Night Falls Fast Understanding Suicide

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 THIS IS A BORZOI BOOK

PUBLISHED BY ALFRED A. KNOPF

Copyright © 1999 by Kay Redfield Jamison

All rights reserved under International and Pan-American
Copyright Conventions. Published in the United States
by Alfred A. Knopf, a division of Random House, Inc.,
New York, and simultaneously in Canada by
Random House of Canada Limited, Toronto.
Distributed by Random House, Inc., New York.

www.randomhouse.com

Knopf, Borzoi Books, and the colophon are registered

trademarks of Random House, Inc.

Owing to limitations of space, acknowledgments for

permission to reprint previously published material
may be found following the index.

Library of Congress Cataloging-in-Publication Data

Jamison, Kay R.
Night falls fast : understanding suicide / by Kay Redfield
Jamison. — 1st ed.
p. cm.
eISBN: 978-0-307-77989-2
1. Suicide—United States. 2. Children—Suicidal behavior—
United States. 3. Youth—Suicidal behavior—United States.
I. Title.
RC569.J36 1999
616.85′8445′00973—dc21 99-311227

v3.1
 For my husband,
Richard Jed Wyatt
With deep love
and
For my brother,
Dean T. Jamison
Who kept the night at bay
 Night falls fast.
Today is in the past.

Blown from the dark hill hither to my door

Three flakes, then four
Arrive, then many more.

—EDNA ST. VINCENT MILLAY

 Contents

Cover
Other Books by This Author
Title Page
Copyright
Dedication
Epigraph
Prologue

I BURIED ABOVE GROUND

An Introduction to Suicide
1 Death Lies Near at Hand
History and Overview
2 To Measure the Heart’s Turbulence
Definitions and Magnitudes
Essay: THIS LIFE, THIS DEATH

II JUST HOPE HAS GONE

Psychology and Psychopathology
3 Take Off the Amber, Put Out the Lamp
The Psychology of Suicide
4 The Burden of Despair
Psychopathology and Suicide
 5 What Matters It, If Rope or Garter
Methods and Places
Essay: THE LION ENCLOSURE

III PANGS OF NATURE, TAINTS OF BLOOD

The Biology of Suicide
6 A Plunge into Deep Waters
Genetic and Evolutionary Perspectives
7 Death-Blood
Neurobiology and Neuropathology
Essay: THE COLOURING TO EVENTS: THE DEATH OF MERIWETHER LEWIS

IV BUILDING AGAINST DEATH

Prevention of Suicide
8 Modest Magical Qualities
Treatment and Prevention
9 As a Society
The Public Health
10 A Half-Stitched Scar
Those Left Behind

Epilogue

Appendix: Resources for Information About Suicide, Mental Illness,

and Alcohol and Drug Abuse
Notes
Acknowledgments
A Note About the Author
 PROLOGUE

S ummer evenings at the Bistro Gardens in Beverly Hills tended toward

the long and languorous. My friend Jack Ryan and I went there often
when I lived in Los Angeles, and I invariably ordered the Dungeness crab
and a scotch on the rocks. Not so invariably, but from time to time, Jack
would use the occasion to suggest we get married. It was an idea with such
patent potential for catastrophe that neither of us had much of an
inclination to take the recurring proposal with too much gravity. But our
friendship we took seriously.
This particular evening, having hooked and tugged out the last bits of
crab, I found myself edgily knocking the ice cubes around in my whisky
glass. The conversation was making me restless and uneasy. We were
talking about suicide and making a blood oath: if either of us again became
deeply suicidal, we agreed, we would meet at Jack’s home on Cape Cod.
Once there, the nonsuicidal one of us would have a week to persuade the
other not to commit suicide; a week to present all the reasons we could
come up with for why the other should go back on lithium, assuming that
having stopped it was the most likely reason for the danger of suicide (we
both had manic-depressive illness and, despite the better and often
expressed judgment of others, had a tendency to stop taking our lithium); a
week to cajole the other into a hospital; to invoke conscience; to impress
upon the other the pain and damage to our families that suicide would
inevitably bring.
We would, we said, during this hostage week, walk along the beach and
remind the other of all of the times we had felt at the end of hope and,
somehow, had come back. Who, if not someone who had actually been
there, could better bring the other back from the edge? We both, in our own
ways and in our own intimate dealings with it, knew suicide well. We
thought we knew how we could keep it from being the cause of death on our
death certificates.
 We decided that a week was long enough to argue for life. If it didn’t
work, at least we would have tried. And, because we had years of
cumulative experience with lifestyles of snap impetuousness and knew how
quick and final a suicidal impulse could be, we further agreed that neither
of us would ever buy a gun. Nor, we swore, would we under any
circumstances allow anyone else to keep a gun in a house in which we
lived.
“Cheers,” we said in synchrony, ice and glass clinking. We sealed our
foray into the planned and rational world. Still, I had my doubts. I listened
to the details, helped clarify a few, drank the rest of my scotch, and stared at
the tiny white lights in the gardens around us. Who were we kidding? Never
once, during any of my sustained bouts of suicidal depression, had I been
inclined or able to pick up a telephone and ask a friend for help. Not once.
It wasn’t in me. How could I seriously imagine that I would call Jack, make
an airline reservation, get to an airport, rent a car, and find my way out to
his house on the Cape? It seemed only slightly less absurd that Jack would
go along with the plan, although he, at least, was rich and could get others
to handle the practicalities. The more I thought about the arrangement, the
more skeptical I became.
It is a tribute to the persuasiveness, reverberating energies and
enthusiasms, and infinite capacity for self-deception of two manic
temperaments that by the time the dessert soufflés arrived we were utterly
convinced that our pact would hold. He would call me; I would call him; we
would outmaneuver the black knight and force him from the board.

If it has ever been taken up as an option, however, the black knight has a
tendency to remain in play. And so it did. Many years later—Jack had long
since married and I had moved to Washington—I received a telephone call
from California: Jack had put a gun to his head, said a member of his
family. Jack had killed himself.
No week in Cape Cod, no chance to dissuade. A man who had been
inventive enough to earn a thousand patents for such wildly diverse
creations as the Hawk and Sparrow missile systems used by the U.S.
Department of Defense, toys played with by millions of children around the
world, and devices used in virtually every household in America; a Yale
graduate and lover of life; a successful businessman—this remarkably
imaginative man had not been inventive enough to find an alternative
solution to a violent, self-inflicted death.
Although shaken by Jack’s suicide, I was not surprised by it. Nor was I
surprised that he had not called me. I, after all, had been dangerously
suicidal myself on several occasions since our Bistro Gardens compact and
certainly had not called him. Nor had I even thought of calling. Suicide is
not beholden to an evening’s promises, nor does it always hearken to plans
drawn up in lucid moments and banked in good intentions.
I know this for an unfortunate fact. Suicide has been a professional
interest of mine for more than twenty years, and a very personal one for
considerably longer. I have a hard-earned respect for suicide’s ability to
undermine, overwhelm, outwit, devastate, and destroy. As a clinician,
researcher, and teacher I have known or consulted on patients who hanged,
shot, or asphyxiated themselves; jumped to their deaths from stairwells,
buildings, or overpasses; died from poisons, fumes, prescription drugs; or
slashed their wrists or cut their throats. Close friends, fellow students from
graduate school, colleagues, and children of colleagues have done similar
or the same. Most were young and suffered from mental illness; all left
behind a wake of unimaginable pain and unresolvable guilt.
Like many who have manic-depressive illness, I have also known suicide
in a more private, awful way, and I trace the loss of a fundamental
innocence to the day that I first considered suicide as the only solution
possible to an unendurable level of mental pain. Until that time I had taken
for granted, and loved more than I knew, a temperamental lightness of
mood and a fabulous expectation of life. I knew death only in the most
abstract of senses; I never imagined it would be something to arrange or
seek.
I was seventeen when, in the midst of my first depression, I became
knowledgeable about suicide in something other than an existential,
adolescent way. For much of each day during several months of my senior
year in high school, I thought about when, whether, where, and how to kill
myself. I learned to present to others a face at variance with my mind;
ferreted out the location of two or three nearby tall buildings with
unprotected stairwells; discovered the fastest flows of morning traffic; and
learned how to load my father’s gun.
 The rest of my life at the time—sports, classes, writing, friends, planning
for college—fell fast into a black night. Everything seemed a ridiculous
charade to endure; a hollow existence to fake one’s way through as best one
could. But, gradually, layer by layer, the depression lifted, and by the time
my senior prom and graduation came around, I had been well for months.
Suicide had withdrawn to the back squares of the board and become, once
again, unthinkable.
Because the privacy of my nightmare had been of my own designing, no
one close to me had any real idea of the psychological company I had been
keeping. The gap between private experience and its public expression was
absolute; my persuasiveness to others was unimaginably frightening.
Over the years, my manic-depressive illness became much worse, and the
reality of dying young from suicide became a dangerous undertow in my
dealings with life. Then, when I was twenty-eight years old, after a
damaging and psychotic mania, followed by a particularly prolonged and
violent siege of depression, I took a massive overdose of lithium. I
unambivalently wanted to die and nearly did. Death from suicide had
become a possibility, if not a probability, in my life.
Under the circumstances—I was, during this, a young faculty member in
a department of academic psychiatry—it was not a very long walk from
personal experience to clinical and scientific investigation. I studied
everything I could about my disease and read all I could find about the
psychological and biological determinants of suicide. As a tiger tamer
learns about the minds and moves of his cats, and a pilot about the
dynamics of the wind and air, I learned about the illness I had and its
possible end point. I learned as best I could, and as much as I could, about
the moods of death.
 I

Buried Above Ground

—AN INTRODUCTION TO SUICIDE—

Encompass’d with a thousand dangers,

Weary, faint, trembling with a thousand terrors.…
I … in a fleshly tomb, am
Buried above ground.

—WILLIAM COWPER
English poet William Cowper (1731–1800) on several occasions tried to
poison, stab, or hang himself. The self-described “lines written during a
period of insanity” were composed after one of his suicide attempts.
 CHAPTER 1

Death Lies Near at Hand

—HISTORY AND OVERVIEW—

A tiny blade will sever the sutures of the neck, and when that
joint, which binds together head and neck, is cut, the body’s
mighty mass crumples in a heap. No deep retreat conceals the
soul, you need no knife at all to root it out, no deeply driven
wound to find the vital parts; death lies near at hand.…
Whether the throat is strangled by a knot, or water stops the
breathing, or the hard ground crushes in the skull of one falling
headlong to its surface, or flame inhaled cuts off the course of
respiration—be it what it may; the end is swift.

—SENECA

N O ONE KNOWS who the first was to slash his throat with a piece of flint,
take a handful of poison berries, or intentionally drop his spear to the
ground in battle. Nor do we know who first jumped impulsively, or after
thought, from a great cliff; walked without food into an ice storm; or
stepped into the sea with no intention of coming back. Death, as Seneca
states, has always lain close at hand; yet it is a mystery why the first to kill
himself did: Was it a sudden impulse, or prolonged disease? An inner voice,
commanding death? Perhaps shame or the threat of capture by an enemy
tribe? Despair? Exhaustion? Pressure from others to spare common
resources of food and land? No one knows.
It is unlikely that Homo sapiens was the first to think of suicide or act on
the thought of it; indeed, from an evolutionary perspective this would seem
rather arbitrary, given the sophistication of the hominids before us. The
Cro-Magnons, we believe, were skilled hunters, makers of blades and
spears, plaiters of rope, users of fire, and reflective, ingenious inventors of
remarkable art forms and elaborate burial rituals. And, there was Homo
neanderthalensis before them, and the hunting apes, such as chimpanzees,
known to be aggressive, social, and cognitively complex toolmakers. At
what point did self-awareness enter into the life of the brain? When did a
conscious, deliberate intent to die veer off from the borderlands of extreme
recklessness and impetuous, life-threatening taking of risks? Violence and
recklessness, profound social withdrawal, and self-mutilation are not, as we
shall see, unique to our species. But perhaps suicide is.
We will never know who or why or how the first to kill himself did (or
herself; we will never know that either). But it is very likely that once
suicide occurred and others were cognizant of it, the act was repeated—in
part because the reasons and means would remain integral to the
psychological and physical environment, and in part because animals and
humans learn, to considerable extent, through imitation. Suicide,
dangerously, has a contagious aspect; it has, as well, for the vulnerable, an
indisputable appeal as the solution of last resort.
Recorded observations about suicide are, of necessity, far more recent
than its first occurrences. Society’s attitudes, as captured in its literature,
laws, and religious sanctions, provide one window into our collective
reactions to self-murder. They give a historical perspective to the evolution
of our perceptions about suicide, perceptions that have varied from our
seeing it as an accepted and valued event to treating it as a sin or a crime, or
conceptualizing it as the consequence of adverse circumstances or
pathological mental states.

Certainly, cultures have varied in their notions of self-inflicted death.

Several—for example, the Eskimo, Norse, Samoan, and Crow Indian—
accepted, and even encouraged, “altruistic” self-sacrifice among the elderly
and sick. Among the Yuit Eskimos of St. Lawrence Island, if an individual
requested suicide three times, relatives were obligated to assist in the
killing. The person seeking suicide dressed in ritual death garb and then was
killed in a “destroying place” set aside specifically for that purpose. To save
commonly held resources of food or to allow a nomadic society to move on
unhindered by the physically ill or elderly, some societies gave tacit if not
explicit approval to suicide.
No early cultural or religious sanctions were attached to the suicides
recorded in the Old Testament or to the only one, that of Judas Iscariot,
described in the New (attitudes toward suicide hardened during the early
years of Christianity). Most of these deaths, like those of the ancient Greeks
portrayed by Homer, were seen as matters of honor, actions taken to avoid
falling into the hands of a military enemy, to atone for wrongdoing, or to
uphold a religious or philosophical principle. Hannibal, for example, took
poison rather than be captured or dishonored, as did Demosthenes, Cassius,
Brutus, Cato, and scores of others. Socrates, who refused to renounce his
teachings and beliefs, drank hemlock. Gladiators thrust wooden sticks or
spears down their throats or forced their heads into the spokes of moving
carts in order that they might choose their own, rather than another’s, time
and way of dying.
Beliefs about suicide varied considerably in ancient Greece. The Stoics
and Epicureans believed strongly in the individual’s right to choose the
means and time of his death. Others were less accepting of the idea. In
Thebes and Athens, suicide was not against the law, but those who killed
themselves were denied funeral rites and the hand that had been used for the
act was severed from the arm. Aristotle regarded suicide as an act of
cowardice, as well as an act against the state; so, too, did Pythagoras.
(Although, according to Heracleitus, Pythagoras starved himself to death.)
Roman law actively prohibited suicide and further prohibited the passing on
to heirs of the suicide’s possessions and estates. The Catholic Church from
its earliest days opposed suicide and, during the sixth and seventh centuries,
codified its opposition by excommunicating and denying funeral rites to
those who died by their own hand. Suicide was never justifiable, wrote St.
Augustine in an authoritative argument for the Church, because it violated
the sixth commandment of God, “Thou shalt not kill.”

Jewish custom forbade funeral orations for anyone who committed suicide;
mourners’ clothes were not encouraged, and burial was generally limited to
an isolated section of the cemetery, so as “not to bury the wicked next to the
righteous.” The Semachot, the rabbinic text on death and mourning, states
that “He who destroys himself consciously (‘la-daat’), we do not engage
ourselves with his funeral in any way. We do not tear the garments and we
do not bare the shoulder in mourning and we do not say eulogies for him.”
Over time, a greater latitude and compassion was extended to suicides
committed while of an unsound mind. “The general rule,” states one scholar
of Jewish tradition, “is that on the death of the suicide you do everything in
honour of the surviving, such as visit and comfort and console them, but
you do nothing in honour of the dead apart from burying them.” In Islamic
law, suicide is a crime as grave as, or even graver than, homicide.
Strong religious and legal sanctions against suicide are scarcely
surprising; it would be odd indeed if society had no reaction to such a
dramatic, seemingly inexplicable, frightening, frequently violent, and
potentially infectious form of death. Dante, writing almost seven hundred
years ago in The Inferno, assigned a particularly grim fate to those who
committed suicide. Condemned to the seventh circle of Hell and
transformed into bleeding trees, the damned and eternally restless souls of
the suicides were subject to continuous agony and fed upon mercilessly by
the Harpies. They who in “mad violence” killed themselves were, unlike all
others who resided in Hell, also denied the use of their earthly human
forms.
The civil desecration of the corpses of suicides was common, as were
attempts to prevent untoward influence upon the living by physically
isolating and constraining the body and its potentially dangerous spirit. The
bodies of those who killed themselves were, in many countries, buried at
night and at a crossroads. The greater traffic over such crossroads was
thought to “keep the corpses down,” and the intersection of paths, it was
believed, would make it more difficult for the spirit to find its way home. In
early Massachusetts, cartloads of stones were unloaded at the crossroads
where a suicide had been buried. Not uncommonly, a stake was driven
through a suicide’s heart, a practice that has suggested to at least one
scholar its similarity to the fate of a fourteenth-century murderer whose
body was discovered years ago in the peat bogs of Sweden. The murderer’s
captors, in order to stop the dead man from “walking,” drove birch stakes
through his back, side, and heart; they then sank his body into a fen, at the
meeting point of four parishes, in the not altogether unreasonable belief that
he would be unlikely to escape.