SUICIDE PREVENTION: IT TAKES A VILLAGE
Vol 8 #10
Caroline Giroux, MD, FRCPC
Associate Clinical Professor, Psychiatrist, UCD Trauma Recovery Center Director, Department of Psychiatry and Behavioral Sciences, UC Davis Health System, Sacramento, CA, USA, [email protected]
A few months ago, my junior and conscientious colleague called me to talk about the modalities of involuntary hold during tele-health sessions. She had been increasingly worried about a patient she had been seeing via video visits. The patient, a single female physician in her 50s, was displaying mood symptoms, an unspecified eating disorder and had been expressing a crescendo of attitudes evocative of given up syndrome and hopelessness, such as writing goodbye letters to people at her job and to her adult child. She had not been following through the medication adjustments recommended by my colleague.
I could palpate the anxiety of my colleague behind her poised voice. I could feel the pressure on her shoulders, the unfair responsibility of keeping a grownup alive. I could totally identify and put myself into her shoes. And with the pandemic and remote visits becoming the standard format for a while, the difficulty of remotely putting people on a hold would likely be a recurring issue.
The more she talked, the more I could identify risk factors for suicide in this physician woman. My threshold to put people on an involuntary hold is usually high; I would rather spend extra time in the session to do crisis intervention or offer options such as intensive outpatient management or partial hospitalization program. But it seems like my colleague had exhausted those possibilities and a higher level of care seemed inevitable.
I wanted to be by my colleague’s side, just like I would like to process my worries with a whole team whenever I deal with a suicidal patient. The issue goes beyond the paperwork involved in a hold, which is often at best a band-aid solution, not really changing the chronic risk factors. The main issue I see arising more clearly now is about what should be a shared responsibility in our field. The fear of losing a patient and all the potential repercussions is certainly not helping the levels of burnout in our profession. Traditionally, because of the special, protected and intimate nature of doctor-patient relationship, the dyadic model seemed to have implied bearing alone, within the confines of record-keeping, the burden of maintaining life or preventing death. If the worst happened to a patient, then it kind of “happened” to the aggrieved psychiatrist and others if they were directly involved in the care.
While we should always strive to prevent or reduce morbidity and promote quality of life, the narrative that seems to have driven our rescuer task as psychiatrists has been not only unhealthy, suffocating, but also unrealistic and unsustainable: keeping a human being other than ourselves alive, and feeling totally responsible for the outcome. Apart from minors and our own children we need to protect, who can bear this total responsibility towards a competent adult? By competent, I mean someone who has the capacity to make decisions about their own life, including their death. But I can also see that there comes a time when people are so deeply stuck in their emotional, spiritual or physical suffering that it almost clouds their capacity to determine whether they want to live or die, and we have a duty to intervene. Their thinking becomes so distorted that they cannot access hope. At that point, we must revise our assessment, offer additional support, crisis intervention and close monitoring. Ultimately, the most important is to attempt to decode each suicidal statement, or behavior, by deconstructing the “I’m suicidal” script and finding one that reflects better what the person is going through such as “I am painfully alone”, “I am deeply ashamed”, or “I feel trapped”. It might be helpful to view suicidality as a phenomenon similar to high body temperature: it simply indicates an imbalance (emotional, spiritual, or general) that must be attended to but it doesn’t tell much about the underlying mechanism.
Therefore, we must identify the cause or factors (recent abandonment, trigger of past trauma, loss of identity through unemployment, substance intoxication etc) involved in the emergence of suicidal tendencies, just like one would do for hyperthermia (fever from infection, or hypothalamic dysfunction, or hyperthermia for intense sun exposure etc). As we are working towards self-efficacy with each at-risk patient, we help them emphasize resilience factors (such as innate abilities, support network) that can help counterbalance the forces pulling them towards the irreversible. Identifying, accessing and expanding the tiny part of themselves that wants to live can also initiate an existential shift. Doing practical coaching by teaching simple defusing techniques under crisis (such as squeezing an ice cube, or counting backwards etc) can be life-saving and help us all to buy more time.
All of the above requires a supportive infrastructure from our field. No clinician or provider should be expected to go through this alone with their patients. Although one health care professional might represent the single point of contact, there should be available processes in place behind the scenes to equip the main provider who is faced with intense emotions experienced by the patient while having to contain their own, such as a back-up or on-call system for suicidal crises. Developing and having a suicidal patient toolkit ready (list of resources, handouts and supportive colleagues’ phone numbers) could also help ground the clinician in the heat of the moment, when our stress response systems become overwhelmed after hearing concerning statements from patients. Role plays can also be a good way to decrease the anxiety around themes of mortality and self-destruction by rehearsing responses that could help shift the patient’s suicide narrative.
Dealing with life-or-death issues such as this case invites co-creativity and longitudinal co-care that only a trans-disciplinary team appears to be able to provide. Even the team members not directly involved in a particular patient care are extremely valuable in the sense that they can still provide consultation or supervision/intervision about the case, monitor progress and also offer direct peer support by allowing the main care providers to process, examine and effectively channel difficult emotions. Additionally, the team should be familiar with a healing circle process in case a suicide or unexpected death does occur.
By using a team or village approach, the psychiatrist or clinician will no longer feel alone and will be more likely to engage in effective detective work with the patient surrounding the suicidal crisis, all with the goal of deepening understanding of the suffering, proposing corresponding solutions and fostering patient’s growth by transcending the suicidal crisis. Given that we are already facing increased emotional distress as a result of global crises, now would be a good time to revise our approaches by keeping in mind that we should all unite to deal with this large scale, social phenomenon, which I believe transcends the boundaries of the doctor-patient dyad. A collective healing like the one we currently need presupposes a collective level of support, accountability and intervention.