STEVE ARTHUR

The Possibility of Hope

Confronting Alberta's high suicide rates.

By Jay Smith

Before she died, Anna Kessler was a promising scholar of Kant. She left Cornell University in 2004 to complete her doctoral studies in philosophy at the University of Alberta. Charming, talented and intelligent, Kessler quickly forged friendships in Edmonton. 

“Anna had such a great life,” says Elizabeth Panasiuk, who along with John Simpson became Kessler’s friend and confidante. “She lived in France for awhile and spoke beautiful French. When she was younger, she was an equestrian rider. She trained dogs. She was a great chef. A brilliant philosopher.” But in leaving Cornell, Kessler was also trying to escape the past.

“She told me she was sexually abused as a child,” says Panasiuk. “Her parents didn’t believe her. She said she started cutting when she was young. She’d cut herself, and go to her father, and he’d just bandage up her arms without saying anything.” Kessler said she developed anorexia/bulimia as a teenager and was eventually diagnosed with borderline personality disorder.

In the time Simpson and Panasiuk knew her, they estimate Kessler made at least six visits to local hospitals following suicide attempts. 

“I think the worst one was when she called and said, ‘I’m going to the High Level bridge to jump.’ ” says Simpson. “We got there… and she’s looking for the ideal spot to jump from the sidewalk on the other side of the bridge. I run across the lanes of traffic, and I take her down. I had her in a weird wrestling hold while people are walking past… The police show up, they take her in the back of the car to the university hospital. Two hours later, they let her out. She called us again.”

Alberta’s suicide rates have ranked well above the national average in every decade since the 1950s.

Friends were asked to meet her at a restaurant near the bridge. “She got up to go to the bathroom, and she wasn’t back as fast as we expected,” says Simpson. “We realized she’d gone out the back door and was heading toward the bridge. We chased her down, took her down; it was the same experience over again.” This time, the hospital kept her overnight.

Kessler would be released again. And she would attempt suicide again.

The story of Anna Kessler’s inability to get the help she needed is complicated. But it’s a familiar story—or would be if we listened. Alberta has historically had the highest suicide rate in Canada, ranking well above the national average in every decade since the 1950s. Today, Alberta’s suicide rate is second only to Quebec’s. In 2007, 462 Alberta fatalities were confirmed suicides. No doubt more suicides were misattributed as “accidents” or “unknown” causes. Annually, suicide in Alberta claims more lives than motor vehicle collisions, AIDS or homicide. For every death by suicide, there are six hospitalizations and 15 emergency-room visits for self-harm.

Not every suicidal person is the same, of course; individual choices and circumstances have to be considered within a complex of socio-economic variables. 

While mental illness is perhaps the strongest predictor of suicidal behaviour, other factors increasing the risk include alcohol or drug use, physical and sexual abuse and previous suicide attempts. The demographic most likely to die by suicide is male between the ages of 35 and 59, likely separated, divorced or single with poor interpersonal skills and low self-esteem. Aboriginals tend to have much higher rates of suicide than the general population, although this varies significantly by community. In our homophobic culture, non-heterosexual orientation increases one’s risk. Unemployed and homeless people, as well as those with a history of incarceration, are also more likely to attempt suicide. In short: the socially marginalized are more likely to kill themselves.

In 2007, 327 men and 135 women committed suicide in Alberta. Men were more likely than women to hang themselves, use a firearm, poison themselves with carbon monoxide, jump from a height or drown. Hanging, firearms and overdoses accounted for nearly 75 per cent of suicides by Alberta males in 2007. In contrast, females were more likely to overdose; this method, along with hanging and carbon monoxide poisoning, accounts for 87 per cent of suicides among Alberta women. Statistics show that men die four times more often than women when attempting suicide, for the simple reason that they tend to employ more lethal means. Yet women are three times more likely to make the attempt.

Perhaps this difference is due to cultural reasons: the economic instability of Alberta’s boom/bust cycles leads to greater domestic abuse. A British Columbia Centre of Excellence for Women’s Health publication entitled “Violence and Trauma in the Lives of Women with Serious Mental Illness” speaks to the interconnections between domestic violence, mental illness and suicidality, arguing that violence has a negative influence on mental health and noting the links between mental health and suicide.

According to Jan Reimer, director of the Alberta Council of Women’s Shelters, Alberta regularly leads the country in levels of domestic violence, domestic homicides and murder-suicides. “Generally, you see spikes when times are good and when times are bad,” Reimer says about the relationship between domestic violence and economic cycles. “In the US, where the recession hit faster, there’s been an increase in domestic violence. Economic uncertainty brings stress.” It also encourages drug and alcohol use, predictors for both domestic violence and suicide. “Women who leave domestic violence relationships had trauma levels as high as veterans from the Vietnam war,” says Reimer. “People who study suicide interventions need to look at how to deal with [that sort] of trauma.”

Although many of the factors contributing to suicide are broadly cultural, experts such as University of Calgary professor of clinical psychology Keith Dobson says government policy is influential. In the 1990s, Alberta cut funding for social programs, including mental health programs. Hospital- and institution-based psychiatric care was replaced by “community care,” which was popularly seen as a euphemism for “throwing patients onto the streets.” In 2009, Alberta Health Services continued the trend Klein started, announcing the closure of nearly 250 acute-care mental health beds at Alberta Hospital Edmonton (AHE)—prompting an outcry from opposition parties, the nurses union, police and the Criminal Trial Lawyers Association, who are concerned that “community care” can’t handle the increased load.

Dr. Brian Bishop left his job as clinical director of general psychiatry at AHE in 1996 and has been critical of the Klein-era system, claiming it deliberately pits hospitals against community service organizations. Lack of funding, the Edmonton Journal quotes Bishop as saying, “force[s] the most severely and chronically ill patients to remain in ‘Cuckoo’s Nest situations’ [in] ‘medieval facilities’ ” and forces hospital staff to “play chicken with people’s lives when they weigh whether to admit potentially suicidal patients.”

“Hospital services were cut, and still haven’t grown back to the place where they should be,” concurs Dobson in more diplomatic language. “Community services were increased, but there were cuts in one without sufficient development in the other.”

Dobson also notes that government policy inadvertently encourages high suicide rates in other ways. “We have one of the most liberal alcohol policies in the country and readily available gambling,” says Dobson. Alberta is the only province with private liquor retailing; Albertans spend more on alcohol ($1,179 per household annually) and gambling ($340) than all other Canadians. “When people get over their heads financially, they become hopeless,” adds Dobson.

Indeed, hopelessness is an overriding predictor of suicidal behaviour. This is why, according to Dobson, people with strong families and strong religious or spiritual beliefs cope better with negative life experiences. 

Obviously, this and other protective factors such as self-esteem and future goals cannot be easily imparted. And while the wounds of other ER patients gush blood or protrude broken bones, mental illness is ensconced in a person’s subjectivity. Medical professionals must diagnose self-reported symptoms. This is no mean feat.

As Kessler and countless others experience, offering “proof” of abuse, trauma or mental illness is difficult. Adding to the complexity, only physicians can hospitalize in Alberta. 

Because few family doctors have admitting privileges at hospitals, suicidal individuals end up in emergency wards, where front-line workers must establish the person’s mental state. According to Dobson, this describes most psychiatric admissions in Alberta. “I’ve heard that for someone acutely suicidal, sitting in emergency for seven to eight hours is typical. It’s not uncommon for people to go to ER, wait for an assessment, and then be told there are no beds. They get an appointment for three or four days down the road. They’re acutely suicidal but can’t get help in the short term.”

Or any help at all. Our provincial culture places a high value on personal freedom and autonomy, and a “pull yourself up by your bootstraps” mentality—values manifest in the Mental Health Act of Alberta. Accordingly, a person cannot be held in a provincial hospital without his or her consent (“under certificate”) unless they can “prove” they are suffering from a mental disorder, that they are in “a condition presenting or likely to present a danger to the person or others” and if they cannot be admitted to hospital any other way. Healthcare systems in provinces such as Quebec, representing a culture less concerned with ideals of personal autonomy, are more willing to accept suicidal individuals into hospital. 

“The truth is, even if someone is admitted and treated promptly, the nature of the services they receive isn’t appropriate,” says Dobson. “There aren’t long-term treatment programs. The institution will try to discharge as soon as possible in order to create vacancies.”

Hospital services aren’t necessarily well organized or even consistent, adds Dobson. Depending on their circumstances and the hospital they visit, the suicidal individual might be put into a day program to talk about depression, be visited by a social worker who can connect them to community services and/or be prescribed medicine. They might also be discharged right back onto the street.

“For many people, hospitalization is not a good long-term intervention anyway,” says Dobson. “It can stop the person from committing suicide right away, but with the pressure just to get people out into the community again, the longer-term problems that led to the suicidal behaviour go unaddressed.”

Simpson concurs with Dobson, arguing that the way the healthcare system treated Kessler varied wildly.

“It was clear that the Royal Alexandra [Hospital] was not sharing information with the University Hospital and Alberta Hospital,” he says. “There was nothing on her file about the pattern [of her attempts]. Another problem was that… she was very smart and could manipulate [healthcare workers]. She knew what they were looking for.”

One time, while being held at the Royal Alex, Kessler called Simpson because she wanted to get out. “We all went and found her in a tizzy,” remembers Panasiuk. “We were trying to calm her down when she walks up to the nurses desk and announces, ‘I want to get out of here so I can kill myself. Can I have my things?’ Because they strip you of all the things you might use to harm yourself while you’re being held, right? Incredibly, the nurse went and got her stuff. Then they released her. We took her and were driving around town with [an acutely suicidal person] in our car, and finally decided to ambush the Alberta Hospital.”

Numerous health professionals consulted say that this was an unlikely and exceptionally poor decision on the part of the Royal Alexandra and that this is not typical procedure. But Avalon Roberts, a psychiatrist and public healthcare advocate, fears that this sort of occurrence is more common than anyone will admit. She points to the case of Diana Yano, an acutely mentally ill woman who killed herself while held “under certificate” (i.e., deemed a risk to herself or others) at the Peter Lougheed Centre in Calgary. Yano had been found not criminally responsible in the drowning deaths of her two children in 1999.

“She was an in-patient at the time. What was she doing? How did this happen?” Roberts wonders whether the training that psychiatric nurses receive is sufficient. Other insiders worry less about the training that registered nurses (RNs) receive during their four-year university degree, and more about their full-time positions that are being replaced by licensed practical nurses (LPNs), whose two-year diplomas entail significantly less expertise but command significantly lower wages.

The fatality inquiry stated that Yano went missing from in-patient care and was found dead several hours later outside the facility. The report also proposes various ways to better track data and analyze “renovations and new construction” of facilities so as to “address and acknowledge an awareness of suicide prevention.” There is no comment on how staff could be better trained to recognize risk.

Panasiuk says Kessler was more likely to be admitted when friends brought her in, acting as witnesses to “corroborate” her mental state.

Other patients verify these assessments of mental healthcare in Alberta. Dawn Davenport has been bipolar since she was a teenager and has visited Alberta ERs seeking help for her suicidal inclinations. “You have to convince [physicians] that you have a plan and lay it out for them,” she says. “If you show up and you can’t do that, they send you home. And then, when you’re in, they boot you out really fast. There’s a lot of pressure: ‘When are you going to leave? Have you phoned someone?’ ”

As a lesbian, Davenport thinks front-line workers need more sensitivity training. “Usually, it’s ‘If you want to feel better, bake a cake. [Or] find a man.’ And I’m just a white dyke…! I don’t know what it’s like to be a person of colour.”

Davenport says that when she doesn’t “correctly” complete the checklist, healthcare workers expect her to sign a contract saying she won’t kill herself. “They say, ‘We’ll give you some sedatives, we’ll make you sign this contract saying you’re not going to kill yourself, come back tomorrow.’ But it feels like they’re just covering their asses—because [counselling] suicide is illegal, they’re no longer responsible, legally, once you’ve signed the contract.”

Jackie Allen is Suicide Awareness Program supervisor for the Support Network, a not-for-profit agency based in Edmonton. She believes the province is getting better at helping suicidal Albertans, especially men, who are less likely than women to reach out for help.

“We’ve done some marketing to target men so that they’ll notice our services,” she says. “That’s been very successful.” In addition to a 24-hour distress line, the Support Network offers free, no-appointment, single therapy sessions geared particularly to men who shy away from traditional therapy.

Allen feels that Alberta is starting to become “very proactive” in suicide prevention. She points to the Suicide Prevention Strategy (SPS), a ten-year program launched in 2006 by the Ministry of Health. The SPS aims are broad: to enhance mental health and well-being, improve intervention and treatment for both those at risk of suicide and those affected, reduce access to lethal means, improve surveillance and increase research on suicidality.

One affiliated program encourages men who have been affected by another person’s suicide to speak with other men at their workplaces. Another, as yet unimplemented, strategy will decrease the availability of potentially lethal drugs to women.

However, an interview with a representative from Alberta Health Services about the SPS was granted only under the agreement that funding issues “not be discussed.” 

Liberal opposition leader and health critic Dr. David Swann says this is for good reason: no one at AHS knows what’s going on when it comes to funding. The future is murky, particularly for programs regarding suicidality, which typically receive funding from various sources.

The amalgamation of regional health authorities into the AHS “superboard” was hasty and disorganized, says Swann. “They transferred a mental health board, advocating for good community and institutional care, into a medical board with very little medical expertise,” he says. “I don’t find any expertise in terms of mental health there, either.”

The provincial government doesn’t understand, he says, “how basic changes could improve everything. Beds. Supporting family doctors instead of specialists. The basics… instead of the high-tech specialty services. Mental health is one of the basics. People need support, medications, supervision, a place to live if they don’t have a place to live.” 

Keith Dobson agrees that solutions need to be focused on the preventive and the long-term. Although suicide prevention hotlines are touted as a low-cost and effective support for suicidal individuals, Dobson claims the research doesn’t support this view. “Putting a hotline into a place doesn’t actually reduce rates. It increases awareness about suicides, delays some suicides, but from an outcomes perspective, there’s not the data to support it.

“What is effective is longer-term counselling and psychotherapy. If a person, for example, has terminal cancer, not much intervention is possible around the cancer, but there is around the meaning of life, the value of the person’s life to other people.”

The day that Kessler died, she was again discharged by the psychiatric ward of the Royal Alexandra hospital. Simpson and Panasiuk expected Kessler to be released at 2:00 p.m. Simpson went to a 10:00 a.m. meeting with Kessler’s psychiatrist on the U of A campus. While Simpson was meeting with the psychiatrist, his cell phone rang. Kessler was calling from the High Level Diner. 

“She said she got out, and goodbye,” Simpson remembers. “There was no way that I could get [there] in time… it was perfectly orchestrated.”

He called police and raced over to the bridge, but by the time anyone arrived, Kessler was gone.

Basic changes would help: “Beds. Family doctors. Medication. A place to live, if someone doesn’t have one.”

Friends wish Anna Kessler had been released into their care. That she’d had more help over the long term. That somehow an alchemy of hospitalization, psychotherapy and medication would have fixed her where she was broken.

Even a system with the proper resources, a deep appreciation for the needs of mental health patients and a focus on long-term care won’t save every suicidal Albertan. Suicide remains, after all other factors are considered, an individual’s decision. But a functioning mental healthcare system and properly supported social services would buy people time to shore up their resources and make an informed decision.

Time, says Dobson, increases the chance that people get the help they need. It allows the possibility of hope. “Then the person can re-evaluate whether suicide is a choice they want to make.”#

Edmonton’s Jay Smith is a journalist, poet and mother of two children. Her most recent AV feature was “Boomcare,” Oct 2008.

RELATED POSTS

The Possibility of Hope

Before she died, Anna Kessler was a promising scholar of Kant. She left Cornell University in 2004 to complete her doctoral studies in philosophy at the University of Alberta. Charming, talented and intelligent, Kessler quickly forged friendships in Edmonton.  “Anna had such a great life,” says Elizabeth Panasiuk, who along with ...

Pushed to the Edge

There are two things you never want to have happen to you. One of them is to suffer a mental illness. The other is to suffer a mental illness and try to get admitted to a hospital. The problem is that the folks who work in emergency units don’t especially care ...

Conundrum of Kites

You suicides are all alike: too strong an imagination. You did what you did, now shut up. — Samuel Beckett My 13, 1987. Six weeks left of high school, six more weeks until we were free. That day, a Saturday, Karl drove his old Volvo station wagon to his father’s cabin. He ...