Residents Psyche – Reflections on Patient Suicide

Residents Psyche – Reflections on Patient Suicide

Reflections on Patient Suicide
By Dr. Crystal Zhou

Late last year, I had my first encounter with the suicide of a patient.

I received the phone call while I was on my way out the door. The staff psychiatrist on the other end, the site director for the hospital where I had my locum, was very kind and supportive. The news was broken in a clear and considerate way. And still, I crumpled to the floor, like a Jenga tower scattering into pieces. Despite my best efforts, I began sobbing while still on the line.

This is the mortality of our work in psychiatry.

I had not personally encountered patient suicide prior in my training, though a fair number of my peers had. It’s not the same – being there for them and being in those shoes. In retrospect, it was probably better that this occurred as a resident. Sure, it felt like a void had opened up – a hellish, vacuum of a starless universe in which I was ice-cold and so very alone. Even as I write this sentence, a part of me shudders, remembering how it felt. How I felt.

As a trainee, however, I think there were more people around than if I had been a staff psychiatrist. There was the caller, who gave me some time to process the news a bit more, promised to call back after a bit of time, and did just that. There was the other staff psychiatrist that was contacted to call and follow up with me – the one who was my back-up during my locum that weekend. She too, was kind and supportive. Still worried about how I was doing (though I didn’t know it at the time), the initial psychiatrist who broke the news to me reached out to my program director, who also reached out to me.

I would not have reached out to anyone.

As the seemingly endless cavern of guilt, grief and numbness alternated with whole-being wrenching emotional turbulence (hello, emotional dysregulation!), I was curled up on the carpeted floor of my apartment. The only thread reaching through the darkness was that of responsibility. At the very least, I knew I had to cancel the appointment with my psychotherapy patient that afternoon and alert the evening group psychotherapy leader. I was in no shape to provide any care to anyone else that day.

The sun continued in its arc across the sky, and in my little corner of the world, I was struggling with whether or not I could reach out to anyone. My parents, normally pillars of my support system, were out. This, I felt, was something that they could not bear the weight of. My husband was still at work, and I did not want to pull him away from it. There were various friends, some in medicine – some even in psychiatry – but I also did not want to burden them. I frankly didn’t feel that I deserved even a shred of comfort. Why would I?

This was my fault. His death was my fault.

Eventually, by the time my husband returned home, I had settled more into a more numbed state. I let him know what happened and then almost shooed him out of the house, forcing him to keep his other commitment for the evening. Alone, I binged on TV, a sufficiently engaging form of distraction that resulted in me feeling somewhat better by nightfall.

I decided to skip dinner – why should I be allowed to eat, given what I did – but my husband brought home a treat for me (poutine, usually one of my weaknesses). I didn’t have the heart to turn it down and disappoint him—or worse, make him suspicious or worried. I ate mechanically. Then I proceeded to continue numbing myself emotionally with TV. At the end of the night, I fell into a troubled sleep.

The next morning proved to me that my tentative calm from the previous night was merely a fragile artifact of avoidance. The short drive in to work offered me enough alone time with my thoughts and emotions that I soon reached that hurting core and wept in various short periods during my drive. Never enough that I felt the need to pull over, though there were moments that I considered doing so.

I wound up weeping again at multiple points that morning, ultimately resorting to hiding in the female staff washroom since I was in a shared office. There was an old shower that no one ever used in there, and I pulled the curtain for privacy. I was able to hear footsteps if anyone were to approach to use the washroom, and so I would quieten my crying until they had finished and departed.

In this miserable (and, in hindsight, perhaps a bit comical) state, my preceptor and I exchanged a couple of texts while I hid in the washroom. She caught me as I was coming out. I had decided that I was calm enough to return to doing some work, but instead got invited her office to touch base. I felt undeservingly lucky to have a caring preceptor when it felt very much like I should be wallowing in the pain. It was the least I could do, after all, my mind whispered. My patient was even not around anymore to feel anything.

As expected, she seemed to see through the wobbly façade I had put up. Our conversation resulted in her giving me the choice of how I wanted to spend my day—stay or no. I really appreciated the control that she put back in my hands. The decision: take the rest of the day off.

I skipped lunch that day. I was physically hungry, but pushed past the hunger. After all, why do you deserve any sustenance? He’s dead.

I tried to do some Christmas shopping – the people I loved should still get their presents, after all. I figured this was probably going to be the most productive thing I could do with this boon of extra time, given my emotional state. But I was so exhausted and heartsick by the brief experience that when I came home, I collapsed into bed and wept into the covers.

That’s right, there’s no one here. You don’t deserve to have anyone here. Never mind that it was the middle of the workday, so logically, that’s where my husband and friends were.

I did not go in to work the next day. Sobbing in the bathroom seemed like a poor use of work hours. Because I had a shared office, I also did not want anyone else to feel uncomfortable in their work space or obliged to comfort this weeping mess rather than attend to their own work.

At home, I tried to make space to feel my emotions, and take the advice of my rotation preceptor. In her office the day before, she acknowledged the darkness of the emotions after experiencing patient suicide—how it feels lonely, and also that no one else can really help that loneliness go away. She encouraged me to consider the different components of the emotions I was experiencing, and consider whether they were warranted or justified. The grief, she acknowledged, is natural. The guilt, she tried to encourage me to consider further and weigh the evidence in support of and against my taking on these feelings.

So, that’s what I spent the day doing. And the everyday of the weekend that came right after.

It was difficult. Cognitively, I knew (and it helped that staff psychiatrists involved in the case also corroborated) that I had done everything “right”. They would not have done anything differently.

And yet, the cerebral knowing was segregated from my emotions. The guilt continued to persist. Repeated cognitive evaluations did help to alleviate things to a point where I began to function again, somewhat. I decided to try being kind to myself over the subsequent days, as punishing myself didn’t seem to make anything better.

Over the ensuing weeks to months, I did reach out to my co-residents. I did debrief more with my husband. I did speak with the preceptors to whom I felt close and who happened to be around. The loneliness and that searing shame began to lessen somewhat.

I continue to think about this patient. In the first week after, I even dreamt that I was at his funeral. It was sad, but bittersweet. I dreamt too, that his mother, with whom I had spoken at length in the emergency department, was grieving but forgave me. I woke up wondering if that would be the case in real life.

I haven’t reached out to her to find out. I don’t know if she would want to hear from me. Would it be selfish of me to reach out to ask how she was, and if there was anything I could do? Would hearing from me cause her more pain? That fear keeps me silent.

I first wrote down my thoughts 10 days after finding out the news of this patient’s death. We are now some months out. The grief is still there. The guilt, a little less so, but not gone.

There is also, I think, a bit of anger. Irrational or not, there it is. In the span of time that I have with patients, whether it is for one emergency department assessment, an inpatient admission or a longitudinal outpatient clinic setting, I learn to care about this person and want the best for them. It hurts that my care was not enough.

Writing it out brings to full force the element of narcissism in there—I mean, why should my care be so special, when they have people who have known them for much longer, cared for them for much longer. But there it is; I hurt and I feel angry. Combined with the grief, and the crippling guilt of the earliest days, there was a part of me that wanted to throw up a wall and keep future patients at arm’s length. There, that way you can’t hurt me. You can’t hurt me if I don’t care. But really, I have no business being in health care if I am not going to care about my patients while providing care for them.

So, I am going to move forward. This experience has changed me, undoubtedly irrevocably, but I don’t think irreparably.

There may be another patient suicide—or more—before my career comes to its close. Even still, I am determined to continue to be fully present and fully emotionally engaged with my patients to the same degree as before. The work of providing mental health care is important, and there is still more in me to give.

If you had something like this happen to you, I hope that reading this helps to diffuse some of the loneliness, the guilt, and/or the shame. We’re all only human, doing the best that we can.

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/ Residents Psyche