As a psychologist, a profession that brings both routine and unpredictability, I try to hold onto – and maybe even control – what I can.
For me, that means starting each day with my cup of coffee (which I often leave on the Keurig until reminded by someone that I made it) and looking at my schedule to plan for my next few days.
There is comfort in the routine and also excitement in the possibilities of the unknown. Together, this dialectic keeps me passionate for what I do with my patients in consultation, therapy, and assessment.
And yet, one possibility, a mostly unspoken fear during my education and at training sites, was the chance that I would lose a patient to suicide.
Throughout my many practica and on internship, I completed numerous risk assessments and hospitalized patients voluntarily and, in a few cases, involuntarily. The focus of those interventions was the preservation of safety and the illusion that I would be able to keep each of those individuals alive. In each case, I experienced stress and a sense of urgency followed by relief and comfort in knowing that I had helped or even “saved” someone from harming themselves or someone else.
Shortly after processing any of those hospitalizations with my supervisors or colleagues, I would often push that unspoken fear to the back of my mind, only to use it when it seemed to fit. Largely, I avoided approaching this fear or considering it as a “real” possibility so that I would not be paralyzed with fear each day.
My First Experience with Client Suicide
Then, one morning near the end of my internship training, I was forced to face the fear head-on.
My fear became a reality.
I had broken my routine that day. I completed an assessment, had my cup of coffee, and was planning for my day after testing instead of first thing in the morning. It was then I discovered the news that a former patient of mine completed suicide.
Before I tell you about my response to this discovery or share some “sage advice,” I want to share that Sam* was one of my very favorite patients. Our rapport was easy and comfortable which laid a foundation for incredible growth for him as a patient and for me as a developing psychologist.
Overall, he was a kind, loving, and caring man. He internalized a great deal of trauma and life experiences for a very long time before arriving in my office.
Sam had tried to cope with his own “demons” in a variety of unhealthy ways prior to seeking formal psychological and psychiatric care. At times, he was reluctant or angry at himself or his circumstances. He was desperate for change, and incredibly receptive to honest feedback and psychological intervention.
In fact, once during our work together, Sam voluntarily and independently admitted himself to a psychiatric hospital ward for suicidal ideation. Following that experience, Sam began to experience hope and acknowledged his own resilience.
After a few months and significant reduction in his symptoms, we concluded care with a spoken understanding that he was armed with resources he readily used, including a return to therapy, as needed.
Sam made a point of stopping by and saying hello when nearby my office. I very much looked forward to these visits, but never really expected them.
In hindsight, I wonder if these visits helped me to know he was going to be alright. Yet, at the time I really just enjoyed his brief hello and his sincere gratitude for helping him overcome what he called his “demons.”
His last visit came about two months before the morning I discovered news of his death. At that time, he reported having found purpose, meaning, and motivation to help others in multiple facets of his life.
The Impact My Client’s Suicide Had on Me
Uncertainty is not comfortable for me.
I do not know what happened in those two months nor will I ever likely find out. What I am certain is that the news of his death affected me in a way I did not expect.
With my illusion of control shattered, I became suddenly vulnerable.
As you might imagine, my emotional responses included sadness, grief, despair, anger, doubt, and guilt. I replayed every session and every conversation I had with him. I reviewed my records and notes. I consulted with my supervisor and his treatment team.
I had lost several individuals in my personal life to suicide, but Sam’s suicide was different. My vulnerability in losing Sam was rooted in perceived responsibility and control.
These were the questions that troubled me:
- Did I do enough?
- Could I have done more?
- Why was I unable to save him?
- Did we as a treatment team miss clues?
- Should I have not ended our episode of care when I did (almost 7 months before his death)?
Had I not had the support of an amazing training director and my supervisors, I likely would have driven myself mad trying to make sense of a seemingly senseless situation. I wanted answers to my questions, ones I knew were not answerable. Instead, I had to “sit with” and process the uncertainty.
How I Recovered
My mentor and training director said this:
“None of us has the power to keep someone alive. There’s a difference between doing what we have to do ethically when a patient is actively in crisis versus magically predicting that they might be in crisis at some point after our care has concluded… Fundamentally, we are not in control of all the contingencies which result in them killing themselves or not. We offer people as much support and hope and help as they are willing to accept and access. That is the extent of what we are capable of doing.”
She is absolutely spot on.
We don’t have fortune telling abilities nor as research indicates are we as a profession very accurate in predicting suicide. More so, we as psychologists value the autonomy and agency of our patients.
Principle E (Respect for People’s Rights and Dignity) of the American Psychological Association’s ethical code says, “Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination” (p. 4).
In the end, Sam’s demons were too painful and he ended his life. He was well-versed in the resources available to him. He previously demonstrated utilization and success in accessing them. So, will I ever know what led to Sam to end his life? No, I will not.
What I do know is this: I did all that I could.
I also know that Sam’s death had a great impact on me personally and professionally. As part of processing the events and my emotional responses, I engaged in self-care (something of which I research but at which I am notoriously very poor in engaging). I allowed myself to grieve. I honored his memory by listening to music and enjoying nature (both of which he loved very much). I allowed myself to cry and to surround myself with family and friends.
So, we can find comfort in the predictable nature of our work and the excitement of the uncertainty it brings. Using our passion for healing and acknowledging our limits as human beings will move us to serve our patients in the best possible way.
Beyond immediate crises, we cannot keep our patients alive. By shattering this illusion, we can allow ourselves to engage fully in the therapeutic process and place the responsibility for our patients’ well-being in their own hands. Allowing ourselves to do so permits us to engage in self-care, seek support and supervision, and minimize the risk of burnout.
How to Recover from Client Suicide
In short, I hope each and every one of you never experience this painful loss. And yet, I am sure at some point some of you will. If you do, remember:
- Seek consultation and support from esteemed colleagues.
- Allow yourself to be vulnerable to the flood of unexpected emotions, whatever they are.
- Allow yourself time to grieve.
- Engage in self-care.
- Make meaning of the experience and use it in your future work.
With my illusion shattered, I still attempt to control what I can. I continue to drink my coffee and plan my day. Yet, in my morning preparation sessions I now actively consider each of my patients’ agency and autonomy in a way I hadn’t before.
I now accept that much remains out of my control. By doing so, I am able to continue to be passionate for the change process.
*Name and identifying information has been changed.
American Psychological Association. (2010). Ethical principles of psychologists and code of conduct.
- Patient Suicide: Reflections on a Shattered Illusion - September 6, 2016
Thank you, Dr. Dean, for sharing such a necessary and poignant article. I have noticed the topic of patient suicide to be a bit of a taboo in our profession, and I greatly appreciate your vulnerability in sharing your experience. I especially loved the last point you shared in making meaning of the experience and using it in your future work.
Thank you for your feedback. I agree the topic is largely avoided in our profession and I really appreciate your comments about the meaning making of the experience. Truly this post sprung from the journaling I did the week of Sam’s death as I worked through processing my own grief and making meaning of the experience in order to continue to be able to do the work that I do.