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Welcome to the nexus of ethics, psychology, morality, philosophy and health care

Monday, August 29, 2011

Repercussions of a Patient’s Suicide

by Robert M. Gordon, PhD, ABPP
The Pennsylvania Psychologist

Dr. Gordon
Psychologists approach their voice-mail messages knowing the full range of human drama might come pouring forth. Entering my 35th year of practice, I was a bit weary of hearing them. Freud warned us never to expect appreciation, no matter how hard one works, from the three impossible professions: parenting, governing, being a psychotherapist. I was not expecting to hear gratitude.

The first message was from five attorneys who were having drinks when they discovered they all had been in treatment with me. On the message, they joked that they were debating over who needed a tune-up. Their appreciation felt good. I will always remember that first message and the one that followed.

The second message began, “Dr. Gordon. You do not know me, but Calvin always spoke highly of you. …”

How nice, I thought, Calvin is referring his friend. Calvin was 45 when he first came to me after the death of his widowed mother about 10 years ago. He was an only child. Calvin was friendly, but very shy. He occasionally dated but never married – except, perhaps, his profession: He was brilliant, a scientist devoted to his work. Calvin had lifelong obsessive-compulsive disorder and Asperger’s syndrome. Following the death of his mother, he had his first major depression. He was seeing a good therapist in his community and continued to see him for years. However, he had found my papers online and asked to see me for consultation. He hoped a psychodynamic approach might provide a more comprehensive perspective. As it turned out, the interpretations helped Calvin feel more deeply understood, which in turn deepened our therapeutic relationship.

Calvin traveled an hour and a half to see me, first weekly, then, after resolving his depression, about once a month for years. He had formed a strong attachment. Before leaving, he had the habit of shaking my hand three times, and saying three times, “Thank you.” One day, quite spontaneously as he left, he said, “I love you.” I said I loved him, too. Frankly, at first I said it to be gracious. But in time, I did feel love for Calvin.

I hadn’t seen him for quite a while, but last year Calvin was let go from his job. His work was his source of identity and reliable connection to this world. He fell into a severe depression. Medications were not working. His psychiatrist suggested hospitalization, but Calvin was terrified of it. He trusted my opinion and I told him it was now necessary. Eventually, only ECT brought him out of his psychotic depression. When I last saw Calvin a month before this call, he was better, but remained lost.

The voice continued, “When I hadn’t heard from Calvin for a few days, I went to his home. I found him in the kitchen. He had shot himself. …”

I felt an internal protest against his words. I heard someone crying and then realized my face was wet. My emotions had outraced my cognition. The tears flowed uncontrollably.

I called Calvin’s friend. I needed details to help process the unbelievable.

I went into professional autopilot for the rest of the day. That evening, as I told my wife, I cried again.

What made it awful was not just his death, but the horror that preceded it. I kept envisioning this gentle person who knew nothing of firearms, buying a powerful gun, writing out instructions so others would know what to do and be minimally inconvenienced. Then, all alone, feeling the most profound despair, squeezing the trigger. No good person should die that way.

Throughout more than 30 years, I had not lost a patient to suicide. To outsiders, I would tell of my skillful rescues. To fellow professionals, I confessed it was mainly luck. And now I was struggling not only with the first suicide of a patient, but the suicide of someone I cherished.

When part of a person wants to end suffering or punish someone from the grave, there is usually enough conflict to send out a verbal or nonverbal message that reads, “Please stop me.” However, when there is little conflict, a person just does it. I know we cannot control others. Nevertheless, I obsessively reviewed what I could have done.

In the weeks that followed, I would overreact to my patients’ suicidal thoughts. I went too soon to discussions of a safety contract, medication, interpersonal supports and even the possibility of hospitalization with clients who wished to die but who were not actively suicidal. For a period, my empathy was compromised by my anxiety. One patient said, “Relax. I am only sharing feelings. I would never kill myself.” If patients do not overtly tell us we are off-target, they may become more symptom-focused and banal in the narrative. They will re-enact how they shut down in the absence of empathy. Patients’ reactions provide immediate supervision to those open to hear it.

In time, my affects eased. However, they unconsciously surfaced as defenses. I would not take referrals if I thought the person was a potential suicide risk, such as someone suffering from borderline personality disorder or major depression. I considered reducing my hours. I shifted from mainly direct care to more diagnostic consultations and forensic work. These decisions were multi-determined, as are all rationalizations. But the fuel beneath was my fear of another suicide.

I found it helpful to share my feelings with close colleagues, but mostly with my wife, a psychoanalytic candidate and my best support. She knew how to listen with empathy, without resorting to psychological Band-Aids.

Then our Pennsylvania Psychologist editor, Dr. Andrea Nelken, wrote that she wanted to do a special issue on suicide in response to military and bullying deaths. She asked whether, if a client of mine had ever committed suicide, I would be willing to write about the experience.

She did not know I had lost my first patient to suicide just two months earlier. I did not want to do it. However, being a psychologist has taught me the value of honestly sharing our pain. Writing this has helped me to accept the reality of this tragedy, even while part of me waits for Calvin to shake my hand three times once again.
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