Sunday, April 7, 2013

Patient Suicide: Part Seven--Training Monkeys/Herding Cats

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

It is nearly two years now since my patient killed herself. As the anniversary nears of her death, I'm thinking a lot about all the subtle and not so subtle ways I have been trained to look away from the experiences of my patients. I've also been thinking a lot about the ways in which I break those rules and don't look away.

Shortly before her suicide, my patient brought in a box full of photos. Her body deeply trembled as she handed me the box. 

"Let's do this quickly," she said. "If I think about it or talk about it too much I won't be able to show you. I've not always been like this. I've not always been so lost."

She handed me a shoe box full of pictures. I knew her sharing was important. I knew that it meant a great deal to her. It hadn't even entered my mind until after I received the call that she had killed herself that this was likely the beginning of her goodbye to me.

I carefully picked up each picture and tenderly held them as if they were a beloved infant. These were her memories--important and treasured and painful. I knew that much. I also knew I needed to treat them with loving respect. I saw pictures of her ex-husband and his children, past hospitalizations, vacationing with friends, and some of her beloved dogs.

These pictures were each representations of something we spoke about. I knew a lot about her ex-husband--how much she loved him and how angry she was that her depression destroyed that relationship. I knew about the terrors of past hospitalizations. I knew about the cold-wet sheet packs that were used to help her "calm down." I knew about the sodium thiopental treatments that "helped" her talk about the childhood sexual abuse. I knew about each of the dogs she had euthanized prior to a suicide attempt. I knew about the joyful practical jokes she played while living with friends.

She shared these stories with me over the years and I never looked away. She shared the pictures with me and I took each one in my hand and  carefully looking and asked thoughtful questions. I tried to take in her whole experience in every way I knew. She mattered to me--and it mattered that I did my best to witness everything she could share with me.

What I didn't know was that I would be among the last to hear these stories. I might, in fact, be the only one who knows these stories. On occasion I've considered violating my patient's confidentiality by calling her ex-husband. It's easy enough to find him. He might like to know how deeply grateful his ex-wife was for the moments of joy she experienced. It's wrong, however, to break the trust my client placed in me and our work. The specifics of these stories will live in my heart until I die. Then they will be gone forever. 

In thinking of these memories, I've been thinking about all the various experiences my clients ask me to look at. I've known clients who have injected noxious chemicals into their bodies, broken their bones, flayed their skin, ingested broken glass, and otherwise took self-injurious actions in the service of finding relief from unrelenting emotional chaos.

I have had some of the best training from the people who train trainers in the provision of Dialectical Behavioral Therapy (DBT). It's considered the best treatment for people who engage in self-injury. Rather than engage in self-injury in the service of regulating their emotions, patients learn new skills that help manage and tolerate previously unbearable emotional experiences. Sometimes, DBT therapy works. Other times, the therapy doesn't work. 

If it doesn't work, I was taught to look at the attitudes of my patient. DBT says that patients need to have a willingness to change. They need to approach therapy and the skills of DBT with a sense of willingness rather than willfulness. There are protocols of how to approach a patient who is not yet displaying an attitude of willingness.

This is the exact point in which I find DBT crashes and burns. Despite thoughtful attempts to present a case to patients that it is in their best interest to be willing, and to accept patients where they are at, an unresolvable power struggle emerges that destroys the therapy and very possibility can destroy the patient.

The message gets delivered to a patient that their behaviors--and experience of the world--is unacceptable. People are placed in an untenable position where they either have to accept the authority of the therapist (do as I say) and reject their own experiences (I hurt, I can only show you the ways that I hurt, I cannot tell you in another way).

I've been thinking this week about all the ways in which I have been expertly trained to deny the experiences of my patients. It all starts with good enough intentions. One wouldn't want to reinforce a self-injurious behavior by allowing a patient to engage in it inside the therapy session. One wouldn't want to teach and reinforce that self-injury is an effective tool of communication.

The model of DBT has consequences for self-injury. Engaged in such a behavior? The therapist is no longer available for a proscribed period of time as a consequence (punishment) for the act. Comply with the therapy and be willing to do what the therapist asks? The patient gets rewarded with extra attention.

It all looks wonderful in a chart. Follow the plan and self-injurious behaviors go down and more effective behaviors go up. People get better and lives are saved.

Unless of course it doesn't work. DBT was a spectacular failure for my patient who killed herself. It gave her yet another thing to feel she failed at.

As a young post-doctoral fellow it seemed more likely that not that the clients who were assigned to me were the ones no one else wanted. The senior staff got the wealthy, pretty, and exotic patients. My fellow post-docs seemed to also share in the wealth--and I use that word intentionally. It seemed that many of those around me were assigned patients that were likely to change, and likely able to be able to afford to pay big bucks for that change.

My clients? Well a mentor summed it up once with this statement:

"You should cut her loose Jason, she is never going to change."

Being the spectacularly stubborn person that I am, I didn't give up. I don't give up. I'd have it no other way. I'm also spectacularly arrogant and just will not accept that I cannot be helpful so long as people are still alive. I've not yet discovered a way to be helpful for people after they are dead. If I do, I'll still keep on working with the dead.

By the way, the one I was supposed to cut loose, they are doing spectacularly well.

Two very important things have happened in my office in the past few weeks. One person showed me their site of self injury and I gasped "I didn't need to see that." Several weeks later a different person, after sitting quietly for some time, asked if I wanted to see her wounded body parts. I sat close to her on the couch and carefully and tenderly inspected the wound.

My different responses to each of these two patients, and their responses to me, has made me think almost non-stop about those two patients, my dead patient, and nearly everyone else I've worked with for the past twenty years.

A good deal of my training as a psychologist has taught me impose a particular view of health upon my patients. I can masterfully wield a variety of cognitive behavioral techniques to colonize the minds of my patients and make them think and feel in more adaptive ways.

Sometimes it's a bit like training monkeys. Other times it feels more like herding cats.

It's a bit icky to write that. It's also true. My profession, in part, is about helping people be effective and productive "normal" members of society. The theories of psychology shape the contours of what is considered normal experience and the interventions of psychology help confine people within those contours.

There is more to my profession. Psychology is not just about training monkeys and herding cats.

There aren't many of us left anymore. Some voices still seek to use psychology as a tool of liberation to transgress the illnesses in our society. There are still voices that try to use psychology to help make the invisible visible, and break the obfuscating silence our notions of mental illness have on experiences of racism, sexism, misogyny, ableism, heteronormativity, homonegativity, xenophobia, sexual violence, and other social ills.

Psychology all too often places the nexus of madness within a person. You're ill because of your maladaptive behaviors or because of your faulty neurotransmitters. Depression got you down? Have a helpful worksheet on how to stop thinking those distorted thoughts. Have a pill that will fix that biological malfunction in your brain that prevents you from being normal.

Our mechanistic and biological metaphors of understanding madness are rapidly making our social ills invisible and shifting the responsibility from a sick society onto the individual who mirrors that sickness back to the world with their mental illness.

I was never able to mirror this way of knowing back to my patient who took her life. A lifetime of treatment that placed her at the center of blame--being taught her biology, her maladaptive behaviors, her way of being were to blame--was too much to fight against. I had no mirror bright enough to cut through the shame and blame to help her see that her condition was a reflection of the illness around her--not a reflection of herself. The madness was returning and she chose to end it with her death.

My patient is dead. There is no other outcome that could possibility have happened since none of us can go back in time and change that which has already happened.

My dead patient left behind something rather powerful. I can be a mirror to help my patients see what they haven't yet been able to see. My patient's also reflect back to me what I cannot see about my self. Together, as we examine these complicated reflections, we might just have a chance.


  1. your last paragraph reminded me of the book, The Wounded Healer by Henri Nouwen; we learn about ourselves as we help others.

    thank you again for sharing such personal feelings and thoughts, and reflecting/helping others to see how best we can serve our clients.

    1. Thanks John. When I got the call two years ago I was so very alone with this. I'm still surprised at the stunning silence so many therapists have about their experiences with patient suicide. I've been treated like I have cooties from some colleagues, and deeply loved and cared for by others. It's something we all need to talk about.

      I am so very glad to hear that these posts point some people into useful directions!

      Thanks for your kind comment.

  2. Sorry to hear about your loss. It's a long time ago but time doesn't matter.

    I was thinking about "the Politics of Experience" while I was reading your post. Like anyone, I'm often lost wondering what's the genuine, dignified relation between human beings, feeling alienated by the lack of authentic communication in everyday life.

    Either in therapeutic situation or even day-to-day conversation, why do we forget the power of shared experience, or more accurately, an obstinate attempt to share experience based on mutual respect and trust? Do I even trust myself to listen to my heart?

    It's very powerful but sad memory to hear that.

    Take care,

    1. Thanks Shuko. So many good questions to think about! In a general sense, I think so many of us are so busy trying to prove who is right and who is wrong, we forget about being curious about the experiences of another.

  3. Hi,
    Someday perhaps our paths will cross and maybe we will have an interesting conversation. This month marks the 10th anniversary of my experience with a student who committed murder suicide. After all the work and one year left in training as an MSW, I see and hear so often about the process immediately after a client completes. Hear the grief of clinicians who have formed relationships and yet we do not train much in how to prepare or allow or support each other in the grief that comes in that unique, goal oriented real relationship. Thank you for sharing and caring about your clients. I agree with your assessment as well that a model works well when it works but may not meet the needs for all individuals. For some the consequence may be a repeat of the past rather than the opportunity to create a new future. And sadly for some completing is the only option in the moment - which we do not prepare for either. Because we are not taught how to accept when the choices they make are theirs no matter how much we give of ourselves. What you gave her was a gift, you witnessed her vulnerability. Sadly we have limited power to do much more. Kim

    1. I'm sure we would have a very interesting conversation, Kim,

      Thanks so much for taking the time to share you experience. I'm sorry to hear about your loss. It's a special knowledge we clinician survivors have. From the grief, from me at least, comes a sense of empowerment in knowing deeply my powerlessness, and a sense of strength in knowing our greatest gift is bearing witness to that which we cannot change.

  4. I just read all the posts about your patient. I'm sorry for your loss.
    I wanted to write something about this post, but I lost my point. I guess instead I will just say thank you for recognizing that the most popular treatments may not always be the best for every client.
    And thank you for putting it so concisely that sometimes the dbt consequences just replay the past...

  5. I'm sorry for your loss.
    My original content disappeared into nothingness.
    I wanted to thank you for recognizing and voicing that the most popular treatment may not always be the best for every client. Sometimes dbt really just replay the past and the whole reason we are as bad as we are at coping...

  6. Thanks for this. I know my therapist is concerned when I'm late for a session. But I never thought of him valuing seeing me, or that he would be remembering where I used to sit, or how we used to be. These are things that should have been communicated to us by our parents. Instead of us just feeling like a burden, and a failure. Thank you also for sharing what a life is "worth".

  7. Thank you for this series. It has touched me deeply as I am in the same struggles as your patient.