Matters of Life and Death

June 4, 2003

It's an odd profession, Dr. M. David Rudd would be the first to admit. To spend one's life devoted to the study of suicide no doubt elicits interesting conversations or awkward pauses at many a dinner party.
"It's an emotional issue with a long history," says Dr. Rudd, professor and director of clinical training in Baylor's psychology and neuroscience department and president of the American Association of Suicidology (AAS). "It's viewed differently from other problems because it involves mental illness."
There are no walkathons organized for suicide prevention, no telemarketing fundraisers, no superstars lending their names to the cause. In fact, it's a topic few want to discuss at all. Suicide still has a social stigma of shame attached to it, as does its deeper cause -- depression. For that reason, the two often are undiagnosed. Most studies estimate that up to 95 percent to 98 percent of people who die by suicide suffered a mental illness, while the vast majority of people who are depressed will not commit suicide, Dr. Rudd says.
The misconceptions about suicide are plentiful. Among them are that talking about suicide exacerbates the problem, somehow making it an option just by discussing it, Dr. Rudd says. Another is that people who talk about killing themselves will not do it. On the contrary, studies show that 80 percent to 90 percent of people who commit suicide had voiced those thoughts to someone beforehand, he says. 
There are all kinds of statistics to address the pervasiveness of this problem in America (see the sidebar "Suicide Statistics"), but here are a few to note:
• 80 people a day commit suicide -- one person every 18 minutes
• Suicide is the 11th leading cause of death; it is the third leading cause of death in people ages 10 to 24
• More than half of suicides are committed using guns, followed by drug overdose, carbon monoxide poisoning and hanging; the majority of women who commit suicide, however, do so by drug overdose.
Here's one more statistic about suicide: In the past three decades, the number of suicides committed by people ages 15 to 24 has tripled. 
Dr. Rudd has spent most of his professional career trying to figure out why young people are killing themselves. After earning his undergraduate degree in psychology from Princeton, he began studying suicide as a University of Texas graduate student. As part of his research, he interned at the Houston Child Guidance Center, working with at-risk teenagers, most of whom had tried to commit suicide. Although he hadn't planned to focus on the suicidal tendencies of youth, his experience there drew him to that specialization.
At the time, psychodrama -- a technique using several therapists at one time to act out family life -- was an experimental form of treatment. Although effective, the program was eliminated in the mid-1980s because of reduced funding and a subsequent wave of insurance reform, Dr. Rudd says.
He wrote his dissertation on suicidal college students, exploring their lack of social support and its relationship to their decision to commit suicide. "Relationships, such as those with family, will buffer people," he says. "But we've found that it's relationships with students and others on campus that are critical at that age. Their very task at that point is to separate from their parents, and they need to have adequate support to do that. 
"Perhaps the central issue, when it comes to support, is not numbers but meaningful relationships," he says. "If a student has one solid, supportive relationship, it can certainly serve to buffer stress in effective ways. It is not necessary to have five to 10 good friends."
What can parents do, then, when peers are truly the most important part of the process? Just what they've always done -- pay attention. "The primary thing I would encourage parents to look for is isolation and loneliness -- both things that often spawn additional problems such as depression, substance abuse and other high-risk behaviors," Dr. Rudd says. "When young adults individuate, they need to establish a supportive network outside the family."
The increase in youth suicides corresponds to the decreased amount of time parents spend with their children, due in part to divorce rates and dual-income couples, Dr. Rudd says. According to a report by the U.S. Census Bureau, the number of divorced people in the United States more than quadrupled from 4.3 million people in 1970 to 18.3 million in 1996 -- representing 10 percent of adults, up from 3 percent in 1970. 
"It's the nature of our society these days. We've lost that intimacy, and it gets exponentially harder to get it back," Dr. Rudd says. "The ability to establish and maintain good relationships is something that is learned early in life and refined as we grow older, as intimacy becomes increasingly important. Often, those who have difficulty as children and adolescents are at a significant disadvantage as adults when the need for intimacy and support peaks and they are trying to tap into a marked skill deficiency."
This is where it gets personal for Dr. Rudd, who has young children of his own. Although the science and subject matter drew him to the study of suicide, he now comes home each evening to a living laboratory of the American family. "I look at it very differently now," he says. "It's a much more personal kind of endeavor since I have kids. There is a difference between emotionally understanding something and intellectually understanding something."
And Dr. Rudd definitely understands it. He served in the U.S. Army as a clinical psychologist during the 1991 Gulf War and now is a consultant to the U.S. Air Force and Department of Defense on a project called "Managing Suicidal Behavior." He also served as chief of the psychotherapy section at Scott and White Hospital in Temple, Texas, before coming to Baylor.
Friend and colleague Dr. David Jobes calls Dr. Rudd a leader in his field, a man he describes as exceptionally smart, highly motivated, truly kind and big-picture oriented. Nor is he surprised at his friend's focus on youth. 
"I think it's just an obvious thing to be drawn to," says Dr. Jobes, associate professor of clinical psychology at the Catholic University of America in Washington, D.C. "When you really understand the data, you start to see that there is tragedy in most suicides, especially when they involve young people. Young people who kill themselves are very convinced that their situation is dire. If you can get them to the other side, then they can be OK. But they don't really have the experience base or perspective that adults may have."
Like Dr. Rudd, Dr. Jobes has seen his share of strange looks when he explains that his specialty is suicide. "A lot of people think this is sort of a morbid, bizarre field. But when you get beyond that initial impression, you realize that suicide is sort of the ultimate fatality of mental illness. It's a hugely preventable leading cause of death. We're not in it to be morbidly fascinated with the underbelly of the human condition. We're in it because it's cool to save lives and also because the field is so extremely understudied and poorly studied. David is one of the leaders in really saying we've got to understand this for what it is and deal with it for what it is."
And people such as Dr. Rudd and Dr. Jobes are making a difference. But further complicating the suicide situation in the United States is the fact that children have increased access to the Internet, violent media programming and guns. According to AAS estimates for 2000, 16,586 suicides in the United States were committed with a gun -- 2,276 by youth. There were almost the same number of suicides by firearm as homicides (16,765). Some argue that limiting a suicidal young person's access to weapons could decrease suicides. International data, however, doesn't support such a claim, Dr. Rudd says.
There are other methods of suicide that need further study, as well. In England, researchers are trying to find solutions to drug overdose as a form of suicide -- and sometimes the answers are surprisingly simple. A researcher at Oxford recommended that England reduce the number of aspirins in one package to a nonlethal dose, reasoning few suicidal people would know that the contents of one package weren't lethal. The researcher was right, Dr. Rudd says; suicide rates specific to aspirin/Tylenol (paracetemol) overdosing have declined in England for the past several years.
Dr. Rudd knows he can't eliminate societal ills, but he is trying to find more effective ways to treat young people who contemplate suicide. Although the common method of treating suicidal patients today is through the insight model, which seeks to gain perspective by focusing on one's past, the emerging method of treatment is the cognitive model, which teaches people how to respond and react in healthier ways, he says. 
The latter is touted by researchers such as Dr. Rudd and Dr. Thomas Ellis, who earned his PsyD in clinical psychology from Baylor in 1978 and now is a professor at Marshall University in Huntington, W.Va. The two researchers were not at Baylor at the same time but in the small world of suicide specialists, they have collaborated on several projects and papers.
"With the insight model, therapists try to gain a greater insight into the origins of your problems," says Dr. Ellis, whose 1996 book, Choosing to Live, is one of only a few self-help suicide books on the market. "The idea is that the insight will help you feel better. The problem is, it doesn't really change the way you approach things in the future. For example, if I believe that my life is a failure if I don't achieve a great deal, then just knowing that or knowing why is not going to make a difference. I need to know how to think about it differently. We find the insight model to be helpful, but it's an incomplete solution." 
The cognitive model, in contrast, teaches people how to think and respond differently. In studying suicide notes of people who attempted or actually committed suicide, Dr. Rudd identified four cognitive themes: 
• Unlovability ("I'm worthless")
• Helplessness ("I can't solve my problems")
• Poor distress tolerance ("I can't stand the way I feel")
• Perceived burdensomeness ("Everyone would be better off if I were dead")
The last theme is potentially the most fatal, Dr. Rudd says. People who mention the belief they are a burden in their suicide notes are more likely to kill themselves. "Those who died uniformly talked about feeling like a burden to everyone else in their lives," Dr. Rudd says.
"They were going to make it more probable that they were going to die." 
He developed a Suicide Cognitions Scale to measure these four motivations for suicide, much as a physical therapist can measure tangible improvements in movement or flexibility during rehabilitation. His scale is being used by a number of researchers around the world and the information has been translated into Dutch. His research now is focusing on the third indicator, studying the fundamental issue of distress tolerance, or low frustration levels.
In addition to teaching new responses to emotional situations, cognitive therapy also strives to provide suicidal people with foundations they somehow did not receive during childhood, Dr. Rudd says. For example, parents need to help children manage emotional experiences, to understand that pain and disappointment will come to an end. Children need to learn techniques to temper extreme reactions and realize their transitory nature, he says.
"Emotion is misleading, but emotional experiences are containable," he says. "Some people don't understand that. They say, 'I would rather be dead than feel the loss I feel because my marriage ended.'"
Suicidologists also study "risk/rescue ratings," which categorize the chances someone has of being rescued. For instance, the chances for rescue might be high if a person mentions to a friend his or her suicidal thoughts; conversely, it might be low if one makes sure he or she is alone and will not be interrupted. 
In view of this, Dr. Rudd advises anyone who encounters a suicidal person to encourage him or her to talk. Research shows that these individuals want someone to listen. As soon as possible, also seek the help of a professional. "Understanding the severity of the problem is critical," he says. 
Dr. Rudd also is involved in three other projects to add to life-saving information and materials. One is a joint project with the AAS and the National Institute of Mental Health, assessing the empirical factors of suicide (age, gender, mental illness). These are not that useful in individual cases, he says, but knowledge of general suicide trends could be helpful for therapists.
He also is working on an AAS study of the warning signs of suicide to develop an "imminent risk" zone of what may be two hours or two days. As Dr. Rudd explains, most people have seen a list of warning signs for cardiac disease, but no such danger list is available on suicide.
Another AAS study follows those with suicidal tendencies over several years, determining whether treatment saved their lives or simply postponed the suicide.
"My hope is to make strides in not just our emotional, psychological, philosophical and spiritual understanding of the problem of suicide, but also in our scientific understanding," he says. "From that perspective, we've taken significant steps -- steps that have led to a better understanding of the problem and innovative treatments and interventions, steps that literally have saved lives."
Science alone, of course, will not stop suicides. "Values, beliefs systems and philosophies of living make a difference. Hope makes a difference," Dr. Rudd says. "At the end of my career, I'd like to be able to say I did my part, advancing the field on both fronts, making a meaningful contribution to this uniquely human dilemma and enriching the human experience."