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Lessons in suicide prevention from the Golden Gate Bridge: means restriction, public health, and the school psychologist.

Youth suicidal behavior is an enormous societal problem both in the U.S. and in other countries. Worldwide, suicide claims the lives of nearly one million people annually, has increased over 60% during the last half-century, and is the second leading cause of death among all people ages 10 to 24 (Miller, 2011). In the U.S., suicide is the third-leading cause of death among 10- to 24-year olds (American Association of Suicidology, 2010), trailing only accidents and homicide. Moreover, for each young person who dies by suicide it is estimated that 100 to 200 more make suicide attempts, and that thousands more engage in suicide-related communication (e.g., suicide threats) and suicidal ideation (Mazza, 2006). Consequently, youth suicidal behavior is a major public health crisis for children and adolescents, their families, and their communities (Miller, Eckert, & Mazza, 2009).

Given the significance of this problem and the urgent need to address it, and because children and adolescents spend much of their time in schools, educational facilities have been identified as critical venues for focused youth suicide prevention efforts (Kalafat, 2003; Mazza & Reynolds, 2008). Although most youth suicides occur in a student's place of residence rather than in school (Berman, Jobes, & Silverman, 2006), other forms of youth suicidal behavior (e.g., suicidal ideation; suicide threats) do occur in schools, sometimes at high rates (Miller, 2011). Moreover, although there are significant methodological problems with many of the studies that have examined the effectiveness of school-based suicide prevention programs (Miller et al., 2009), there is increasing evidence that schools can increase the knowledge that students and school personnel have about youth suicidal behavior, and that this can lead to an increased number of referrals to school-based mental health professionals (Mazza, 1997; Reis & Cornell, 2008; Suldo et al., 2010). Further, research indicates that presenting information to students about youth suicide can help change their attitudes about it (Kalafat, 2003), and that training peers and increasing school connectedness can enhance protective factors (e.g., social support) associated with reduced suicide risk (Wyman et al., 2010). Perhaps most important, there is some preliminary evidence suggesting that comprehensive school-based suicide prevention programs can decrease the number of student suicides (Zenere & Lazarus, 1997), and do so over a sustained period of time (Zenere & Lazarus, 2009).

Unfortunately, it appears that many schools do not offer suicide prevention programs (Miller, 2011), placing them at risk not only for potential student deaths by suicide but also possible litigation (Berman, 2009; Jacob, 2009; Jacob, Decker, & Hartshorne, 2011). This is problematic, given that school personnel --including school psychologists--have a legal responsibility as well as an ethical duty to prevent youth suicide whenever possible (Jacob, 2009). Although school psychologists play an important role in school-based suicide prevention efforts, most of their work in this area typically involves suicide risk assessment and crisis counseling with suicidal youth (Miller, 2011). Although critically important, crisis counseling only occurs after a child or adolescent has been identified as being potentially suicidal and is therefore reactive rather than proactive. A more population-based, proactive role for the school psychologist is needed to maximize the effectiveness of school-based suicide prevention efforts. Some important lessons for accomplishing this goal can be found in a perhaps unlikely source: the Golden Gate Bridge.

Suicide and the Golden Gate Bridge

Located in San Francisco, California, the Golden Gate Bridge is considered one of the seven wonders of the modern world and has been described as "a global icon, a triumph of engineering, and a work of art" (Starr, 2010, p.1). It also has the dubious distinction of being the site of more suicides than any other single place in the United States (Joiner, Van Orden, Witte, & Rudd, 2009) and perhaps the world (Friend, 2003). Completed in May of 1937, the year 2012 marked the 75th anniversary of the bridge. Since its completion, over 1,500 people (the exact number is unknown and current figures are likely underestimates given undetected nighttime jumps; Starr, 2010) have jumped from the bridge to their deaths (Bateson, 2012). For every person who dies by suicide at the bridge--which occurs about once every two weeks on average (Friend, 2003)--two or more others are restrained from doing so, usually by members of the California Highway Patrol (Joiner, 2010). Of those individuals who do jump, the vast majority (an estimated 97%) die either at impact or by drowning (Friend, 2003).

Although calls for systematic prevention efforts have been ongoing since at least the 1950s, the current system for preventing suicide on the Golden Gate Bridge is what bridge officials refer to as a "non-physical barrier" (Friend, 2003, p. 13). These components include several security cameras and 13 telephones, which potentially suicidal people can use to contact the bridge's control tower. The other important component is randomly scheduled patrols conducted by the California Highway Patrol and Golden Gate Bridge personnel, who monitor pedestrians walking across the bridge via squad cars, motorcycles, bicycles, and on foot (Friend, 2003). However well intentioned, a significant problem with these programs is that they are dependent on a potentially suicidal individual actively seeking help (which often does not occur) or on situations in which an individual patrolling the bridge is within reasonable proximity to an individual attempting to jump from it.

A bridge barrier, which would potentially solve both of these problems, has been proposed for decades but has been repeatedly voted down by the authorities in the San Francisco Bay area. Typical reasons cited for not erecting bridge barriers include their cost, view obstruction, and aesthetic concerns (Friend, 2003). Perhaps the most important impediment to building a bridge barrier, however, is the apparent belief among many that any attempt at preventing suicides at the Golden Gate Bridge would ultimately be ineffective, because individuals who were prevented from jumping from the bridge would simply attempt and most likely die by suicide in some other manner, in some other place, and at some other time (Joiner, 2010).

Myths and Method Substitution

There are many myths about suicide (Joiner, 2010), with perhaps the most dangerous being the faulty notion that there is little or nothing anyone can do if a particular individual wants to die by suicide. That is, limiting access to a lethal means of suicide would only temporarily prevent a suicide from occurring, because an individual thwarted from attempting suicide via one method would simply adopt another one. This theory, commonly referred to as method substitution, would suggest that restricting access to lethal means in one area (e.g., restricting access to jumping off the Golden Gate Bridge through the placement of bridge barriers) would simply result in an increase in another suicide method (e.g., firearms), and the overall suicide rate would remain unchanged (Miller, 2011).

In regard to the Golden Gate Bridge, a study asked a national sample of 2,770 respondents about what effect a physical barrier might have had on the fate of the people who had already died by suicide at the bridge. Thirty-four percent of the respondents indicated their belief that every single person would have found another way to die by suicide, even if a barrier was present; an additional 40% believed that most would have done so (Miller, Axrael, & Hemenway, 2006). These results are consistent with other reports regarding public reactions to physical bridge barriers. For example, even though many college student suicides have taken place on the campus of Cornell University in upstate New York, where students have leaped to their deaths from bridges overlooking deep gorges, a recent report conducted at Cornell found that 43.6% of undergraduate students opposed implementing permanent safety structures on campus bridges (Cross, 2011).

The respondents who opposed the use of physical barriers in these studies were clearly unaware of a now-classic study conducted more than 30 years ago by Seiden (1978), who examined the records of 515 individuals who were restrained from jumping off the Golden Gate Bridge from 1937 (the year the bridge was completed) through 1971. The method substitution theory would predict that most of these individuals, perhaps the large majority, would have died by suicide at a later date after being prevented from jumping from the Golden Gate Bridge. Results of the study revealed, however, that only 6% later died by suicide--the remaining 94% did not (Seiden, 1978). A number of subsequent studies (e.g., Bennewith, Nowers, & Gunnell, 2007; Reisch & Michel, 2005) and literature reviews (Beautrais, 2007; Beautrais & Gibb, 2009) examining the effects of bridge barriers on suicidal behavior have reported similar results, indicating that placing physical barriers on bridges (i.e., engaging in means restriction) can save lives.

Moreover, the issue of method substitution and suicide does not apply only to bridge barriers. Public policy initiatives that have restricted the use of firearms (particularly handguns) is associated with a reduction in suicide by firearms and suicide overall, especially among young people (Berman, Jobes, & Silverman, 2006; Leenaars, 2009). Reductions in suicide rates have also been reported when public access to toxic gas has been decreased (Joiner et al., 2009) and when certain drugs and medications (Leenaars et al., 2009) and alcohol consumption (Wasserman & Hadlaczky, 2009) are restricted. Although there are some instances where method substitution may occur (De Leo, Dwyer, Firman, & Nellinger, 2003), it clearly is not inevitable. Additionally, if an individual is prevented from dying by suicide, there is a high probability that person will not engage in subsequent suicide attempts (Berman et al., 2006). For example, among the few known survivors of those who jumped from the Golden Gate Bridge, none have subsequently died by suicide or even made an additional suicide attempt (Joiner, 2010).

As a result of these findings, it has been increasingly recommended that a public health approach to suicide prevention on the Golden Gate Bridge be implemented. A central tenet of a public health approach is its emphasis on prevention and early intervention with entire populations rather than individuals (Doll & Cummings, 2008; Strein, Hoagwood, & Cohn, 2003). The first public health programs began as simple policies to clean up communities, followed by local, state, and eventually federal initiatives to provide vaccinations and environmental improvements for a wide variety of medical problems (Strein et al., 2003). More recently, public health approaches have been applied to education in the form of a three-tiered model of prevention and intervention (Shinn & Walker, 2010), where it has been used to address a variety of problems in schools, including academic problems (Martinez & Nellis, 2008), aggression and bullying (Swearer, Espelage, Brey Love, & Kingsbury, 2008), substance abuse problems (Burrows-Sanchez & Hawken, 2007), child poverty (Miller & Sawka-Miller, 2009), depression (Mazza & Reynolds, 2008), non-suicidal self-injury (Miller & Brock, 2010), and youth suicidal behavior (Miller, 2011; Miller et al., 2009).

A public health approach to suicide prevention on the Golden Gate Bridge would emphasize the use of means restriction (i.e., bridge barriers) and public education about suicide, including debunking the many myths that surround it, the fact that suicidal behavior is typically the result of treatable mental health problems, and that suicide can be effectively prevented (Joiner et al., 2009). As of this writing, however, bridge barriers have been proposed but have not yet been constructed at the Golden Gate Bridge. Several years ago, however, a barrier was constructed (at a cost of five million dollars) between the bridge's walkway and traffic, designed to protect bicyclers on the bridge from onrushing cars (Joiner, 2005). This occurred despite the fact that no bicyclist has ever been killed on the bridge. As noted by Joiner (2005), "five million dollars and zero deaths for bicyclists; zero dollars and over a thousand deaths by suicide: it is difficult to avoid the conclusion of stigma and bias" (p. 27). To better understand why there is still no prevention barrier on the Golden Gate Bridge, it is first necessary to understand the relationship between suicide and stigmatization.

Suicide and Stigmatization

It has been suggested that suicide may be the most stigmatized form of human behavior (Joiner, 2005). Stigma, which "combines fear with disgust, contempt, and lack of compassion, all of which flow from ignorance" (Joiner, 2010, p. 272), has been associated with suicide for centuries (Miller, 2011). Why are suicidal people stigmatized? The answer to this question is complex, but appears in part to reflect evidence that individuals who are believed by others to play a greater role in their condition are stigmatized to a greater degree than are individuals who are perceived as being victims of circumstances beyond their control (Joiner et al., 2009). In fact, the stigma associated with suicide is so pervasive that there have been cases in which the families of youth suicide victims made requests to coroners that their son's or daughter's death by suicide should be altered and that some other cause (e.g., an accident) be attributed as the cause of death (Nuland, 1993). Similarly, Joiner (2010) reported the case of one chief medical examiner who stated that he never records a youth's death as a suicide, even if the evidence clearly supports it, because he does not want to "stigmatize" the youth's parents. Clearly, suicide is a frequently taboo topic that often stigmatizes the suicide victim as well as his or her family (Miller, 2011).

Because of the stigma associated with it, the notion of having frank and candid discussions about suicide is distressing to many people, and the topic of youth suicide seems to make many people particularly uncomfortable (Miller, 2011). This may be due to the myth that asking questions or talking with children or adolescents about suicide will increase the probability of its occurrence (Mazza, 2006). Despite fears to the contrary, there is no evidence for this belief (Gould et al., 2005). In fact, research suggests that youth who are given the opportunity to openly and frankly discuss the topic of suicide with trusted adults typically have more beneficial outcomes than youth not given this opportunity, as do their peers who also may be at risk (Mazza, 2006).

Implications for School Psychologists

The lack of effective means restriction procedures on the Golden Gate Bridge, and the stigmatization of suicidal people that appears to be a cause of the reluctance to implement them, provides valuable lessons for school psychologists interested in promoting effective school-based suicide prevention programs. In particular, school psychologists will need to make use of their consultative skills, including their skills in organizational consultation and systems intervention (Meyers, Meyers, Proctor, & Grayhill, 2009), and adopt a systems-level, public health approach to suicide prevention (Miller, 2011; Miller et al., 2009). Public health approaches to prevention moves the focus away from remediating problems for individuals toward a greater focus on preventing problems for populations (Hoagwood & Johnson, 2003; Strein et al., 2003). For example, in the context of youth suicide, school psychologists will likely have to take the lead in dispelling a variety of myths associated with suicidal behavior, including the "just world" belief that people essentially deserve whatever happens to them (Albee, 1986), the mistaken belief that if someone really wants to die by suicide there is little or nothing that can be done to prevent it (Joiner, 2010), and the false notion that questioning or talking with youth about potential suicidal behavior will "put ideas into their head" and increase the probability of suicidal behavior (Gould et al., 2005).

In addition, school psychologists need to be cognizant of the issues of means restriction and its effects on suicidal behavior. Given that most youth who die by suicide use guns as their method of choice, the issue of means restriction has particular relevance when considering firearms (Miller, 2011). There is clear and compelling evidence that the presence of firearms in a child or adolescent's home --particularly unlocked, loaded handguns--is associated with significantly increased risk for suicide (Simon, 2007). In addition, the risk conferred by guns is proportional to their accessibility and the number of them available, and if a gun is used in a suicide attempt a fatal outcome will occur 78-90% of the time (Berman et al., 2006). Public policy initiatives that have restricted the access to guns have been associated with a reduction of suicide by firearms and also suicide overall, especially among young people (Miller, 2011). As such, it has been suggested that potentially one of the most powerful youth suicide prevention strategies is removing guns from the home environment, or at least restricting access of youth to them (Berman et al., 2006).

School psychologists are encouraged to collaborate with parents and members of the community to emphasize greater means restriction in homes and communities, such as ensuring that all guns are kept locked and stored out of the reach of children and youth. Additional roles for school psychologists in this process may include coordinating efforts between schools and communities to provide youth and adults with gun safety training and advocating for mandatory background checks and waiting periods prior to making gun purchases (Garland & Zigler, 1993). Although it is recognized that restricting the use and/ or access to guns is a politically and sometimes emotionally charged topic, the evidence is clear that (a) most youth who die by suicide do so via firearms, and (b) individuals who own guns or who have easy access to them are more likely to die by suicide than those who do not (Leenaars, 2009)

School psychologists are also encouraged to work with parents to ensure that other potentially lethal materials are given limited and controlled access to suicidal youth, including knives and many types of medications. For example, Berman and his colleagues (2006) suggested that limiting prescription doses of potentially lethal medications to a restricted time frame might be beneficial, and there is some evidence that this can be an effective strategy for reducing suicidal behavior (e.g., Hawton, 2002; Leenaars et al., 2009).

To help reduce the stigma associated with suicidal individuals, school psychologists need to find ways to encourage students to seek help when necessary for themselves and/or their peers. Unfortunately, a major impediment to this process is the consistent finding that youth with the highest risk for suicide are frequently the least likely to seek help from others (Berman et al., 2006). Ironically, it appears that suicidal thoughts and other suicidal behaviors may act as a barrier to getting help for some children and adolescents, a condition known as help negation (Rudd, Joiner, & Rajab, 1995). For example, Carlton and Deane (2000) found that the presence of suicidal ideation was negatively associated with help seeking in a sample of New Zealand high school students. This finding was later replicated among both Australian (Deane, Wilson, & Ciarrochi, 2001) and American (Fur, Westfield, McConnell, & Jenkins, 2001) university students. In the study involving American students, only 20% of the participants (out of a sample of 1,455) who reported suicidal ideation sought some form of treatment for it.

A variety of factors may affect the help seeking behaviors of children and adolescents in regard to suicidal behavior and other mental health problems (Srebnik, Cauce, & Baydar, 1996). For example, Cigularov, Chen, Thurber, and Stallones (2008) examined the barriers to help seeking among 854 high school students in Colorado. The most prominent barriers to getting help for themselves were (1) an inability to discuss problems with adults, (2) the belief that one should handle such problems without assistance from others, (3) a fear of hospitalization, and (4) lack of perceived closeness to adults. The most prominent barriers students identified for helping their friends included (1) concerns about making the wrong judgment about their friends, (2) the perceived lack of approachability of adults in the school, (3) the fear of a friend's possible hospitalization, and (4) underestimating their friends' problems.

These results, as well as the results from other studies demonstrating a clear reluctance among vulnerable students to seek help for their problems (e.g.., Carlton and Deane, 2000; Zwaaswijk, Van der Ende, Verhaak, Bensing, & Vernhulst, 2003), has important implications for school psychologists. In particular, research suggest that school personnel need to form closer bonds with students generally, so that students are more likely to perceive them as approachable and helpful adults, whether in regard to their own possible suicidal behavior or that of their peers (Miller, 2011). The need for school personnel to extend themselves to students and demonstrate their support for them is especially important for adolescent males, given that they have a much higher probability of dying by suicide than females (Miller & Eckert, 2009).

School psychologists are also encouraged to work with school personnel to ensure that students are aware that the mental health problems that typically underlie suicidal behavior (e.g., depression) are very common and readily treatable, and that getting help for a mental health problem is analogous to getting help for a physical health problem. Highlighting the fact that biological factors are highly associated with depression and suicidal behavior may be helpful for some youth, particularly male students, who may be reluctant to identify themselves for their mental (rather than physical) health issues, especially if they perceive themselves as deserving "blame" for them or needing to handle their problems on their own (Miller, 2011). School psychologists can also work with school personnel to communicate and reinforce the notion that getting help is not a sign of weakness but rather a sign of strength, and that at times everyone has problems for which they need help from other people.

These ideas were adopted by the U.S. Air Force after an alarming increase in suicide rates among its members in the mid-1990s. Air Force leaders made proactive efforts to conceptualize suicide prevention as a community-wide responsibility rather than an isolated and individual problem. Key components of the Air Force program included (1) ongoing commitment from Air Force leaders; (2) consistent and frequent communication around the topic of suicide prevention with Air Force personnel; (3) destigmatizing the notion of getting help for mental health problems; (4) improving collaboration among prevention agencies within the Air Force community; and (5) identification and training of suicide prevention gatekeepers. A significant and sustained drop in the suicide rate among Air Force personnel was demonstrated after this program was implemented (Knox, Conwell, & Caine, 2004), and it provides a useful model of applying a population-based, public health approach to suicide prevention in the schools (Miller, 2011).

School psychologists should also have the necessary knowledge and skills to recognize the various risk factors and warning signs of suicide, formulate and conduct suicide risk assessments and screenings, distinguish between suicidal youth and those engaging in non-suicidal self-injury, reintegrate a student back into school following the student's suicide attempt, implement effective postvention procedures if a student suicide does occur, and be cognizant of the various legal and ethical issues associated with school-based suicide prevention (Berman, 2009; Berman et al., 2006; Miller, 2011), including the fact that ethical requirements are often more stringent than legal ones (Jacob et al., 2011). Regarding this last point, although school psychologists should behave in a manner consistent with legal mandates and their particular code of professional ethics (e.g., National Association of School Psychologists Principles for Professional Ethics), meeting these requirements should only be viewed as the minimum standard expected and neither encompasses nor limits what school psychologists can do to assist potentially suicidal youth. That is, although best practice in school-based suicide prevention should be informed by legal requirements and ethical responsibilities, it need not be limited by either of them (Miller, 2011).

Finally, all school-based suicide prevention programs or interventions should be based, whenever possible, on evidence-based practices. This term refers to "a body of scientific knowledge defined usually by reference to research methods or designs, about a range of service practices (e.g., referral, assessment, case management, therapies, or support services" (Hoagwood & Johnson, 2003, p.5). More recently, however, evidence-based practices have encompassed "a model of practice that integrates research evidence for treatments with clinical expertise and patient characteristics" (Merrell, Ervin, & Gimpel Peacock, 2012, p. 156). In the context of suicide prevention programs in the schools, evidence for effectiveness is often lacking (Miller et al., 2009), particularly in areas such as suicide postvention. Nevertheless, school personnel, especially mental health professionals such as school psychologists, need to be cognizant of current as well as emerging best practices in suicide prevention.

Conclusion

The Golden Gate Bridge has now been an iconic part of the California landscape for over 75 years. Despite the fact that over 1,500 people have died by suicide at the bridge during that time, effective prevention strategies (e.g., bridge barriers) have not been implemented; a fact that appears to at least partly reflect the stigma associated with people who exhibit suicidal behavior (Bateson, 2012; Joiner et al., 2009). These issues, which have shaped efforts to more effectively prevent suicide on the Golden Gate Bridge, have clear parallels in the recent movements in schools toward public health models of prevention and intervention. School psychologists are encouraged to adopt a public health approach to potentially suicidal youth, to effectively collaborate and consult with their school-based colleagues regarding this frequently stigmatized and marginalized population, and to take leadership roles in developing, implementing, and evaluating suicide prevention programs. Ironically, the Golden Gate Bridge, the site of more suicides than any other place in the U.S. and perhaps the world, would appear to have some important lessons to impart in this process.

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David N. Miller

University at Albany, State University of New York

Correspondence regarding this article should be send to: David N. Miller, University at Albany, State University of New York, 1400 Washington Avenue, ED 215, Albany, NY 12222. Email: dmiller@albany.edu

David N. Miller, PhD, is an associate professor of School Psychology at the University at Albany, State University of New York. Currently president-elect of the American Association of Suicidology, his research and clinical interests include suicidal behavior and related internalizing problems in children and adolescents, particularly issues in school-based suicide prevention. He has published widely in these areas, and is the author of Child and Adolescent Suicidal Behavior: School-Based Prevention, Assessment, and Intervention (2011).
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Author:Miller, David N.
Publication:Contemporary School Psychology
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2013
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