“There is but one truly serious philosophical problem,”
Albert Camus wrote, “and that is
suicide.”
How to explain why, among the only species capable of pondering its own
demise, whose desperate attempts to forestall mortality have spawned
both armies and branches of medicine in a perpetual search for the
Fountain of Youth, there are those who, by their own hand, would choose
death over life? Our contradictory reactions to the act speak to the
conflicted hold it has on our imaginations: revulsion mixed with
fascination, scorn leavened with pity. It is a cardinal sin — but change
the packaging a little, and suicide assumes the guise of heroism or
high passion, the stuff of literature and art.
Todd Hido for The New York Times
Todd Hido for The New York Times
Todd Hido for The New York Times
Beyond the philosophical paradox are the bewilderingly complex
dynamics of the act itself. While a universal phenomenon, the incidence
of suicide varies so immensely across different population groups —
among nations and cultures, ages and gender, race and religion — that
any overarching theory about its root cause is rendered useless. Even
identifying those subgroups that are particularly suicide-prone is of
very limited help in addressing the issue. In the United States, for
example, both elderly men living in Western states and white male
adolescents from divorced families are at elevated risk, but since the
overwhelming majority in both these groups never attempt suicide, how
can we identify the truly at risk among them?
Then there is the
most disheartening aspect of the riddle. The National Institute of
Mental Health says that 90 percent of all suicide “completers” display
some form of diagnosable mental disorder. But if so, why have advances
in the treatment of mental illness had so little effect? In the past 40
years, whole new generations of antidepressant drugs have been
developed; crisis hotline centers have been established in most every
American city; and yet today the nation’s suicide rate (11 victims per
100,000 inhabitants) is almost precisely what it was in 1965.
Little
wonder, then, that most of us have come to regard suicide with an
element of resignation, even as a particularly brutal form of social
Darwinism: perhaps through luck or medication or family intervention
some suicidal individuals can be identified and saved, but in the larger
scheme of things, there will always be those driven to take their own
lives, and there’s really not much that we can do about it. The sheer
numbers would seem to support this idea: in 2005, approximately 32,000
Americans committed suicide, or nearly twice the number of those killed
by homicide.
But part of this sense of futility may stem from a peculiar element of
myopia
in the way we as a society have traditionally viewed and attempted to
combat suicide. Just as with homicide, researchers have long recognized a
premeditation-versus-passion dichotomy in suicide. There are those who
display the classic symptoms of so-called
suicidal behavior,
who build up to their act over time or who choose methods that require
careful planning. And then there are those whose act appears born of an
immediate crisis, with little or no forethought involved. Just as with
homicide, those in the “passion” category of suicide are much more
likely to turn to whatever means are immediately available, those that
are easy and quick.
Yet even mental-health experts have tended to
regard these very different types of suicide in much the same way. I
was struck by this upon meeting with two doctors who are among the most
often-cited experts on suicide — and specifically on suicide by jumping.
Both readily acknowledged the high degree of impulsivity associated
with that method, but also considered that impulsivity as simply another
symptom of mental illness. “Of all the hundreds of jumping suicides
I’ve looked at,” one told me, “I’ve yet to come across a case where a
mentally healthy person was walking across a bridge one day and just
went over the side. It just doesn’t happen. There’s almost always the
presence of mental illness somewhere.” It seemed to me there was an
element of circular logic here: that the act proved the intent that
proved the illness.
The bigger problem with this mental-illness
rubric is that it puts emphasis on the less-knowable aspect of the act,
the psychological “why,” and tends to obscure any examination of the
more pedestrian “how,” the basic mechanics involved. But if we want to
unravel posthumously the thought processes of the lost with an eye to
saving lives in the future, the “how” may be the best place to look.
To
turn the equation around: if the impulsive suicide attempter tends to
reach for whatever means are easy or quick, is it possible that the
availability of means can actually spur the act? In looking at suicide’s
close cousin, murder, the answer seems obvious. If a man shoots his
wife amid a heated argument, we recognize the crucial role played by the
gun’s availability. We don’t automatically think, Well, if the gun
hadn’t been there, he surely would have strangled her. When it comes to
suicide, however, most of us make no such allowance. The very fact that
someone kills himself we regard as proof of intent — and of mental
illness; the actual method used, we assume, is of minor importance.
But is it?
As
it turns out, one of the most remarkable discoveries about suicide and
how to reduce it occurred utterly by chance. It came about not through
some breakthrough in pharmacology or the treatment of mental illness but
rather through an energy-conversion scheme carried out in Britain in
the 1960s and ’70s. Among those familiar with the account, it is often
referred to simply as “the British coal-gas story.”
For
generations, the people of Britain heated their homes and fueled their
stoves with coal gas. While plentiful and cheap, coal-derived gas could
also be deadly; in its unburned form, it released very high levels of
carbon monoxide,
and an open valve or a leak in a closed space could induce asphyxiation
in a matter of minutes. This extreme toxicity also made it a preferred
method of suicide. “Sticking one’s head in the oven” became so common in
Britain that by the late 1950s it accounted for some 2,500 suicides a
year, almost half the nation’s total.
Those numbers began
dropping over the next decade as the British government embarked on a
program to phase out coal gas in favor of the much cleaner natural gas.
By the early 1970s, the amount of carbon monoxide running through
domestic gas lines had been reduced to nearly zero. During those same
years, Britain’s national suicide rate dropped by nearly a third, and it
has remained close to that reduced level ever since.
How can
this be? After all, if the impulse to suicide is primarily rooted in
mental illness and that illness goes untreated, how does merely closing
off one means of self-destruction have any lasting effect? At least a
partial answer is that many of those Britons who asphyxiated themselves
did so impulsively. In a moment of deep despair or rage or sadness, they
turned to what was easy and quick and deadly — “the execution chamber
in everyone’s kitchen,” as one psychologist described it — and that
instrument allowed little time for second thoughts. Remove it, and the
process slowed down; it allowed time for the dark passion to pass.
Quite
inadvertently, the British gas conversion proved that the incidence of
suicide across an entire society could be radically reduced, upending
the conventional wisdom about suicide in the process. Or rather it
should have upended the conventional wisdom, for what is astonishing
today is how little-known the British coal-gas story is even among
mental-health professionals who deal with suicide. Last November, I
attended a youth suicide-prevention conference in New Hampshire at which
Catherine Barber, a member of the Injury Control Research Center at the
Harvard School of Public Health, gave a PowerPoint presentation on
creating physical barriers to suicide — or “means restriction,” in
public-health parlance — to a large group of mental-health officials and
school counselors. While giving a brief history of the approach, she
came to several slides describing the British gas-conversion phenomenon
and paused.
“Is everyone familiar with the British coal-gas story?” she asked. “If so, I’ll just skip over this.”
Among the 150 or so attendees, only about a half-dozen hands went up. Instead, most looked quite baffled.
In Northwest Washington stands a pretty neoclassical-style bridge named for one of the city’s most famous native sons,
Duke Ellington.
Running perpendicular to the Ellington, a stone’s throw away, is
another bridge, the Taft. Both span Rock Creek, and even though they
have virtually identical drops into the gorge below — about 125 feet —
it is the Ellington that has always been notorious as Washington’s
“suicide bridge.” By the 1980s, the four people who, on average, leapt
from its stone balustrades each year accounted for half of all jumping
suicides in the nation’s capital. The adjacent Taft, by contrast,
averaged less than two.
After three people leapt from the
Ellington in a single 10-day period in 1985, a consortium of civic
groups lobbied for a suicide barrier to be erected on the span.
Opponents to the plan, which included the
National Trust for Historic Preservation,
countered with the same argument that is made whenever a suicide
barrier on a bridge or landmark building is proposed: that such barriers
don’t really work, that those intent on killing themselves will merely
go elsewhere. In the Ellington’s case, opponents had the added
ammunition of pointing to the equally lethal Taft standing just yards
away: if a barrier were placed on the Ellington, it was not at all hard
to see exactly where thwarted jumpers would head.
Except the
opponents were wrong. A study conducted five years after the Ellington
barrier went up showed that while suicides at the Ellington were
eliminated completely, the rate at the Taft barely changed, inching up
from 1.7 to 2 deaths per year. What’s more, over the same five-year
span, the total number of jumping suicides in Washington had decreased
by 50 percent, or the precise percentage the Ellington once accounted
for.
What makes looking at jumping suicides potentially
instructive is that it is a method associated with a very high degree of
impulsivity, and its victims often display few of the classic warning
signs associated with suicidal behavior. In fact, jumpers have a lower
history of prior suicide attempts, diagnosed mental illness (with the
exception of
schizophrenia) or drug and
alcohol abuse
than is found among those who die by less lethal methods, like taking
pills or poison. Instead, many who choose this method seem to be drawn
by a set of environmental cues that, together, offer three crucial
ingredients: ease, speed and the certainty of death.
So why the
Ellington more than the Taft? In its own way, that little riddle rather
buttresses the environmental-cue theory, for the one glaring difference
between the two bridges — a difference readily apparent to most anyone
who walked over them in their original state — was the height of their
balustrades. The concrete railing on the Taft stands chest-high on an
average man, while the pre-barrier Ellington came to just above the belt
line. A jump from either was lethal, but one required a bit more effort
and a bit more time, and both factors stand in the way of impulsive
action.
But how do you prove that those thwarted from the
Ellington, or by any other suicide barrier, don’t simply choose another
method entirely? As it turns out, one man found a clever way to do just
that. With a somewhat whimsical manner and the trace of a grin
constantly working at one corner of his mouth, Richard Seiden has the
appearance of someone always in the middle of telling a joke. It’s not
what you might expect considering that Seiden, a professor emeritus and
clinical psychologist at the University of California at Berkeley School
of Public Health, is probably best known for his pioneering work on the
study of suicide. Much of that work has focused on the bridge that lies
just across San Francisco Bay from campus, the Golden Gate.
Since
its opening in 1937, the bridge has been regarded as one of the
architectural and engineering marvels of the 20th century. For nearly as
long, the Golden Gate has had the distinction of being the most popular
suicide magnet on earth, a place where an estimated 2,000 people have
ended their lives. Over the years, there have been a number of civic
campaigns to erect a suicide barrier on the bridge, but all have
foundered on the same “they’ll just find another way” belief that made
the Ellington barrier so contentious.
In the late 1970s, Seiden
set out to test the notion of inevitability in jumping suicides.
Obtaining a Police Department list of all would-be jumpers who were
thwarted from leaping off the Golden Gate between 1937 and 1971 — an
astonishing 515 individuals in all — he painstakingly culled
death-certificate records to see how many had subsequently “completed.”
His report, “Where Are They Now?” remains a landmark in the study of
suicide, for what he found was that just 6 percent of those pulled off
the bridge went on to kill themselves. Even allowing for suicides that
might have been mislabeled as accidents only raised the total to 10
percent.
“That’s still a lot higher than the general population,
of course,” Seiden, 75, explained to me over lunch in a busy restaurant
in downtown San Franciso. “But to me, the more significant fact is that
90 percent of them got past it. They were having an acute temporary
crisis, they passed through it and, coming out the other side, they got
on with their lives.”
In Seiden’s view, a crucial factor in this
boils down to the issue of time. In the case of people who attempt
suicide impulsively, cutting off or slowing down their means to act
allows time for the impulse to pass — perhaps even blocks the impulse
from being triggered to begin with. What is remarkable, though, is that
it appears that the same holds true for the nonimpulsive, with people
who may have been contemplating the act for days or weeks.
“At
the risk of stating the obvious,” Seiden said, “people who attempt
suicide aren’t thinking clearly. They might have a Plan A, but there’s
no Plan B. They get fixated. They don’t say, ‘Well, I can’t jump, so now
I’m going to go shoot myself.’ And that fixation extends to whatever
method they’ve chosen. They decide they’re going to jump off a
particular spot on a particular bridge, or maybe they decide that when
they get there, but if they discover the bridge is closed for
renovations or the railing is higher than they thought, most of them
don’t look around for another place to do it. They just retreat.”
Seiden
cited a particularly striking example of this, a young man he
interviewed over the course of his Golden Gate research. The man was
grabbed on the eastern promenade of the bridge after passers-by noticed
him pacing and growing increasingly despondent. The reason? He had
picked out a spot on the western promenade that he wanted to jump from,
but separated by six lanes of traffic, he was afraid of getting hit by a
car on his way there.
“Crazy, huh?” Seiden chuckled. “But he recognized it. When he told me the story, we both laughed about it.”
The offices of
the Injury Control Research Center are on the third floor of the
Harvard School of Public Health building in Boston. The center, directed
by David Hemenway, consists of an internationally renowned team of
public-health officials, social scientists and statisticians, and over
the past decade they have been in the vanguard of a movement that looks
at suicide prevention in a new and very different way: call it the
Band-Aid approach.
“One of the differences between us and those in
mental health,”
Hemenway explained, “is that we focus on the ‘how’ of suicide. What are
the methods used? Is there a way to mitigate them? And that’s where
examples like the British coal-gas story are very instructive, because
they show that if you can somehow remove or complicate a method, you
have the potential of saving a tremendous number of lives.”
Animating
their efforts is one of the most peculiar — in fact, downright perverse
— aspects to the premeditation-versus-passion dichotomy in suicide. Put
simply, those methods that require forethought or exertion on the
actor’s part (taking an overdose of pills, say, or cutting your wrists),
and thus most strongly suggest premeditation, happen to be the methods
with the least chance of “success.” Conversely, those methods that
require the least effort or planning (shooting yourself, jumping from a
precipice) happen to be the deadliest. The natural inference, then, is
that the person who best fits the classic definition of “being suicidal”
might actually be
safer than one acting in the heat of the
moment — at least 40 times safer in the case of someone opting for an
overdose of pills over shooting himself.
As illogical as this
might seem, it is a phenomenon confirmed by research. According to
statistics collected by the Injury Control Research Center on nearly
4,000 suicides across the United States, those who had killed themselves
with firearms — by far the most lethal common method of suicide — had a
markedly lower history of
depression, schizophrenia,
bipolar disorder,
previous suicide attempts or drug or alcohol abuse than those who died
by the least lethal methods. On the flip side, those who ranked the
highest for at-risk factors tended to choose those methods with low
“success” rates.
“We’re always going to have suicide,” Hemenway
said, “and there’s probably not that much to be done for the ones who
are determined, who succeed on their 4th or 5th or 25th try. The ones we
have a good chance of saving are those who, right now, succeed on their
first attempt because of the lethal methods they’ve chosen.”
Inevitably,
this approach means focusing on the most common method of suicide in
the United States: firearms. Even though guns account for less than 1
percent of all American suicide attempts, their extreme fatality rate —
anywhere from 85 percent and 92 percent, depending on how the statistics
are compiled — means that they account for 54 percent of all
completions. In 2005, the last year for which statistics are available,
that translated into about 17,000 deaths. Public-health officials like
Hemenway can point to a mountain of research going back 40 years that
shows that the incidence of firearm suicide runs in close parallel with
the prevalence of firearms in a community. In a 2007 study that grouped
the 15 states with the highest rate of gun ownership alongside the six
states with the lowest (each group had a population of about 40
million), Hemenway and his associates found that when it came to all
nonfirearm methods, the two populations committed suicide in nearly
equal numbers. The more than three-times-greater prevalence of firearms
in the “high gun” states, however, translated into a more than
three-times-greater incidence of firearm suicides, which in turn
translated into an annual suicide rate nearly double that of the “low
gun” states. In the same vein, their 2004 study of seven Northeastern
states found that the 3.5 times greater rate of gun suicides in Vermont
than in New Jersey exactly matched the difference in gun ownership
between the two states (42 percent of all households in Vermont opposed
to 12 percent in New Jersey). From these and other such studies, the
Injury Control Research Center has extrapolated that a 10 percent
reduction in firearm ownership in the United States would translate into
a 2.5 percent reduction in the overall suicide rate, or about 800 fewer
deaths a year.
Beyond sheer lethality, however, what makes gun
suicide attempts so resistant to traditional psychological
suicide-prevention protocols is the high degree of impulsivity that
often accompanies them. In a 1985 study of 30 people who had survived
self-inflicted gunshot wounds, more than half reported having had
suicidal thoughts for less than 24 hours, and none of the 30 had written
suicide notes. This tendency toward impulsivity is especially common
among young people — and not only with gun suicides. In a 2001
University of Houston
study of 153 survivors of nearly lethal attempts between the ages of 13
and 34, only 13 percent reported having contemplated their act for
eight hours or longer. To the contrary, 70 percent set the interval
between deciding to kill themselves and acting at less than an hour,
including an astonishing 24 percent who pegged the interval at less than
five minutes.
The element of impulsivity in firearm suicide
means that it is a method in which mechanical intervention — or “means
restriction” — might work to great effect. As to how, Dr. Matthew
Miller, the associate director of the Injury Control Research Center,
outlined for me a number of very basic steps. Storing a gun in a
lockbox, for example, slows down the decision-making process and puts
that gun off-limits to everyone but the possessor of the key. Similarly,
studies have shown that merely keeping a gun unloaded and storing its
ammunition in a different room significantly reduces the odds of that
gun being used in a suicide.
“The goal is to put more time
between the person and his ability to act,” Miller said. “If he has to
go down to the basement to get his ammunition or rummage around in his
dresser for the key to the gun safe, you’re injecting time and effort
into the equation — maybe just a couple of minutes, but in a lot of
cases that may be enough.”
It reminded me of what Richard Seiden
said about people thwarted from jumping off the Golden Gate Bridge. When
I mentioned this to Miller, he smiled. “It’s very much the same,” he
said. “The more obstacles you can throw up, the more you move it away
from being an impulsive act. And once you’ve done that, you take a lot
of people out of the game. If you look at how people get into trouble,
it’s usually because they’re acting impulsively, they haven’t thought
things through. And that’s just as true with suicides as it is with
traffic accidents.”
I met Debbie in the lobby of a resort
hotel just outside Burlington, Vt. She is a very pretty woman who looks
far younger than her 50 years, and her shoulder-length blond hair neatly
conceals the damage to the right side of her head. She has no
difficulty speaking, certainly none with
memory.
In fact, it is only when she stands that her injuries are apparent;
leaning on a cane, she moves slowly, shifting her partly paralyzed left
side much like someone who has suffered a stroke. “People often think I
was in a car accident or something,” she said with a tentative smile.
“If they ask, I usually just say, ‘It’s a long story,’ and leave it at
that.”
Until the spring of 2004, Debbie lived a particularly
Rockwellian version of the American middle-class experience. Married to
an investment banker and residing in a picturesque village in northern
Vermont, she worked part time at the local town hall while playing
soccer mom to her two children, a boy and a girl. That spring, however,
with both her children off to college, she became increasingly aware of a
certain aridness in her marriage and felt besieged by the demands of a
new full-time job. After she and her husband endured a hellish cycle of
trial separations followed by brief rapprochements, he finally asked for
a divorce. The day before they were to sign divorce papers in May 2005,
Debbie drove to a nearby gun store and told the manager she wanted to
buy a handgun for self-protection. After her driver’s license was run to
make sure she had no felony convictions, Debbie walked out of the store
with a .38-caliber revolver and a packet of hollow-point bullets. The
whole process took about 15 minutes.
“I just didn’t see any other
way out of the situation,” she said. “I seemed incapable of making a
decision about my marriage, about my job. I just felt so overwhelmed
with everything.”
Back home, she went up to her master bathroom
with the gun and closed the door behind her. Not wanting to leave a
mess, she thought to lay a dark towel in the shower, then stepped inside
and sat down.
Paradoxically, it may have been Debbie’s
fastidious streak that saved her life. Unfamiliar with guns and without a
mirror to guide her hand, she set the revolver to her head at an odd
angle. The bullet cut a path through a portion of her brain before
exiting at the back of her skull, but it also left Debbie as one of the
very few people ever to survive a hollow-point shot to the head.
She
remembers feeling a moment of intense pain and then nothing else for a
long time. Her next memory is of her husband, standing over her and
screaming, “What have you done?” and the sound of an approaching
ambulance. She found she could speak, but all she kept saying over and
over was: “I don’t want to die. Please, I don’t want to die.”
As
with every other survivor of a near-lethal suicide attempt that I spoke
with, Debbie told her story with an almost eerie poise. There was one
moment, though, at which she suddenly fell silent, where words failed
her.
“You know, I hear myself describing all this,” she said,
“but it seems completely surreal. I feel like I’m describing a movie I
saw or a book I read. Even sitting here now and looking at that” — she
motioned to her cane — “it’s hard to believe this is something I
actually did.”
I suspected part of her incredulity stemmed from
the recentness of the event; it had been less than three years. But
perhaps it was also rooted in something more profound. What united all
the survivors I spoke with was a sense of having been so utterly
transformed by their experiences that, in essence, they had become
different people.
In California, I met with Ken Baldwin, a
schoolteacher who, in the grips of a deep depression 22 years ago, leapt
from the Golden Gate Bridge.
“I’ve had two lives,” Baldwin said.
“That’s the only way I’ve ever been able to describe it. Up to the day I
jumped, that was one life, and now this is another. I’m not so much a
changed man as a completely different one, and that’s why it’s so hard
to even recollect what I was like back then, what I was thinking.”
One
aspect of the survivors’ personalities that appears to have been left
behind is whatever mind-tumble caused them to try to kill themselves in
the first place. Since their attempts, none of the survivors I spoke
with had experienced another impulse toward suicide. Nor had they spent
much time seeing
psychologists
or hanging out in support groups. In Baldwin’s case, he attended just
five therapy sessions after his jump from the Golden Gate.
“And
after that fifth session,” he recalled, “the therapist said: ‘You know, I
really don’t think you need to do this anymore. You seem to have it all
put back together.’ And he was right.”
For each, it’s almost as
if their near-death experience scared them straight, propelled them back
to a point of recovery beyond even their own imagining. But that’s
actually not so unusual; just as Seiden found that less than 10 percent
of people thwarted from jumping off the Golden Gate Bridge went on to
kill themselves, a host of studies show that same percentage holds among
those who carry out “near fatal” attempts but somehow survive.
Beginning in the 1970s, Dr. David Rosen, a psychiatrist and Jungian
psychoanalyst, tracked down and conducted lengthy interviews with nine
people who survived leaps from the Golden Gate, as well as one who had
gone off the nearby Bay Bridge.
“What was immediately apparent,”
Rosen recounted, “was that none of them had truly wanted to die. They
had wanted their inner pain to stop; they wanted some measure of relief;
and this was the only answer they could find. They were in spiritual
agony, and they sought a physical solution.”
In September 2000,
Kevin Hines, a 19-year-old college student suffering from bipolar
disorder, leapt from the Golden Gate. Along with Ken Baldwin, he is one
of only 29 known survivors of the fall. Today Hines controls his bipolar
disorder with medication and a strictly controlled regimen of
diet
and exercise and sleep, even while maintaining a frenetic schedule.
Having recently married, he is frequently on the road lecturing for a
suicide-prevention network while simultaneously working toward a
psychology degree. One of his most intense ambitions, though, is to finally see a suicide barrier erected on the Golden Gate.
“I’ll
tell you what I can’t get out of my head,” he told me in his San
Francisco living room. “It’s watching my hands come off that railing and
thinking to myself, My God, what have I just done? Because I know that
almost everyone else who’s gone off that bridge, they had that exact
same thought at that moment. All of a sudden, they didn’t want to die,
but it was too late. Somehow I made it; they didn’t; and now I feel it’s
my responsibility to speak for them.”
Scott Anderson is a frequent contributor to the magazine. His last article was about the war in Lebanon in 2006.
