Suicide Prevention: A View from the Bridge Norman L. Farberow, Ph.D.

ABSTRACT: The future of suicide prevention activities is seen in terms of developments over the past decade. Seventy-four suicide prevention services have been established since the Los Angeles Suicide Prevention Center was opened in I958. While many models have developed, principles of crisis therapy, transfer of patients rather than referral, use of the telephone in therapy, integration of the center into the community network of helping agencies, and use of nonprofessional volunteers are present as common elements in all. Predictions are offered for the differential development of independent suicide prevention centers and inserted suicide prevention services. Future emphasis is predicted for primary prevention of suicide crises, as well as continued refinements of secondary intervention procedures already developed. The current scene in suicide prevention is gratifying when viewed through the past, a history both short and vigorous. It is also stimulating when viewed in its present state, a panorama of activities impressively wide and varied. But the current scene is most exciting in its portents for the future and its challenge for innovative changes to meet the as yet unfilled needs and predicted new demands. Let us, therefore, pass quickly through the past and the present of the suicide prevention activities so that we may dwell on the future, not only of the Los Angeles Suicide Prevention Center, but of all suicide prevention centers and of suicide prevention in general PAST AND PRESENT When the Los Angeles Suicide Prevention Center was established in r958, there was no field of suicide prevention and there were no precedents from which it could develop. The Center emerged from the need to provide some resource for persons who had attempted suicide and had entered a hospital where they had received medical treatment, but were then returned to the environment and conflicts that had contributed to and produced their suicidal crisis (Farberow & Shneidman, x96z). In its development the Center underwent many changes. The first concept of the Center was as a bridge, which attempted suicides could not cross on their discharge without being interviewed and recommended to a treatDr. Farberow is Co-director, Suicide Prevention Center, Los Angeles; Professor of Psychiatry {Psychology), University of Southern California, School of Meclicine; Principal Investigator, Central Research Unit for the Study of Unpredicted Death, Veterans Administration Center, Los Angeles. Community Mental Health Journal, Vol. 4 (6), 1968

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ment plan. The first major change in the functioning of the Center occurred with the development of the telephone as the primary means of contact with persons needing help, a procedure much different from the staff wandering through the wards of the County Hospital looking for patients admitted for a suicide attempt. With the acceptance of the telephone, the Center was able to focus on people who were calling for help before they hurt themselves rather than after the suicidal acting-out had occurred. As the case load zoomed, it forced a basic conceptualization of a suicide prevention center: the center best serves as an emergency, crisis-oriented community agency, focusing on the immediate stressful situation and offering crisis therapy, not long-term rehabilitative care. This developed another basic concept: that the center is but one agency in the community in the web of helping resources for emotionally disturbed individuals, and that it can function only in dose liaison with them all (Litman, Farberow, Heilig, Shneidman, & Kramer, ~965). TURNING POINTS Two turning points for the Center arrived quickly: (-r) the establishment of training activities, with the advent of students and professional personnel seeking experience and training in the area of suicide prevention, and (z) the initiation of the Night Watch, offering for the first time an around-the-clock and weekend service. The last significant change occurred when the apprehensions of the professional staff were relaxed sufficiently to allow the introduction, training, and use of the nonprofessional for direct patient contact (Heilig, Farberow, Litman & Shneidman, :c968) The past decade has seen the establishment of suicide prevention centers throughout this country, a movement which began slowly but has since increased to its much more rapid present pace. As of today, by the latest count, there are 74 suicide prevention centers and services in the United States, following a wide range of models, with variations in staffing, place of operation, forms of support, and types of services offered. That the movement will continue to grow is indicated by the fact that there are at least the same number of communities that have indicated interest in establishing their own suicide prevention centers; that a national program for training in suicidology is already well on its way; that an American Association for Suicidology will emerge from this first meeting; and that it will probably affiliate with the already established International Association for Suicide Prevention. TODAY'S LOOK The Los Angeles Suicide Prevention Center has now been in existence for nine and one-half years. With the changes that have occurred, what does it look like today? The Center has always included in its functioning the three fundamental areas of clinical service, training and education, and research (disregarding for the moment the important ad-

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ministration activities). The clinical services occupied a major portion of its focused attention for the earlier part of its existence. The number of cases that the Center has handled and the contacts it has had with the community in response to suicidal persons, their families or other communities have increased at a geometric pace. In x962, the case load for the Center was 5,oo7; in :~964, it was 3,865; and in :~966, it was 6,88o. The case load could continue to grow for several years at the same rapid rate, easily doubling, were we to so desire. However, we can see no advantages to increase in mere size, but rather feel the need is more pressing for increasing understanding through research and for training others in the techniques of prevention (Shneidman & Farberow, in press). The training and education program has seen the greatest proportionate increase, especially within the past three or four years. Regular training programs have been established for a number of different groups, such as professionals (training institutes, workshops, field placements, preceptorships); semiprofessionals (students interning for varying lengths of time, and Night Watch personnel); and nonprofessional persons who help man the telephones in daytime. Training of ancillary groups within the community, such as police, physicians, lawyers, etc., has grown to a large degree, and many of the staff are occupied with workshops, symposia, and continuous seminars. Research has always been an essential activity in the Center. Much of the early research was in the clinical area, focused on the development and evaluation of procedures for handling suicidal people. Theoretical or experimental research has been on a relatively lower frequency level. Today's functioning of the Center has seen a shift in emphasis. The clinical services have decreased, the training activities have increased, and research programs are planned for a major expansion. Within the clinical service, the volunteers now receive and handle around 6o percent of the calls that come into the Center during the day. The Night Watch functions smoothly, and much of the staff's time is taken up with consultation and supervision of the volunteers during the clay and the training activities currently underway. What does the future hold for the field of suicide prevention? Changes will occur, and we should be making them rather than have them occur to us. In general, I would like to talk about four areas of concern: (5) the future of suicide prevention centers; (2) the future of the Los Angeles Suicide Prevention Center; (3) the continuing problems for the suicide prevention service; and (4) the future focus of suicide prevention activity. FUTURE FOR SUICIDE PREVENTION CENTERS New suicide prevention services will continue to appear. It seems likely the next four or five years will see the continuation of the two trends already emerging in the establishment of new services. In one, the service will be inserted into already functioning mental health agencies such as clinics, mental health centers, neuropsychiatric and GM&S

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hospitals, mental health and hygiene departments, and currently developing community mental health centers. In these services, because of the setting, the primary role will be played by the professional personnel, but I would expect that the agencies, if they have not already done so, would initiate the use of nonprofessional or semiprofessional personnel as their manpower problems become more pressing. For the second trend, we will see many more suicide prevention centers established independently and functioning for the sole purpose of suicide prevention. I anticipate these would be supported by community groups such as local mental health associations, churches, clubs, private citizen philanthropists, or community welfare organizations. While these centers will be primarily nonprofessionally staffed, they will use professional personnel from the community for consultation, organization and direction. I predict that the independent, community-based suicide prevention centers will continue for many years. The nonprofessional workers, perhaps by this time more appropriately designated mental health counselors, receive great satisfaction from the provision of a much needed service. Their clinical activities fill a void in most communities, and enthusiastic, highly motivated individuals will see to it that such centers obtain continued support. I would anticipate, however, that the inserted suicide prevention services will gradually broaden their interests and might even disappear as a separate identity either through merger or modification. The general direction will be toward the broad area of emergency mental health that will encompass all crises in emotional disturbances, of which suicide is only one. Professionals in mental health will not be content to stay focused on one symptom, overt and dramatic as suicide is. This trend is even now emerging in the concept of the community mental health center, which has already adopted the two key words characterizing any suicide prevention center, accessibility and availability, or "next door" and "no waiting." The development of community psychology and psychiatry may help in the initiation of pre-crisis prevention programs, the next step in suicide prevention. There has been a mutual stimulation between suicide and community mental health. Suicide is now most readily seen as merely one kind of reaction to socio-psychological disturbance. With the increased appreciation of the role of social and cultural contributions to suicide, and the exploration of interpersonal, interactional influences, more disciplines will become involved. For example, it might be the cultural anthropologist who would be the most useful person for the intensive examination of the culture and the local subculture within which any suicidal behavior must be understood. The statement that a man is "out of kilt with his cult" may be just as meaningful, if not more, than that he is a sociopath. I would anticipate an increasing complex of professions, interests, theoretical fields, and disciplines staffing future mental health centers, which are oriented to operating not only within the doors of their own buildings but in the homes, offices, stores, and streets of prospective clients.

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FUTURE FOR THE LOS ANGELES CENTER The Los Angeles Suicide Prevention Center, primarily through the development of its research activities, will evolve into an institute, probably named "The Institute for the Study of Self-Destruction." The title will reflect not only the involvement of many related disciplines but also the broadening of the subject area to include many pertinent topics, ranging from overt suicidal behavior to indirect self-destructive behavior seen in diabetes, circulatory and heart syndromes, alcoholism, drug addiction, obesity, traffic accident, violence and aggression, risk-taking behavior, and others. It becomes apparent that some familiar indirect self-destructive behavior is well within the scope of usual, normal behavior. The training activities of the Center will also increase. The Los Angeles Suicide Prevention Center is, as of now and probably for the next several years, the primary source in this country for training in suicide prevention. The Center is even now expanding its program of training of professionals, semiprofessionals, nonprofessionals, and related groups in the community, coordinating in the training of fellows in suicidology, and assisting in the development of films, training tapes, manuals, and other training aids. A complete library is being developed, and a continuing active role is planned in educational activities directed primarily to the general public. PROBLEMS OF THE PREVENTION MOVEMENT Problems continue for the suicide prevention movement, some of which may be enumerated. For example, there is the ever-frustrating problem of what to do with the chronic, borderline suicidal person who needs ready but not continuous care, with a structured environment that does not mollycoddle but that does provide a chance for reconstruction and possible reparation. Continuing refinements in the institutional care for suicidal persons are necessary, especially in overcoming the as-yet-unsolved conflict of patient independence versus patient protection. On the other hand, is a telephone contact enough? Should there be serious effort put into the exploration of a "befriending" organization to combine with the telephone contacts? The "befrienders" system has worked well in England; why not here? Is it possible to establish a "buddy" system or a "Suicides Anonymous" for suicidal individuals? And how shall we determine whether we are doing any good in preventing suicide, that old bugaboo of evaluating effectiveness? Are we reaching the right people in our suicide prevention efforts? The highest rate is in the older, white, sick males, but these make up only a small proportion of our case load. Also, are we training the right peopIe, and if so, how do we keep up their interest and enthusiasm, forestalling feelings of omnipotence or professional detachment? Ultimately, the problem reduces to a continuing attack on taboos around suicide, and this is essentially a matter of education. But how can we best accomplish this? Does it suggest incorporation of materials on death and suicide into courses on mental health that will become a routine part of the curriculum of schools?

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FUTURE FOCUS Finally, this leads to the area of development in the future of suicide prevention activity. I see this as essentially a movement from secondary to primary prevention. Using the public health model, crisis and emergency activity fall within the area of secondary prevention. A person becomes highly suicidal and calls a suicide prevention center. The center works with him through the crisis and refers or transfers him elsewhere where the tertiary prevention phase of reparation and cure occurs. Primary prevention will focus on prevention, that is, establishing procedures and techniques that will forestall the suicidal crisis. In planning for such activities, there are two areas where such focus might occur: (z) the kind of crisis stimulus, and (z) the individual. For each of these, there is the unanticipated and the anticipated: Under crisis, one can cite unanticipated emergencies such as catastrophes and disasters, natural and human, that may occur to any individual or group, including sudden death, or loss of a loved one. Anticipated crises are those that occur through the natural process of human development and the passage through familiar stress points. Some examples are: promotions, loss of job, marriage, divorce, or death or loss of a loved one. For the individual, the unanticipated will be a suicidal reaction in someone who had given no prior indications of self-destructive tendencies, a relatively unusual event, for most suicidal behavior has been amply suggested beforehand. The anticipated concept, under individual, helps by identifying those previously determined to be a high risk, high suicide potential population, such as those with a history of prior suicidal activity: the older white, sick, lonely male; the mentally ill; and the socially disturbed such as alcoholics, drug addicts, and others. It should be possible to study various groupings, as indicated above, and to evolve procedures for identification, establishment of contact, and initiating of interventive activities prior to the efflorescence of the suicidal crisis. When this occurs, suicide prevention will have added a heretofore lacking but basic activity, i.e., crisis prevention, before impulses to self-injury or harm can develop, as compared to the current scene of crisis intervention, when the self-destructive impulses are in open expression. REFERENCES Farberow,N. L., & Shneidman,E. S. (Ed.) The cry for help. New York: McGraw-Hill,I96i. Heilig, S. M., Farberow,N. L., Litman, R. E., & Shneidman,E. S. The role of nonprofessional volunteers in a suicide prevention center. Community Mental Health Journal, i968, 4, 287-295. Litman, R. E., Farberow,N. L., Heilig, S. M., Shneidman, E. S., & Kramer, J. A suicideprevention telephoneservice.Journal of the American Medical Association, I965, I93, 2I-25. Shneidman,E. S., & Farberow,N. L. The SuicidePreventionCenterof Los Angeles.In H. L. P. Resnik (Ed.),The diagnosis and management of the suicidal individual. New York: Little, Brown, & Company,in press.

Suicide prevention: A view from the bridge.

The future of suicide prevention activities is seen in terms of developments over the past decade. Seventy-four suicide prevention services have been ...
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