Lessons Learned From a Patient Suicide Attempt

Is "knowing the signs" of distress sufficient?

Posted Sep 18, 2020

After an attempted or completed suicide, good leaders often struggle with a sense that, because they did not see the danger someone was in, they must somehow have failed.

Clinicians who are on the front lines of mental warfare feel this as well, though we often fail to be vulnerable enough to share this. So, let’s go there.

On Feb. 24, 2012, I was in the hospital, bringing my newborn daughter into the light of the life ahead of her. A few weeks later, when I returned to my job as a front line psychologist in a clinic serving veterans, I discovered that on the same day, at the same time as my daughter was being born, one of my patients was in a different unit of the same hospital—having his stomach pumped after he tried to extinguish the light of life within himself.

I’m ashamed to admit this, but my first reaction was anger. My first thought was “How could he do this to me?!” As a psychologist, I know that anger is usually a cover-up for more vulnerable emotions. When I dug below my anger, I found a deep well of fear and sadness and helplessness.

As I write about in my recently published book WARRIOR: How to Support Those Who Protect Us,  this was a familiar mix of emotions: I had seen it before, on the faces and in the eyes of my patients, when they came to sessions after losing a battle buddy, someone who had survived the onslaught of the enemy but then fallen—to their own hand.

In these sessions, as for me now, there was an initial surge of rage that bounced around the room, with no clear target. And just below this rage, there was fear and sadness and helplessness. Like me, they asked questions with no clear answers, gut-wrenching questions like:

“What does it mean about me and our relationship that he didn’t tell me how much pain he was in?”

“Why didn’t she trust me with this? Doesn’t he know that I would have dropped everything and gotten on the next plane if she had just trusted me with this?”

“If someone this strong could die by suicide, what does that mean for me?”

In addition to the fear, there were pervasive doubts about things like: "If I couldn’t see this coming, then what does this mean for others that I could lose? What else am I missing?”

These questions, this agony, are common to many people, and the theme is that those who care are the ones who struggle with these painful feelings.

After the suicide of a patient, clinicians tell me that, for a while, they often struggle to trust their clinical instincts. They may experience heightened hypervigilance about the potential loss of another patient.

Suicide prevention programs often emphasize teaching people to recognize the signs of suicide. We seem to hold the assumption that the signs are likely to be detectable.

For those of us whose clinical focus is treating service members, veterans and first responders, what I think we forget sometimes is that our nation’s warriors are professionally good at concealing their pain. I’m not saying that it’s bad to be trained in recognizing the signs. It’s good to know the signs—but it’s also important to balance this with the understanding that no one has psychological X-ray vision.

And it’s not realistic to put pressure on leaders—or clinicians—to read between the lines as though they do have some sixth sense. The other half of the equation is this: We must also overcome the barrier of stigma and shame and set a culture where people can feel safe to say “I’m not OK.”

The suicide attempt of a soldier, sailor, marine, airman, or a clinical patient to suicide is not sufficient as evidence of a failure of exercising one’s role. Feeling responsible for things we cannot control only causes pain that is often unproductive. If people turn this pain into guilt or a sense that they “should have done” something else, then this can even put them at heightened risk for negative outcomes themselves.

Knowing signs is not sufficient; responsibility also lies with us when we suffer to step across the line of fear and tell those we love and trust that we need them. In any relationship, even in the clinical relationship, trust is a two-way street.