By John N. Brewer

That statistic equates to more than 30,000 deaths per year. In Oklahoma, suicide claims the lives of more than 450 Oklahomans annually. Recent statistics reflect that one member of the Oklahoma Bar Association dies from suicide each month. The ripple effect of suicide spreads grief throughout the family and circle of friends of the decedent. All of the surviving family and friends are victims of the tragedy. It is estimated there are 4.47 million survivors of suicide in the United States (those who have lost a loved one to suicide). In many cases, the suicide becomes a “hush-hush” matter because suicide can carry an unfortunate stigma. Anyone who has not experienced a suicide by a family member or friend is fortunate.

In 2000, there were more suicides than homicides in the United States. It was the 11th most frequent cause of death for both genders; eighth for men; third for young people aged 15 to 24. The thought of a young person, with a lifetime of opportunity ahead, succumbing to suicide is a sad thought. More than half of all completed suicides occur in males aged 25 to 65. However, females attempt suicides more frequently. A startling statistic involves firearms stored in the house. Fifty-four percent of people who die by suicide use a firearm, and guns stored in the house are used 40 times more often for suicide than for self-protection.

Take note that this article will not use the term “commit suicide.” One does not commit suicide, s/he is a “victim of suicide” or “succumbs to suicide” or terms of similar character. The term “commit suicide” ignores the reality of the circumstances leading to the end result of suicide.

The stigma associated with mental illness and suicide works against prevention by discouraging persons at risk for suicide from seeking life-saving help and further traumatizes survivors of suicide.

Consider the impact of the following personal account by a member of the OBA.

SURVIVING SUICIDE

I was running some errands when I got the call. I needed to come home right away. When I got home, he sat me down and told me my twin sister was dead, she had killed herself. At first, I did not believe it. There had to be some mistake. I just spoke with her last night; there was no hint of anything wrong — or at least, nothing out of the ordinary. When it was confirmed a few minutes later, I was devastated. But still, there was denial. No, this couldn’t have happened; she would never kill herself; she would never do that to me; they are wrong; someone else must have done this; this couldn’t have happened; why didn’t I know?

My sister, Rose, was living 1,500 miles away in Toronto. She had gotten married a few years before, and there had been some rough patches. But she had so many friends; had just completed a tough exam for professional certification and was one of the first to pass. She was in counseling but was getting better — in fact, the doctor said she was planning to end their sessions in a few weeks. I was working too hard with two small children at home. I had been distracted when she had called the night before. I had invited her down; told her I could come up in the spring; told her of plans for my daughter’s seventh birthday party.

I have played that last conversation over and over in my mind, questioning why we spoke of such trivialities. I wonder — where were the clues that I missed? On the plane, all I could think was… if you had told me you needed me I would have been on the next plane — here I am, on the next plane — why didn’t you let me know?

No one knew. Not her friends, not her co-workers, not her husband; not her therapist. After her memorial service at the hospital where she worked, everyone came up to me — from the president of the hospital to the janitor — to let me know how special she was. That was Rose — she never met a stranger. Her kindness and compassion toward others was truly remarkable. Why couldn’t she show the same kindness and compassion toward herself?

Of course there was the pain and the grief. And there was the surrealistic feeling of being a ghost in my sister’s world. We looked so much alike — it was upsetting to some and comforting to others. I am lucky — I don’t need photos — just a mirror to see her. Although we had lived apart for many years, I had always believed we would grow old together. I still miss her. But, I have learned things from this experience. And, as it may help others, I will share what I think I know.

Time helps. It gets better. Really, it does. Counseling and medication can be helpful or not, but time will always help one to heal. I found the medications to be disorienting; some of the counseling was idiotic. The suicide survivors support group was the most helpful. But it was time which helped me to heal and granted me perspective.

People kill themselves because they feel they have no other choice —well, that’s not exactly right; they feel they have the choice of more pain or ending pain. Their vision has telescoped so those are the only two options they see. They cannot endure more pain, and the only other option they can see is death (I think it moves the pain from the suicide to the loved ones, but that’s not the point). Some people can be stopped if reached in a timely manner; others cannot.

The coulda/shoulda/wouldas will eat one up. Take the time to spend time with friends and loved ones. Anything can happen. No one lives forever. You may have to accept that you will never know “the reason” — which straw breaks the camel’s back? Your heart will know that if you had known, you would have done something. Rose gave me no chance; gave off no clues. She was getting better, getting on with her life, her career. She appeared fine; her closest friends had no hint that she was planning to kill herself. There was no note, no final explanation. But she knew I would be there and cleaned house and had all her important papers ready and at hand.

I also learned that what a person gives you is always yours, even if that person is no longer around. My sister’s love and wisdom are still with me. Rose’s death taught me compassion. And, I learned that how a person dies is not as important as how a person lives. Perhaps that is the greatest lesson.

THE SIGNS

The recurrent theme with persons who have attempted suicide is the word “pain.” Mental pain can be excruciating and is just as real as any other type of physical pain. It is also persistent if untreated.

Suicide can be prevented, and caregivers are constantly searching for better ways to help. The feelings that lead to suicide are complicated and may include psychological, biological and social conditions. Effective suicide counseling will include medication, counseling and social support. Up to 90 percent of people who commit suicide have a treatable mental illness. These conditions are often undiagnosed, untreated or both. Mood disorders and substance abuse are the two most common conditions. Schizophrenia, depression, schizoaffective and bipolar disorders have a biochemical cause and are treatable. When both mood disorders and substance abuse are present, the risk for suicide is much greater, particularly for adolescents and young adults. Research has shown that when open aggression, anxiety or agitation is present in individuals who are depressed, the risk for suicide increases significantly.

Some of the behaviors to watch for are:

The risk for suicide is greatest for people who feel hopeless about the future, or individuals with mental illness who have recently been discharged from a hospital. In addition, those with a family history of suicide or anyone who has made a previous attempt are more likely to attempt suicide in the future.

SOME BACKGROUND ON MENTAL ILLNESS

The term mental illness refers to a disease of the brain. Our culture often views mental illness as the result of some sort of moral weakness. In reality, it is a medical disorder of the brain. Mental illness is more common than the average person realizes.

Schizophrenia is a devastating brain disorder that affects approximately 2.2 million American adults, or 1.1 percent of the population age 18 and older. Schizophrenia interferes with a person’s ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions and relate to others. The first signs of schizophrenia typically emerge in the teenage years or early 20s. Most people with schizophrenia suffer chronically or episodically throughout their lives and are often stigmatized by lack of public understanding about the disease. Schizophrenia is not caused by bad parenting or personal weakness. A person with schizophrenia does not have a “split personality,” and almost all people with schizophrenia are not dangerous or violent toward others when they are receiving treatment. The World Health Organization has identified schizophrenia as one of the 10 most debilitating diseases.

Major depression is a serious medical illness affecting 9.9 million American adults, or approximately 5 percent of the adult population in a given year. Unlike normal emotional experiences of sadness, loss or passing mood states, major depression is persistent and can significantly interfere with an individual’s thoughts, behavior, mood, activity and physical health. Among all medical illnesses, major depression is the leading cause of disability in the United States and many other developed countries.

More than twice as many women (6.7 million) as men (3.2 million) suffer from major depressive disorder each year. Major depression can occur at any age including childhood, the teenage years and adulthood. All ethnic, racial and socioeconomic groups suffer from depression. About three-fourths of those who experience a first episode of depression will have at least one other episode in their lives. Some individuals may have several episodes in the course of a year. If untreated, episodes commonly last anywhere from six months to a year. Left untreated, depression can lead to suicide.

Major depression, also known as clinical depression or unipolar depression, is only one type of depressive disorder. Other depressive disorders include dysthymia (chronic, less severe depression) and bipolar depression (the depressed phase of bipolar disorder or manic depression). People who have bipolar disorder experience both depression and mania. Mania involves abnormally and persistently elevated mood or irritability, elevated self-esteem and excessive energy, thoughts and talking.

Dual diagnosis services are treatments for people who suffer from co-occurring disorders – mental illness and substance abuse. Research has strongly indicated that to recover fully, a person with co-occurring disorder needs treatment for both problems - focusing on one does not ensure the other will go away. Dual diagnosis services integrate assistance for each condition, helping people recover from both in one setting at the same time.

Dual diagnosis services include different types of assistance that go beyond standard therapy or medication and may include assertive outreach, job and housing assistance, family counseling, even money and relationship management. The personalized treatment is viewed as long-term and can be begun at whatever stage of recovery the person is in. Positivity, hope and optimism are at the foundation of integrated treatment.

According to reports published in the Journal of the American Medical Association, roughly 50 percent of individuals with severe mental disorders are affected by substance abuse. Thirty-seven percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness. Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs.

Schizoaffective disorder is one of the more common, chronic and disabling mental illnesses. As the name implies, it is characterized by a combination of symptoms of schizophrenia and an affective (mood) disorder. There has been a controversy about whether schizoaffective disorder is a type of schizophrenia or a type of mood disorder. Today, most clinicians and researchers agree that it is primarily a form of schizophrenia. Although its exact prevalence is not clear, it may range from two to five in 1,000 people (i.e., 0.2 percent to 0.5 percent). Schizoaffective disorder may account for one-fourth or even one-third of all persons with schizophrenia.

To diagnose schizoaffective disorder, a person needs to have primary symptoms of schizophrenia (such as delusions, hallucinations, disorganized speech and disorganized behavior) along with a period of time when he or she also has symptoms of major depression or a manic episode. There may be two subtypes of schizoaffective disorder:

It is readily apparent that suicide is a medical condition and requires the assistance of a mental health professional. Family and friend support is important as are empathy and understanding. The good news is that in the great majority of cases, treatment and recovery is possible although medication therapy may be required for the duration of a person’s life – not unlike diabetes.

The following advice will NOT work: “suck it up” or “tough it out” or “work through it.” Those attitudes are a recipe for disaster.

The Oklahoma Department of Mental Health and Substance Abuse Services estimates that approximately 3.3 percent of all adult Oklahomans suffer from a major mental illness. In addition, the department estimates that approximately 5.6 percent of all adult Oklahomans abuse alcohol or an illicit drug. Funding to adequately address this public health need is inadequate. Consequently, many of the mentally ill (including those who have not committed any type of violent crime) are warehoused by the Department of Corrections or in our county jails. The majority of Oklahomans with a major mental illness are either undiagnosed or not receiving treatment. These conditions are an embarrassment to a culture that considers itself morally responsible.

WHAT TO DO IF ONE SEES THE SIGNS

If signs are observed that someone is considering suicide, ask the person how they feel. Ask, “Are you thinking about hurting yourself?” Ask, “Are you thinking about suicide?” If the answer is yes, ask if they have considered it recently and whether they have a plan. If the risk appears serious, encourage them to speak with a physician or mental health profession immediately. Persons in this condition should not be left alone as this is an emergency. Some people may be uncomfortable with the idea of seeking help from strangers. In these cases, it may be helpful if a friend offers to accompany the individual to a healthcare center. When in doubt as to the severity of the risk, the general rule is to err on the side of caution.

It is important to observe a person carefully if there is a change in that person’s medication. The risk of suicide may increase during the descending and ascending portions of mood swings and changes in medication may cause a mood swing.

The following are recommendations from the American Association of Suicidology.

TITLE 43A PROVISIONS

One often hears the term, “EOD” – Emergency Order of Detention. Technically, there is no such thing except in the popular vernacular. There are procedures for involuntary commitment that are set out in Title 43A O.S. §§ 1-101 et seq. Readers are referred to an excellent article by Renee Hildebrant in the Oklahoma Bar Journal, titled “Understanding the Involuntary Civil Commitment Process” (76 OBJ 421). The 2006 regular session of the Oklahoma Legislature made substantial changes to the law regarding involuntary civil commitment. The House Bill is quite lengthy and was signed by Gov. Brad Henry on April 25, 2006. It is advised that one read the bill carefully since the emergency was attached but the effective date is delayed to July 1 and Nov. 1 for some sections.

EMERGENCY TELEPHONE NUMBERS

It is always appropriate to call 911 and ask for emergency assistance. In Oklahoma City, ask for a CIT (crisis intervention team) officer. CIT officers are specially trained officers who respond to mental health emergencies, and suicide is a mental health emergency. Tulsa also has specially trained police officers and a program known as COPES (Community Outreach, Psychiatric, Emergency Services). Other communities also have a limited number of CIT trained officers. Ask the 911 operator if a CIT officer or team is available. If the person is in another community, call the local 911 number and ask to patch the call through to the 911 system where the person is located. If a patch is not available, the local 911 operator should be able to tell the caller how to reach the remote 911 system.

Other numbers that may be helpful:

A Web site that has excellent and extensive information about suicide is www.suicidology.org.

“My grief lies all within,
And these external manners of lament
Are merely shadows to the unseen grief
That swells with silence in the tortured soul”
— William Shakespeare

AUTHOR’S NOTE:
The author interviewed a number of lawyers and family members for this article and is especially appreciative for the personal contributions of Jody Nathan and Ken Bodenhamer, each of whom are practicing attorneys in Tulsa. The contributions of the other lawyers and family members who were willing to share their personal experiences are also greatly appreciated. 

About the Author

John Brewer is a graduate of the OU Law School (1974) and practices law in Oklahoma City. He is active in the Oklahoma Chapter of the National Alliance on Mental Illness (NAMI) and is certified to teach the NAMI Family-to-Family course and to facilitate mental health support groups. He states that his NAMI training has made him a better lawyer. Further information regarding NAMI, including local affiliate information, can be found at www.nami.org.