Suicide: Main Theme of Meeting in San Francisco May16-18 2013

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Suicide is the 11th leading cause of all death in the United States. It is one of most important issues which mental health professionals are concerned about in their clinical work. The American Academy of Psychoanalysis and Dynamic Psychiatry of which I have the honor of currently being President, has designated the title of its 57th annual meeting as: Psychodynamics: Essential to the Issue of Suicide and Other Challenges to Modern Day Psychodynamic Psychiatry.  It is fitting that the meeting is being held in San Francisco which although not on the top 15 cities with the highest suicide rate does have the Golden Gate Bridge as its symbol which is the second most common suicide site in the world.(see previous posts on this subject)  Any mental health professional is cordially invited to register and attend this meeting (see AAPDP.org) which will take place May 16-18 2013.

images-1Mental health professional must always consider the suicidal potential of any patient especially when that patient is depressed or experiences significant distress. I recall as a junior psychiatry resident when I first was given the responsibility of making a decision to hospitalize  patients (even against their will) because I felt he or she was a danger to themselves (or others). As much as this is a heavy burden, it is likewise a major responsibility not to hospitalize a suicidal patientand face a situation where this person has ended their own life.  In the latter case there also is the possibility of legal consequences.

If a person is determined to end his or her own life, they will ultimately succeed. However when the desire to do it is due to a mental condition that we can treat, there is a good chance that we can prevent the suicide if we can intervene and facilitate proper treatment. Unfortunately this is not always the case since patients who are in treatment or who have had treatment do kill themselves.

Depression is the most common condition which has the potential to lead to suicide. This may be part of biological condition with genetic components which brings about severe bouts of depression. Depression may be part of the grieving process or it may be due to complicated psychological reasons which lead  some people  to be so depressed that they want to end their lifeimages-2.

Sometimes there is anger at a lost object (person) that gets turned inward leading to self destructive acts. When the ability to test reality is lost, the  reasoning for suicidal actions can be quite bizarre and may include internal voices commanding the persons to hurt or kill themselves. There are still other situations where a person does a self destructive act, not with intent to commit suicide but rather with an intent to suffer or manipulate others but inadvertently does die as a result of this gesture. There are certain personality patterns where there may be repeated suicidal gestures which have the potential to be fatal or very harmful. Drugs and alcohol and complicate the problems and may actually be the cause of suicide.

There are some special circumstances where a patient with a serious, very painful  or perhaps  fatal illness may want to end his or her life or may ask the doctor  to facilitate their demise. There are ethical discussions how should this be handled. In some of these situations, if pain and discomfort is better controlled this may not be an issue.

The treatment for a patient with suicidal potential is a delicate situation. First the decision needs to be made if the treatment is to be inpatient or outpatient (sometimes a combination of both). There needs to be a treatment plan that will almost always require psychotherapy frequently with a combination of psychopharmacology. In rare situations ECT (Electric Convulsive Treatment) will be utilized. Family and close friends often play an important role in the support of the person with suicidal thoughts. While psychotherapy needs to be confidential, the patient needs to understand that under certain circumstances where the therapist believes that the patient is an immediate danger to self or others, the therapist may have to break the confidentiality for the benefit of the patient. It goes without saying that there needs to be a trusting relationship with the therapist so the patient understands that there are two people working together in the best interest of the patient.

Many of these  topics and others  are going to be addressed at the San Francisco meeting of the American Academy of Psychoanalysis and Dynamic Psychiatry  May 16-18 at the Westin St Francis Hotel which was mentioned at the beginning of this blog.  All mental health professionals are welcome to register  either in advance or onsite and attend the meeting . Go to AAPDP.org for more information or you can contact me if there are any questions. There will three plenary sessions by Drs Mardi Horowitz, Jeste Dillip and Herbert Pardes as well as  many panels and workshops. There will also be a very interesting documentary about suicide titled, Don’t Change The Subject  with a discussion with Mike Stutz,  the filmmaker after it is shown. A few of these presentations will be made available to Auto-Digest subscribers but if you are able to attend in person, I suggest that you  do so. I look forward to meeting any attendees at the meeting.

 

60,000 Empathic Responses

There is a website titled Postsecrets to which people send artistic postcards with a secret on it. Recently someone from San Francisco wrote a postcard indicating an intention to jump off the Golden Gate Bridge.
There was an outpouring of responses which resulted in special page on Facebook linked to this postcard on which over 60,000 people have responded with words of support. This phenomena as a form of social empathy is discussed.

In a recent blog I wrote about empathy and how we might try to teach medical students to be empathic physicians. Psychiatrists, other physicians and therapists try to put ourselves into our patient’s shoes (or skin) in order to understand how they are feeling in regard to the things which are troubling them. When we do psychotherapy we often approach this with an added dimension. We know that the patient will usually experience the therapist in a similar manner to how they experienced important people in their early life, most probably their parents and/or siblings. Freud has dubbed this situation as transference and for certain types of psychotherapy understanding the transference and using it in the therapy can be very helpful. In fact, for psychoanalytic and much of psychodynamic therapy, it becomes the essence of the treatment.

Social Empathy

I was recently made aware of another aspect of empathy which I never thought about before and which I would now label  “social empathy” . My consciousness to this form of empathy was raised when I read about a blog called Postsecrets which weekly displays anonymously mailed-in secrets on artistic postcards from across the country. It has been around for several years and has long been known for revealing suicidal secrets. It has set up a phone hotline in response since the blog began in 2004. Recently a postcard read, ” I have lived in San Francisco since I was young…I am illegal…I am not wanted here. I don’t belong anywhere. This summer I plan to jump off the Golden Gate Bridge.”  According to a blogger Kristi Oloffson .within 24 hours nealry 20,000 people had signed up for a Facebook group titled “Please Don’t Jump, which was later linked beneath the secret on the Postsecrets blog , linking in thousands of supportive comments. On the group’s page, sympathetic users posted comments ranging from simply “I want you here” to “If I knew when you’d be at the bridge, I’d drive all the way from Ohio to meet you there, and hold you until you changed your mind.”  A video about this phenomena has become the most viewed video on the Time Magazine web site.  ( For information about the issue of suicide from the Golden Gate Bridge please see two previous blogs I have written on this subject , Suicide Jumpers From the Golden Gate Bridge and  More on Jumpers, The Movie ).

I checked it out and sure enough and as of this writing there are more than 60,000 people  who have tuned in to this secret and obviously felt an empathic response which they posted on the Facebook site. It may have been that this group comes from a populations which were drawn to the  Please Don’t Jump Facebook page because  they themselves are in touch their own secrets and feel for someone who has this one.  Others without being aware of their own secret may also just want to reach out to someone else whose pain they can feel. It is also clear that people responding to the would be San Francsico jumper are not mainly other immigrants who are in a similar plight. They seem to come from all age groups, geographic areas and different backgrounds as best as I could tell scrolling through a sample of the now more than 60,000 responses.  I believe that it is the identification with loneliness  and isolation which  is the universal  piece that many people have felt at some time in their life which is connecting people with the San Francisco postcard sender.

Implications For Psychotherapy

I don’t believe that social medial will replace the role of psychotherapy. However, it does appear that there is a natural role that it is playing in the support of people who are feeling psychological pain. This new media is clearly interdigitating with other  forms of psychological support and there is no reason whey they can’t overlap. We should be asking patients if they have had  previous psychotherapy, whether they have been treated by any self help groups as well as including an an inquiry whether they  have been interacting with the social media in regard to their current or other problems.

More on Suicide Jumpers: The Movie

As a follow-up to my November 11th blog about suicide jumpers from the Golden Gate Bridge, this is a review of a beautiful and poignant documentary film titled The Bridge . In 2004, 24 people died from jumping off this famous bridge. Filmmaker Eric Steel and his crew caught the last moments of many of these people’s lives. They also were able to interview many of their friends and families in order to tell their story and the effect on the people who cared about them. Included was a dramatic interview with a 25 year old man who survived the jump and became a spokesperson for suicide prevention. An added dimension to the Netflix DVD are interviews with the camera crew who worked on this project for over a year and were and were greatly impacted by it.

This past November 11ththe title of my weekly blog was Suicide Jumpers From the Golden Gate Bridge. It was based on an article in the American Journal of Psychiatry that analyzed the phenomena  of the large numbers of people jumping from a place  where more people kill themselves than any other in the world.

One of the comments that I received on the blog was from Dr. David Goldberg a psychologist from Birmingham, Alabama who noted that there was a powerful and chilling documentary film titled  The Bridge about this group of people.  I put this DVD on my Netflix queue and just recently viewed it.

The Making of the Movie

In 2003 Eric Steele a film maker living in New York read an article  in the New Yorker titled Jumpers by Tad Friend which described the unsuccessful 50 year campaign to put a barrier on the Golden Gate Bridge to prevent suicides. Steele imagined the human misery that people must be going through as they take their last walk and became inspired to make this film. He gathered the huge amount of equipment that was necessary for this project and journeyed to San Francisco. The BridgeHe placed ads in venues like Craig’s List and gathered a film crew who, while  impressed with the filmmaker, had some trepidations about the project. After obtaining all the permits needed and teaching the novice camera people about the technique, they first encountered the National Guard who thought they were terrorists with 9/11 only two years behind them. After this misunderstanding was clarified they  trained their cameras on the bridge and set up their death watch for the entire year.

24 People Committed Suicide from the Golden Gate Bridge in 2004

In the year 2004, 24 men and women died from the tremendous impact of hurling themselves from the Golden Gate Bridge. Many of these people were filmed as they took their last walk and their final fatal action.images-2 Some appeared to ponder the meaning of their anticipated suicide as they stared at the water or the beautiful San Francisco’s skyline  for varying amounts of time  before lifting themselves over the railing. One man made several cell phone calls before going over. Some appeared to be flailing as they fell, one dove like a bird, another fell backward and  one woman was grabbed back to safety before she could jump by a nearby tourist who happened to be taking pictures

The Fatal Jump and the Pain of Family and Friends Captured on Film

The end result of this project was a beautiful and poignant film, which not only captured the last moments of these troubled folk’s  lives but also was able to tell their stories and show the impact on the people who knew them. The filmmakers were able to gain access to many of the families and friends of the ill-fated twenty four people who ended their own lives. They created an atmosphere where these people seemed very comfortable talking to the film makers and talk they did.

As I watched the 94 minute movie unfold, I was initially listening with my clinical ear. This person obviously was schizophrenic, that person had a bipolar condition and another person was a methamphetamine user. It registered on me how many were taking their medications or appeared to be under vigilant psychiatric care. Others seemed to be making the decision to jump after they stopped their medication. One woman couldn’t sleep because of side effects of medications. Were they giving clues as to their intent? Was there a history of a cry for help.? At first I was thinking to myself wouldn’t this film be ideal to show to mental health professionals because it has so many good clinical vignettes.

But probably a images-3quarter of the way into the film, I easily put aside my intellectual analytic approach as I felt the emotions of  the personal stories. I became  acutely aware of the continued  suffering of the victims who eventually chose to go over the rail and so much of the deep pain of those who knew them quite well. My heart would race as the camera scanned the faces of those looking out into the abyss, never knowing which one would be the one who could bear living no longer and would suddenly lift themselves up and leap into the water. I was deeply saddened as I heard the parents who understood the hopelessness of their child who ultimately took the plunge. I could feel the frustration of the people  who had dealt with previous suicidal threats of friends but didn’t think that they would ever do the deed. Although no clinicians of the jumpers were interviewed I could empathize with the therapists who must have know that some of these people were chronic suicidal risks but had chosen or felt that they had no choice but to do their best to treat then as outpatients.

The Story of One Who Survived the Jump

Probably the most dramatic part of the film was an interview with a 25 year old man who survived a jump from the bridge and ultimately became a spokesperson for suicide prevention. He had a bipolar disorder and was suicidal many times before and had depressive episodes at least three times after the jump. His story was similar in many ways to the case reported in the journal article I mentioned at the beginning of this blog but was actually a different person. Bridge survivor The moment he let go of the rail of the bridge and began his descent, he regretted his decision. He miraculously successfully positioned himself to hit the water in a survival position although going probably at least 120mph . He fractured bones and vertebrae and his initial survival was apparently aided by a seal which held on to his body while rescuers were arriving. There also was an interview with his father who received the word that his son jumped from the bridge that should be inevitably fatal but he was told he was alive. He will never get over what has happened that day nor will all those who knew the other fatal jumpers. Most will get on with their lives, some with therapy, some without but no one will forget .

It is All on Netflix With Three Special Features

Netflix DVDs often have some extra features which in this case consisted of an interview with the filmmaker Eric Steel, another of a brief public service announcement for suicide prevention by the guy who survived the jump and a third piece which were interviews with the young men and one women who were the camera crew over this year project. They did not quite realize what they in for when they signed up for this gig. They told of their initial experiences of scanning the faces of so many “suspicious“ people who  might be potential jumpers, as they had  one finger on the their cell phone connected with speed dial to the bridge police and the other on the camera button. They did capture the last moments of people jumping from bridge which appeared to have a profound impact on them. One of them said that he is  sure they will live with that experience for the rest of their lives.

Impact on  the Camera Crew

Those of us in the mental health field know how dealing with traumatic events can have a long lasting effect on the observers. We sometimes set up group discussions for the helpers and on occasion some personal therapy may be useful for such caretakers. At various times in the past I was involved in providing such services for members of our burn unit at a hospital where I worked as well as nurses working with dialysis and transplant patients and also various personnel including members of the media after the World Trade Center attack in New York. We know that most people have the resiliency to come through such  event without requiring formal therapy but it should be Bridge editavailable when needed.

While this camera crew may carry indelible memories of what they have seen, they have also , helped to make these tragic events a little bit more understandable to the people who see this film whether they be lay people or mental health professionals. So in some way they have allowed the abrupt tragic ending of troubled lives to have some beneficial meaning to future generations.

Suicide Jumpers From The Golden Gate Bridge

The Golden Gate Bridge is probably the most popular suicide site in the world. By the year 2008 approximately 2000 people had jumped off the bridge and committed suicide. 99% of the jumpers from this bridge do not survive. A recent article on this subject in the Journal of the American Psychiatric Association by Drs. Mel Blaustein and Anne Flemming is reviewed in this blog. The building of a barrier to prevent suicides at this bridge is also discussed. Understanding and preventing suicidal behavior is the goal of all mental health professionals. A quotation from one of the few people who survived a jump off the Golden Gate Bridge makes the case for making every effort to identify and help people who are suicidal.

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About year ago we took a family vacation in San Francisco and I walked across the Golden Gate Bridge with my granddaughter who was just becoming an avid reader. At various intervals on the walk we encountered a  suicide hotline telephone and a sign which said There is Hope. Make the Call. The Consequences of Jumping From This Bridge are Fatal and Tragic. This put me in the difficult position of trying to explain to a seven year girl why people might want to kill themselves and why do they choose this bridge to do it.

I first encountered this special characteristic of this beautiful bridge during my rotating internship at San Francisco General Hospital  when I had the opportunity to examine would-be jumpers who were brought to the ER or to the Psychiatric Service. An update on knowledge known about this subject, some of which I will discuss in this blog, just came out in the October 2009 issue of the American Journal of Psychiatry in an article titled Suicide From the Golden Gate Bridge by Drs. Mel Blaustein and Anne Fleming.

It Wasn’t Suppose to be A Place For Suicide

In 1936, Chief Engineer Joseph Strauss wrote, The Golden Gate Bridge is practically suicide proof. Suicide from the bridge is neither possible nor probable. It turned out however that the Golden Gate Bridge is the most popular suicide site in the world. By 2008 it was calculated the number of suicidal deaths form this bridge was close to 2000.

The bridge is really quite an accessible site to someone determined to use it for suicide. It has a pedestrian walk, a four-foot railing, a bus stop and a parking lot.

What is the Attraction of This Bridge For Suicide?

It certainly is a beautiful bridge offering breathtaking views of San Francisco, Oakland, Berkeley, Alcatraz and the San Francisco-Oakland Bay Bridge as well as the Pacific Ocean. There is often a morning and evening mist. It may be the most photographed man-made structure in the world.

Between 2005 and 2008 Dr. Blaustein interviewed 63 people who had threatened to go to the bridge to commit suicide. 49 of them were male with a mean age of 38. The reasons that they gave for selecting the bridge included accessible/easy (N=36), romantic (N=15), painless (N=6), other reason (N=16). It is quite doubtful that it is painless. Jumpers fall over 200 feet and hit the water in 4 seconds at 75 mph. They die from massive injuries to the chest, heart, central nervous system (spine and brain) or by drowning. The fatality rate is 99%. One report of an interview of 6 of the survivors revealed that all of them said that their suicide plans involved only the Golden Gate Bridge.

People who commit suicide from the Golden Gate Bridge do not have a greater degree of mental illness than suicides in general. 40 % were under psychiatric care at the time of their deaths. 22% had made prior attempts and 25% had left suicide notes. The majority of them were believed to have been employed. Suicide jumpers at the Golden Gate Bridge according to the Blaustein & Flemming article come from all walks of life including a county medical society president, a pastor of a Lutheran church, a president of the Oakland Real Estate Board, the founder of Victoria’s Secret and the son of President Kennedy’s press secretary.

I use to think that San Francisco was a magnet for people from all over with problems and those who wanted a try a new lease on life. I had thought that perhaps suicide from the bridge might be more likely to occur in those who came there and still couldn’t deal with their problems. However it turns out that mostly local residents commit bridge suicides.  Only 5% of jumpers between 1995-2005 were non-Californians. Apparently there are similar statistics at Niagara Falls where during one time period the 141 people who committed suicide lived within a 10-mile radius of the Falls.

Will a Special Barrier at the Bridge Prevent Suicides?

Many people have wanted a barrier to be built at the Golden Gate Bridge to prevent people from jumping off the bridge. Barriers have been shown to reduce suicides at a given location. Barriers at the Eiffel tower, Empire State Building and the Harbor Bridge in Sydney, Australia have virtually eliminated suicides at these locations. However, clinicians have known that if people are determined to kill themselves, there is no foolproof method of stopping them from eventually carrying out this desire.

That being said, many studies have shown that reducing a lethal means can reduce suicide statistics. When non-lethal gas was substituted for coal gas, which was previously known to be the cause of 1/3 of suicides in England, the suicide rate fell 25%.  Building a suicidal barrier at the Duke Ellington Bridge in Washington D.C. reduced the number of suicides in a seven year period from twenty-three to one. The suicide rate from the nearby Taft bridge that doesn’t have a suicide barrier did not increase Similar examples are sited from Augusta, Maine, Bern, Switzerland and Bristol, England.

One study examined 515 people who were restrained by police or bridge workers from jumping off the Golden Gate Bridge between 1937-1971. As of 1978 94% either were still alive or had died of natural causes. Only 6 % were believed to have subsequently committed suicide.

Blaustein and Flemming in their excellent article offer some suggestions as to how a barrier at the Golden Gate Bridge might work to prevent suicide beside the obvious one of blocking access to a lethal method of killing oneself. They note that even if people were diverted to another method to attempt suicide, it is likely that such a method would be less lethal. They also discuss the theory that suicidal individuals may interpret a barrier as a “sign of care” and possibly reduce their despair. Finally they speculate that certain sites such as the Golden Gate Bridge may become suicide magnets and may even catalyze or amplify suicidal feeling in vulnerable individuals therefore a barrier at such a site could be effective in reducing suicides.

In October 2008 an effort by many organizations led by the Psychiatric Foundation of Northern California was successful in getting the Golden Gate Bridge Board to approve the construction of a suicide barrier. Environmental studies and a funding plan need to now be developed before it can be built.

Understanding Suicidal Behavior and Preventing It

Psychiatrists and other mental health professionals have been studying suicide for many years with the hope that the more we understand it, the better that we will be in treating suicidal people and preventing suicide. We believe that the treatment of depression with medication, psychotherapy and often in combination is probably one of the more effective deterrents to suicide.

Research has shown that there are biochemical differences in various parts of the brain in people who become suicidal. There also has been evidence that higher levels of impulsive aggression in individual as well as a family history of suicidal behavior appear to be predictors of suicidal behavior in individuals. These characteristics are not simply explained by the presence of depression. It also has been shown that a history of childhood sexual abuse can be associated with subsequent suicidal behavior as an adult.

Do Ask and Do Tell !

Mental Health professionals know that one of the best methods of determining if someone might be suicidal is to ask them. It is a misconception that when a caring person inquires about suicidal thoughts, this will somehow give a person this idea or intensify any such tendency. Much more likely, the presence of someone who cares enough to ask them will make it possible to get that person to accept help.

We know that people who are depressed do come out of this bleak mood. Not only does the support of others make a difference but also treatment for depression does work. This is why the irreversible act of suicide is all the more tragic. Perhaps this is best illustrated by the words of one of the few people who survived a jump off the Golden Gate Bridge as reported by Blaustein and Flemming in the American Journal of Psychiatry.

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I just looked out over the water to the city and it was beautiful. I felt that this was the right time and place to kill myself. The last thing I saw leave the bridge was my hands. It was at that time that I realized what a stupid thing I was doing and there was nothing I could do but fall. The next things I knew I was in the water hoping that someone would save me saying, “Please God, save me, somebody save me.” It was incredible how quickly I had decided that I wanted to live once I realized everything that I was going to lose, my wife, my daughter, the rest of my family.

This man is currently in his 30th year of marriage. He is a high school teacher and part time coach. His daughter is an elementary school teacher.

Your comments are welcome.