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— Boston Globe
"Rigorous, wide-ranging, informed, and humane...Provides much sorely needed wisdom; it will not arrest the crisis, but it could save some lives."
— Andrew Solomon, author of The Noonday Demon: An Atlas of Depression
"An utterly fascinating, admirably well-written, and sad book...The literature on the subject — and the survivors — are greatly enriched by his evocative treatment of it."
— The New York Times Book Review
During the months that followed September 11, 2001, I could not help noticing what pains the op-ed pages of America's newspapers took to make clear that the terrorists who steered jets into the World Trade Center towers and the Pentagon were not real suicides. The implication was that these men had nothing in common with the troubled souls we think of -- and feel compassion toward -- when we hear the profoundly unsettling word suicide.
It is understandable that we would be reluctant to find any commonality between unhappy people who deserve our sympathy and mass murderers -- and, to be sure, there are great differences. And yet the terrorists were suicides, albeit of a particular but hardly unique strand in the history of self-destructive behavior. Indeed, the post-9/11 editorialists seemed unaware that for much of recorded history, suicide has been seen primarily not as a private act of desperation but as a public statement with a larger social meaning. Suicides have often been depicted not as miserable, helpless victims but as rational masters of their own fates, sacrificing themselves in the name of protest, idealism, or subversion by committing what the French sociologist Émile Durkheim called altruistic suicide (a difficult label to apply to the events of 9/11, but, from its executors' skewed perspective, an accurate one). These terrorists were nothing new -- except, perhaps, in the magnitude of their destruction.
To find an analogue, one need look back only fifty years to the kamikaze, the Japanese pilots who flew their fighter planes into American aircraft carriers in the South Pacific during the waning months of World War II. One could, of course, look much further back, to the early Christian martyrs, who believed that by killing themselves they would receive posthumous glory and enter the kingdom of heaven in a state of blissful sinlessness. (Indeed, so many Christians killed themselves in the first few centuries AD that the church was forced to redefine suicide as a mortal sin.) By contrast, the contemporary terrorist earns cultural veneration for killing others, and his suicide is merely a lethal side effect. By the standards of antiquity, the September 11 hijackers could well have seen themselves as modern versions of Samson, who knew that when he pulled down the Philistine temple, he, too, would die.
At the same time, they -- along with the Palestinian, Iraqi, and Tamil suicide bombers who populate our front pages -- may not be as different as we might think from the despondent, often psychiatrically distressed people we consider to be "typical" suicides (as if there were such a thing). As time has passed, a more complex picture has emerged in which such terrorists appear to be neither selfless martyrs nor (as the 9/11 editorialists would have it) vindictive cowards but troubled young men and, occasionally, women who, finding little meaning in their lives, are psychologically and culturally primed to be swept away by a cause, especially one whose apparent largeness of purpose might lend them dignity. They are less akin, perhaps, to clear-eyed Cato and the other so-called rational suicides of antiquity than to those cultists who swallowed poisoned Kool-Aid and followed Jim Jones to their deaths in the Guyana jungle, or to the harried zealots in Waco, Texas, who, at the behest of a charismatic leader named David Koresh, fired on federal agents until they were themselves killed. In their confusion, rage, and feelings of powerlessness, they had something in common with the boys who turned their guns on their schoolmates at Columbine High School before turning them on themselves. In some ways, in fact, they may not be that far removed from any despairing person who looks, often in the wrong places, for something that will lend his life meaning and ends up finding death.
Though their motivations may differ, people who kill themselves, whether they are suicide bombers or depressed teenagers, believe -- mistakenly -- that there are no alternative paths. Indeed, in the months after 9/11, my mind kept returning to those men and women on the upper floors of the World Trade Center who, with fire behind them, jumped to their deaths. This seemed to me the literal expression of the psychological experience faced by most suicidal people: they feel they have no choice.
I raise these points as a way of suggesting that when it comes to suicide, there is very little new under the sun. Suicide has likely been with us as long as life and death have been with us. In the fifteen years since the original version of this book was published, the essentials haven't changed. People are killing themselves at about the same frequency, in about the same ways, and for about the same reasons as in 1991. At the same time, there have been a number of developments in the intervening years that make updating and revising this book not only worthwhile but necessary.
In 1991, Americans were horrified by the soaring rate of adolescent suicide, and by the way these suicides seemed to come in bunches. Schools were rushing to get suicide prevention programs into place; the question of how these programs worked -- or whether they worked at all -- was just beginning to be asked. Since then, the adolescent rate has plateaued and fallen, there has been a wealth of new research into the causes of youth suicide, and the debate about how to prevent it has been heated. These developments will be discussed in part one. Nevertheless, the adolescent rate remains far higher than it was in the 1950s, and communities continue to be devastated by clusters of teenage suicides.
When this book was first published, suicide was understood to be caused by a variety of psychological, sociological, biological, and spiritual factors. Fifteen years later, the conceptual framework hasn't changed, but the relative emphases on these factors have shifted. The past decade has seen an expanded understanding of the biological ingredients of depression and suicide. Part two brings the history of suicide up-to-date by describing the work of neurobiologists who track down chemical changes in the brain that tell us why some people may be more prone to taking their own life. Part three, which discusses the range, patterns, and motivations of suicidal behavior, has been updated to reflect current trends: for instance, that suicide rates are growing in rural areas; that gay suicide is a subject of increasing controversy; and that rates in many of the former states of the Soviet Union have become the highest in the world.
When I originally wrote this book, Prozac, the initial entry in a class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs), had recently been introduced. These new medications have undoubtedly saved many lives; some credit them with the drop in the adolescent suicide rate. But they have not come without controversy. Several studies have suggested that though the SSRIs are more effective than their less sophisticated predecessors in reducing depression, they may actually be responsible for triggering suicidal behavior in some young people. The advent of the SSRIs has encouraged a related development. Fifteen years ago, the treatment of depressed and suicidal people, to be discussed in part four, usually involved a combination of psychotherapy and psychopharmacology, working in a more or less equal (if at times uneasy) partnership; since then, the biological approach has become ever more dominant. The result of the trend toward medication, reinforced by the ascendancy of HMOs, which emphasize treating mental health in primary-care settings, is that a suicidal person today is far more likely to be treated by an internist or a family physician than by a psychiatrist, psychologist, or social worker.
When this book was first published, it had been only a few weeks since the Hemlock Society, a group advocating the legalization of physician-assisted suicide and euthanasia, had published Final Exit, a manual for the terminally ill that offered detailed instructions on how to take one's own life. It had been only ten months since Jack Kevorkian had used his suicide machine to carry out the first of his more than 130 so-called medicides. Yet only the most optimistic right-to-die advocate -- or her most pessimistic opponent -- could have foreseen that within three years, Oregon voters would make it legal for doctors in their state to prescribe lethal doses of medication for terminally ill patients. Perhaps nowhere in the field of suicide has there been a more dramatic evolution than in what has been called the right to die. Although the ethical issues have changed little in fifteen years -- or in fifteen centuries -- the legal and practical developments have come at an astonishing rate. Not surprisingly, the right to die, which will be discussed in part five, remains a raw and contentious subject, as evidenced in the collective national hysteria occasioned by the case of Terri Schiavo in the spring of 2005. Indeed, as this book went to press, the Supreme Court was due to hear an appeal by the federal government that would, if approved, essentially void the Oregon Death with Dignity Act.
In 1991, the devastated friends and family members left behind after a suicide were just beginning to speak out. Since then, survivors of suicide, as they are known, have become a powerful voice in suicide prevention: advocating for research, bringing attention to depression and suicide as public health issues, and chipping away at the stigma that has encrusted the subject of suicide over the last two millennia. Their story is told in part six.
When I began the reporting for this book, my personal experience with suicide was minimal. In the years following its publication, this seemed to surprise and, occasionally, even to disappoint people. Just a few months ago, a man I met at a dinner party, who had himself suffered suicidal depression decades earlier, challenged my right to write about a subject with which I had no intimate experience. I explained that my book was not a memoir but a work of journalism, in which I had sought out and learned from those people who had had intimate experiences with suicide. I also explained (as I wrote in the preface to the first edition) that I believe all of us, to varying degrees, have been touched in some way by suicide -- whether someone we know has considered, attempted, or completed suicide; whether we have considered or attempted it ourselves; or whether we've acted in self-destructive ways that fall short of the actual act.
Since the book was published, however, I have, unfortunately, had closer contact with the subject. One of the people I love most in the world made what researchers call a "nearly lethal" suicide attempt. (He survived and, with the help of psychotherapy and antidepressant medication, put a life back together that is now full and happy.) Several years later, my beloved mother-in-law, a member of the Hemlock Society, took her own life while suffering from terminal breast cancer and Parkinson's disease. In the former instance, I experienced a kind of sorrow that made my previous experiences of sorrow seem unworthy of the word; in the latter, my sadness was leavened by the knowledge that my mother-in-law had ended her life with the determination and independence with which she had lived it. These experiences made me return to this project both with a greater admiration for those who have struggled with self-destructive impulses and with a more profound empathy for those whose lives have been bruised by suicide, including -- and especially -- those people I interviewed for these pages. Although I did not say this to my dinner companion, if I had had that loss and that near loss before I had started work on this book, I suspect I would never have been able to write it.
This book was originally published as The Enigma of Suicide, a title selected by its publisher. I would like to be able to say that I changed it for this edition because it was no longer true. Alas, despite the strides we have made over the last fifteen years, suicide remains an enigma. The first time around, I had hoped the book could be called November of the Soul, a phrase that for many years had struck me as an uncannily accurate description of the feeling that lies at the heart of that enigma. This time my publisher agreed.
On the first page of Moby-Dick, Ishmael describes the onset of a morbid depression that makes him pause before coffin warehouses and bring up the rear of every funeral procession he meets. He calls it a "damp, drizzly November in my soul." Whenever that feeling comes over him, Ishmael knows what he must do. "Cato throws himself upon his sword," he tells us; "I quietly take to the ship." Would that all suicidal people knew they had a choice other than death.
Copyright © 1991, 2006 by George Howe Colt
Preface to the First Edition
1 Adolescent Suicide
II The Slot Machine
IV Something in the Air
VI "Use the Enclosed Order Form to Act Immediately.
You Could Save a Life"
VII Beginning to Close the Door
I Primitive Roots: The Rock of the Forefathers
II The Classical World: "He Is at Liberty to Die
Who Does Not Wish to Live"
III Renaissance and Enlightenment:
"It Is His Case, It May Be Thine"
IV Science: Moral Medicine and Vital Statistics
V Faith, Hopelessness, and 5HIAA
3 The Range of Self-Destructive Behavior
I Winner and Loser
II Under the Shadow
III The Manner of Dying
IV The Numbers Game
V Backing into the Grave
IV Social Studies
V Life or Liberty
5 The Right to Die
I A Fate Worse Than Death
II "Your Good End in Life Is Our Concern!"
III "The Limits Are Obscure...and Every Errour Deadly"
IV A Model Hemlock Couple
I Merryl and Carl
II The Mark of Cain
III Merryl: The Torture Chamber
IV The O'er-Fraught Heart
V Merryl: The Jigsaw Puzzle
VI A Safe Place
VII Merryl: The Building Blocks
VIII A Place for What We Lose
IX Merryl and Carl