Sunday, December 22, 2013

Patient Suicide: Part Eight--On Scarves and Lessons Learned

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

''And I've become more humbled by how little one can do, ultimately, to keep someone alive.'' -- Joan Wheelis, MD

I've been wearing the scarf my dead patient knitted for me the last few weeks. The scarf is made from yarn of yellow and green and blue. Soft to the touch and just a bit too short, it isn't really a scarf that I'd pick for myself. Nevertheless, I've liked having it near me, on me, and around me. I am, in fact, wearing it now while I write this entry. I'm aware of no specific reason why. I suppose the most true thing I can say is that I've been feeling particularly close to my memories of her these last few weeks.

I'm sure an analyst somewhere would have all sorts of interpretations.

Some of them might even be right.

I haven't always wanted to wear the scarf. There are times when I haven't even wanted to see it.

She gave it to me for Christmas--four months before she died. She was knitting scarves and hats as a form of distress tolerance. Some went to cancer patients being treated at a local hospital. Some went to babies who were born prematurely. One of them went to me. I kept the scarf in the closet for months. I considered giving it away. I considered throwing it away. I didn't want to see it.

I hated it.

I hated her.

The scarf made me feel guilty. I felt guilty for hating her. I felt guilty for my anger toward her. I felt like a failure because she was dead. I hated that she was dead and I hated that I felt like a failure. I hated that I hated.

I wanted all my feelings about my dead patient to go away.

I couldn't make them go away. The best I could muster was to stuff those feelings into my closet and repress them. Store them away. Bring them out later for inspection.

I didn't save her.

I couldn't save her.

She didn't want to be saved.

She couldn't be saved.

I didn't want to learn these lessons. I didn't want to learn that I cannot rescue those who cannot be rescued. I didn't want to learn that some people don't want to be saved. I didn't want to learn that no matter how hard I try, Humpty can't always be put back together.

These are some of the lessons I learned. 

I'd rather have not learned them. I'd rather my patient still be alive.

We don't always get what we want.

I'm not angry anymore. I don't feel guilty. I don't blame myself. I miss my dead patient. Sometimes a little, sometimes more intensely.

Another lesson has been bubbling up. Perhaps this is the reason why I've worn the scarf nearly every day since it's gotten cold this year.

In the wake of my patient's suicide I've become strong. I've become strong in ways that I never anticipated. I feel calmer--not just around issues of suicide, but around everything else that happens in my office. I'm learning the difference between the things I have power to influence and things that are outside my power as a psychologist.

Suicide no longer frightens me as a clinician. 

I hope it doesn't happen, and yet I don't fear it. 

There are days when I feel a little hysterical at the thought of going through this all over again. Those feelings don't last too long. I hope I'm always just a little hysterical at the thought of someone dying. 

Mostly, I welcome suicide into my office. Every day it becomes a little easier to talk about. 

I wish she didn't have to die, and yet in her death, she made suicide something that is mentionable for me--something really mentionable. Rather than frightening and silencing my patients with threats of hospitalizations and retribution, I've become more skillful and inviting suicide into the room. It's become a thing that can be spoken. A thing that can be known. A thing that is mentionable and therefore more manageable.

“Anything that’s human is mentionable, and anything that is mentionable can be more manageable. When we can talk about our feelings, they become less overwhelming, less upsetting, and less scary. The people we trust with that important talk can help us know that we are not alone.” -- Fred Rogers


  1. I have just finished reading this eight part series of entries. Thank you Jason. Thank you for putting professionalism aside and showing your humanness. As a long term therapy patient who suspects her therapist cares deeply but never dares to actually truly believe it, it is deeply impacting to read of your raw response to this tragedy.

    1. Hi Anonymous, and thanks for taking the time to read and comment. What you thanked me for--for putting aside professionalism and showing my humanness--did you realize what a powerful observation about therapy and therapists is contained within your words. How sad is it that we've all accepted the notion that for a psychotherapist to be professional, and psychotherapist must not expose themselves to be human.

      It saddens me deeply to think how many seek therapy to find a path toward their own humanity only to be stuck in a system that cannot find ways to thoughtfully and ethically include the humanness of the therapist.

      Here's to challenging that system, and imagining a way for all of us to find, safely explore, and celebrate our humanity.

  2. Hi, Jason -
    Thank you for this post . . . as a client who has danced with wanting to die for most of my life, it has been a relief to have a therapist who allows me to talk about it as much as I need to with him . . . I believe that has made the idea less appealing for me. I'm so glad you welcome that topic in your sessions!

    1. I'm so glad you found a therapist that helps keep a space open to make the things that were once unmentionable mentionable.

  3. We all gotta swim for long distance. You can provide a big, peaceful island, but we all have to swim to somewhere again. Sometimes it's stormy, sometimes we don't know where is the island or when we can reach the island again. We have no choice but swimming alone. I only can guess what your patient was like but I'm sure she felt at ease in your island.

  4. Thanks for allowing us on this journey with you, Jason. Have a beautiful Christmas and New Year.

  5. I just finished reading the entire series, and I thank you so much for putting your experience out there, Jason. I found so much of myself in your words about your client as I continue to struggle with my own challenges. Reading your experience is just wow, and makes me appreciate all my therapist and treatment team have to work through. My most peaceful place in the world is in my therapist's office, and she's helping me try to find that same peace in my own home. I don't have much else to say other than thank you for opening my eyes to the true aftermath of such devastation.

    1. You're welcome, Purple Dreamer. I'm glad you found some meaning in my writing. I think sometimes one of the cruelest things about depression is the ways in which people can lose access to knowledge about how deeply they impact people, and how deeply people care. I also think it's particularly difficult as a therapist to negotiate a way to be present with our feelings and yet not burden our clients with those feelings.

      I'm sorry to hear of your struggle. At the same time, I'm glad you found a place where you can do this work and find your peace.

  6. Thank you for exploring this experience and writing about it. I have posted a link in my blog under the title

    Jason Mihalko on "inviting suicide into the room". Please let me know if you want me to change anything:

    1. Thanks so much for sharing my blog post, Ingrid. I'm thankful you were moved enough by it to what to share it.

  7. Dear Jason,
    I have been busy the past few months and not able to visit as often as before.
    Thank you for your continued vulnerability that we may all learn and share. It sounds like you are creating your own meaning and continuing to heal. Perhaps she gave you a final gift from your that you have been determining if and how to accept, process and define alone without her.
    I share with my adolescent clients that we can openly talk about suicide. We discuss it being like chocolate cake in the kitchen. That even though we may want to eat it all, we can choose not to because the consequences would not be great if we did. It sounds simplisitic and they frequently give me an odd look but it makes it ok to discuss it and not quite so scary. We talk about riding the wave and waiting for it to pass and who would need to support them through it. I frequently invite them to choose a rock gathered from the shore of Lake Ontario and we talk about the harsh cold waves that batter the rocks. But the rocks are smooth and beautiful by riding out the waves. They learn to ground themselves using the rocks, doorjams, walls and floors. By taking away the taboo and learning what really happens if they call the crisis number they gain power and control. I realize that working with spontaneous adolescents there will be more suicides in my future as a social worker. At the same time I recognize that they have the freedom to make choices and am recognizing that the same things that put them at risk for suicidal ideations are the same characteristics that I consider a blessing in working with them. Humans are such amazing fragile and resilient creatures that the risk in working with them and having my heart broken outweighs the sadness of not being invited to join them on their journeys.

  8. Jason, I've also just read your 8 part series. I'm someone very similar to what you patient seemed to be like, meaning a long, long time of being depressed and suicidal. I really liked what you wrote about DBT and how things don't work for some people. I've already written more then I wanted. All I really wanted to say was that it is comforting to know that you thought of how alone your patient had to be when she died, obviously that is the way suicide generally happens, it sucks because it is hard to be so alone. I believe your patient would want you to know that even though nothing had stopped her pain while she was alive, that when she was struggling and looked at you for help, even though there were no answers for you to give her, she at least was able to express her despair to you. That is all some of us get. I do believe that for certain people that suicide is the means to end decades of horrible pain, where the traditional words of 'Rest in Peace' have the strongest meaning. I believe if your patient were able to give you a message it would be - be happy I have found my peace.

  9. Hi Anonymous, thanks stopping by and commenting. I don't have any knowledge about the after life, if there is one, so I don't spend much time dwelling on if people find peace or not. I do, however, think it is very powerful for a therapist (or anyone, for that matter) to be present with someone in the face of feelings and situations in which there are no answers.

    I'm not happy that she is dead. Her death was an end of her story, and it's the only way this story could end as that is what happened. For those that are left behind--or stories continue and are influenced by our own experiences and thoughts. I'm very sad that she wasn't able to find a way to liberate herself from her various struggles and have a life on this planet that was worth living.

  10. Dear Jason,
    I am getting ready to do a training with our staff on the issues faced by clinicians who lose clients to suicide. I have lost clients indirectly, as the supervisor in a large MH Clinic. Good treatment was given, I felt I knew the clients, and I was deeply impacted. But that is so different than the very personal, deep relationship of one on one long term therapy like you were having with your client. I don't know how I would cope with that. I believe I would eventually get strong. But I know it would be devastating. Even though I do know the serenity prayer very deeply at this point of my life. Yesterday I chose to refer on a deeply suicidal man whom I saw for the first time. I knew that right now I could not risk being present for his level of pain and his extremely high risk for eventual suicide. I am glad I could know and choose not to take that on. We all have limits. I hope he will be safe. I hope my training will help the staff in some way to be ready when/if it happens. To know it can be talked about. To know they are not alone. I hope my training will help me too. I am including your website as one of the resources for them. Thank you for sharing - you touched me.

  11. Hi Jason,

    Thank you for this. I read the whole thing, crying through most of it, both for you and for your client.

    I've felt suicidal for months. I have not one, not two, but three rare disorders (physical illnesses), all of which are research orphans, one of which is progressive, and none of which have cures. I've been a crime victim twice in the past year, and was injured seriously in one of the crimes. Both criminals walk free, completely free of any consequences, in part because of errors in the investigations that have spawned unjust results in court.

    I'm too alone because I lost several very close friends to unexpected deaths during the last few years I took care of my mother in her terminal illness. Because of illness and physical pain, I now lack the physical stamina to go do the things I might otherwise do to try to make new friends. My family is dysfunctional and occasionally evil. I have a cat and a dog. My animals love me. I love them. It's not enough. A few months ago, when the third illness hit, I became pretty sure that God has forsaken me.

    I don't find it remarkable that I feel suicidal. I find it remarkable that I haven't taken my life yet. The quality of my life is unacceptable.

    A few weeks ago, the office manager at the practice where I used to go for counseling, for reasons unknown, came out into the communal, public waiting room and proceeded to breach my confidentiality by discussing details of my records for all those present. I got very upset, and badly triggered by this event (it's unfortunately not the first time something like this has happened to me). I have been suffering from that, as well as a lack of a proper apology from the practice that has kept me from returning there. What I've learned from this situation is never assume that an already unacceptably difficult life can't get worse.

    I'm so sorry you lost your client. And what I know from my experience is that each of us has a limit to our resilience, and each of us is fragile and lost and hopeless when that limit is passed. I was myself for most of my life extraordinarily resilient and now I'm past the limits of my own resilience, and it's difficult for anyone else to understand or accept this because I have such a track record of coming back from unspeakable tragedies. But I can't fight any more. I am weary. I am knocked over, and I can't get up by myself.

    And, my former psychologist apparently works with people who can't resist discussing my private information in public.

    It doesn't sound like you did anything bad, anything that would have become that straw that made your client's burden unbearable. It sounds like you really cared, and by writing what you did here, you are making an effective plea for others like you to communicate in ways that matter. You are in effect giving your client the significance that her life deserved.

    Before the hell that broke loose in his waiting room, my counselor's last words to me were, "I want to help you find your happiness." I wonder what that would have been like. I don't think I'll ever know, because the communication in the aftermath of the breach has been cold and defensive.

    I've learned that hope is just a cruel prelude to disappointment. It's worse than useless. It sets me up for loss.

    Thank you for listening. For what it's worth, I think you're one of the good guys.

    And I think there was a time when my own life mattered enough, to enough people. It's just that that time has come and gone. Remnants of a life do not equal a life. If/when I decide to surrender those remnants, I would say to anyone tempted to judge me: please don't. I've tried as hard as I can for as long as I could, and I've put a lot of good into the world, and now I'm tired and ill and in pain and too alone. If you were carrying my burdens, you might have dropped them long before I did. So, please don't judge me.