Losing someone to suicide

As a clinician and suicide treatment researcher, I have contemplated for decades the prospect of losing someone to suicide. I regularly think about risking to care for people who struggle with thoughts of suicide. Like so many, I have personally known several people who have died by suicide. There was a painful loss of a friend and faculty colleague, who was literally across the hall from me. Tom took his life in the midst of four of us in my department conducting suicide research. Losing Tom was heartbreaking; the eyes of our graduate students were fixed on us faculty as they wondered how could you all have missed this? How could you have let this happen? I have often reflected on the moment a few days before Tom died when he stopped by my open office door to say “hi” and have a quick chat—something we both did countless times over the years as office neighbors. But this particular time after a brief exchange, Tom lingered at my door for a couple of beats as I turned to my computer to respond to my emails. In hindsight, I wish I had taken his subtle cue to invite him into my office to talk in more depth which was something we regularly did. But alas I did not and three days later Tom ended his life. Could my talking to him have prevented Tom’s suicide? I tell myself no, but I nevertheless regret what I failed to do in that moment, given what came to pass. I miss Tom both as a friend and faculty colleague.

Patients who are seriously suicidal

When I was in graduate school I worked as a Psych-Tech on an inpatient psychiatric unit. Within this role I helped avert several suicide attempts (two of which were patients on “15-minute checks” in the middle of hanging themselves in their rooms). While no one died, two patients came within a hair’s breadth of taking their lives. Some years later toward the end of my clinical internship within a V.A. Hospital, I gave a Rorschach Inkblot Test to a veteran who was deeply depressed. This patient struggled with the testing and we feared a closed head injury prompting us to pursue neuropsychology testing. But this testing never occurred because a few days after I met him, this profoundly depressed patient (a father of three young kids) laid down in front a bus as it departed from the hospital bus stop crushing him to death. Did I miss this patient’s potential for suicide? Yes, I had no inkling that this patient would soon be dead. I had met with him for 40 minutes before stopping the Rorschach given his abject inability to do the test. Do I have regrets about missing his suicide risk? Yes of course, but I do not blame myself for missing it.

Losing patients to suicide

As a practicing clinical psychologist for over 35+ years I have likely worked with thousands of patients in the V.A., in university counseling centers, and then as a private practitioner right up to the present day. Over my career, I have seen and treated hundreds of patients who have been suicidal. And while I have cut back on my clinical practice, I still see a couple of patients who are periodically suicidal. Over these years, I have had a half dozen patients make suicide attempts, a few of which could have been fatal but for twists of fate. As I reflect on clinical practice, I have no illusion that I will not lose a patient to suicide just because I am an expert on the topic. When it comes to suicide, no provider is infallible. Indeed, two of my beloved mentors lost patients to suicide. The late Dr. Terry Maltsberger, known for his seminal work on suicide-related countertransference, worked at McLean Hospital and Harvard Medical School, and he maintained a vibrant private practice. Over his career Terry counted himself “lucky” for never losing a patient to suicide after decades of seeing countless patients whom were highly suicidal. But then Terry lost a private practice patient shortly before he retired. Over the years that Dr. Marsha Lineman developed DBT within randomized controlled trials (RCTs), she always saw high risk patients and lost several of her patients to suicide. Thus, even these giants of clinical suicidology were not immune to losing patients.

The need for evidence-based treatment

In more recent years as I have dialed back my clinical practice, I have expanded the clinical trial research of CAMS, resulting in 9 published open clinical trials, 5 published RCT’s, along with two independent meta-analyses that support the effectiveness of CAMS. Given the risk, it is perhaps not surprising that we have also lost 4 patients to suicide who were in CAMS clinical trials. A particularly painful reality for my graduate students and me is watching sessions (on a secure platform) to ensure that CAMS providers are adherent and that RCT fidelity is assured. But in watching these cases for research purposes, we get drawn in and care about the clinicians and their patients. In one particularly challenging case, a CAMS study patient received over 20 sessions only to take her life as she seemed to deteriorate on video before our eyes. This death occurred despite an adherent provider who heroically used CAMS with the best consultation we could provide. We were heartbroken by this patient’s suicide and a tearful grad student asked me, “…after all these years, how do you handle a suicide like this?” My answer: “While losing this patient breaks my heart, and sobers me, it does not deter me from doing what we are doing…and actually it compels me to work even harder…we are not going to not do this kind of research because of this tragedy…we have to remember that we have helped save many more lives than we have lost and that fact keeps me going so others do not have to die this way.”

Using CAMS can help clinical confidence and may comfort family

I have a colleague who attended two early trainings of CAMS and she routinely used it in her counseling center work. After much success using CAMS with counseling center clients, she saw a grad student in chemistry who had a serious history of suicide risk (including two inpatient stays). The provider engaged this client in CAMS for six sessions, but the patient used an “exit-bag” to take his life by inhaling helium. In the midst of her grief, the clinician reached out to me for consultation and together we reviewed de-identified copies of the client’s SSFs during a phone consultation. With the wisdom of hindsight, I noted a few observations for improvement, but overall I felt that the clinician did an excellent job and she was certainly adherent to model. During our call I shared my heartfelt support and gave her encouraging feedback as I expressed my sincere condolences. I reassured her that she had done right by this client. Some six months later, this clinician re-contacted me for a follow up consultation in which I learned that the client’s parents had come across a file folder in their son’s desk entitled “Therapy” with copies of his SSF’s from his CAMS sessions. In that same folder was a printout of internet information about obtaining and then using an exit bag for suicide. The clinician told me that she spoke to the mother, and later the father who joined the 2-hour phone call. Towards the end of the call the bereft mother asked the provider, “…and what can we do for you? Because of course you lost our son too…are you doing okay?” The father finally noted, “…at least we have the comfort of knowing that the counselor who saw our son did not have her head in the sand when it comes to suicide…thank you for what you tried to do for him.”

The risk to care is worth it

When working with suicide risk there are obviously perils and the potential for heartbreak which must be balanced with the promise and rewards of life-saving care. One does not come without the other. What keeps me going is a grim acceptance that no clinician is immune to losing a patient. But I do take comfort and draw strength to persevere in the knowledge that I am able of provide the best possible care that I know to render. What more could I ever aspire to do when faced with the perils of suicide? For me, the risk to care continues to be worth it, because it can literally mean the difference between a death and saving a life. And I find great inspiration in doing right by my patients and endeavoring to foster that same feeling in other providers so they too can provide the best possible care to help save lives.