Not Always a Cry for Help

This is not your grandmother's take on suicide. It's not just a
whole new way of looking at suicide, it's a counterintuitive view of
self-destruction that makes many mental health professionals
squirm.

But in nearly 20 years of studying threats, attempts and events
leading up to the deaths of young people who killed themselves, and
implementing policies to prevent it, psychologist Paul Joffe, Ph.D., has
come to see that suicide isn't always a cry for help. Sometimes--perhaps
more often than not, especially among people of college age--it's an
instrument of power and control.

The idea that pain and distress lead to suicide makes so much
common sense that no one stops to question it, says Joffe, who is head of
the suicide prevention team at the University of Illinois and a clinical
counselor in the student health center.

"If suicide is a cry for help we should wait and assume that person
is going to come in on their own as soon as they make that cry," he
recently told a national conference on Depression on College Campuses,
which was sponsored by the University of Michigan. There's only one
problem. Evidence he has gathered and scrutinized shows that they don't,
certainly not on their own. "They refuse to make use of
resources."

And it's not because of stigma, he insists. Rather, it's part of a
longstanding dance with death, what's known in the psych biz as a
"suicide career." These are not victims but masters of their own fate,
people for whom the thought of suicide takes up long-term residence in
the brain and for whom the risk of suicide doesn't fade after a threat or
attempt. Suicidal intent is less a natural response to distress than a
"virulent ideology." "Suicidal ideation hardens into a stiff shell of
belief. These students feel good about suicide. It makes them feel in
control," Joffe says. They contemplate, fantasize, plan, practice and
rehearse taking their own lives.

Because they have been thinking about it for years, suicide becomes
part of their personal identity. They feel proud of the power to control
their own fate. They feel superior to others in that they have this
avenue of power that others don't.

"A young adult committing suicide is in a basic power struggle
either with their feelings or the environment around them," Joffe claims.
"They're basically saying, 'You can't fire me; I quit. You can't control
how I feel; you can't direct the circumstances around me. I'm going to
trump you by making myself unavailable to those consequences.'" It's not
so much a matter of a person being in so much pain they can't see any
other option. It's more a refusal to accept either emotional or
interpersonal consequences.

"It would surprise campus administrators to know that while
suicidal student might or might not feel distressed about conditions in
their lives, they generally don't feel distressed about being suicidal.
Many will openly admit that being suicidal; it's one of the few, if not
the only, bright spots in their lives."

Joffe began his career as a psychologist by examining coroner's
reports and other data on 19 University of Illinois students who had died
by suicide between 1976 and 1983. Most had demonstrated prior intent to
kill themselves. Twelve of the 19 had made overt attempts before their
successful one. None had seen a counselor on the university staff.

When, in 1984, the university became the first to introduce a
formal suicide prevention program, the goal was to "invite and encourage"
students to meet with psychologists after a suicide threat or attempt. In
the three months the program existed in that form, it was "totally
ineffective" at increasing the rate of contact.

But when he did manage to contact students who had recently made a
suicide threat or attempt, Joffe couldn't miss a power struggle, a
"contest of privilege." Students would deny they had made threats despite
hard evidence, such as suicide notes and eyewitness accounts, they had
done so. Or they'd dismiss threats as "ancient history." Or with a
"ferocity of response," they would tell him "you have no right here; this
is my right to do this. It's not an area of my life that I'm going to
discuss with you."

Or they would agree to make an appointment with a counselor but not
actually do it, or make an appointment and just not show up. If they kept
the appointment they would never even discuss the fact of the suicide
threat. "If suicide was a cry for help and we were offering help, they
weren't accepting. We met denial and resistance. It was a power struggle
to make contact and to talk about what happened."

Even if you stick to the belief that suicide is a distress signal,
in its nature and style the request for help has a power-and-control
aspect as well, observes Joffe, "Most of us ask for help
straightforwardly; we put it on the table that there is some kind of
need."

But asking for help by engaging in self-destructive behavior has a
compulsory aspect to it that hijacks the interpersonal environment. It's
tantamount to saying, "Well, you have to help me because the stakes are
so high and my life is on the line."

Looking at it this way has enabled Joffe to evolve a suicide
prevention program that is singularly effective. The new policy,
implemented in October 1984, abandoned "invite and encourage" and
mandates four sessions with a counselor by all enrolled students who
attempt or threaten suicide. The first appointment must be within one
week of the incident or release from the hospital and the remaining
assessment at weekly intervals.

Students are informed that if they don't follow through they risk
withdrawal from the university. The program takes considerable effort;
sometimes a counselor has to make 20 phone calls to get a student to
complete four visits.

It has cut the death rate by more than 55%, while the suicide rate
at other universities has remained stable over the same time frame. In
the seven years before the suicide prevention program was started, there
were 16 suicides at the University of Illinois, or 2.3 per year. In the
18 years since, there have been 19 suicides, or 1.05 suicides per
year.

The program has been 100% successful in eliminating suicides among
students who engage in "public rehearsals" prior to their actual suicide.
The suicides that have occurred have been limited to those that were "out
of the blue," in which the students made no prior attempts or
threats.

The percentage of students in therapy following a suicide attempt
is now more than 90%. By contrast, a mere 5% engaged in therapy before
the program was instituted.

Now in its nineteenth year, the program has had experience with
1,531 reported incidents. Twenty students, all of them male, have
died--representing an overall decline in suicide deaths of 55%. All 20 of
the completed suicides were so-called "out of the blue," or
unforeseeable, in which the students had never had prior contact with a
mental health professional.

The dramatic decline of suicides at Illinois stands in high
contrast to what has been going on elsewhere during this time. The
national rate of suicide among all 15- to 24-year-olds increased 2%. The
suicide rate among students at Big Ten universities increased 9%.

While the program has been remarkably successful in reducing
suicides among undergraduates, it has not impacted deaths among graduate
students. These students are more private about their intent.

The conventional "distress model" of suicide is actually dangerous,
Joffe contends. To regard threatened or attempted suicide as a cry for
help that flows naturally from overwhelming distress invites compassion
and pity. But not attempts to challenge that or intervene--because of the
prevailing belief among professionals that that just might push someone
over the edge, that the suicidal are fragile and on the brink and the
caring response is to pull back and support them.

But to Joffe, the suicidal students he dealt with didn't seem too
frail, certainly strong enough to engage in a power struggle. And he came
to see that "it doesn't pay to give that person that kind of power.
There's a community responsibility to challenge that person and to make a
statement about violence and violence to yourself." He thinks the
community-based challenge to the student's privilege to heap violence
upon himself may be the most important ingredient of success.

The program not only saves lives, it keeps students in the
educational system. What it isn't is politically correct. It recalibrates
rights and responsibilities to put some responsibilities on
students.

In general, universities promote rights and privileges, Joffe
asserts. While agreeing with that general trend, his program singles out
two areas in which responsibility is emphasized. One is that students
have a responsibility to self-welfare, self-guardianship and self-care.
The second is that they have a responsibility to the university community
to carry themselves in a way that is not violent or disruptive.

Students are held accountable. Among those students who have
threatened or attempted suicide, protecting themselves becomes a
condition of living in the community. That's the leverage a college can
exert: as the University of Illinois does, it can make self-guardianship
a condition of continued enrollment.

It's the standard of guardianship that is novel. "The main problem
with suicide prevention is that in the absence of a standard of
self-welfare, there's little the mental health community can do to help."
He points out that suicide prevention has something to learn from
statutes to prevent cruelty to animals. "In at least 48 states, it's now
a crime to commit violence to companion animals, and in six states
there's mandated treatment. The privilege of ownership that permitted
violence towards a pet has been replaced by a standard of guardianship.
Something similar needs to happen with suicide. Perhaps we don't have the
privilege to harm ourselves."

College and suicide are "unlikely companions," says Joffe. College
is a time of promise and hope. Suicide is seen as the last resort of the
hopeless. If college is an unlikely setting in which to commit suicide,
it is the ideal setting in which to prevent it.

Phil Satow agrees. Satow knows a lot about suicide, and he learned
it the hard way. He runs the Jed Foundation, named for his son, who
committed suicide "out of the blue" while a student at the University of
Arizona in 1998. The foundation has a very clear mission: to dramatically
lower the suicide rate on college campuses.

He thinks Joffe's approach to dealing with kids who talk about or
attempt suicide is necessary. And he admires Joffe's concept of
self-guardianship. "You have a responsibility for taking care of
yourself," says Satow. "It becomes part of the culture of the campus. And
you take care of other kids in the community. That creates a healthy
environment."

But no single approach to preventing suicide is sufficient. Satow
contends that the long-term answer is not waiting for kids who attempt
suicide. He would go all the way to having prevention strategies that
change the culture on campus to promote health.