Night Falls Fast Read online

  Glorifying suicide or persons who commit suicide. News coverage is less likely to contribute to suicide contagion when reports of community expressions of grief (e.g., public eulogies, flying flags at half-mast, and erecting permanent public memorials) are minimized. Such actions may contribute to suicide contagion by suggesting to susceptible persons that society is honoring the suicidal behavior of the deceased person, rather than mourning the person’s death.

  Focusing on the suicide completer’s positive characteristics. Empathy for family and friends often leads to a focus on reporting the positive aspects of a suicide completer’s life. For example, friends or teachers may be quoted as saying the deceased person “was a great kid” or “had a bright future” while avoiding mentioning the troubles and problems the deceased person had. As a result, statements venerating the deceased person are often reported in the news. However, if the suicide completer’s problems are not acknowledged along with these laudatory statements, suicidal behavior may appear attractive to other at-risk persons, especially those who rarely receive positive reinforcement for desirable behaviors.

  Through guidelines of this sort, and through other initiatives, the Centers for Disease Control and Prevention has demonstrated the potential benefits of active leadership from public health authorities.

  Society also has other ways of curbing suicide, most notably by limiting access to deadly methods. Many of the safeguards we now try to put into place have been used by other cultures in earlier times. Olive Anderson traces the threads of modern suicide prevention to eighteenth- and nineteenth-century attempts to set up social agencies to provide help for those in danger of killing themselves. By the end of the eighteenth century, for example, English police regularly patrolled London parks and bridges to thwart suicide attempts, and by the midnineteenth century laws aimed at limiting the availability of poisons—the Arsenic Act of 1851 and the Sale of Poisons and the Pharmacy Act of 1868—had been passed. The development of new technologies inevitably led to new methods of suicide—carbolic acid for cleaning, potassium cyanide for photography, gas cookers, newly developed pesticides, and railways—and legislation was hard pressed to keep up. Firearms could be regulated, and were, but razors, ropes, and railway lines could not.

  The twentieth century has seen many attempts to curtail access to fatal methods: a drastic lowering in the carbon monoxide content of domestic gas; the introduction of catalytic converters; major restrictions on the prescription of barbiturates and other potentially deadly drugs; and the development of less toxic antidepressant medications. These changes have shifted the pattern of methods used for suicide, but debate rages over whether, if deprived of one method, a suicidal person will simply reach out for a different one. The answer is unclear. Certainly, detoxification of gas and limitations on access to deadly drugs have caused suicide rates to fall in some countries. People do not automatically switch to another method, but there are some who do. The extent of the substitution of one suicide method for another is not entirely clear, and any increase or decrease in suicide rate is seldom attributable to just one thing. During perestroika, for example, Soviet premier Mikhail Gorbachev instituted a massive, if short-lived, campaign to decrease alcohol consumption; prices shot up and sales of alcohol plummeted. So did the suicide rate, which fell by 35 percent between the years of 1984 and 1988. Given the impact of alcohol on depression and impulsive behavior, it would be surprising if the ebb in suicide rates were not to some extent due to the restrictions on alcohol use. Yet during this same time there were also extraordinary social changes in the former USSR—changes that, however, increased overall mortality rates in other segments of the population. It is hard to disentangle complicated social influences from their disparate effects on the public health.

  Gun control (and, to a lesser extent, alcohol restriction) are fiercely partisan issues. Passions run feverishly high in the United States, for example, whenever the topic of gun control is raised. But in 1996, 60 percent of the suicides in this country were carried out with guns; indeed, the number of suicides by firearm exceeded the number of firearm homicides. In study after study, a gun in the home has been shown to be significantly associated with a higher risk of suicide, especially among the young. Impulsivity, when coupled with an accessible and deadly method, adds to the psychological and psychiatric vulnerability in this age group.

  Public health officials, trauma surgeons, emergency room doctors, medical examiners, and mental health professionals have voiced professional outrage over the proliferation of handguns and assault weapons. It is they who cannot staunch the bleeding from bullet wounds, who must fill out the death certificates, inform the parents, or dictate the autopsy reports. The American Academy of Pediatricians, the American Pediatric Surgical Association, and the American Trauma Society, among others, have adopted or proposed policies for the control of the skyrocketing increase in suicides and homicides from firearm violence. A survey of one thousand surgeons and internists, published in 1998, found that 84 percent of the surgeons and 72 percent of the internists thought that physicians should be more actively involved in firearm injury prevention, including the prevention of suicide. Most said they had received little or no education on the subject, but virtually all of them expressed a desire to receive training that would help them deal with the issue.

  The American public shares many of the same concerns. A national survey of adults conducted in 1998 found that 88 percent favor childproofing guns (installing trigger locks or guaranteeing safe gun storage); 71 percent, the personalization of guns (so-called smart guns, which will fire only after “recognizing” the owner’s fingerprints, hand size, or specific radio transmissions from a wristband); 82 percent, the use of magazine safeties (which prevent a gun’s firing if the magazine or clip is removed); and 73 percent, the use of devices that indicate whether a gun’s chamber is loaded. These seem like intelligent, if minimal, actions for society to take. It is hard to imagine any justification for making it easy for a child or an adolescent to kill himself.

  The Swedish National Program to Develop Suicide Prevention has set specific priorities for reducing the availability of other “instruments of suicide.” In transportation, they recommend introducing modified ignition locks that open only when the driver’s exhaled air contains no alcohol; introducing idling shutoff devices activated by high carbon monoxide concentrations; extending exhaust emissions controls to include carbon monoxide as well; introducing better-designed exhaust systems to prevent carbon monoxide suicides; making air bags standard on all cars; designing locomotive front ends so that, on impact, a person will be pushed aside instead of run over; equipping with various forms of protective device those subway stations that have a high frequency of accidents and suicidal acts; and setting up protection (fences or nets) and SOS telephones at particularly frequent suicide sites (tall buildings, bridges). For weapons, it recommends safety grips on guns; separate storage of weapons and ammunition; taking suicide risk into account in drawing up regulations for weapon possession; and limited access to weapons for suicidal people. Finally, for prescription drugs, it recommends developing less toxic drugs, as well as suitable forms of administration and packaging; cautious prescription routines; careful follow-up of patients; and efforts to restrict possession of toxic prescription drugs by suicidal people.

  Sweden, along with several other countries, including Norway, Finland, New Zealand, and Australia, has developed a comprehensive strategy to reduce the rate of suicide. Most of these national strategies include a strong component of public and media education; a focus on increasing the awareness and treatment of alcoholism, depression, and other mental illnesses; reduction of access to deadly methods; and intensified training of health and other professionals. The World Health Organization has outlined six basic steps for the prevention of suicide, most of which center on reducing the availability of methods: more effective treatment of mental disorders, gun possession control, detoxification of domestic gas, detoxification of c
ar emissions, control of toxic substance availability, and toning down suicide reports in the media.

  Several years ago, the United Kingdom set a specific goal for its national health campaign: to reduce, by the year 2000, the rate of suicide by 15 percent. The Royal College of Psychiatrists has run an active Defeat Depression campaign throughout Britain. Its goals have been to reduce the stigma associated with depression, to educate the public about depression and its treatments, and to encourage those suffering from depression to seek treatment earlier rather than later. Preliminary studies indicate that public attitudes toward depression and psychological counseling have improved but that many people still regard antidepressants as less effective than counseling or as potentially addictive. It is too soon to know what effects the efforts of the British government, and those of the Royal College of Psychiatrists, will have on the suicide rate. There is also in Britain, as in most countries, a gap between the availability of mental health services and the public’s awareness of that availability. In April 1999, the Mental Health Foundation in London released the results of a survey taken of three thousand people who had been asked to locate the telephone number they would call if they, or someone they knew, needed immediate psychiatric care. Fifty percent of the respondents were unable to locate the contact number of a local or national hot line or their local social services; 30 percent could not find the telephone number of their local National Health Service mental health service.

  The United States waited until the last months of the twentieth century to propose a coherent and comprehensive national strategy to prevent suicide. There were, of course, many excellent suicide prevention programs in place throughout the country, but there had been no unifying concept or sustained and funded national leadership. In 1997, Senator Harry Reid of Nevada, whose father killed himself and whose state consistently has had the highest suicide rate in the nation, introduced a resolution in the U.S. Senate. Unanimously passed, it read in part:

  Resolved, That the Senate—

  recognizes suicide as a national problem and declares suicide prevention to be a national priority;

  acknowledges that no single suicide prevention program or effort will be appropriate for all populations or communities;

  encourages initiatives dedicated to— preventing suicide;

  responding to people at risk for suicide and people who have attempted suicide;

  promoting safe and effective treatment for persons at risk for suicidal behavior;

  supporting people who have lost someone to suicide; and

  developing an effective national strategy for the prevention of suicide; and

  encourages the development and the promotion of accessibility and affordability, of mental health services, to enable all persons at risk for suicide to obtain the services, without fear of any stigma.

  The Senate resolution was an eloquent and important beginning and acted as a catalyst for many government health agencies, suicide prevention programs, mental health advocacy groups, and an imaginative, active grassroots organization, the Suicide Prevention Advocacy Network, which is an alliance of community activists, many of whom have lost a family member to suicide. Working with Senator Reid, this network provided much of the impetus for a recent consensus meeting, which developed a national strategy for suicide prevention. These groups were brought together under the leadership of the Surgeon General of the United States, David Satcher, a physician and former director of the Centers for Disease Control and Prevention. Satcher is a natural leader, one whose intelligence and compassion have eased the way for building the kind of coalition necessary to put together a national strategy on suicide prevention. His 1999 Surgeon General’s Report on Suicide is the first published on the subject in the two hundred years of his office. The report calls for an increase in public awareness of suicide and its risk factors; an improvement in population-based and clinical services; and an investment in the advancement of the science of suicide prevention.

  The federal government has made a good start on the problem of suicide, but the effort will not go far without support from the public and without funding from the Congress and the state legislatures. Nor is major success at suicide prevention a realistic goal if treatment for mental illness remains unaffordable and out of the reach of millions of Americans because health insurance is poor or nonexistent; if hospital stays for the severely mentally ill are limited to days, rather than weeks; or if society continues to be unaware of the suffering of so many people in its midst. Streets and jails are no places for the mentally ill.

  The challenges to policy remain substantial. But increasing numbers of successful approaches promise important gains for directed public action. Much remains to be learned about how to prevent suicide. But, as the Surgeon General’s report convincingly argues, much can now be done.

  SHORTLY BEFORE he killed himself, D.C. Council Chairman John Wilson spoke to the Mental Health Association about suicide and mental illness in the black community. “Suicide,” he said, “is the number one killer among young black people, but we call it gunfire.… We don’t even like to talk about it. We’ve got to change the way America feels about depression.” He was right, as usual.

  I miss John Wilson very much, and I can still hear him saying in his passionate, inimitable way, “We can’t put it all in God’s hands. God’s busy.”

  CHAPTER 10

  A Half-Stitched Scar

  —THOSE LEFT BEHIND—

  … Time does not heal,

  It makes a half-stitched scar

  That can be broken and again you feel

  Grief as total as in its first hour.

  —ELIZABETH JENNINGS

  SEVERAL MONTHS ago my husband and I were having dinner with an old friend of his, a psychiatrist, who toward the end of the evening asked me what I was working on. I told him I was writing a book about suicide, and this, as is not uncommonly the case, seemed to unbell the cat. A short silence followed. Then he said, with the remarkable certainty of someone whose thin understanding of suicide is belied by thirty years of private practice, “I was suicidal once, when I was eighteen. But I decided I couldn’t commit suicide because it would be so terrible for my family and friends. I certainly couldn’t now. I’m a doctor. Think what it would be like for my patients. How incredibly selfish!” A slight sense of moral superiority hung in the air.

  I kicked my husband’s shins under the table to encourage him to ask for the bill, and then I reminded his friend, who knew it well, that I had tried years earlier to kill myself, and nearly died in the attempt, but did not consider it either a selfish or a not-selfish thing to have done. It was simply the end of what I could bear, the last afternoon of having to imagine waking up the next morning only to start all over again with a thick mind and black imaginings. It was the final outcome of a bad disease, a disease it seemed to me I would never get the better of. No amount of love from or for other people—and there was a lot—could help. No advantage of a caring family and fabulous job was enough to overcome the pain and hopelessness I felt; no passionate or romantic love, however strong, could make a difference. Nothing alive and warm could make its way in through my carapace. I knew my life to be a shambles, and I believed—incontestably—that my family, friends, and patients would be better off without me. There wasn’t much of me left anymore, anyway, and I thought my death would free up the wasted energies and well-meant efforts that were being wasted in my behalf.

  All of what our colleague said was true, however. Suicide is awful beyond expression for those who have to spend their lives with its reality. No one who is a parent or child, a brother or a sister, a friend, a doctor or a patient would say otherwise. Most would agree with him that it is, on the face of it, a selfish act; most have yelled in their hearts, if not out loud, “How could you have done this to me?” All have asked themselves over and over again, and then a thousand times beyond, Why? What could I have done differently? Why?

  The sting of death is always, as Arnold Toyn
bee writes, “less sharp for the person who dies than it is for the bereaved survivors.” This is, he said, “the capital fact about the relation between living and dying. There are two parties to the suffering that death inflicts; and, in the apportionment of this suffering, the survivor takes the brunt.”

  Those who are left behind in the wake of suicide are left to deal with the guilt and the anger, to sift the good memories from the bad, and to try to understand an inexplicable act. Most of all, they are left to miss a parent or child whose life was threaded to theirs from its very beginning, mourn a spouse whose bed and love and trust they shared, or grieve the loss of a confidant with whom they spent long days and evenings of friendship.

  How can killing oneself, in the context of other lives, ever be seen as anything but a highly personal, cruel, and thoughtless act? Yet suicide is tangential to reason and consideration and is almost always an irrational choice, the seemingly best way to end the pain, the futility, the voices, or the hopelessness. Decisions about suicide are not fleeting thoughts that can be willed away in deference to the best interests of others. Suicide wells up from cumulative anguish or is hastened by impulse; however much it may be set in or set off by the outer world, the suicidal mind tends not to mull on the well-being and future of others. If it does, it conceives for them a brighter future due to the fact that their lives are rid of an ill, depressed, violent, or psychotic presence. A young chemist, before committing suicide, put it succinctly: “The question of suicide and selfishness to close friends and relatives is one that I can’t answer or even give an opinion on. It is obvious, however, that I have pondered it and decided I would hurt them less dead than alive.”