HOW NOT TO COMMIT SUICIDE
3 of 9 pages
From those who work the phones.
Like the other 200 suicide prevention telephone hotlines in the U.S.,
the Marin Suicide Prevention Center holds several 11-session training
classes a year. I sat in on one of the introductory sessions. It looked
like any suburban adult education class --- sixty fidgety people of all
ages in chairs too small for them, and two instructors, the Center's Acting
Director Noreen Dunnigan and the Program Director, David Nolan. After
a warning that statistics are misleading, Dunnigan jumped in.
"For every 100,000 people in the United States," she said, "an average
of 12.5 attempt suicide each year. At this center we get 1200 calls a
month, from 250 clients. Most people call more than once. Wednesday is
our busiest day. ("It's the day most therapists take off," Nolan interrupted.)
80% of the people call about themselves; the rest are clergy, friends,
family -- calling because they're worried about someone. The later the
hour, the higher the number of calls. 34% of the callers are male, 66%
female. Can anybody guess why?"
"Men aren't as used to reaching out for help," said a man, the only black
person in the room.
Dunnigan nodded and went on: "54% of the callers are not in a suicidal
crisis. 46% have problems with alcohol or drugs. 35% live alone. Once
every 50 hours, in what we call active intervention, we send someone in
-- an ambulance or friends, or clergy, or someone else goes over to their
house, because we ask them to."
"What do you mean by suicidal crisis?" asked a studious-looking woman.
"You don't mean 46% are actually trying suicide?"
David Nolan replied. "No, the 54% are people who don't mention suicide
at all. They have some other problem -- loneliness, maybe -- and they
want somebody to talk to. 26% have suicidal ideation. They're thinking
about it. 13% are threatening suicide. 6% are attempting it as we talk
to them. The rest, we don't know about; the calls are too short or we
don't find out.
Noreen Dunnigan gave some statistics from the Marin coroner's office about
people who did kill themselves. "The highest rate of suicide is in May.
We'll talk more about what happens to people in spring. The second highest
is January, just after the holidays. The older the person the higher the
suicide rate. The average age for males is 41. The average for females
is 45."
"That doesn't mean anyone was actually at those specific ages," Nolan said.
"There were 47 known suicides in Marin in 1980. (There are others we don't know about.) 34 were male. 13 were female. 14 people shot themselves. All but one of them were male. Six people died from car exhaust. Four jumped off the Golden Gate Bridge. The rest were drug overdoses."
Dunnigan described the established theories about why people commit suicide. Freud, for instance, thought most people have two basic instinctual drives -- the wish to live (Eros) and the wish to die (Thanatos). Karl Menninger said a suicidal person acts out a wish to be killed ("I don't deserve to live"), a wish to kill someone else, or a wish to die. Old people usually fall into the latter category ("I can't go on."). Young people usually with to die or be killed.
"There also is a need for attention," she said. "A lot of these people have worn out their family and friends. The coroner's office tells us that they can usually tell most people didn't really want to die. According to their suicide notes, they wanted to be rescued. Anyone here can be suicidal given the right circumstances or the proper amount of stress.
"When someone calls, we assume they are ambivalent, no matter suicidal they say they are. Otherwise, they wouldn't call. For myself I want the right to choose to live or die -- for example, if I were terminally ill I don't know how I'd choose -- but anyone who calls here will have a hell of a battle.
"They let us know that there's a glimmer of hope and that's the side we work with. We feel them out -- we ask if they are thinking of killing themselves. We try to find alternatives -- not giving them our alternatives, but asking them what they did the last time they felt this way, getting them to remember when they didn't feel this way."
About half the people in the room were taking notes. A woman in her twenties asked, "What do you say after you ask 'Are you thinking of killing yourself?' and they say 'Yes'?"
"Well, often the simplest response is that you don't want them to die. It's not easy. Dealing with suicidal people is usually unrewarding. They're the toughest for therapists, and in fact dealing with them makes some therapists become suicidal." A bearded man in his thirties nodded his head.
A teenage girl with glasses and short-cropped brown hair said, "You say to the person, 'I don't want you to die' and the person says 'Why'? What's your answer?
"You say, 'I don't want you to die because I care about you.'"
"They go for that?"
"Yes, they do, if you're sincere." She paused. Nobody said anything. The girl looked dubious. "Have you ever cared about anyone who wanted to die and not been able to come up with a reason why they should go on living? Usually by the time I'm on the phone awhile I have a rapport going, and by that time I usually do have a reason that I care about them. A very intimate relationship builds up very quickly on the phone. Some of you may not be able to dredge up any feeling for some of your callers and in that case you shouldn't lie to them. They can spot a phony right away."
The girl still looked unconvinced, but nodded. Someone else asked, "What do you do with your emotions?"
"You talk to fellow counselors, you talk to staff," Noreen Dunnigan said. "You don't let any individual callers get into a personal relationship with you. In fact, any counselor who meets a caller outside of the Center is automatically suspended -- not suspended - what's the other word for final?"
"Expelled," someone called out.
"Expelled. We don't use the word terminated here."
Laughter. More talk about what to say to people on the phone. "We want them to explore their death fantasies and deglamorize them. How do you know there's a life hereafter? Have you known anyone who came back? You won't be able to see your own funeral, and show everyone you were serious. If you overdose you'll probably choke on your own vomit. Your bowels will go. Who's going to find you.
"Get used to saying, 'I want you to flush the pills away now,' instead of saying, 'Would you mind putting the pills away for us?' We want to assert ourselves. We ask, what will your children think when they find you? What kind of example would this be for your children as a way to solve problems? We use all the things we can think of and sometimes they sound manipulative. They are manipulative. We want to get the person through the crisis. We want them to take the gun away and put it on a shelf where they can't see it. Or put it out of the house, better yet.
"We find out what has given meaning to their lives. Has it always been this way? What was it like when it was not this way? Sometimes people say they've always felt this way. You say, 'Let's count back and see if that's true.'"
"But isn't that denying what they just said?" someone asked.
"No, you acknowledge their feeling but you want to do a little reality test with them. 'It sounds like you've always felt this way but let's talk more about it.'"
"It sounds like you're trying to instill guilt."
"We don't want them to feel any worse than they already do. But often they haven't thought about everything. It's like tunnel vision. Usually is hasn't dawned on them who it will affect or what the long-range effects of their act will be. Once they realize it they often don't want the suicide to happen. They don't want to die; they want the pain to stop. People who are sure about killing themselves rarely call the suicide hotline."
Telephone crisis hotlines didn't exist until 1958, when two Los Angeles psychologists stumbled across a bulging file of suicide notes in the coroner's office. Intrigued by the lack of research on rescuing or preventing suicides, they made themselves available for emergency consultation to suicidal patients. Soon it seemed like daytime hours weren't enough, so they set up a phone where patients could call day and night, and manned it with seven staff members. This was the first telephone crisis hotline of any kind, ever. After a few months the paid staff couldn't handle the number of calls, so the doctors trained volunteers.
By trial and error they worked out the principles that most suicide prevention work is based on now. Find out first how lethal a person's intentions are and defuse their plans as quickly as possible. Don't talk about how much there is to live for; ask the callers what their options are. Encourage callers to talk to a different counselor every time they call, so one doesn't get overloaded. Assume that because they called they are asking for help and you have a mandate to save their lives however you can, including tracing the call and sending the police.
Personally, I feel suicide prevention volunteers, like volunteer firemen, are among the truest altruistic community heroes we have. Telephone hotlines are probably the readiest and least manipulative escape valves available for the lonely or depressed. A lot of their value comes form the quality of the people who put in time on them. Most work six to eight hours a week, and the people I've talked to or heard about say they volunteer mainly because they like the other people who work there.
Some volunteers got their start with the drug abuse-bad trip hotlines of the sixties, and drug and suicide hotlines co-evolved, taking methods, enthusiasm and staff people from each other. Other hotlines like poison control or sex information developed later from these.
The upper-echelon professional suicidology scene is more like an academic industry. Edward Shneidman and Norman Farberow, those two Los Angeles psychiatrists who started it all, have 13 books in print on the subject between them. Most are collections of essays by respectable social scientists. Farberow's latest, The Many Faces of Suicide (1980; $21.95 postpaid from McGraw-Hill Book Company, Princeton Road, Hightstown, NJ 08520), says that sky-diving, intervening in violent crimes, drunk driving, prostitution, gambling and taking risks in general are all suicidal, and implies they can be treated psychiatrically.
In suicide prevention much of the training is learning to listen and react to people. You have to ask direct questions, like "What happened next?" instead of trying to smooth over bad feelings. You have to learn to keep someone who sounds apathetic about everything on the phone until you dredge up something they can get excited about. You have to find out what's going on at the other end -- are the callers drinking? Have they abused a child? Are they calling so they can masturbate while they talk to you? -- and you have to find out without making judgement about any of those things.
The end of every call is supposed to involve a contract. The caller agrees they will call again before they try suicide, or they will set a small goal for themselves, like writing a letter, and do it. Or they'll go for therapy. The exception is six percent of people who commit suicide before or during the telephone call. They get the police and ambulance sent to their door.
"Someone calls up and says, 'I just took all these pills and now I don't want to die' -- that's easy," David Nolan said. "They're willing to give you their address. One counselor stays on the phone with them, the other calls for the emergency vehicles. It's a code 3 - lights and sirens - but we like them to turn them off when they get near the house.
"Other times a caller says, 'I just took 50 valiums and I'm drinking a quart of vodka and I want to talk to you while I die.' We don't do that. If we think a life is in danger, we take over. Getting them to tell us where they are depends on the skill of the counselor. 'I need to know where you are and I need to know right now. You are dying.' It's extremely eerie when a person is told he is dying.
"If we have to we will hold them on the line and trace the call. In Marin, tracing takes 30 minutes to two hours, so we usually don't do it. Other places, we hear, are faster. Once it's traced, we tell the people that we are sending over an ambulance. (Not every suicide prevention center tells them, but it's our policy.) 'You called suicide prevention,' we say, 'and you're dying, and I'm sending you some help.' We ask them to turn on the lights and unlock the door. We don't break contact over the phone until the emergency people get there."