Why Talking About Suicide May Be Our Best Hope for Stopping Suicide

"I fell screaming. It changed everything."

Kelly Bowie was 22 when her father killed himself. The week before, he had stormed out of the house with a gun and disappeared to his favorite bar. She chased after him assuming the worst. He shooed her away. He told her everything would be fine.

Walter Rodgers went by the nicknames Wally or Gator. He was the quintessential tough guy — drank heavily, experimented with drugs and occasionally rode a motorcycle. He delighted in joking with friends that he always carried a picture of his "pride and joy," not a photo of his family but the dish detergent.

Nevertheless, Bowie convinced herself she was daddy’s little girl. That changed after Rodgers killed himself.

"How could he do that to us? He knows what it’s like to be left behind. He went through it," she said.

Bowie never thought her father would die by suicide. He was orphaned at 17 when his own father killed himself, just one year after his mom died from cancer. That Rodgers would follow in his dad’s footsteps hadn’t occurred to Bowie despite years of warning signs.

More than one million people attempt suicide every year — just shy of Philadelphia’s total population. In 2015 alone, 44,193 people took their lives, according to the Centers for Disease Control and Prevention.

In Pennsylvania, nearly three times as many people die by suicide every year as by homicide.

That number is only going up and experts don’t know why.

"In the past 25 years we have seen an increase in suicide rates that is very hard to explain," said Dr. Maria Oquendo, president of the American Psychiatric Association and chair of psychiatry at the University of Pennsylvania’s Perelman School of Medicine.

One of the leading authorities on suicide, she believes a deep examination of the topic is overdue.

"Really, we need to understand what leads people to behave in this way."

More than 20 years after her father's death, Bowie wonders what drove him to suicide. Anger and confusion over his death led to years of depression and, perhaps ironically, thoughts of killing herself. With a family history of mental illness, Bowie spiraled downward.

"Driving off the road seemed like the next logical step," she said.

Like her father, Bowie struggles with depression. Therapy has helped her make amends with his memory but she still marvels that one day soon she will be older than he was when he died. An ankle tattoo both memorializes him and serves as a reminder of what not to do.

Perhaps her biggest disappointment, however, is that Rodgers could not walk Bowie down the aisle on her wedding day. Instead, she attached a small photo of him to her bouquet and threaded his wedding band onto an ankle bracelet. She keeps these and other heirlooms hanging in her kitchen.

In 1988, crisis intervention expert Dr. Earl A. Grollman described suicide as "a whispered word, inappropriate for polite company."

"Suicide is a taboo subject that stigmatizes not only the victim, but the survivors as well," Grollman wrote in his seminal work, Suicide: Prevention, Intervention, Postvention.

The notion was not new or even groundbreaking at the time. Suicide had largely been considered a private matter to be handled quietly by loved ones behind closed doors. Survivors say the silence is deafening and alienating. Experts say the stigma does nothing to save lives.

HISTORY OF SUICIDE

Recorded instances of suicide date back to antiquity. Perhaps the most famous case was that of Athenian philosopher Socrates. He was found guilty of corrupting young people with his impious attitudes towards gods of the time. Socrates was given a choice: renounce his heretical beliefs or drink a deadly dose of hemlock. He chose the latter.

When Socrates was alive, scholars considered suicide a symptom of mania or melancholia, two conditions traced to a "malfunction" in the human body. Women, children and the senile were most at risk, the ancients believed. They treated depression with mandrake root, a toxic member of the nightshade family that induces sleep when ingested in small quantities.

Suicide was largely seen as cowardly, except in the cases of soldiers or leaders who had fallen out of grace. In those instances, killing oneself with a sword was considered an honorable alternative to living life in chains or in disgrace.

Religion has largely shaped how Americans regard suicide. Honor does not weigh into the equation, but sin does. The Judeo-Christian tradition condemned the act throughout much of history, teaching that only God can give and take life. Catholics who die by suicide cannot receive absolution. In the Jewish tradition, someone who died at their own hands could not be buried in a Jewish cemetery. Both major religions have somewhat softened on the issue. According to the Catholic Digest, "pity, not condemnation, is the view" of that particular religion.

Still, stigma persists. Society views depression as an emotional malfunction rather than a psychiatric disorder. We continue to say someone "committed" suicide as if an actual crime had occurred, something advocates want changed.

Suicide is considered a whispered word. But those who have experienced it are sharing their stories to heal and help others in crisis. Watch our full-length special report.

(Published Tuesday, June 6, 2017)

This misconception remains pervasive and helps to explain why the nation’s first suicide prevention center didn’t open in the United States until 1958. Three years later, the United Kingdom decriminalized so-called "self murder." Yet many states on this side of the pond continued to penalize families of people who killed themselves by seizing assets. This practice occurred not only in the United States, but throughout Europe, as well.

Untangling the legality of suicide is tricky. Few states have overt language deeming suicide legal or illegal. Pennsylvania, for instance, only addresses suicide in the case of involuntary emergency examination and treatment for minors. According to state law, people between the ages of 14 and 17 can be forced into treatment if they have threatened suicide or left a suicide note. Pennsylvania law does not mention adult suicide, however. Neither does Delaware nor New Jersey.

While no federal law prohibits suicide, six jurisdictions — D.C., California, Colorado, Oregon, Vermont and Washington — have decriminalized physician-assisted suicide. For many people, death with dignity is easier to comprehend. The idea of dying honorably and maintaining one’s self-respect dates back to antiquity. But to die as a result of perceived weakness is seen as a failure.

The judgemental way society talks about suicide has contributed to a chilling silence among people affected by it. Rather than seek help, many remain quiet.

"There are millions of people right now who are wishing they were dead," said Susan Stefan, a legal expert of disability law and author of Rational Suicide, Irrational Laws.

"In our society, they are not allowed to talk about it even though talking about it might be the most helpful thing they could do."

One of the most prevalent myths is the contagion theory — that talking about suicide can lead to someone attempting suicide. Experts say the opposite can be true when the topic is handled carefully. They recommend not lingering on the method, something many in the behavioral health community lament about the Netflix show 13 Reasons Why. Several episodes carry graphic content prompting show producers to include trigger warnings before the most difficult-to-watch scenes. But in a world of binge-watching, some say the show isn’t going far enough to protect viewers.

Suicide was again thrust into popular culture when musician Chris Cornell killed himself in May. Sordid details of his drug use and final moments became Internet fodder for weeks following his death. But instead of using his suicide as a catalyst to discuss mental health, Cornell's struggle was turned into a circus.

That circus is not unique to celebrities. Hospitals and first responders sometimes add to the stress and chaos of a suicide attempt. In her book, Stefan argues that hospitalization can act as a deterrent to suicidal people getting the help they need. In one scenario, a person thinking about dying might remain quiet for fear of being committed to a hospital or institution. In the reverse scenario, medical professionals might hesitate to treat a suicidal person for fear of being sued if something goes wrong. Either way, the patient loses.

When photographer Dese’Rae Stage attempted to kill herself, a small army of first responders descended on her house. The all-male contingent wouldn’t allow her to change in private or put on a bra. At the hospital, she sat in the corner for hours before being evaluated.

"I felt like a dunce," she said.

Rather than seek help there, Stage checked herself out of the hospital. The humiliation was too great. She was told to contact the hospital in two days but was given an improbable phone number: (000) 000-0000.

This is a copy a hospital discharge paper Dese'Rae Stage received after being released from the emergency room following her suicide attempt. The number she was told to contact was listed as 000-000-0000. Dese'Rae Stage

Countless similar tales of impatience and disregard have prompted some mental health officials to reconsider the industry’s approach towards suicide.

"Suicide, like drunken driving, is a public health problem," said David Miller, former president of the American Association of Suicidology. "In order to reduce it, we need to address it."

Because suicide was perceived as a crime for generations, punitive measures were frequently taken against those who attempted. Forced hospitalizations were common prior to the 1980s. A patient could be institutionalized for anything ranging from dissociative identity disorder — previously called multiple personality disorder — to drug addiction. It was a convenient, if not entirely humane, way to stash away difficult patients with disorders doctors didn’t fully understand.

After former President Ronald Reagan took office, jails and prisons replaced hospitals and institutions for these patients. Federal funding for mental health care decreased by 30 percent in 1981 when the Budget Reconciliation Act repealed former President Jimmy Carter’s community health legislation. That number dipped by another 11 percent in 1985. People who could not afford to pay for extended or private treatment flooded the streets and the subsequent homeless crisis continues to plague many urban centers to this day.

Fast forward to the Great Recession of 2008 when states again cut $4.35 billion from public mental health program spending. The number of hospital beds reserved for people with mental disorders plummeted by nearly 97 percent from 1955 to 2016, according to the Treatment Advocacy Center. Philadelphia is one of few American cities that maintains enough hospital beds for people with mental health needs.

The pendulum is slowly swinging in a different direction as more experts take a public health approach, which includes screening patients and spreading awareness. Rather than associating suicide with a specific event — the loss of a job or relationship, for instance — medical professionals are looking at the bigger picture. This could include a family history of depression, substance abuse, bullying and undiagnosed mental health conditions.

"Suicide almost never happens without some kind of psychiatric condition," Oquendo said, adding that a recent spike in suicide rates could be related to an increase in diagnosing mental disorders.

Today in the U.S. one in four people suffer from mental illness with depression expected to be the leading disorder by 2030, according to Oquendo. Still, suicidal people are frequently judged as weak or sensitive, as though they can’t tell the difference between a bad day and a bad life.

Dr. Tami Benton, psychiatrist-in-chief at the Children’s Hospital of Philadelphia, estimates that at least 50 percent of people who die by suicide have an undiagnosed mental health disorder. Oquendo puts that number closer to 90 percent. The disparity comes from differing assesssments of underreported suicides: some families don’t want to admit how their loved one died while others simply never knew their loved one had a mental disorder.

Bowie’s dad, for instance, was never treated for depression, yet years of drinking and a family history of suicide put him at high risk. While there is no genetic marker associated with suicide, underlying mental health disorders can be passed down through generations and, in extreme cases, lead to suicide. This is why breaking the silence is so important.

"Just like you tell your kids that breast cancer runs in the family, if suicide runs in the family, we have to talk about it," said Oquendo, who is researching the genetic link between suicide and behavioral health.

Suicide in High School...or Earlier

Suicide is the second-leading cause of death for people between the ages of 10 and 34, according to the CDC. When adolescents attempt suicide the likelihood they will attempt it again later in life increases exponentially, according to Benton.

Experts point to heightened pressure at school and ruthless cyberbullying as possible reasons why a teen would consider ending their life. Because abstract thinking and long-term coping skills develop as they mature, young people "catastrophize those things and become more anxious," Benton said.

"At times, 11-year-olds and 12-year-olds say … 'If I don’t get straight A’s in seventh grade, I’m not going to get into AP courses in ninth grade … and I’m not going to get into a good college. If I don’t get into a good college, I’m going to be homeless,'" she said.

Even those external pressures don’t entirely explain why someone like Kiersten Killian, now 15, would have made her first suicide attempt when she was just 9 years old.

These days, the Lancaster County teen is a dedicated big sister and high school cheerleader. But at around 8 years old she started to kick doors closed and rip up notes. She said mean things to her mom. One Christmas Eve, Killian lunged for a kitchen knife.

"It’s hard to comprehend that a child would even know what suicide is," her mother, Ashley McDonnell, said. "I struggled immensely with that — not knowing how to help her, not knowing what to do because when I contacted a doctor or a hospital they told me that basically I was crazy."

Medical professionals blamed Killian’s hormones and McDonnell’s divorce. Stuck, McDonnell enrolled her daughter in 12 hours of weekly therapy. It seemed to help at first, but Killian’s depression was never far behind. On several occasions she opened the door to her mother’s moving car in an attempt to jump out.

"It got to the point where I didn’t want to bring her in the car because I was afraid she would … try to get out while I was driving 60 miles per hour," McDonnell said.

Killian fixated on a less lethal and more discreet method of self-harm: cutting. When McDonnell took her to the hospital, she was once again turned away and advised to try more therapy despite not being able to afford it.

Then came the second attempt.

After an argument with McDonnell’s husband, Killian swallowed pills. Forty-five minutes passed before the gravity of what she had done set in. Scared, she confessed to her mother and was rushed to the hospital in time to be saved.

Even now, Killian’s fragility lingers just below the surface. McDonnell removed her bedroom door until recently. Only Killian’s best friends know why she missed school for more than two months.

"They were very surprised because they always said I was so happy in school. I never looked sad, always smiling, always telling jokes, always friendly. They said they never thought that it would happen [to me]."

Many attempt survivors later say they regretted the attempt — not just months or years later, but immediately after. Experts point to the impulsive nature of suicide as one reason why, in prevention strategies, the method matters.

Approximately 50 percent of all suicides are completed with a firearm, and roughly 80 percent of those are by men. Women are more likely to attempt suicide but less likely to die because they use other means: cutting and overdosing, in particular. The one exception is women in the military. Familiarity with firearms increases their likelihood of using a firearm to kill themselves.

Bowie’s father used a gun. That night he disappeared after an explosive fight with her mom. She found him drunk at a bar. He was uninterested in seeing her.

"I don’t want you here," he told her.

One week later, he turned that gun on himself.

People who use firearms have a 90 percent completion rate compared to people who use other methods, according to the CDC. The lethal nature of guns has prompted experts to develop innovative approaches to "means reduction." The concept is simple — prevent suicides by reducing access to a firearm while in crisis.

"That can be very counterintuitive to people," said Cathy Barber, director of Harvard’s Means Matter initiative. "They will say someone can always find other means. But most people are not staying acutely suicidal for long."

Moving From Grief to Action

"I want to welcome everybody to Life Resurrected."

That’s how suicide prevention advocate Cathy Siciliano greeted a group of parents, partners and relatives to a Huntingdon Valley Catholic church on a cold Thursday night in February. "This is a survivor of suicide loss support group. This is a safe environment."

The dozen or so people sitting under fluorescent lights and huddled around the table are familiar with each other and with the grief they are about to share. One woman lost her sibling 20 years ago. A couple lost their son and a nephew in the span of three years. Another woman sits next to the girlfriend of her late son — he killed himself just four weeks before they found their way to this meeting.

There is nothing anyone here can say to bring back what was lost, but Siciliano hopes that sharing can lessen the pain. Members of the group recount their personal tragedy every time they meet. Survivors don’t shrink away from breaking their silence.

"It’s the most complicated grief you can go through," Siciliano said to the group’s newest member. "There is anger, sadness, confusion. No one can possibly understand that."

Like those gathered inside the rectory, Siciliano likes talking about the son she lost. Anthony was 26 years old, a volunteer firefighter who was hoping to land a job with the Philadelphia Fire Department. He once described himself as Icarus wanting to change the world, but worried about flying too close to the sun.

The two spoke every morning at 6:30 while Siciliano drove to work. It was their ritual that went uninterrupted until the Sunday before Thanksgiving. On that particular day Anthony had a sinus infection and cut the call short. "I’m going to take my medicine and lay down," he told her.

When she didn’t hear from him the next morning, Siciliano sent her husband to check on Anthony. He found his son lifeless and alone in his bedroom.

"People need to come forward. People need to listen." Kiersten Killian, 15, is breaking her silence around suicide. She attempted twice and now she wants to use her story to help others. Hear and read other stories about how you can help prevent suicide in your community with our special report, Preventing Suicide: Breaking the Silence.

(Published Monday, June 12, 2017)

Siciliano still doesn’t understand what prompted her son to kill himself. He was diagnosed with ADHD years earlier but didn’t take medication because of unwanted side effects. His toxicology report came back clean, and neither she nor her husband had noticed any major change in his attitude or behavior in the days leading up to his death.

The Huntingdon Valley school teacher tortured herself trying to remember every detail of their interactions: What had she missed? There was one small sign. Usually an entertainer, Anthony spent a family gathering barricaded in the garage texting a girl he dated for a short while. Now Siciliano wonders what they were texting about.

"He was like the Pied Piper with his cousins, yet he was removed from us that day," she said. "It was so subtle of indications that something was different about him, but no red flags."

Siciliano always assumed mental health disorders came with obvious symptoms. She never suspected that mere quietness or aloofness could signal something as final as suicide.

When Cathy Siciliano's son, Anthony, took his life, she was crushed. In the aftermath, family and friends suggested that she not tell others that Anthony died by suicide. Cathy balked at the notion and soon channeled her grief into action to help others affected by suicide.

(Published Monday, June 12, 2017)

It’s a familiar refrain for parents whose children have died by suicide. While some kids might have a well documented history of depression or suicidal behavior, countless more go undiagnosed. Benton, CHOP’s foremost expert on adolescent suicide, estimates that up to 90 percent of families she has treated noticed a change in their loved ones just before their death.

Parents frequently shy away from having frank conversations with their children about suicide and mental health. They fear planting an idea. Schools avoid mental health screening for similar reasons. But experts point to the power of human relationships as one of the most powerful deterrents to suicide.

At Drexel University’s Center for Family Intervention Science, just steps away from 30th Street Station, the approach is rooted in the idea that parents have an instinctual desire to protect their children even when they don’t understand what a young person might be experiencing or feeling. Therapists treat families struggling with depression, sexual identity and trauma, as well as parents who assume teens are merely acting out for attention.

"It can be very dangerous for a parent to not take certain signs seriously," Dr. Guy Diamond, the center’s director, said. "We try to repair that relationship before it’s too late."

CHOP also believes in early intervention. Benton’s team spreads suicide awareness to places where people gather but don’t necessarily talk about mental health: community groups, recreation centers and churches. The goal is to educate people about the warning signs of suicide and encourage people to intercede if they notice a friend or relative is struggling. Frequently, asking a person directly if they are contemplating suicide can lead to a bigger conversation and, hopefully, treatment.

Breaking the Silence

The risk of speaking out is great. Siciliano’s closest friends and relatives advised her to never share the manner of Anthony’s death, but she felt as though keeping his struggle a shameful secret wronged his memory.

This kind of stigma prevented La Salle University senior Amanda Johncola from speaking out about her multiple suicide attempts.

Until now.

Quiet and delicate, she didn’t understand the sudden sinking feeling of depression that descended on her when she was 8 years old. It was like a fog, heavy and involuntary.

Her parents didn’t get it either. She was bullied at school and suffered from severe anxiety and later body dysmorphia. Everything felt wrong until she got to college, where she hid her pain by drinking. Eventually, typical college partying gave way to frequent blackouts and then sexual assault.

At first, Johncola didn’t think it was rape because she couldn’t remember what happened. She went to a party and the next morning woke up in a stranger’s bed.

"I told myself these things happen," she said. "But then I started having flashbacks."

Those flashbacks, coupled with years of clinical depression, led to a suicide attempt. It wasn’t her first and it wouldn’t be her last. In high school, she cut herself and played the choking game in hopes of dying. By college she had graduated to more lethal means.

The university gave her a lifesaving ultimatum: visit a crisis center or enroll in intensive therapy. The latter has proven fruitful. Her therapists are kind and accepting. Her new friends buoy her when she feels low. She now sees depression as a clinical issue that can be treated rather than a life sentence.

The 21-year-old has yet to confide in her parents about the attempts. She worries they will blame themselves. She worries what her siblings will think. She worries that her already distant relationship with her family will only grow more fraught.

Yet, the promise of letting go and leaving the pain behind is more urgent than any fear of retaliation. She has learned to take things as they come.

"You can't let your story stop — you have to keep pushing forward," Johncola said. "You don’t know what your life’s purpose is until you reach out and find it. Killing yourself isn’t a purpose."

Each suicide directly impacts six people, according to experts, with 129 more also touched by the loss. If suicide has historically been a whispered word, its effects are more aptly described as an earthquake with multiple, often recurring, aftershocks.

The pain of a mother is not the same as the grief of a daughter or the ongoing struggle of an attempt survivor. Each experience is different and unique, yet the voices all have something in common: the urgent need to speak out.

It’s not a radical concept, but it does demand a radical rethinking of how society perceives mental illness. If those who have survived suicide’s touch are not afraid to speak out, then we should not be afraid to hear them. Suicide will remain a whispered word until we say it aloud.

If you are in crisis, call the National Suicide Prevention Lifeline at 800-273-8255 or reach out to the Crisis Text Line by texting 'Home' to 741741.