The Power of Rescuing Others

"I said I love myself... The very minute the word myself came out of my mouth I knew I had been completely transformed because up until that point I would have never said that. I would have said I love  you because I had no sense of my self. I thought of myself as you. And the minute myself came from my mouth I knew--and I've always known ever since--that I would never ever cross that line again to being crazy."  --Marsha Linehan



Read more here.

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

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

Mondays with Alan: God, Atheism, Good, and Suicide

Suicide, An Unheard Cry: Vintage Views of PTSD

I've recently discovered that the National Archives has its very own YouTube channel. Where have these marvels of history been hiding all my life?

Here are two clips to get you started:

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.

Patient Suicide: Part Six--Leftovers

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

Suicide Note
by Anne Sexton

a matter of my life" - Artaud

"At this time let me somehow bequeath all the leftovers 
to my daughters and their daughters" - Anonymous

Better,

despite the worms talking to

the mare's hoof in the field;

better,

despite the season of young girls

dropping their blood;

better somehow

to drop myself quickly

into an old room.

Better (someone said)

not to be born 

and far better

not to be born twice

at thirteen

where the boardinghouse,

each year a bedroom,

caught fire.

Dear friend,

I will have to sink with hundreds of others

on a dumbwaiter into hell.

I will be a light thin.

I will enter death

like someone's lost optical lens.

life is half enlarged.

The fish and owls are fierce today.

Life tilts backward and forward.

Even the wasps cannot find my eyes.

Yes,

eyes that were immediate once.

Eyes that have been truly awake,

eyes that told the whole story--

poor dumb animals.

Eyes that were pierced,

little nail heads,

light blue gunshots.

And once with

a mouth like a cup, 

clay colored or blood colored,

open like the breakwater

for the lost ocean

and open like the noose

for the first head.

Once upon a time

my hunger was for Jesus.

O my hunger! My hunger!

Before he grew old

he rode calmly into Jerusalem

in search of death.

This time

I certainly

do not ask for understanding

and yet I hope everyone else

will turn their heads when an unrehearsed fish jumps

on the surface of Echo Lake:

when moonlight,

its bass note turned up loud,

hurts some building in Boston,

when the truly beautiful lie together.

I think of this, surely,

and would think of it far longer

if I were not... if I were not

at that old fire.

I could admit 

that I am only a coward

crying me me me

and not mention the little gnats, the moths,

forced by circumstance

to suck on the electric bulb.

But surely you know that everyone has a death,

his own death,

waiting for him.

so I will go now

without old age or disease,

wildly but accurately,

knowing my best route,

carried by that toy donkey I rode all these years,

never asking, "Where are we going?"

We were riding (if I'd only known)

to this.

Dear friend,

please do not think

that I visualize guitars playing 

or my father arching his bone.

I do not even expect my mother's mouth.

I know that I have died before--

once in November, once in June.

How strange to choose June again,

so concrete with its green breasts and bellies.

Of course guitars will not play!

The snakes will certainly  not notice.

New York will not mind.

At night the bats will beat on the trees,

knowing it all,

seeing what they sensed all day.

Patient Suicide: Part Five--Treat People Like They Matter

Between Light and Dark

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

My patient who killed herself told me once that when she died she wanted no obituary, no service, no tomb stone--no marker of any sort that made mention of her life. She wanted there to be "no memory that my sad life ever existed on this planet." She was a woman who was suicidal for more than half of her fifty some odd years on this planet. She was a woman who faced an unrelenting depression that possessed such strong gravity that it was hard for any emotion to break free of the soul-crushing grip of its power.

I've been thinking her wishes a lot these last couple of weeks. From time to time I think I might be comforted by visiting her grave. My experience of her death seems incomplete. She was alive one day, coming in for twice a week appointments, engaged in future planning, and talking about her beloved pet. The next day there was a phone call and she was dead. Gone. There was no space between life and death for me. I'm beginning to understand that one powerful thing rituals surrounding a death provide is a space to experience this moment in time--the moment between here and there, life and death. 

I broke my long standing rule of never using Google to search for a patient. It appears that her family respected her wishes. There was no public funeral. No obituary appeared in the paper. No record of a burial exists anywhere I look. A few of my patient's friends are looking for her, hoping she is safe. Beyond that, it as if she was never here. She got her wish and was erased from the record of this world. Or did she?

Patient Suicide: Part Four -- What's a life worth?

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

I made several calls after I received the phone call telling me that a patient had killed herself. The one that stands out in my mind this evening was the call I had with my attorney. She's what one might called detail-oriented. She also has a laser sharp focus. I suppose these are two very useful qualities in an attorney. Despite having had prior conversations with her, I found myself taken aback by her sharp focus when I spoke to her the morning after my patient killed herself.

My attorney asked me a few pointed questions about my patient. I gave some clinical history and some information about her treatment.

"Look Jason, I'm going to say this directly to you," my attorney said. "This is likely going to be difficult for you to hear. We as psychologists (my attorney is a JD/Ph.D.) are trained to think we can do something about suicide. We are trained to think that we can predict it, we can prevent it, and we can save people. We help many people, but we can't help everyone. We cannot be ultimately responsible for the lives or deaths of our patients. We can only be responsible to not commit malpractice"

My attorney went on to quote some statistics. I felt like I should take notes. Mostly though, I was just numb.

"This is going to sound strange to you, and you might even think I am being cold."

I could have used  a better warning of what was about to be said. Really. You will be shocked.

"Attorneys look at the relative worth of a person when making a decision about whether to take on a malpractice case against a psychologist. Young children have value. Someone who is the primary earner in a family has value. Someone who is active in their community has value. Someone who has people who depend on them has value."

I wanted to make this conversation stop. I knew what was coming and I didn't want to hear it. I knew my attorney was doing what attorneys do: evaluating risk, evaluating the law, justice is blind and blah blah blah. My feelings had no place here.

"From this perspective, your client's life wasn't worth very much. She probably knew that too. That was probably part of her pain, part of the destruction left behind by her illness."

This phone call clearly needed to end. I heard what I needed to hear. I did what needed to be done. I sought out consultation. Consultation received. Stop talking. Go away now.

I needed to hang up so I didn't find a way to crawl through the phone and rage against my attorney. Misplaced anger, really. I wanted to rage against myself. I still do, sometimes. If I could have just found the right thing to say maybe she wouldn't have died. If I paid closer attention perhaps I would have detected some sort of warning sign. Maybe. Maybe. Maybe.

Many have told me that it is not my fault. It's a nice thing to say. Honestly. I know you all mean well. It's not really helpful. When you say that you really are just making yourself feel better. The same goes when I'm told that it's natural to feel rage and be angry at the client. Respectfully I say, screw off. I say it respectfully because I know that none of us are ever really taught how to be present with another person's pain. Really, I think that none of us are ever really taught how to be fully present at all.

This business about presence is important--so don't screw off just yet.

Mostly now I'm just plain sad. I miss her, too.

What haunts me most is when I think about the actual moment of her death. I'm sad she was alone. I'm sad to think how afraid she might have been. Sometimes I have a clear picture in my mind of the terror and panic in her eyes. Her desperation for deliverance from her pain mixed with the terror of her own impending demise. I know that look well as she would frequently find herself in that crucible of pain when sitting with me in my office.

Most of all, however, I'm sad thinking that she left this world thinking she didn't matter and that she was a failure in life. It wasn't my patient that failed life. She was already here. She already had life. That's the easy part. Life failed her. We all failed my patient. We've created a society where we don't value people for their presence here on this planet. We raise our children to think their value is in what they do or what they provide. We increasingly treat each other as serviceable others: we see others as objects to use for our satisfaction.

That's crazy. I think we all need to cut that out. Immediately.

We forget that the greatest mystery--the greatest gift--is the mere fact that we are present here in the universe for our few short moments of life. The important this is that we show up, we are present, and we exist.


My patient was once worth something. She was once alive. She was once present. Fully present. Now, of course, she is gone. In that empty hollowed out space she left behind in my heart I have learned this to be true: we matter because we are. That is the miracle  That is the mystery. The rest is just crap we create to make it difficult (if not impossible) to see the beauty in our presence.

The weekend she killed herself she sent me an e-mail. Perhaps it was a day or two before her suicide, perhaps it was just a few moments before her final act. I will never really know.

I am not a bad or horrible person - I totally realize that. Just suffer a lifetime of mental illness that makes life difficult for me and those around me.

I'd like to think that in these last few moments of life, my now dead patient was finally able to show up and be alive. I'd like to think that she died alive, present, and in possession of the knowledge that she mattered because she was.

The unbearable tragedy is that if I am right, her life was but a moment. We can do better. We owe it to ourselves. Don't you think?

Patient Suicide Part Three: Fully Present

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 was a couple of days after I got the phone call that my patient had died that a patient managed to see right through me. It was unnerving and of course, her observation was right.

"What just happened? You looked so very sad. I've never seen that before. I've never seen such deep sadness in your eyes."

I felt like I might as well have been nude. What else was there to do but respond truthfully?

"You are right. I got distracted thinking about something that happened recently was very sad. Thank you for noticing it--and noticing me. I'm sorry that I got lost for a moment and wasn't able to be there for you."

She was the only one who saw me like that. That is, she is the only one who saw me like that and mentioned noticing the sadness in my eyes. At the moment my client noticed me drifting into my own fantasy world, I was thinking about how my patient had killed herself and wondering what she experienced. I felt so very sad I couldn't be there with her.

I have some trepidation sharing this particular part of my experience. It seems almost too personal. It seems even a little dangerous. In my first draft of this part of the story I wrote something that was essentially true, but also essentially a lie. I wrote what I think a therapist is supposed to think. I wrote that I wished that I could be there so I could have saved my client. I wrote that I wished I could have been there so I could have done something.

Of course, in a way, that is true. I do wish that I could have saved her. I do wish that I could have done something. Given the opportunity I would have done anything in my power to alter this outcome. I couldn't. I have no special power to go back in time. I have no special power that allows me to alter history. This woman is dead and no fantasy can change that.

I remember the hours I spent sitting with this client. I remember exactly how she looked when she was scared and overwhelmed. I remember how her shoulders would gently roll forward. I remember how she would rock every so slightly forward and back. I remember how she would clasp her hands together and wring them. I remember her mouth moving silently speaking things that could could not be spoken. I remember how Maggie the therapy dog would gently come to her in these moments. She'd nudge her with a paw, lay her head on her foot, or crawl up in her lap and gently lick the tears off her face.

Most of all, I remember her ice blue eyes. I remember how she would eventually look up at me. She would look right into my eyes and silent beg for what she could never find: relief, comfort, and an end to her pain. She would beg me for what I could never give.

It's that image that haunts me. It's the thought of her having that experience alone in her last moments of life that is almost too unbearable for me to stand. It is my one enduring wish that I could have been with her in that last moment looking right back into her eyes, always steady, always sure. It is my wish that I could have done the only thing I ever can really do for another--offer a sense of comfort and relief by being fully present.

An Open Letter to Senator Scott Brown

July 31, 2011

The Honorable Senator Scott Brown

United States Senate

359 Dirksen Senate Office Building

Washington, DC, 20510

Dear Senator Brown:

The It Gets Better Project, launched in September 2010, is a response to a number of young people who committed suicide in the wake of bullying in school. Since that time, there have been over 10,000 user created videos that have been viewed over 35 million times. Who has made these videos? President Barack Obama, Vice President Joe Biden, Secretary of State Hillary Rodham Clinton, Rep. Nancy Pelosi, Adam Lambert, Anne Hathaway, Mathew Morrison of “Glee”, Joe Jonas, Joel Madden, Ke$ha, Sara Silverman, Tim Gunn, Ellen DeGeneres, Suze Orman, the staffs of The Gap, Google, Facebook, Pixar, the Broadway community; people of faith such as Bishop Mark Hanson, Bishop Gene Robinson, the United Church of Christ, Jewish Seminary Schools, and small congregations like St James Episcopal Church in Groveland Massachusetts; and thousands of everyday people around the world.

A few days ago all but one of our elected officials who represent the Commonwealth of Massachusetts added a clip of their own to this project. I offer my sincere and deep thanks to Senator John Kerry and Representatives Ed Markey, John Tierney, Jim McGovern, Bill Keating, Stephen Lynch, Richard Neal, Niki Tsongas, John Olver, Mike Capuano, and Barney Frank.

As a psychologist who works with teens and a voter in the Commonwealth of Massachusetts, I stand with these courageous, outstanding, and dedicated legislators. I support our teens. I support the deep desire to make the world a little better place to be. As Barney Frank said in the closing of the sixty second clip, “It will get better. It will get better because you are helping it to become better—and this is in the end going to be the kind of world you want to live in.”

            Senator Scott Brown chose not to participate in making a sixty second clip. Through his spokesperson, Senator Brown’s office said: “Scott Brown has a strong record at the state and federal level against bullying and believes that all people regardless of sexual orientation should be treated with dignity and respect.” The spokesman went on to say “his main focus right now is on creating jobs and getting our economy back on track.”

The Senator doesn’t have the time to be the eleventh voice in a sixty second video clip?

            As for Senator Scott Brown believing that “all people regardless of sexual orientation should be treated with dignity and respect”—the facts add up to neither dignity nor respect. A simple search reveals the following about our senator (all facts found on the website Think Progress and then verified elsewhere):

-          OPPOSES SAME-SEX COUPLES RAISING CHILDREN: In 2001, Senator Brown attacked state Sen. Cheryl Jacques and her domestic partner, Jennifer Chrisler, for deciding to have children, calling it “not normal,” though later said he chose the wrong words.

-          CALLED OUT YOUNG PEOPLE WHO SUPPORT EQUALITY: In 2007, Brown “crossed the line” when he quoted profanity from a Facebook group and identified the students who used it when he was invited to King Philip Regional School District to discuss his opposition to marriage equality.

-          TRIED TO BAN SAME-SEX MARRIAGE MULTIPLE TIMES: As a Massachusetts state senator, Brown voted twice in 2007 to ban same-sex marriage after voting for two similar amendments in 2004.

-          TRIED TO CENSOR HOMOSEXUALITY IN SCHOOLS: Brown cosponsored the “Parents Rights Bill,” which would have allowed Massachusetts parents to prevent their students from learning anything about same-sex families in school.

-          TRIED TO OVERTURN DC MARRIAGE EQUALITY: Brown took a “state’s rights” position on same-sex marriage in his campaign for U.S. Senate, but in March of 2010, Brown voted for a referendum to overturn marriage equality in the District of Columbia. This was in contradiction to previous statements leaving marriage to the states. 

-          OPPOSES NONDISCRIMINATION PROTECTIONS: Brown has made it quite clear that he would oppose passage of the Employment Non-Discrimination Act (ENDA), which would protect LGBT employees from unfair hiring practices.

-          ACCEPTED MONEY FROM ANTI-GAY GROUPS: Many of Brown’s electoral victories have been thanks to the support of anti-gay PACs and organizations like hate-group MassResistance and the National Organization for Marriage.

-          NO SUPPORT FOR ANTI-BULLYING BILLS: Though Brown’s spokesman said he has a “strong record…against bullying,” Brown has not signed on to support any of the anti-bullying bills currently before Congress.

The senator has a strong record of supporting the dignity and respect of all American’s regardless of sexual orientation?

I’ve grown very angry and tired listening to politicians tell me what they think I want to hear. I’ve grown very tired of hearing politicians lie and get a free pass.

I’m sending this letter to Senator Scott Brown—and sharing it publically—to request that he respond to me and the citizens of Massachusetts with truthful, thought out, and reasoned opinions. If Senator Brown indeed supports dignity and respect for all Americans, I’d like to know how he specifically supports the dignity and respect of the citizens of the Commonwealth that are gay, lesbian, bisexual, or transgender. I would like to see specific legislation he has authored, supported, or voted for that documents his support.

Most importantly, I want to know the specific ways in which Senator Brown supports LGBT youth in the Commonwealth. How does he envision a better world for teens? How does he envision a better world for teens who are bullied, victimized, and lost in our schools?

What do you say Senator Brown? Will you be a stand up sort of guy and support our youth? Will you rise above party politics and strategy and respond with your specific thoughts and beliefs about how we can make our world just a little bit better for those youth who need a stand up sort of guy?

The world needs to be a little better. The world needs you to be a stand up sort of guy Senator Brown. I need you to be a stand up sort of guy Senator Brown. Stand up and support our LGBT teens. Stand up against bullying. Do it because it's the right thing to do.

Sincerely,

Jason Evan Mihalko, Psy.D.,

Licensed Psychologist

C: Boston Globe, Lowell Sun

Patient Suicide: Part Two -- 30 Minutes to Think

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

Those of you who are therapists are likely well acquainted with just how much one can get done in ten minutes. Phone calls, a bite to eat, a quick trip to the restroom, and maybe a quick game of solitaire. I've done all of these in ten minutes--and sometimes more.

The day my phone rang and I learned that a patient of mine had killed herself I was "lucky". I happened to have a full 30 minutes free. Part of that time was spent listing to the voice mail a friend of my patient left. I just simply couldn't believe what I heard. It didn't compute. It didn't make any sense. I thought perhaps I heard it wrong. My patient had tried to kill herself and was in the hospital. That must be what I heard. I entertained the notion that maybe this was an elaborate practical joke. My patient had a wicked sense of humor. This wasn't funny.

In the end, I heard the message clearly. My patient used an extremely effective method to take her own life. She was dead and wasn't coming back.I had a very short window of time to get my act together--to figure out what to do.

I had of course no idea what to do. You would have thought I would. After high school I logged twelve more years of education. I had over 20 years of work experience in a variety of mental health settings. I logged well over 10,000 hours of supervised clinical experience.

I know exactly how to conduct a suicide risk assessment. I know myriad steps at reducing the risk of suicide. Not a single class, reading, or moment of supervision about what to do if a client took their own life. Whoops.

Maggie the therapy dog needed her afternoon walk. The friend of my patient, the person who made the call to me, needed a call back. My patient's psychiatrist needed a call. I figured calling the family of the patient was the right thing to do, too.

I made the phone calls. I don't really remember what I said. I remember saying how deeply sorry I was for the loss of this human being. I remember offering up my time. "Come in to my office, if you'd like." I figured the only thing I could do is that which I do best: listen to the experience of of those who were left behind. No one available, of course. I left a lot of voice mail messages.

The call to the psychiatrist was surreal. I've never had to be the first person to tell another person that someone they know was dead. How does one do that? After I hung up the phone after leaving and deleting the message for the psychiatrist. My fifth and final version came right from the role modeling I received after years of viewing ER and Grey's Anatomy.

Are you kidding me? Twenty years of experience and I'm using what I learned from prime time TV? Crazy.

Maggie the therapy dog knew something was up. I remember her pressed against my leg while I was making the phone calls. Still not sure of what to do, I figured I'd mobilize some resources. I called my partner, who was at work and of course not available. I called to friends who were psychologists. They of course were with patients. I called my supervisor I worked with when I was a post-doc. She'd know just what do do. She of course wasn't free, as she was with patients, too.

Maggie and I went for a walk to the river. I think it was raining, though I really don't remember. My half hour came to a close. I dried Maggie off from the rain and got myself a fresh cup of water. I sent Maggie out into the waiting room and she brought in my next patient. We saw five more patients before the day ended. I didn't think of my patient and her death again until I was walking out the door.

How did I manage that one? I don't know. Maybe it's a defense mechanism. Maybe it's mindfulness. Maybe it was shock.

As I walked to my car that evening I started thinking more about what I should do. Does confidentiality survive a patients death? Yes, it does. I could talk to her family, I figured. I could talk about my experience. I couldn't talk about the patient's experience. I didn't have a release. It seems like a human failure thought to not talk with the family about the patient. What was I going to do about that? At least I clearly knew I could talk freely with her psychiatrist: we had a release.

What about me? Who do I talk to? I thought about the law, the reason why we have laws about confidentiality, and what that confidentiality means. I also thought about the very human nature of this experience. What's the human thing to do? How do I balance the law with the humanness of this situation?

I thought about what the right thing to do was. My patient had a long term relationship with another psychiatrist and psychologist. We had many conversations together when my patient started working with me. I decided that the human thing to do -- and within the legal framework of confidentiality -- was to call them and let them know what happened. I called them, and left a message for both of them. I also knew I'd need an ethical consult. I made a note to call my malpractice insurance the next morning to schedule time with the JD/Ph.D. they have available to talk to in such situations.

30 minutes to think. That wasn't a lot of time. I was in shock. I was confused. I had more patients scheduled who needed my attention, time, and energy. The generous interpretation was that I was mindful. I set aside my thoughts and focused on what was in front of me. Part of what happened was mindfulness. That's for sure.

Part of how I made it through the rest of the day was the process of grief. It's what we do. We set things aside, we deny what has happened. We store it way for when the time is right to take it out again and look at what happened.

Walking out  my office I knew there was no denial strong enough to make this untrue. My patient was dead. I wouldn't see her again. I wouldn't be able to ask her about what happened. The place she sat in would forever be empty.

Months later I'm still reminded of her absence. Twice each week during her regular appointment times I notice the place where she sat. I notice it is empty. I notice the questions that will never be answered. I notice the life that no longer is.

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.

Whoops.

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. 

Marsha, Marsha, Marsha

I spent a portion of the last six months of my internship traveling around the country interviewing for a job. I came close a few times. One was particularly exciting: a community college in Oregon was hiring an assistant director of their counseling center. As I was for every other job I got an interview for, I was named the runner up. Runner up wasn't going to get me employed.

So my internship was coming to a close and I was become a little concerned. I call a friend, who calls a friend, who calls me back. They told me about this clinic in Cambridge that has a post-doctoral training program. I made a few phone calls and before I know it, I'm on Harvard Square for an interview. 

The whole interview experience was a hoot. It was a hot humid day, I was recovering from a minor surgery, and the person I interviewed was interested in giving me a hard-hitting stress interview. It took me nearly a year to forgive the psychologist who interviewed me. In the end, he became one of my favorite mentors. I'll have to leave this story for a future blog post.

In the end I was offered a part-time postdoctoral fellowship that paid just over the poverty level. I made a few other phone calls and arranged for another part time job at a local counseling center. I was busy--and barely made enough money to pay my bills--but I had the pieces I needed to get my post-degree hours in so I could sit for my license.

Apparently I interviewed for a fellowship that involved working with adolescents who were highly suicidal and engaged in self-injurious behavior. Who knew? I remember hearing something about Dialectic Behavioral Therapy (DBT) in my doctoral program. That was my main role in my fellowship: working with adolescents in an intensive day treatment program as well as in an outpatient clinic doing DBT.

Marsha Linehan and her followers can sometime take on the aura of a cult. Sometimes it feels that those "on the inside" think that DBT is the only treatment--the only way--to work with people. They have done some fantastic research. That's for sure. They've done some fantastic research in highly controlled settings with highly controlled patient populations. In real-world practice, DBT provides a useful tool to use in combination with other useful tools. Empirically supported treatments work a bit differently when they are taken out of the lab.

Below is a great clip of Dr. Linehan explaining DBT. She said something early in the clip--something important and worth highlighting (and is the point of this blog post). At 1:04 Linehan says "I love her so much." What? A psychologist loving a patient? That's not supposed to happen, right?

To date I have four examples of psychologists who I have heard talk about loving patients: Marsha Linehan, Irene Stiver, Robin Cook-Nobles (a former training supervisor and mentor), and Judy Jordan (another mentor who deeply influenced my training).  Check out the companion blog entry to this one called "A Few Notes on Love."

I think talking about love is an important dialogue for psychotherapists--and it's something that I'd like to hear Linehan talk more about. As a fellow, and then later as a psychologist in private practice, I've heard scores of psychologists, social workers, psychiatrists, and counselors talk with contempt about their patients. I watch in horror as these folks lose their ability to see the humanity in those that they work with and reduce their patients down to a list of bothersome symptoms.

One of the gifts of what Linehan offers in DBT is acceptance--acceptance of patients--acceptance of feelings--and acceptance that people are doing the best they can. Many get blinded by the tools, language, structure, and research of DBT. They loose the basic humanity--the acceptance and love--of the the patient.

Here is Linehan's entire talk. It's worth watching--especially the parts where you catch her humanity, acceptance, and love.

Suicide Doesn't Improve the World

It seems that I have a lot to say this weekend.

There has been a lot of great attention drawn to the problems with bullying. Dan Savage started the It Gets Better Project where people from across the world record their own messages to teens telling them that indeed, things can get better. Local and national news stations are beginning to air the normally silent stories of struggles that young people face. The attention is good--it's raising awareness, starting a dialogue, and building a platform for change.

This morning I watched a video on Towle Road. Sean Walsh was, a 13 year old who killed himself after being bullied, left behind a suicide note. His mother made the decision to read his suicide note and tell his story on YouTube. My heart aches for Wendy. I hope her video can make a difference in an adults life by teaching them to speak up about bullying. If you'd like to watch the video, I'm including it in this post. It's sad, raw, and powerful. If you are feeling a little vulnerable you might not want to watch it.

Sean wrote, "I will hopefully be in a better place than this shit hole... Make sure to make the school feel like shit for bring you this sorrow."

There is a problem here. We aren't teaching our children that things can be better now. We aren't showing children other children who have lives of joy, compassion, and excitement. We aren't teaching children how to be resilient, how to resist bullying, and how not be be bullies. We are failing our children.

The narrative of much of what I hear is something like this:  It can't be better now--you have to wait for it to get better. Youth are suffering and miserable and need adults to rescue them. 

I am filled with sadness for the loss of Sean and the grief his mother is experiencing.

Suicide doesn't change the world. Suicide isn't an effective way to punish a school or a bully. In the end, suicide means someone is dead, some people experience profound bone breaking grief, and the rest of the world moves on. 

There are so many more effective ways to resist a bully and change the world. We ought to be teaching our youth these skills. We ought to be teaching our youth about other youth who use these skills. It can save a life--and change the world.