Millions of people worldwide have been rocked by the recent and very sad death of Robin Williams. Although suicide is part of our daily work as clinicians, we are mostly focused on assessing our patients for suicide risk, exploring suicide thoughts and planning, and treating the cognitive patterns directly or the underlying psychiatric illnesses. In other words, safety and prevention. When we lose a patient to suicide, we enter another world, mostly a foreign and frightening one, a dark and lonely place where we’d rather not be. When I first learned of Mr. Williams’ suicide on August 11, my heart went out not only to his wife and children, but also to any and all mental health professionals who had been his caretakers. As a clinician who has experienced patients’ death by suicide, I’d like to share some of my reflections and insights.
Don’t forget why we chose psychiatry as our field. Most applicants to psychiatry residency include in their personal statement an anecdote about how they have been affected by a family member, friend, or patient in medical school struggling with a mental illness. They cite the marginalization, stigma, and challenge of psychiatry. They want to alleviate suffering, make a difference. But most have never talked to a clinician or mentor who has shared his or her story about losing a patient to suicide. They know about it but don’t fully grasp the painful reality. We must never forget the anxiety in our trainees, including the denial, about one of their patients taking his or her own life.
Suicide is a unique form of death. Losing a patient to suicide is very different from losing a patient to diabetes, coronary artery disease, kidney failure, or cancer. Our bereavement, and the mourning of the decedent’s loved ones, are distinctive. We wrestle with a host of emotions—shock or surprise, confusion, loss, sadness, anger, fear, failure, guilt, and, almost always, shame. Shame is why so many psychiatrists do not easily discuss or write about their experiences. Even though multiple studies have tested suicide-prediction models based on standard risk criteria and none has demonstrated any ability to predict suicide, most clinicians struggle with varying amounts of responsibility and self-blame. I know this firsthand from attendee disclosures at my courses and clinical case conferences on losing patients to suicide at APA annual meetings. At the end of the day, suicide is very humbling.
Suicide is a fundamental element of our work. Of all mental health professionals, we have the most intensive and lengthy training in suicidology. I believe that we have a moral imperative to diagnose and treat the most seriously ill and dangerously suicidal patients. Although “cherry-picking” exists among our ranks, I pose this question: Would an oncologist ever state, “Sorry, I don’t accept patients with metastatic disease”? In fact, when I have lost patients to suicide who have been living with protracted treatment-resistant mood disorders, including comorbid recalcitrant substance use disorders, and cascading losses and demoralization, I feel like an oncologist. My mantra is “My patient has died of his disease. He fought a long and tough battle. He’s now at peace.”
Reach out to the grieving family. I have always believed that our humanism should eclipse our fears of medical legal consequences, namely, being sued. Can that happen? Of course, and even despite our best efforts. Research shows, however, that the chances of being sued are decreased (not eradicated) by being “physicianly” to our patient’s loved ones. Should we attend the wake, funeral, or memorial service? Absolutely—unless we’ve been told that we are not welcome. Should we express our empathy by saying “I’m sorry for your loss”? Absolutely. But it is extremely important and advocated by attorneys and our malpractice insurers not to utter any self-incriminating or guilty statements to family members.
Do not isolate. We must take care of ourselves in whatever way necessary. This includes talking to our families and colleagues. Attorneys advise against discussing clinical details, but seeking support is acceptable and salutary. Psychotherapy and/or spiritual sustenance can provide comfort and restoration of equilibrium. Two wonderful resources are the clinician survivor task force of the American Association of Suicidology (www.suicidology.org) and the Physician Litigation Stress Resource Center (www.physicianlitigationstress.org).
Of the scores of articles that I’ve read since Mr. Williams’ death, there are two that stand out. Both address the shroud of stigma around mental illness and suicidality. In her beautiful op-ed piece, “To Know Suicide,” which appeared in the August 16 New York Times, psychologist Kay Redfield Jamison, Ph.D., wrote with gratitude about the lifesaving treatment provided by her psychiatrist, who was “well versed in using lithium and knowledgeable about my illness, and who was also an excellent psychotherapist.” She added, “We expect well-informed treatment for cancer or heart disease; it matters no less for depression.”
In the August 22 New York Times, columnist Roger Cohen described his journey to try to uncover the reasons for his mother’s absence during much of his childhood. He began with the evocative sentences: “My mother was a woman hollowed out like a tree struck by lightning. I wanted to know why.” He learns about her diagnosis of bipolar illness and suicidality. “The hidden hurts most,” he wrote. “Mental illness is still too clouded in taboo. It took me a long time to find where my mother disappeared to. Knowledge in itself resolves nothing, but it helps”.
I hope this article helps too. ■