How Patient Suicide Affects Psychiatrists
Mental-health practitioners whose clients kill themselves can face stigma from their colleagues, lawsuits, and a toll on their own psyches - making them less likely to take on suicidal patients who need their help.
By Sulome Anderson
Atlantic Monthly, Jan. 20, 2015
It's hard to listen to a psychiatrist who sounds so broken. I expect a mental-health provider to seem healthy, detached. But even over the phone, the weariness in Dr. Brown's voice is palpable.
"This is what we do when people die," he says. "Even if they die an expected death, it seems to be human nature to go back over [it]. What should I have said that I didn't, or shouldn't have said that I did? Could I have done more or did I do too much? This seems to be a part of the grieving process. I think it's especially intense in a situation where you have direct responsibility for helping the person get better."
Brown lost a patient to suicide last year. She was a long-term client of his, the mother of a large, loving family. Right after a session with him, she went home and killed herself. Two months later, Brown's son did the same thing.
He doesn't want to talk about his son. It's still too immediate and painful. But he does tell me how he felt after his patient died. "I went to the funeral," he says quietly. "I stood for the entire service ... it was completely packed with people just standing and so I was thinking, as I was listening to this service, that I was the only person in that room who had that particular relationship with that woman. Everybody else knew her in some different way. They were friends, they were family, they were relatives, maybe they knew her in the congregation and I was the only one who had been working with her, seeing her the day before, trying to prevent this. I felt unique and not in a very flattering way."
Suicide is the third leading cause of death for young adults, and the 10th leading cause of death for the general population. The doctors I spoke with about this gave me different statistics on the number of mental-health professionals whose patients commit suicide. One says 51 percent of psychiatrists; another tells me it's as high as 80 percent of all people who work in the mental-health field-including psychologists, social workers, etc. But the stigma of suicide is so strong that it's often an issue left unspoken, even by doctors. Many psychiatrists refuse to treat chronically suicidal patients, not only because of the stigma that surrounds it even in their profession, but because suicide is the number-one cause of lawsuits brought against mental-health treatment providers.
Until a few years ago, I would often comfort myself with the fact that if the pain got bad enough, I would be able to end it. When I was 21, I was diagnosed with a severe mental illness-borderline personality disorder-but I didn't really start to understand what it was until a couple of years later. All I knew was that when I was sober, the only thing I felt was a deep, boundless shame at my very existence, the conviction that I was irreparably flawed, rotten from the inside out. So for almost 10 years, I was rarely sober.
As far as borderline patients go, I was never particularly suicidal. I made a couple of half-hearted attempts when things were really bad, and during my fits of hysterical depression, I would almost never take the agony out on my own body. Almost. But that's not the norm for people with my diagnosis. An estimated 80 percent of borderline patients attempt suicide, with an average of three attempts per person. According to most statistics, about 10 percent succeed, making BPD one of the most lethal existing psychiatric illnesses.
Thanks to much hard work, medication, and therapeutic treatment-as well as a financial investment so large I don't even like to think about it-I no longer fit the diagnostic criteria for the disorder. But many of the friends I made along the way still do, and Margaret is one of them. I recently drove to Boston to visit her in the mental hospital that's been her home for four months. Every time she was discharged, she attempted to kill herself again. The last time, she tried to hang herself; the time before, she almost stepped in front of a train. After the hanging incident, her doctor decided to stop working with her, and now she can't find a new one.
"I completely fell apart after my therapist quit, because I relied on her very heavily," she says. I can hear the medication in her voice-she sounds sleepy and is slurring her words a little. She's almost childlike in her manner and wears a pink bow in her hair. "I got really attached to her, and it's so hard when someone you care about, that you trust, decides not to work with you anymore. It makes you feel like they think you're never going to get better. It felt like she gave up on me."
I ask her if she knows why she can't find another doctor who will take her on as a patient, and she sighs.
"Because I take up so many more resources than other patients," she says. "When you call your therapist because your boyfriend left you and you're sad about it, they can wait a few hours before calling you back. When you're going to kill yourself, they have to immediately drop what they're doing. I tried calling people from Psychology Today-you know how they have those listings? They're nice at first, but when I tell them how suicidal I've been, all of a sudden, they don't really have time, and they don't know anybody they can refer you to ... nobody wants to work with someone like me. It's a risk, because if we do kill ourselves, it's traumatizing and messes them up. And also, they can get sued."
As her friend, that's heartbreaking to hear. But it makes me wonder what it's like for the doctors who have lost a patient to suicide. I approach doctors to ask them; they don't respond. I call the office of a doctor whose patient committed suicide earlier this year, after which the patient's family sued the doctor. When I tell the receptionist what I'm writing about, she speaks with me for about 15 minutes. It sounds like she needs to talk.
"I doubt he'll call you back," she says. "He's still so devastated. We all are. We saw this man twice a week for years. I don't believe he even lets himself think about it."
After a few failures, I connect with Nina Gutin, one of the co-directors of the Clinician Survivor Task Force, a support group for mental-health providers who have lost someone- a patient, friend, or family member-to suicide. The group operates under the auspices of the American Association of Suicidology. She posts my request on the listserv she runs, and that's how I meet Brown and others who want to share their stories. One thing I hear from all of them is fear-the fear that they didn't do enough, that this might happen to them again, that they'll be sued.
Jennifer is a master's-level mental health clinician. Fourteen years ago-almost to the week, she tells me-one of her patients shot himself; and his family brought a lawsuit against her.
"I'd seen this individual for four appointments, and on the fifth appointment, he did not show," she says. "The next week I heard that this had happened ... I was just beside myself with grief. I'd never lost a client before, and I had many suicidal clients. It was very tragic that this had been the outcome; we had barely enough time to really scratch the surface on issues. Immediately when things like this happen, you're advised by legal counsel not to talk to anybody when it becomes clear that there is going to be litigation. In my profession, you isolate. You don't talk. Even with your colleagues, there is a certain stigma."
Jennifer says the patient didn't express any suicidal urges to her. He had come to see her at the behest of a girlfriend, to deal with some anger issues he was struggling with. When advised to take medication, he refused. Then the girlfriend left him, and he killed himself. Yet the family still filed suit against Jennifer and when the judge threw out the first case, they re-filed under a different charge. She says these proceedings dragged out for five years.
When asked why she thinks they sued her, she pauses for a moment. "I think the family was left with a lot of questions and in their mind they needed to find someone to blame for this," she says. "There was nothing to substantiate [the lawsuit]. My board cleared me. But it was a grieving family. I mean, I feel for them every Christmas. Every time I put my Christmas tree up around this time of year, it brings me right back there."
The flip side of that equation is when a doctor fails to meet the professional standard of care, in ways that can be quite obvious. Skip Simpson is a suicide-malpractice attorney, but from talking to him, he doesn't seem vengeful. He says he's interested in bettering the current mental-health system, not bringing frivolous lawsuits.
"If we were to talk for 30 minutes there would be two people in the United States who would die from suicide within that period of time," he tells me during our conversation. "There is a basic duty to prevent harm, for example, at a hospital. If those charged with treatment of mentally disturbed patients know the facts from which they could reasonably conclude that a patient would be likely to harm herself in the absence of reclusive measures or interventions to protect them, then they must use reasonable care under the circumstances to prevent that harm. That's not just in hospitals, but also in outpatient care too."
This type of lawsuit is personified in Denise Vitali Burne's case. Her brother Matt, 37, committed suicide in 2004, while at The Meadows, an inpatient treatment facility located in Arizona.
"He was our rock," Burne says during a phone conversation, starting to cry almost immediately. "He was our golden-haired boy. He was 37, dual-degree at John Hopkins. Totally drug- and alcohol-free ... he had an MBA. He was really solid, brilliant, and funny."
Matt decided to admit himself to The Meadows after falling into a deep depression. According to Burne's retelling of the story, he had undergone many medication changes before his admittance, and The Meadows decided to take him off a heavy dose of Xanax as soon as he was admitted.
"He got in on Wednesday," Burne says. "On Friday, they pulled him off Xanax so fast that he went into paresthesia on Saturday ... for four days he told them all he could think about was killing himself. He wanted to hang himself. He thought about nine ways of killing himself, and he settled on hanging. He basically said, 'I'm suicidal, I'm suicidal, I'm suicidal, I'm suicidal.' Well, they never locked him down. They never took his belt away from him."
According to Burne, that Saturday night, on Thanksgiving weekend, Matt attended a 12-step meeting that left him emotionally vulnerable. "He got up and he left the meeting," she says. "Two patients followed him out and he turned around and said to them, 'If I were home right now I would hang myself.' He went back to his room that night. He talked to his roommate, he took his meds, and he went to bed. At 6 o'clock Sunday morning the 28th, his roommate went to the nurse's station for a blood draw and said to the nurses-there were two nurses on staff for 70 patients in three separate buildings-'Oh, by the way Matt's not in his bed. He hasn't been in there since 5 o'clock when I woke up.'"
"They didn't rush to go look for him, and then when the shift was changing the one nurse was leaving and walked around the outside of the building," she continues. "She looked down the hill and she saw my brother kneeling and she later said she thought he was picking grass to feed the horses ... he had walked out the back door undetected because for some reason, in the acute wing of a psychiatric hospital, there were no bells, no whistles, no walks, no cameras, no nothing, just the fence. He went down the hill and hanged himself on a tree. They found him at 8:05 in the morning."
The lawsuit Burne's family eventually filed against The Meadows was settled out of court, and she started up her own nonprofit, called Break the Silence, in memory of her brother. But she says the system is irreparably flawed, and blames doctors for much of its deficiency. Neither The Meadows nor its legal representation returned requests for comment.
"He did everything right," she says of Matt. "He reached out for help and he was miserably and irreversibly failed ... I just think that caregivers really need to understand that every person is an individual, and if they can't put the time and effort and energy into really knowing their patient ... then they're in the wrong field. They have to go back to their own conscience and wonder about the care they gave that person. Did they give that person the best care that they could at that moment? Did they trust in the system? Did they not pay attention to their gut? I can't answer for them. I would just think if you see somebody that's vacillating-and maybe I'm wrong, but from what I've seen, I don't think happy smiling people just in five minutes go and kill themselves. I think there are signs."
Christine Moutier is Chief Medical Officer at the American Foundation for Suicide Prevention. She says this type of sentiment is normal among many family members who have lost someone to suicide, and sometimes warranted. "I think there are many actual mistakes that get made," she says. "There are doctors who simply don't meet the standard of care. And then there are doctors who may not have made a single actual mistake, but the family perceives the treatment as not going well. Human nature is to need to find a reason for things. But if you get asked the same question about an oncologist who loses a patient to cancer, the family is much more likely to understand that the person had a terminal illness, so the best care happened but the outcome was still death. We tend to not think of [mental illness] usually in such black-and-white terms, as terminal illness.."
According to many doctors I spoke with, there is also a severe lack of training for mental health professionals-not only on how to deal with suicidal patients, but how to process a patient's death. Paul Quinett, a professor in the department of psychiatry and behavioral science at the University of Washington School of Medicine, is heavily involved in teaching clinicians how to do both.
"I think most of us believe that when we hire a licensed mental-health professional, that they've had training in how to assess and manage suicidal patients, when in fact, the majority do not," he says.
I mention a survey where a group of doctors and nurses were asked if they think it's possible to prevent someone from committing suicide. More than half answered that they didn't think it was.
"Well, I don't believe that," he says firmly. "I believe that's a convenient myth ... but so many clinicians are not well-prepared for that outcome. There are lots of clinicians who lose patients to suicide in the course of their career ... in a way it's almost an occupational hazard. That's why people need the very best training they can get, to learn how to work effectively with people considering ending their own lives."
For clinicians who have lost someone, it can be incredibly hard to continue doing their jobs. Molly, a licensed graduate social worker, was working with a man at an inpatient facility for about a year and a half. Thirteen months ago, she found him hanging in his room.
"I was devastated," she says. "I actually debated, pretty extensively, leaving the field because I just was like, 'I can't do this. I can't set myself up for this to happen again.' I'm still working, but it took me a really long time to come back to it."
"Would you ever treat another suicidal patient?" I ask her.
"I don't really plan to, to be honest," she says. "That would be very, very hard for me. Maybe down the road, that'll be different. I think the trauma of finding him is a big piece of that. I think had I not had that extra layer, I could picture myself being able to eventually, but I need to get past it first."
I can't help but think of my friend and how lost and alone she is right now. I imagine the reality she's lived for four months-medication, doctors, the cold clean halls of the hospital. Head-banging, cutting herself, restraints, more pills. It's a world I danced on the edge of for years, and I managed to leave it behind for a life where I laugh more than cry, and hurt without despairing. I want that for her so much, but how will she ever reach that point when no doctor will take her on?
"I get why they don't want to work with me," she says during another one of our conversations. "I'm more complicated. I'm just a difficult patient. I've been told that."
"No one is saying they don't think I can get better," she says flatly, almost without emotion. "They just don't want to be the ones to help me get better."