Approximately 80 per cent of all firearm deaths are suicides. Nearly 20 per cent of all people who die by suicide use a gun.
LOSING A CLIENT TO SUICIDE - RUMINATIONS OF A SAFER COUNSELOR
As Coordinator of SAFER (Suicide Attempt Follow-up Education and Research) I am privileged to manage the 9 skilled therapists and 2 dedicated support staff that make up our team, a service under the auspices of Vancouver Coastal Health. SAFER offers counseling and support to three groups of people – those who are feeling suicidal or who have made a suicide attempt, those who are concerned about someone who is suicidal, and those who have had a loved one die by suicide. I have also worked as a therapist in the program for eighteen plus years. A few days ago I met with a Case Manager from another agency who was devastated by the loss of a client to suicide. I was prompted to give her something I had written awhile back, and then to think the piece might have broader value. Here it is.
I want to share some of my experiences as a clinician who has, as far as I know, had four clients die by suicide. (I have altered identifying information in referring to their stories.) I do not write to justify insensitive or unprofessional behaviour by clinicians, me or anyone else, after a suicide death. I do know this happens. However my wish is to underscore that clinicians are survivors too. These losses can touch us deeply. We also struggle with shock, horror and sadness, feelings of guilt, self-recrimination, inadequacy, shame and despair when someone we have worked with kills themselves.
These responses have significant ramifications. They impact our capacity to respond to the survivors of our deceased clients. They can also compromise our ability to work effectively with others who are feeling suicidal – not only when engaging with new clients, but also when we must re-establish trust in an existing therapeutic relationship after a suicide attempt, arguably the time when this relationship is the most important. There really is not much of a roadmap for us at such times. So I hope my ruminations may help readers who are clinicians see why breaking silence to seek or offer support when a client dies by suicide is crucial to good practice. And for you who have lost a loved one to suicide, perhaps these thoughts will help you understand some of the reactions of helpers in the aftermath of the tragedy.
I was speaking recently with a psychiatrist about our work at SAFER. “Do you ever have anyone die by suicide?” he asked. “Yes”, I said “We have lost a number of people over the years.” “Good.” he replied, and then, when my eyebrows shot up, “I say that Dammy, because if you guys didn’t lose someone periodically I would know you weren’t seeing the right people.”
It’s said that there are two kinds of therapists, those who have lost a client to suicide and those who will. This is a fundamental context of our work, frequent enough in Mental Health to be viewed as an occupational hazard: more that half of almost 700 psychiatrists recently surveyed had lost patients to suicide, many early in their careers. When I speak with clinicians they generally tell me this was not discussed in their training, nothing was offered to prepare them for their own emotional responses, help them reach out appropriately to the client’s family, manage challenges with their employing institution in the wake of the death, or handle possible negative reactions from their colleagues, families and friends. Unaddressed distress may lead to deliberate avoidance of future dealings with clients who are suicidal, or in some cases to leaving the field altogether. What is particularly unfortunate is that we also know the intensity of the grief a clinician experiences when they lose a client is not related to the quality of their performance with this person, but to the closeness of the connection that was established. In other words what makes us good, the ability to engage in a close and caring way with someone, is also what makes us vulnerable.
To deal with the impacts of suicide loss it is important for clinicians to have clear channels for communication, consultation and support from peers and from more experienced colleagues. But sometimes in the face of the family’s suffering it can seem trite, selfish, or even unprofessional to seek some acknowledgement and support to deal with your feelings and reactions. “What will they think if they see I’m struggling – I’m supposed to know how to manage this.” And worse yet, what if you did miss something, how do you deal with that, who do you talk to?
My first client to die by suicide was a big, handsome, awkward guy in his late twenties - about the same age as I was at the time. He was lost, bitterly unhappy, out of work, and under his sadness was a simmering anger. His wife had left him a year earlier and taken the kids with her. She now had a lover - and a restraining order – because my client had taken to following her and had been physically violent more than once. He had been referred to an Anger Management Group at another agency, and then, after he overdosed following an alcohol-fueled shouting match with his ex and her new boyfriend, to SAFER. I was a brand new clinical social worker, in my first year on the job. I felt comfortable working with this fellow’s sorrow and aimlessness but the anger scared me, so I was relieved about the group referral. There was an edge – he was vague, defensive and very prickly about his temper and saw his aggression as entirely justified, so I danced around it, rationalizing this as better dealt with in the group. After an initial phone call I didn’t talk with the Group Leader again, nor did I ask my client, after the first huffy response, about his progress with this work. I kept it supportive and comfortable. When he found a girlfriend a few months later I did not stop to wonder if he was ‘fleeing into health’, he seemed happy so I was happy for him. Not long after they got together he decided to stop seeing me, saying he was fine. I left the chart open for a month or so and then closed it when there was no further contact. Perhaps three months later his girlfriend called and told me that he had killed himself where he was certain his wife would find his body.
His girlfriend wanted to come and see me. Although worried about how this would be I invited her in. She told me it was helpful to talk to me. I saw her a couple of times. But hindsight can feel like 20/20, so while I did not think this profoundly distressed young woman knew how I felt and did not seem to hold me responsible in any way, I certainly blamed myself. He hadn’t stuck with the anger management and I was sure he had died on impulse and in a rage. Would things have been different if I had pushed, honed in on the anger, the impulsiveness, the alcohol use - had at very least maintained contact with the Anger Management Group? I had no answers. The file was closed so there was not an audit. At the time this seemed to me a blessing but truly it was not. There was no formal opportunity to analyze, to process, to explore what I might have done differently, to learn from my mistakes. I felt guilty - ashamed to ask for supervision, wondering if I had any business doing this kind of work, afraid of being found a failure.
I started to withdraw. Anyone who knows me will tell you this is not usual. A senior colleague soon figured out something was up. He coaxed me out for a drink after work where everything soon came out. He had also lost clients to suicide. Over the next while he helped me realistically assess my responsibility and understand the limits of my power. He supported my grief and helped me track down some additional training for working with anger. Ultimately there were also some changes to our clinical supervision, particularly for new staff, and we were able to use what I learned to improve our practice. But such positive outcomes remain unusual in the broader system. Good training for working with suicidal people is still limited, education and support concerning the aftermath of suicide remains inadequate. It’s still very difficult for clinicians to ‘come out’ and speak openly about their losses.
“Four clients as far as I know.” I wrote this because I’ve ended therapy with someone who was steady and stable, only to see her name a few year’s later on a coroner’s list and learn she had fallen back into substances and ultimately killed herself. There may well be others I do not know about. I carry a provisionality about what we do, my fingers are always crossed with respect to the hundreds of people we have worked with over the years. There is also caution about my ‘absorptive capacity’. After a loss or a serious suicide attempt, or even when I have had a number of high-risk clients on my caseload, concern about this capacity has made me reluctant to take on yet another client who is challenging or high risk. But it is also true that when I am shielding myself against potential hurt I really am not as receptive or emotionally available to my clients. Simply put, the more stressed I am the less effective I am. On that basis self-care and stress management are primary requirements, especially because stress is so inherent in the job. We second-guess ourselves every day. A client, perhaps even one who seems improved, doesn’t call to cancel, doesn’t show for the appointment, doesn’t respond to phone messages. How long do you wait before you call Mental Health Emergency Services or 911 to go see if they are OK? And then you learn they’re fine – they nearly always are - but they’re embarrassed or perhaps even angry about being checked on, so they decide they won’t do this counseling thing any more after all.
Stress puts blinders on you. As a therapist my self is the primary tool I bring to the work. Any time I am not 100% on it is possible to miss something. But no one is 100% on100% of the time. That means it’s always possible to miss something. I know I’m human and fallible, that there are real limitations to what I can do. That being said it is very easy to fall into self-doubt and self-blame when a client dies by suicide.
Blame is a normal part of the grief process – we all search for explanations that will restore a sense of control when terrible events shatter our assumptive worlds. The literature tells us that therapists fear being blamed, even sued, after a suicide death and this is one of the reasons they avoid reaching out to surviving family members. I once heard someone ask whether to tell the family you were sorry for their loss could be interpreted as an admission of liability. This is not true, but it underscores the existence of a mostly unrealistic fear. We can also speculate about how much of this fear is a projection of the therapist’s self-doubt.
As far as I know, I haven’t been blamed by surviving family or friends. However I have been in situations where I felt blame towards the family. That is not to say the families were actually at fault. I cannot ever know that for certain. But a client shared with me very painful stories about the abusive behaviour of certain family members when she was a child. I found it difficult to reach out to this family when my client killed herself. I was angry with them. I attended the funeral in support of my client’s partner, thinking to lose myself in the crowd, but there were very few people there. I felt I was betraying her when her relatives shook everyone’s hand at the door to thank them for coming, but confidentiality did not allow for sharing my feelings or corroborating my client’s story. I felt frozen. I know I was stiff and wooden. I was grateful to debrief later with a colleague who attended the funeral with me. I would suggest that when clinicians consider whether to attend a client’s funeral they think about having a colleague come along.
Now I know my clients histories are their perceptions and might be inaccurate, incomplete, distorted. However our work requires us to be there for our clients, and it’s hard not to be influenced. Probably it would have been better had I not attended this particular funeral. That being said, there was another client, an elderly lady…I thought she was delightful… although also eccentric, willful and demanding. Probably a lot like I’ll be when I am her age! Her adult children lived across the country and contact with them had been filtered through the family physician. My sense they had abandoned her rapidly dissipated when they came to see me after their mother’s death and shared some of the struggles that characterized the relationships with their intensely private and fiercely independent Mom. My attending her memorial was helpful – for me and I think for her family too.
I was seeing this client twice a week when she died, so the death was thoroughly audited by my own team and the broader system too. This was a supportive, compassionate and thorough examination of the events that culminated in her suicide, which she saw from the very beginning as a rational act, her work with me just a way to make sure she fully explored all the angles. Everyone told me I had gone above and beyond in my efforts to prevent her death. I knew it myself, yet I remained very anxious and also very sad. Over the next few months I reviewed again and again all the things I said and did – and didn’t say and didn’t do. I’m sure my other clients, and my family too were affected by the sadness and the awful helplessness that I could not share with them, and also by my hypervigilence in defending against this helplessness. I remember around that time my older daughter saying to me, “You know Mom just because all the people you see are suicidal doesn’t mean everyone who has a problem is going to kill themselves.”
We need clear heads, open hearts, honed intuition and balanced lives as well as sound clinical skills to work with suicide. Our work cannot be accomplished without support and it cannot be done in isolation. Learning about suicide risk assessment and management and the potential impacts of this work on us must be included in everyone’s clinical training. So must discussion about how to respond appropriately to others and take care of ourselves in the face of suicide death. You cannot manage risk, to others or to yourself, unless you accept and understand it. However I believe it is equally important to have ready access to regular clinical supervision, consultation and support by trusted senior colleagues who have worked with suicidal clients and also when needed access to someone who is themselves a survivor of client suicide. This approach is born out not just by my experience but also in the literature. However these conversations can’t happen unless we clinicians also break our silence around suicide, openly talk about our experiences and what we have learned from them. Then whatever learning emerges through these profoundly painful events will not be wasted and our capacity to remain emotionally open and available to all those who grapple one way or another with suicide will be supported. This understanding underpins the work we do at SAFER. We believe it should be a cornerstone of clinical practice in all of mental health.
For me it is also crucial to remember that 90% of the people who make one suicide attempt do not go on to make another, that the work I do every day is in support of people building lives they want to live. A few weeks ago and out of the blue, I got a card from a client I have not seen for many years, someone who struggled with a history of abuse, addiction, rage, isolation and suicide attempts and was frequently at very high risk. He wrote to say thank you. To say he’s been clean and sober, without thoughts of suicide, for 15 years now. He mentioned some hard won accomplishments and heart-warming community contributions. He’s in a relationship he thinks is healthy, in a job he finds fulfilling. It was a profound privilege to get that card and know I had been part of this man’s remarkable journey. That is what the work is all about.
I’ll end with a quote from Antonio Machado:
“I dreamed I had a beehive inside my heart. And the golden bees were making combs and honey from my old failures”.
Dammy Damstrom-Albach, MSW, MA
Coordinator, SAFER Counselling Service
Vancouver Community Mental Health Services
Vancouver Coastal Health
#300 - 2425 Quebec Street
Vancouver BC V5T 4H6
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