Learning to Detect the Enemy Within

By

Thomas Curwen

"Do you have shells for any of your guns?"

"Bought some shells last weekend. I hid 'em in the lockbox. Makes me feel better knowin' they're there."

Billy Parker's world is coming apart, one question at a time. His life and his problems are fictitious, but he is modeled after real soldiers in trouble: He wants to kill himself.

He has a plan all worked out, and he'll sit and talk about it onscreen with anyone who has a computer. Conversations last from 15 to 45 minutes. They are a wild, sad ride through a mental maze of desperation and hopelessness.

Billy is on CD-ROM. The three-disk set, created by the U.S. Army, Johns Hopkins University and a Canadian company that specializes in suicide prevention training, was distributed this summer to Army bases here and abroad. It is both technologically sophisticated and surprisingly radical in its assumptions about how to teach ways to determine the seriousness of suicidal behavior.

The program presents Billy's problems, like those of real people, as unpredictable. He can be depressed, teetering on the edge of suicide, far removed from it, or somewhere in between. But the interplay of risk and of the complex details of his life makes the program more advanced than other interactive software.

As technology, the CDs are a human-less approach to suicide, a decidedly human problem. This makes them both disconcerting and promising. Such training is typically done in group settings, through one-on-one role-playing. The CDs, however, are less encumbering. They are available to anyone with a laptop.

Given to trainees at the end of a two-day suicide prevention course, they enable officers and enlisted persons to practice at their convenience what they have learned.

The Army hopes the program will make talking about depression and suicide less taboo so more soldiers can be helped when the pressures of their jobs overwhelm them.

If it works, it could have implications for suicide prevention everywhere.

A Life in 2 Gigabytes

"How have you been feeling?"

"I don't know. Nothing is going right. Nothing happens the way I want. I keep getting into arguments with everyone. It's just I'm so mad all the time. I wanted more from life. Something better... "

Double-click on a question, or read it aloud into voice-recognition software, and suddenly Billy Parker fills the computer screen. Two gigabytes on a hard drive -- 802 questions and 1,534 answers -- contain the story of his invented life.

He was born in 1979 and grew up in a small Kentucky town. His dad couldn't hold a job, drank a lot and was divorced from Billy's mother -- then disappeared. Billy was in middle school when it happened.

His mother is a little eccentric. She likes Halloween stories year-round and repaints the kitchen every summer. But nothing beats her pecan pies. When he was younger, Billy and one of her boyfriends built what she called a pie safe, out of wood and tin, to keep them in.

Billy is especially close to Cindy, his kid sister. At one time, he was close to an uncle, who died unexpectedly young. Some said it was a heart attack, but Billy knows the truth: His uncle shot himself.

Earnest and likable, Billy wears his battle-dress uniform on the screen. He has short hair, a sallow complexion and a 5 o'clock shadow.

He is easygoing -- until he thinks about his job, his marriage or his future.

Then he shrugs, swallows hard and looks at the floor.

He wants children, but Teresa, his wife, doesn't. She seems more interested in taking in stray cats. She also has a new job at the mall and has started yoga with a girlfriend.

Feeling estranged, Billy rides his motorcycle and throws himself into a part-time job at a garage in town. He just finished fixing up an old Mustang and is particularly proud of it.

Lately, however, he mainly just sits around and watches TV or listens to music.

Nothing seems to make sense anymore.

There's a stream near his trailer park. He likes it because it's so peaceful. No one would hear his gun down there, and Teresa is going away this weekend.

'You Don't Get It'

"It would be a tragedy if you killed yourself. Your whole life is ahead of you... "

"Yeah, a life full of pain. You don't get it. Have you been listening to me?"

More than 30,000 people kill themselves in the United States annually -- nearly twice the homicide rate. Ruling out illnesses, suicide is the second- leading cause of death after accidents.

More distressingly, for every suicide there are 25 attempts.

In the Army, the numbers are similar. One out of 10,000 soldiers commits suicide, and there are up to 100 interventions a day.

As the largest branch of the military, with nearly 480,000 soldiers, the Army is a discrete and heterogeneous population, which makes it an ideal environment in which to study the effectiveness of prevention programs.

What works in the military could be used elsewhere. "The military is good at transferring information to other communities," says Lt. Col. Elspeth Cameron Ritchie, who until she recently accepted a new assignment oversaw mental health policy for the Department of Defense.

No one is closer to Billy Parker than Lt. Col. Jerry Swanner, in charge of the Army's suicide prevention programs.

"When I was first asked to think about suicide and suicide prevention, I thought: 'Not me. This isn't my experience,' " says Swanner, who took the job after 17 years of postings throughout the world.

Swanner at first thought it was ironic "that someone like me, trained as an infantryman, would get into this field -- trying to save lives." But then he got used to the idea. Next to his computer on his desk at the Pentagon, he keeps a picture of Pvt. Nolan Stites.

Stites was 18 years old and nearly eight weeks into basic training at Ft. Leonard Wood, Mo., when he took his own life. His death was all the more tragic because he had shown signs of being seriously depressed and overwhelmed by the pressures put on new recruits.

"Stites died unnecessarily," Swanner says. "He is my poster child... He looks me in my eyes and asks me what have I done today." Somehow, it's never enough.

Life-Saver at Arms Show

"How are things going for you and Teresa?"

"Great. She doesn't like it here. She wants to move back home. We argue all the time, and she's always on me for dumb stuff like ... like smoking. Last week we had this fight. She ticked me off so bad, I put my fist through a wall. Sometimes I think she cares more about her stupid cats than me."

Billy Parker was first imagined 2 1/2 years ago at a convention hall in Orlando, Fla. During an annual showcase of military simulation software, Lt. Col. James S. Boelens, a chaplain for the Army, saw something odd.

Amid clashing weapons systems and fighter jets, he noticed a man having a conversation with a computer. It was disarmingly simple.

A face on a monitor was answering questions about $40,000 missing from a bank teller machine; no one seemed to know where the money had gone.

It was an interactive program designed to help FBI agents detect deception.

As Boelens watched, he began to think about another application. Could this technology be used to detect suicidal behavior?

"Chaplains are noncombatants," Boelens says. "Our whole purpose is to care for the soldier as a person. We have to be able to relate and empathize and gather information and assist." Few things could be as difficult in an environment such as the Army, where feelings often are considered irrelevant. But here was a device that might train people to understand that feelings are important.

Boelens introduced himself to Timothy Frey, a technician from the Johns Hopkins University Applied Physics Laboratory in Laurel, Md., who was operating the program.

Frey immediately understood why his exhibit appealed to the chaplain. "Ours was the only human-to-human interface," he says. All the other displays were about firepower and search-and-destroy scenarios; this was about "communication and negotiation." Ten months later, the Army Materiel Command took Boelens' idea and $300,000 and set about developing a suicide prevention training CD package. It used the work of Swanner; Frey; Dick Ramsey, president of the Canadian company LivingWorks Education; and Deborah Scher, a scriptwriter.

Together they came up with Billy Parker.

Drawing upon suicide reports and interviews with surviving family and friends, they imagined Billy as a young Army specialist whose problems -- marriage and finances, two common sources of anxiety and depression -- cut to the quick.

"Billy had so many problems," Swanner says, "that [sometimes] we had to step back from the project, because we realized that there were actual people out there who were living the life that Billy lived."

The Five Faces of Billy

"Billy, I realize it's not easy to talk about this, but I do want to know."

"I don't know, man. At first, all I thought about was if I did it, how I could escape all this, get free of everything. And it'd be easy. I could just get my gun and do it. That's what I've been thinking lately."

In their CD package, the team was able to develop enough information to create five Billy Parkers, who changes from session to session during training. One is at no risk for suicide, another at low risk, two at medium risk and one at high risk.

In each instance, the details of his life reflect these psychological shadings.

Interview questions are connected to as many as nine responses, which are in turn connected to another set of questions and answers. The program updates the question-and-answer exchanges constantly to maintain consistency in conversations and in subject matter.

In one instance, for example, if Billy mentions riding his Harley-Davidson, he won't talk later about his Ninja.

Scher wove the various strands of Billy's life.

"I had to put myself in Billy's circumstances," she says. It took her into a world of guns, motorcycles, truck rallies, wrestling tournaments and depression. By the end of most days, she was drained.

Swanner added military details.

In one early draft, for instance, when Billy was asked about his plan, he mentioned a garage and carbon monoxide. Swanner changed the script, because trailer parks near Army bases seldom have garages.

In another, Billy talked about a "gun." Swanner changed it to a "Glock" or a "9 mil." To bring Billy alive, Swanner and Frey picked John Slone, an actor with roles in community theater and commercials. His answers -- by necessity, brief and direct -- are poignant and affecting.

"You want to crawl in there and take Billy by the hand and help him out," Swanner says. "There were times in the filming when we were actually crying for what he was going through."

'Help Me Understand'

"Billy, help me understand why you're thinking about suicide now."

"Well ... uh ... I just got this thing in the mail saying we missed too many payments on the trailer. They're threatening to throw us on the street."

Suicide-prevention training must teach interviewers how to respond to a hopelessness so intense it can be unnerving. It means immersing into a world where everyday activities, comforts, expressions and advice, so often taken for granted, are suddenly meaningless.

Suggest that Billy take better care of his uniform, attend church or start getting more exercise, and he might walk out of the room.

Interviewers must learn to suspend moral, ethical and religious judgments. They must establish rapport, develop trust and be willing to ask four critical questions:

* Are you thinking about committing suicide?

* Do you have someone you can talk to?

* Have you ever attempted suicide or harmed yourself in the past?

* Do you have a plan for committing suicide?

And interviewers must be ready to listen to suicide plans that have already been fully considered.

Developing such expertise takes practice. For Dale Olsen, who developed the technology that made the Army's CD package possible, the central concern was this: Could a computer teach people to listen and to advise as someone shares his most intimate fears?

Employed by the Johns Hopkins Applied Physics Laboratory for nearly 30 years before starting his own company in 2002, Olsen became convinced that, paradoxically, computers could restore a lost form of communication.

"We have gone from gathering at the water cooler to sending an e-mail," Olsen says, "from having porch conversations with neighbors to watching TV." Computer games, he says, can teach us how to reconnect with one another. "We want to bring people back to dealing with people." Putting Billy Parker on computers presents a number of obvious advantages. First, he can be accessed anyplace, anytime, by anyone with a computer. Second, conversation with him is private, eliminating inhibitions that might arise from asking a wrong question or giving wrong advice in a group setting.

Moreover, the CD package provides assistance.

If a trainee is not certain what to say, he may click an on-screen coach, and a cue pops up. Ask the wrong question, and the coach shakes her head. Ask the right question, and she applauds.In the end, if the training is successful, Billy agrees to see a counselor and talk about his problems with a professional.

Finally, the CDs ask trainees to rank Billy's risk for suicide. The program calculates the replies into a running evaluation of the trainee's interaction with Billy and then offers a score, from 0 to 100 points.

'I've Found a Way Out'

"You said that sometimes thinking about suicide makes you feel in control. What do you mean?"

"I feel like everything's so outta control. Like I can't get a grip, you know. But when I think about how easy it would be to kill myself, I feel like I can handle it. Like I've found a way out."

As sophisticated as the CD package might be, its success depends upon follow-through. In most cases, that means placing soldiers at risk of killing themselves on suicide watch and into counseling. But sometimes even that isn't enough.

Nolan Stites, for instance, was counseled and placed on a suicide watch -- but he found a way to take his own life.

At the Aberdeen Proving Ground, 90 minutes north of the Johns Hopkins Applied Physics Laboratory, Sgt. 1st Class Timothy Hebbard, a senior drill sergeant, described placing a soldier on suicide watch. It happened not long before the Billy Parker program was developed.

On a Saturday at about 6:30 p.m., he said, after his soldiers had been released to the mess hall, he was told that one of his troops had a problem.

"I went down to the barracks," he said. "The soldier was sitting on his bunk, crouched over, and should have jumped up when I entered the room, jumped to parade rest -- but he didn't. My first instinct was to order him to his feet, to order him to stop sniffling, to pull himself together, to soldier on."

But then Hebbard remembered his training.

"I asked him if he had any thoughts of hurting himself, and he said yes. I asked him if he had a plan, and he said no." The thoughts were enough.

Hebbard moved the soldier's bunk into a secluded room and ordered him to remove his belt, shoelaces and the dog tag hanging around his neck. Then he assigned other soldiers to watch him constantly until he could get professional help.

Suicide watch is severe, but Hebbard wanted to take no chances. "Losing a soldier in battle is one thing," he says. "Losing a soldier in garrison is another."

Treatment Is Tricky Part

"How about if I call a counselor now and set up an appointment for you tomorrow?"

"Uh ... OK ... If you know someone, sure."

Once a soldier is determined to be at risk for suicide, he is referred to a behavioral health professional for counseling.

Developing an effective treatment is the largest challenge of all suicide-prevention programs, whether they are applied to Army personnel or civilians.

"Treatment always seems to lag behind assessment," says Morton Silverman, director of the National Suicide Prevention Technical Resource Center in Newton, Mass. But he says improvements are coming.

Silverman likens suicide-prevention efforts today to screening recommendations developed by the American Cancer Society and the American Heart Assn. 10 years ago.

"What was lagging was what you did when someone showed up. But since then we have made great advances in the field of cancer and heart disease." Suicide, he says, is no different.

One of the struggles is simply getting people to feel comfortable just saying the "s-word." "CD-ROMs are helpful," he says, "because people often avoid the s-word. Getting people to feel comfortable saying 'suicide' and having a repertoire of answers and probes when the answer is 'yes' is a major step."

Anything less than that confidence, and Billy Parker will politely step around questions, all the while brooding about his problems and thinking about his favorite gun, that peaceful stream behind the trailer park and the empty weekend that lies ahead of him.

Copyright 2003, Los Angeles Times. Reprinted with permission.