Friday, June 24, 2011

Patient Suicide: Part One--The Phone Call

This is part of an ongoing story about a patient suicide. Click here for Patient Suicide Part One: The Phone Call, here for Patient Suicide Part Two: 30 Minutes to Think, here for Patient Suicide Part Three: Fully Present, here for Patient Suicide Part Four: What's a Life Worth, here for Patient Suicide Part Five: Treat People Like They Matter, here for Patient Suicide Part Six--Leftovers, here for Patient Suicide: Part Seven--Training Monkeys/Herding Cats, and here for Patient Suicide: Part Eight--On Scarves and Lessons Learned

With some well trained and carefully manicured hubris in place, it was a phone call that I thought could never happen to me. I've had 12 years of post-secondary education, over 10,000 hours of supervised clinical practice with some of the most brilliant psychologists in the country, and more than two decades of work experience. Arrogance and hubris, right? Denial, too. I knew this phone call would come some day. I just hoped I'd make it a little longer.

In the months since I've received the phone call, I've struggled with whether I should speak openly about the call. I've convinced myself every way I know how that I shouldn't write this. Psychologists do not violate the privacy and dignity of their patients. Yes, that's right. However the phone call isn't really about a patient. It's about a psychologist's response. I can't find protection from this topic behind the veil of confidentiality.

Psychologists don't self-disclose. That one almost got me. One wouldn't want to share thoughts or experiences that are too deeply personal or too deeply private. Psychologists just don't do that. It might contaminate my work with patients. This of course is just poppycock. Therapists engage in self-disclosure. Our choices in office decor, clothing, attitude toward therapy--all are forms of self disclosure. Psychologists are masters at self-disclosing for a purpose. We are not--and cannot--be an invisible blank screen. We always are disclosing something--the question is are we aware of what we are sharing and aware of the reasons we are sharing.

Fine then. I cannot hide behind confidentiality or arbitrary rules about self-disclosure. Maybe I just don't want to share. That's a perfectly good reason. Right? Well yes it is. Of course I can always decided to keep something private if I want to. Of course. But why, why do I want to keep it private?

It became clear to me today that the only reason I've not yet written this is fear. Fear of judgement. Fear of being viewed as a failure. Fear of finding out that I indeed, actually did fail. Fear. That's not a very good reason to stay silent.

It's likely that if I'm having this experience, there are many others who are having this experience. Who am I to disagree with Irv Yalom when he says "the recognition of shared experiences and feelings among group members and that these may be widespread or universal human concerns, serves to remove a group member's sense of isolation, validate their experiences, and raise self-esteem."

Fine Irv. I was almost able to resist you and your logic, and then Marsha Linehan had to chime in. I read an article today from the New York Times in which Dr. Linehan disclosed her personal sturggle with mental illness. She said "so many people have begged me to come forward, and I just though--well, I have to do this. I owe it to them. I cannot die a coward."

So really. What's a psychologist to do? Ignore Irv's observation about the curative power of bringing a universal experience into the public eye? Ignore Marsha (as if one could do that) and die a coward?

So I write.

It was late in the afternoon when my phone rang. I already knew what the message was.

Never early, never late, I would open up the door when the church bells behind my office rang marking the new hour and find my patient walking in the door. The day my phone rang my patient wasn't there. "Strange", I thought. She never missed an appointment. She was never late, never early. I knew there was something wrong well before the phone ever rang.

While I was busy telling myself that there was clearly going to be some sort of funny explanation for her no-show, on a deeper level I started preparing for the storm that was to come. While I wasn't emotionally ready, I did exactly what I was trained to do.

I waited for 15 minutes and then called my patient. As I rule, I never call patients the day they miss an appointment. This time I made the call. I knew the risks facts for this patient. I knew the signs. I knew just what to do. I called my patient. No answer on her mobile. No answer at home.

Still not fully aware of the storm I was preparing for, I went into crisis mode. I knew with urgency that I needed to start taking increasingly more aggressive steps to contact my patient. On a deep level, I knew what I was going to find out.

A storm was coming. Be prepared. It was like a well choreographed dance. I left messages, and gave a deadline.

"I'm worried," I said into the voice mail.

"You're never late, you're never not here."

"Please call me as soon as you get this. If I don't hear from you in an hour I'm going to contact your friend. If your friend hasn't heard from you I'll have the police come to your house to do a wellness check. If the police can't find you and tell me that you are okay I'll have no choice but to fill out papers to have you involuntary hospitalized. Please call. I'm worried."
For those of you who aren't therapists or are therapists who are still in training, you should know that in the jurisdiction in which I'm licensed, if I'm concerned about the safety of a patient I have a range of options available to me. The least invasive is a wellness check. A psychologist, or concerned person, can contact local law enforcement, explain the situation, and ask for a wellness check to be done. When I feel a patient is in imminent danger, I am allowed by law to loosen the laws of confidentially in the service of protecting my patient--this is why I felt comfortable with the plan of contacting the best friend of my patient and then contacting the police. The key here is that once I signal to the outside world that I'm concerned about a patient's safety (e.g., contacting a friend, doing a wellness check) I have to keep working and finding and assuring that patient is safe until I either exhaust all reasonable options, get the patient to safety, or otherwise feel sure that the patient is safe.

My patient's appointment time came and went. My next patient came, and that hour ended too.

"I'll check my voice mail", I thought. Surely my patient will have called by now. Right? I entered my password to get into my voice mail. One new message. Good. Something must have happened. She called. She'll feel guilty she missed her appointment. We'll talk about that. We'll move on.

The phone call came. The one I always knew I would get. The one I hoped I would never get.

"Hi Dr. Mihalko," the strained strangers voice said. "This is so-and-so, a friend of your patient so-and-so." She used xxxx over the weekend to kill herself. She left a note. The one thing she asked me to do was to call you and tell you what happened."

The phone call had come.

A patient had died.

I felt like I had been slapped.

I sat down in the chair my patient had always sat on. My dog came to me, wagging her tail, looking up to me as if to say she knew. We both knew before the phone call came.

"I must have heard this wrong," I told Maggie the therapy dog. "I think she said so and so tried to kill herself, and that she is in the hospital." I listened to the message again. I must have missed the part where I was told what hospital she was in. I'd call her psychiatrist, call the hospital, and maybe arrange to visit.

I listened to the message again. Nope. It was the call. My patient wasn't in the hospital. She was dead.

"No no no Maggie," I said again. I'm not hearing this right. I listened to the message a third, fourth, and finally a fifth time before I alternated between laughing and cursing at Elizabeth Kubler Ross. Damn her for being right that the first stage of grief is denial.

The phone call that I always knew would come had arrived. That call I always hoped would not happen had finally happened. Twelve years of post-secondary education, more than 10,000 hours of supervised clinical experience, twenty years of experience in a variety of counseling settings... All those experiences brought me this single point in time.

I reached the absolute limit of my training.

I had state-of-the art training in the assessment, management, treatment, and prevention of suicide.

No one ever told me what to do after the phone rang.


So I write. This is part one. There will be more parts. I don't yet know how many parts I will write. I don't know over how long of a span of time I will write about this. I will write. That I know.

I write because I have learned that psychologists and other therapists don't want to talk about this. There is a secret club of clinician survivors of suicide. Many of us are hidden. Some are silent because they are afraid of what people might say. Other's stay silent because no one will listen. Many will avoid us because they are afraid of what will happen when their phone rings some day.

There are lots of you out there who aren't clinicians who are also in this club of suicide survivors. I'm writing for you too.

I write for those of us who have already received the call and are struggling to make sense of it. I write for those who have not yet received their call.

 I hope these words give you a guide. 


  1. Mary L. NadrowskiJune 24, 2011 at 10:28 AM

    I lived in fear for years ever since the first time I became aware that my son was using. Rehab, after rehab, police troubles, strange friends dropping him off in altered stated....yes, I feared 'that one phone call'. I hated that feeling. I would go to sleep every night and pray for my son, pray and wonder where he was, where was he sleeping, what was he taking, will he be alright, will he live. That was all I was asking, that he 'live' through this. Fifteen years later, that 'call' came. I was in Wisconsin celebrating my grand daughters birthday. The call was from a police detective asking me to call him asap. When I got back into phone range, hours later and listened to the message, I knew, my heart knew, and I began to shake. On the phone I identified my son by his tatoo that said, 'I LOVE MOM'. The dectective now confirmed my worst fear, it was my son. I screamed and screamed. I was so far away. It took three hours to get home and I screamed all the way. My worst fear had come true - but now what? How do I go on without him? no one could tell me.

  2. I have a friend who works for a local mental health agency.
    One of her colleagues recently got that call. Because of where she works, she had a lot of moral support, but it affected the whole staff deeply.It's easy to blame your self, but you have to get past that. Easy for me to say, I've never been there. Just mourn the patient, and realize that probably one one else could have helped either.

  3. Marilena KaramatsoukiJune 27, 2011 at 6:22 AM

    I didn't receive a call. Instead, there was a policeman at the door, asking if I knew where my dad was. He informed my mom (I was 12 at the time) that her husband was found dead in our family car. Suicide... Even at 12, I tried to figure out how I could have helped him. Now, many many years later, being a clinical psychologist myself and having undergone personal therapy, I realize that I probably couldn't. Easier said than done..
    I haven't yet received that call as a clinician; I am terrified I will.

    Thank you for your courage. You will certainly NOT die a coward.

  4. Kudos to you Jason for summoning the courage to write about this and to try to use it for the benefit of fellow clinicians. After all anything that happened to one of us can happen to all of us and from that point of view I feel like I was there with you receiving that phone call...

  5. @Mary. I don't think anyone can tell another how to experience their grief. It's something that has to be felt in our own way and at our own pace. Thank you for sharing your experience.

  6. @Linda. Nothing like a little radical acceptance: accepting things as they are and knowing that they couldn't be different than they are!

  7. Thanks for commenting, Marilena. I think all of us--whether clinician survivors of a patient suicide or survivors of a family member's suicide, have very similar experiences--experiences that are important to share in ways that make sense.

  8. @Anonymous. Thank you, too. It's my hope that people will be able to borrow my point of view when reading this series of posts about the aftermath of a patient's suicide.

  9. My thoughts are with you. I am a 45 year old first year grad student at Adler. The topics that you handle today with grace and bravery we are just reading about and talking about in distant terms...somedays, and this may happens...My thoughts are with you, and please accept this gentle reminder that self expression is an act of bravery and your gift of self disclosure, gracious, indeed. I will learn more from you than any well researched polished text. Natalie

  10. @Natalie. Thanks so much for your comments. I deeply believe in the importance and need for thoughtful and planned self-disclosure in the therapeutic enterprise. Too many of us are trained to not do this--and in having that training, we lose the courage and vulnerability to connect with those with which we work.

  11. Dear Jason,
    Thank you so much. I look forward to reading more. Or do I? I relate on so many levels. I attempted suicide a total of 8 times and was on life support for 4 of them and in a coma for 3. How I still have a brain I don't know. I have never made any amends to my family because I blamed them so much for what happened. God give me strength to forgive. The last time I had a therapist and he did not see it coming at all...neither had I.
    Today I am a therapist too. And I have survived the suicide of a friend and a former client both. (I had to go back and write former, lest you think I was his therapist when it happened...why is that? Thou knowest.) The friend died a month before I found out. At her memorial I messed up her name and to this day (14 yrs later) I feel shame for messing up her name. When the former client died I was angry, angry that he gave up the fight and angry that he left his little children behind and angry that I couldn't help. And then oh so sad.
    Life has gone on but the pain can still bring me to tears, like now.

  12. This is such a powerful piece that you wrote.
    I struggled with self disclosure when I wrote a memoir about my mother's suicide (In Her Wake) . I knew I didn't want to treat my mother as if I was analyzing her as psychiatrist but also wanted to help others. I am sure that you and your readers may be aware of the american association of suicidology support group for clinician survivors. Also John Mann wrote a great article in AJP talking with what helped clinicians who had lost someone to suicide. Hearing other people talk about their experience was one of the most helpful supports.
    I can send you article if you email me at
    Nancy Rappaport

  13. @Anonymous. Thank you for sharing. The memories and feelings come in waves, don't they?

    @Nancy. Thanks for the suggestion about the book. I'll be getting to talking about the American Association of Suicidology in a future post!

  14. Jason, I am not a suicide survivor, nor am I a psychologist. However, I do know something about dealing with difficult situations.

    I think the key to dealing with your feelings here is to ask yourself if you really did your best. If you did, then there isn't more you could have done. If you have a niggling doubt somewhere that maybe you didn't do your best, then take this for the future, and make sure that you always consider that in the future.

    I have a friend who had an employee he was annoyed with for a while. The man worked in his apartment complex and lived on the premises. He had to go to the hospital and after he came home, my friend kept telling himself he should go visit the guy, or check on him. He didn't do it. A few days later he found him dead in his apartment (having been sent home too early from the hospital, and not having any family). He's had to live with that guilt.

    I'm a teacher, and I try to tell all of my students that we really have to do our best to keep all of our "business" finished with friends and family members as best we can, because we just never know when is the last time we are going to see that person. I think the same applies here. If you know you did all you could, as a therapist, now it's time to forgive yourself.

  15. Jason, thank you for starting this conversation. It is one that is too easy to dismiss or deny.

    I am sorry for your loss and look forward to learning from your journey.

    It's an important story to be told; and, it underscores your courage and personal integrity to tell it.

  16. Dear Jason,

    Thank you so much for sharing this. I look forward to reading your other posts about this.

    I had a similar-but-completely-different situation recently.

    I'm a pastoral counselor, I know the limits of my scope of practice, and I'm well-trained on when to refer. I was about as well-prepared as I could be. And yet in so many ways, not prepared at all.

  17. Hi Jason

    I am an adoptee, engaging with my own grief through psycho dynamic, weekly therapy. I read with resoect and gratitude your post. Your honesty, integrity and humanity are a source of encouragement to me. Thank you for being brave and writing and sharing your experience to help all of us connect and understand each other a little bit better.


    1. Thanks so much for stopping by, reading, and commenting. It means a lot to me that you've found what I wrote helpful.

  18. I came across this article and I am so sorry for your loss. Very sad.

  19. Jason,
    This was touching to read. While gaining an understanding of your experience I began to reward myself for not completing my own suicide. I think sometimes in those moments we don't appreciate enough how our act affects our loved ones. Empathizing with you here reinforces life.

    Then my eyes became watery when you repeated "I will write" .. that you didn't know how many posts until you're done. I took it in is as a chant, a dedication to the only path out of despair. I feel this is part of your grieving and I am so touched by this thank you sincerely for posting.

  20. Thank you so much for writing this. To the several people who said to the effext of "this could not be helped" or "no one could have helped" - that is alarming and appalling to me, honestly.
    I don't want anyone to feel inappropriate guilt, but there is so much research that says means restriction and delaying action are very effective means of prevention. We need to think very carefully about the implications of believing that people "cannot be helped." Just as much care as we use in placing blame/fault when a person take their own life.

    1. Thanks for your comment, Anonymous. It's shameful how little training therapists have in encountering suicide.