In the rushed cadences, the sharp edges, the interruptions of a stranger, I heard the voice of a friend whom we had all somehow failed and of the friend who had failed us.

Sometimes, after taking such a call, I would imagine talking to Hilda.

The questions I imagined asking came easily.

"Where do you hurt?" I would ask.

If she cried, it wasn't out of sadness but desperation. She worked the swing shift as an LVN at a convalescent hospital. Her husband recorded truck weights for a local trash company. They shared a small rented cottage in Seal Beach with their Australian shepherd, and her life was falling apart. Nothing was good anymore. She found herself swimming in darkness.

Some things I already knew.

I'm manic depressive – that's why we didn't have kids – only it's gotten much worse. When I was younger, I used to shoot heroin; then I kicked the habit. It's so hard to stay straight. I suppose I'm smoking too much, but who cares? I'll have a beer when I get home from work just to unwind; I'm trying hard. I'm really trying hard.

My doctor? He retired. And I'm scared to start with someone new. I'm sick of taking lithium; it's messed up my insides. Some days I can't sit still, I tear around the house as if there isn't enough for me to do. Today's different. I'm boiling inside but nothing makes sense anymore.

In those final weeks of Hilda's life, we were drifting, all of us. But we had refused to see that drifting, as if by seeing it, we would find ourselves farther apart. We never asked the hard questions that might have saved marriages or a life.

"Has anything happened in particular?" I ask now.

She falls silent.

If I were a good counselor, I'd know that even if she answered, it might not tell me what I wanted to know. In the strange algebra of suicide, discovering all the variables doesn't tell you "why?" But I'm not a good counselor; I'm too close to this caller's story. And so my next question is not to Hilda, but to God or the cosmos: Why do some of us rush our dying?

I've never been to Hilda's grave. I don't know how to contact any of her friends or her family. My past disappeared, and I have married again, and I am always mindful of what can go wrong so suddenly. Suicide lurks beneath the surface of every life. It occupies a secret, submerged world, as it does in "Moby Dick." We may think we understand it. We may see the symptoms: He'd been drinking for days; she'd been sad for weeks. We may see the clues: credit card debt, spurned love, a mental illness.

But each time we think we understand, we imply that suicide under such circumstances makes sense. It never does.

Perhaps the ancients were right. Suicide is caused by the devil.

Perhaps the Marxists were right. Its roots are in society.

Perhaps the Freudians were right. It lies in the psyche.

Perhaps the doctors are right. It's all in the brain.

Or maybe, as I've come to think, what we see in someone's suicide is a mirror of what we fear most in ourselves. How we answer the "why" says more about our fears than about the suicidal impulse. What we imagine to be the cause is only a window upon our own inability to tolerate and redress pain.

But if Shneidman is right – that each suicide is unique – then to fret about the devil, society, the psyche or the brain is really to shirk our responsibility.

What you or I can do – what I should have done with Hilda, perhaps – is to ask "Where do you hurt?" and "How may I help you?"

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WHERE TO GET HELP

National Suicide Hotline
1-800-SUICIDE (1-800-784-2433)

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NATIONAL RESOURCES INCLUDE:
American Assn. of Suicidology
4201 Connecticut Ave., N.W., Suite 408
Washington, D.C. 20008
(202) 237-2280
fax: (202) 237-2282
www.suicidology.org

*

American Foundation for Suicide Prevention
120 Wall St., 22nd Floor
New York, N.Y. 10005
(888) 333-2377 or (212) 363-3500
fax: (212) 363-6237
www.afsp.org

*

American Foundation for Suicide Prevention
Western Division
7974 Haven Ave., Suite 250
Rancho Cucamonga, Calif. 91730
(800) 344-0500

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Centers for Disease Control and Prevention
National Center for Injury Prevention
and Control
Division of Violence Prevention
Mailstop K60
4770 Buford Highway NE
Atlanta, Ga. 30341-3724
(770) 488-1506
http://www.cdc.gov/ncipc

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National Depressive and Manic-Depressive Assn.

730 N. Franklin St., Suite 501
Chicago, Ill. 60610-3526
(800) 826-3632 or (312) 642-0049
fax: (312) 642-7243
www.ndmda.org

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National Institute of Mental Health Suicide Research Consortium
NIMH Public Inquiries
6001 Executive Blvd., Room 8184, MSC 9663
Bethesda, Md. 20892-9663
(301) 443-4513
fax: (301) 443-4279
http://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml

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National Suicide Prevention Directory
www.angelfire.com/biz/
http://www.themereproject.org/nspd1.html

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SPAN
(Suicide Prevention Advocacy Network)
5034 Odin's Way
Marietta, Ga. 30068
(888) 649-1366
www.spanusa.org

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LOCAL RESOURCES INCLUDE:
SPAN-California
(Suicide Prevention Advocacy Network-
California)
29004 Northbay Road

Rancho Palos Verdes, Calif. 90275
Phone/fax: (310) 377-8857

*

Survivors After Suicide
Suicide Prevention Center of Didi Hirsch Community Mental Health Center
Culver City, Calif.
(877) 727-4747
(310) 391-1253 (outside L.A. County)
http://www.suicidecrisisline.org

NOTE: This piece was completed prior to the Fellowship year of the writer and is included at his request.

Copyright 2001. Used with permission from The Los Angeles Times.