Which Suicides Get Media Attention and Which Don't.

I had a chance to speak with a veteran North Suburban writer this week regarding the media coverage of the Lake Forest and Barrington Suicides.  Being a Police Psychologist in the North Shore suburbs I often run into the reporters from various local publications including the Pioneer Press and the TribLocal.  Tuesdays before noon seem to be the optimum time for them to stop by the station and read through the daily call logs for the previous week.  As an aside, for those of you who fear being identified in the local crime blotter for the week (the most read section of the papers reportedly), it's best to have your run in on Tuesday's or Wednesday's as they are the oldest dates by the time the reporters read about them; just a thought.

In any event, when discussing the media coverage of the Lake Forest and Barrington suicides with the veteran (who, by the way, did not know about the most recent Lake Forest Metra suicide) I was told the factor used to judge whether a suburban suicide was published or not was the "street test."  Apparently the street test comes down to whether or not the body could be seen from the street.  All things being equal, those that occur out of public sight are not written about and those that can be seen from any street are written about.

While I can appreciate the attempt at sensitivity I'm left with wondering about the validity of any story written by reporters who know there is an appreciable difference between actual suicides on the North Shore and those that are reported.  This is especially true when they begin to use words like cluster or crisis.  In other words why, when you already know several suicides have occurred but are private do you then pull the trigger on sensationalizing those which are public?  Put another way, as a reporter you know there are suicides on a monthly basis and you refrain from writing about them but when 2 or 3 occur which are public, you make it a point to write ongoing stories for weeks and sometimes months?  And you use words like cluster or contagion?

I suspect I know the answer and it involves readership but you also know it's really not a valid or reliable basis for your conclusions?

Having been taught long ago not to pick fights with people who buy ink by the gallon or paper by the pound I have no interest in condemning you on the basis of this the practice but I do have an interest in utilizing some sanity and sensitivity in the process of public acknowledgement.  

I don't prescribe to the idea of hiding the facts regarding suicide and it's regular occurrence in the North Shore Suburbs of Chicago.  I just believe a greater adherence to guidelines that might inhibit suicide contagion is a good idea for all, especially when it comes to our children and adolescents or is suggestive that somehow our North Suburban Schools or Communities are in crisis when they are not. 

 

We Don't Seem To Be Learning Regarding Suicide And The Media

The recent loss of another young person in Lake Forest to an apparent suicide appears to have taught us little. Lake Forest Illinois has now had three highly publicized deaths of adolescents since January 1st of this year. Before that is was Barrington Illinois where 5 individuals took their lives over a three year period and where the media focused it's attention. Before that it was St. Charles, Naperville and Elgin that caught our attention.

Many have rightfully suggested that suicide clusters have been spurred by contagion, also known as the "Werther Effect" (a synonym for media induced imitation effects of suicidal behavior).

A suicide cluster is defined by Scientists as three or more suicides in a specific location that occur over a short period of time. Contagion is a term used to identify those situations where there is some linkage between the deaths such as personal knowledge of each other, a shared identity as in school attendance or simply an age range within a specific geographical location. While the term cluster denotes a linkage of location, contagion describes an hypothesized relationship that is in some way related to cause and effect.

As a police psychologist in an affluent northern Illinois suburb I am directly aware of the various numbers and types of death that occur within our Village limits. Some are suicides, some due to accidents and some related to the normal aging process and health deterioration. Few of them are publicized except when the local press takes special interest such as obvious suicides or car accidents. I can tell you that each and every year there are more than enough self inflicted deaths that meet the criteria of a cluster, yet are not publicized. If I include the number of attempted suicides in our town (as well as others that touch our Village limits, based on the radio traffic of dispatchers) then there are easily 4 or more per month within a population of approximately 50,000.

An interesting side point here is that for years, local writers have tried to get at some measure of how many actual suicides there are in the affluent North Shore Suburbs. When you combine that with the suicides of persons who live here but take their life at other locations (downtown, at weekend homes or on trips of various types) my educated prediction would be it easily tops two per month and more. This prediction covers all age ranges and is not limited to adolescents who comprise a much smaller segment. A careful review of the local obituaries for a 6 month period should get you all the information necessary to concur.

Getting back to the issue at hand; are we learning from any of this? The answer is sadly, no. We continue to publicize suicides, especially those of adolescents and young adults, in a manner and fashion that promotes contagion. But, please before you try and burn me at the stake for my position consider the studies that have been done and the information learned from them. Then decide for yourself if we have learned anything.

Johansson, Lindqvist, and Eriksson (2006) found in Sweden that it is important to bear in mind the risk of further suicides and the risk of cluster formation in a society struck by a teenager suicide.
 

Niederkrotenthaler, Herberth, and Sonneck (2007) found that in "Austria, "Media Guidelines for Reporting on Suicides", have been issued to the media since 1987 as a suicide-preventive experiment. Since then, the aims of the experiment have been to reduce the numbers of suicides and suicide attempts in the Viennese subway and to reduce the overall suicide numbers. After the introduction of the media guidelines, the number of subway suicides and suicide attempts dropped more than 80% within 6 months. Since 1991, suicides plus suicide attempts - but not the number of suicides alone - have slowly and significantly increased. The increase of passenger numbers of the Viennese subway, which have nearly doubled, and the decrease of the overall suicide numbers in Vienna (-40%) and Austria (-33%) since mid 1987 increase the plausibility of the hypothesis, that the Austrian media guidelines have had an impact on suicidal behavior." The Austrian guidelines can be found here; http://www.iasp.info/pdf/task_forces/austrian_media_guidelines.pdf

The World Health Organization (WHO) has also published guidelines for media coverage of suicidal acts (2008).

1. Avoid language which sensationalizes or normalizes suicide, or presents it as a solution to problems.
2. Avoid prominent placement and undue repetition of stories about suicide.
3. Avoid explicit description of the method used in a completed or attempted suicide.
4. Avoid providing detailed information about the site of a completed or attempted suicide.
5. Photographs or video footage of the scene of a given suicide should not be used, particularly if doing so makes the location or method clear to the reader or viewer.
6. Use of the word ‘suicide’ in the headline should be avoided, as should be explicit reference to the method or site of the suicide.
7. Take particular care in reporting celebrity suicides.
8. Show due consideration for people bereaved by suicide.
9. Provide information about where to seek help.

http://www.who.int/mental_health/prevention/suicide/resource_media.pdf

When you take both guidelines into consideration, you can see that our press has learned very little when judging the reporting of the most recent Lake Forest tragedy.

I for one, fully expect even more sensational headlines and the resultant increase in adolescent suicides. I wish it wasn't so but it doesn't look like anyone is putting into practice what we've learned. I wish they would learn.

Suicide Assessment on The North Shore: Why The System Fails.

The intent of using a picture of a coffin in this post is to drive home the point that half measures are no option considering the subject matter. I apologize for the discomfort to those who have been victimized by the suicide of a loved one but I believe you especially will understand the intent is to be as serious as possible when discussing this subject.

Here in the North Shore area of (Winnetka, Northfield, Northbrook, Wilmette, Kenilworth, Lake Forest, Glencoe, etc) Illinois the options for dealing with suicide (uncovering high lethality suicide ideation and doing everything to prevent it) are covered by three basic occurrences: 1) your loved one verbally admits to thoughts of suicide, 2) you believe, for any of a variety of reasons, an attempt is possible/probable and/or 3) an actual attempt has been made.

Situation 1 is where lethality or seriousness of the contemplation begins to come into play. It's here also that the system begins to break down. There are some very well trained mental health clinicians who understand suicide and handle these sorts of situations competently and professionally. The vast majority of clinicians however are only minimally trained (if at all) to deal with death let alone suicide ideation and the assessment of lethality. They often quickly suggest hospitalization and take action that is directed more to covering any possible liability issues and their own emotional discomfort than it is in dealing with the situation from a position of competency. I don't blame them and neither should you. All clinicians have comfort zones in terms of training and experience. The unfortunate fact is that death in general and suicide specifically, lies outside that zone for many.

The accurate assessment of suicide ideation and lethality requires calm and focused intervention. Sending the person along the continuum of mental health care to more prepared clinicians (hospital emergency room personnel) is legitimate but also sets the stage for a breakdown of communication and the loss of valuable information. The situation can also become adversarial as the person being evaluated is now faced with possible psychiatric hospitalization or at least the use of medication, both of which carry possible physical problems and/or social stigmatization. Statistics on the exact numbers of people evaluated for suicide ideation and the outcomes of those evaluations are not available. Neither are accurate numbers of people who have been evaluated and then gone on to complete a suicide within the following year (some suggest 1 completed suicide per 100 to 200 attempts). What we do know is the majority receive anti-depressant medication and some are hospitalized for a short period of time. The period of time for hospitalization is now more a function of the person's insurance coverage (or lack thereof) then it is about the person's needs in general. The standard time is three to 5 days of hospitalization and then follow-up with a psychiatrist and other mental health clinicians for outpatient treatment. Along this continuum, patients drop out of care and/or stop taking their medications. Current Illinois Mental Health Law makes it very hard for all but the most determined family members to maintain the patient in the proper care necessary to prevent further crisis if the patient is unwilling. It's this frustration that wrongfully leads many to the mistaken belief that if someone is really determined to take their life that there is no way to effectively stop them.

In situation #2 people find themselves wondering about the possibility of a loved one taking their life. As a loved one you see problems such as financial, emotional or physical pain have over taken a persons life. You watch as they struggle, detach from life and generally become sullen. Their attitudes become negative and you suddenly wonder just what it is they are looking forward to, if anything. During heated conflicts they may voice statements that everyone would be better off if the person wasn't there or they describe life as meaningless and unnecessary. They haven't given you enough of a threat to force evaluation of some kind and they're resistant to therapy or psychological intervention. You're left in a position of constant fear and paralyzed from taking positive action because none seems available or a clear option doesn't appear to exist. Perhaps you're even feeling restricted or blocked from helping as the person is confined to a local jail or facility for incarceration due to some recent behavior. In such cases contact is often limited and regular correctional staff will not listen to your pleas for caution. The sad fact is often mental health services are lacking within jail settings even though the suicide rates within incarceration facilities are the highest among any group at approximately 38 per 100,000.

In situation #3 people often feel the most helpless to ensure the safety of a loved one. One or more attempts have already occurred. In some case the attempts were extremely serious and left no doubts as to the persons intent to end their life. It was only through some miracle that the attempt was interrupted in some fashion or that it was unsuccessful. As a loved one you know previous attempts are highly correlated with eventual suicide success. The mental health facility or hospital is about to discharge the patient and the only obstacle standing in the patients way of another attempt is medication and an appointment to see a mental health clinician upon discharge. These situations are perhaps the most dangerous for the elderly and adults between the ages of 45 and 54.

The mental health system fails in all three situations outlined above due to several breakdowns along the way (http://www.chicagotribune.com/news/local/ct-met-northwestern-suicides-20120628,0,4291050.story). First, the system has become complacent with the idea that passing the patient along the continuum to a perceived higher level treatment provider (mental health facility, hospital or physician able to prescribe medication) who is assumed to be better able to care for the person, is the best option. This idea is neither accurate in reality nor based on anything personally and immediately relevant to the persons current life circumstances. At the extreme end of this continuum, the final option is to either physically or chemically (sometimes both) restrain the patient and attempt to provide mental health treatment and support. The obvious problems here are that during periods of restraint the person is totally unable to participate in any type of mental health therapy and there is no medication on the market (nor will there likely ever be) that is designed specifically to inhibit or prevent suicide. The outcome at this level of care (not that it can be correctly called care at this point) is simply to keep the patient still, quiet and docile; unable through restraint to harm themselves. At NISA we believe that once you've created this type of standoff with a patient, you've almost completely assured that the only viable option for the patient is to feign health until such point in time as they can safely achieve discharge and most assuredly attempt once again to take their life.

Second, by placing the patient into a conflictual position where their physical and/or emotional freedom could be taken away through hospitalization (at least the threat of) serves to insert a barrier between the patient and their treatment providers. Free will and choice are removed from the patients resources and thinly veiled coercion is introduced into the mix. It's only the most skilled and talented mental health clinician that can foster and develop a therapeutic relationship with patients under these circumstances.

Third, families and loved ones are often ignored in the treatment process due to preferences for individual treatment or inherent failures of privacy in medical care laws that allow adult patients to keep their medical care and information from being released to anyone except insurance carriers. In many cases loved ones are prohibited directly by the patient from knowing anything about their care or treatment. In these cases families are often left to hope for information about medication and/or the time of their loved ones next outpatient mental health care appointment and even who their mental health practitioner is. In situations involving suicide it seems illogical that disinterested third parties such as insurance companies should have access to information for treatment monitoring purposes while family members do not.

If you have any doubts about a loved one, especially those being released from the hospital after either an attempt or threat of an attempt, we suggest a second opinion. Second opinions are obvious choices in any complex and life threatening medical situation. Shouldn't they also be an obvious choice in a mental health crisis as well, especially when a life is on the line?

Warning Signs of Suicide From The American Association of Suicidology

Know the Warning Signs

How do you Remember the Warning Signs of Suicide?

Here’s an Easy-to-Remember Mnemonic:

IS PATH WARM?

I	Ideation
S	Substance Abuse
P	Purposelessness
A	Anxiety
T	Trapped
H	Hopelessness
W	Withdrawal
A	Anger
R	Recklessness
M	Mood Changes

A person in acute risk for suicidal behavior most often will show:

Warning Signs of Acute Risk:

• Threatening to hurt or kill him or herself, or talking of wanting to hurt or kill him/herself; and/or,
• Looking for ways to kill him/herself by seeking access to firearms, available pills, or other means; and/or,
• Talking or writing about death, dying or suicide, when these actions are out of the ordinary.

These might be remembered as expressed or communicated ideation. If observed, seek help as soon as possible by contacting a mental health professional or calling 1-800-273-TALK (8255) for a referral.

Additional Warning Signs:

• Increased substance (alcohol or drug) use
• No reason for living; no sense of purpose in life
• Anxiety, agitation, unable to sleep or sleeping all the time
• Feeling trapped - like there’s no way out
• Hopelessness
• Withdrawal from friends, family and society
• Rage, uncontrolled anger, seeking revenge
• Acting reckless or engaging in risky activities, seemingly without thinking
• Dramatic mood changes.

At Northern Illinois Suicide Assessment we specialize in the evaluation of individuals for the determination of suicide probability before a crisis develops or your worst nightmare is realized. We're glad to answer your questions within 72 hours. Email questions to NISA.

For immediate emergencies call 911 and ask for help; we are not a 24 hour help line and cannot provide emergency help.

Your Worst Nightmare: Things We Fear.

One of the absolutes I've come to recognize in life is that it's impossible to define the exact worst human fear. For many it's the death of a child. For other's it's the loss of their most significant other or the threat of a life ending illness. I can tell you that loss in general is feared by all and that suicide in particular is the worst nightmare for almost all parents or partners. It's difficult at a minimum to understand how someone we love could take such a horrific action as ending their life and the emotional impact is devastating on the survivors left in their wake.

Mental Health experts from every discipline endeavor to discover the causes of suicide and to prevent it's occurrence. Currently suicide is the 11th leading cause of death in the USA (almost double the rate of homicides) and the 3rd leading cause of death among children/adolescents up to the age of 21.

The most common reaction to a suicide attempt is emergency hospitalization for mental illness. The most common reaction to a verbal suicide threat is evaluation at the hospital emergency room. The problem with common reactions is they denote action only after a crisis. In response, programs geared to prevention and identification have rightfully sprung up all over the Country. Their goals include education of the general public and specific educational strategies for teachers, parents and peers in order to help spot individuals who are suffering and likely to make an attempt. Educational prevention programs have no doubt saved countless live's and are an important aspect in successfully addressing suicide. They tend to be geared toward adolescents specifically but many also address the elderly and adults in general.

The result today is that suicide rates have been reduced in some populations while among others they are on the rise. The most recent data from the Centers for Disease Control (CDC, 2005) indicate that suicides per 100,000 are 9 for 10-21 year olds, 11 for all ages combined, 14 for those aged 65 and over, 26 for Police and Firefighters and 38 for incarcerated individuals. Interestingly the rates for incarcerated individuals have fallen the most dramatically (over 100 in the 1990's) most likely as a result of litigation. Researchers in the area of suicide by incarcerated individuals point to in depth and accurate assessment as the main reason for the significant reduction. What this says to those of us that investigate such things is that the use of systematic evaluations based upon well researched assessment devices can be of enormous help in the identification and treatment of suicidal individuals well before a crisis develops.

At Northern Illinois Suicide Assessment we specialize in the evaluation of individuals for the determination of suicide probability before a crisis develops or your worst nightmare is realized. We're glad to answer your questions within 72 hours. Email questions to NISA.

For immediate emergencies call 911 and ask for help; we are not a 24 hour help line and cannot provide emergency help.