Here is what is known: On a Monday afternoon in June, a woman drove to the mall. She had no purse or identification with her. When she arrived, this woman went to the top floor and under the glass tented skylight, jumped off the railing. It is presumed that she died on impact, when her head hit the marble floor between the up and down escalators. I knew this woman in a small but important way — I was one of her psychiatrists in the hospital, where my colleagues and I treated her for depression over several weeks. The day she was discharged from the hospital is the same day she died.
Before the fall, this woman — whom I'll call Betty — survived an alcoholic husband, created a career in advertising, watched her children grow into themselves, found love again. Somewhere along this path, something changed. Betty stopped being able to sleep, and the next 6 months of her life were a series of psychiatric hospitalizations during which doctors tinkered with various cocktails of medications. She left better, but not fixed. Betty found her way to us after she left the hospital for a third time and overdosed on whatever pills she had on hand. She was discovered by her boyfriend and swept into the ICU. For a little while, she was kept alive with machines, then transferred to us once she had regained consciousness.
When I met her, she reminded me of a shell-shocked animal, a field mouse that had just sensed an owl overhead. She was a small woman, fully enveloped in the hospital gown, with dark hair and dark eyes. For several weeks, Betty and I had the same daily conversation. She would apologize for her suicide attempt, describing it as a moment of “feeling overwhelmed,” and talk about how guilty she felt for hurting her family. She would ask me, anxious and hopeful, if she would ever get her old life back. She wanted to be with her family, to return to her job, and most of all to get a good night's sleep.
Betty was unfailingly polite and thanked everyone for their time and attention. On an inpatient psychiatric unit, that type of civility can be hard to find, and it was easy to like her. The last time I saw her, she was dressed in her typical uniform of black yoga pants and a pink workout top, with her hair slightly mussed and flattened from ECT electrode glue. She was optimistic, with the kind of hard-bitten energy of a marathoner nearing the finish line.
I heard about her death over the phone, two days after it happened.
After Betty's suicide, as happens after any “adverse outcome,” a hospital meeting was convened. The subject line of the e-mail I received was “Ad Hoc IRC” — no one explained what IRC stood for, and I was too embarrassed by my inexperience to ask. My guess is that it stands for Institutional Review Committee, as the meeting was peopled by familiar and strange doctors, social workers, administrators, a member of the hospital's board and “folks from Legal.” Everyone seemed to react differently to the suicide, which was disappointing as I was hoping to learn what the right way might be.
These were a few of the figures at the table: The head of the psychiatric unit, Dr. M. While I was on the unit, Dr. M. often talked about suicide in a calm and matter-of-fact way, by dissecting out modifiable from non-modifiable risk factors. He taught us about the importance of understanding and accepting our limitations as physicians. I had expected him to be confident and serene, and it was especially strange to see him at the meeting with his head bowed and looking slightly pale. He introduced himself as the “unit chief and attending of record for the patient's discharge,” a phrasing that implied he had already decided to take on full responsibility for the outcome. It was as though Dr. M had tied himself to the whipping post and was waiting for lashes to come and then to end. No such resolution came, which left me with an uneasy feeling and an intimation that when I gain age and experience, it might not come with mastery.
At the other side of the table was the board member — I didn't catch her name, but she was a noticeable presence. She wore bright clothing and brighter blush and didn't hesitate to speak loudly and often. During introductions, the board member said, “Before we begin, I just have a few things to say” and proceeded to deliver a string of platitudes. I don't remember the exact words, but generally she talked about how “some people just don't tell anyone how they are feeling” and “maybe suicide helps release someone from their pain.” While she spoke, the rest of the room was respectfully and attentively silent. I resented the board member because she didn't speak our careful language and didn't seem to understand our delicate science.
The substance of the meeting was combing through Betty's story and the treatment decisions that were made. At every choice we had made, there were pauses allowed for questions and challenges. By the end, we were collectively forgiven. The neutral psychiatrists in the room rendered judgment, saying that they would have done what our team did. One doctor sitting in the only shadowed corner of the room said, with his fingers bridged thoughtfully into a tent, “I have found in my experience that some people, as long as suicide remains an option for them, cannot be diverted from that course.”
The actual outcome of the meeting was a literal epitaph — an extra section added to the bottom of all of our notes detailing a list of suicide risk factors with corresponding points to be tallied. This way, there could be a number that quantified a patient's suicidality, which I suspect is very reassuring to the folks from Legal.
Afterwards, I told my other attendings about Betty's suicide. One said with a wink and a nudge, “Ah, now you're a real psychiatrist.” Another reacted with motherly concern, expressing such worry about my well-being that I started to question whether I was sufficiently distressed by the experience. Several others asked out of natural curiosity about the particulars of the case, and I went through the process of being scrutinized, judged, and forgiven again.
A reasonable argument can be made that psychiatrists should expect some number of suicides — that like any other medical illness, psychiatric disease has fatal outcomes. It is a hard idea to hold on to. In heart failure, strokes, or cancer there is some inkling of what failed and derailed the exquisite anatomic machine. It is less clear what breaks down in suicide — is it a matter of errant neurons and chemical signal dysfunction? Or is it something less tangible or defined — a failure of will?
There is a section on the American Psychiatric Association website called “Helping Residents Cope with a Patient Suicide,” which lists typical reactions and suggests methods of processing this kind of event. According to the website, initial emotional responses include “shock, disbelief, denial, depersonalization” and progress to “grief, shame, guilt, fear of blame, anger, relief, behavioral changes, and feelings of specialness.” To manage these emotions, the recommendations include taking a day off work, being mindful of self-care, talking to others, reading about the subject, maybe even writing about the experience.
After Betty's death, I was angry at her because I thought that she had been lying to me and to everyone. None of it made any sense to me — the pieces did not add up to the whole. Over the next several months, my anger smoothed into loneliness, a vacant feeling that I thought was revelatory in some way. I thought that I had discovered a truth, a unifying theory of public violence that would explain why Betty killed herself in front of a crowd. In this theory, violence is an outgrowth of loneliness, acting as a form of intimacy forged by the contact of one body with another. Through this lens, a stranger in a crowd raises a gun or a fist against others out of a desire to know and be known by them. After all, what is a more intimate than shared pain? This theory, like all generalizations, is only a reflection of me — exposing my own grasping wish to meaningfully connect.
I don't know if I was invited to Betty's funeral — I don't know what I would have done if I had been. About a year later, I sent a letter to Betty's daughter asking for permission to write about my experiences with her mother and to share these in whatever capacity I eventually would. Betty's sister, April, called me on my cell phone the next week. She asked, “Why do you want to write about my sister? You didn't really know her.” I didn't know her, but I did care about her, I replied. I told April that the week before, a younger psychiatrist in my program lost a patient to suicide and I wanted to say something to this past version of myself. April's voice gradually softened, and she said that my description of Betty was “her, you really captured her.” She asked if we had really done everything we could and asked me what I would tell this younger doctor to do differently. Maybe nothing can be done differently, I said. Maybe all I can do is warn that when death stops being hypothetical, it hurts.
It is naïve to hope for a lesson from Betty's death, some simple and tidy revelation to make all of this instructive and worthwhile. What I do know is that I had spun a fragile thread of connection to Betty. I knew the contours of her illness and I witnessed in some way what it was like to be her. When she died, that disappeared, and I was left with this dangling story with the edge bluntly cut.
I still treat suicidal patients, knowing that I will likely be wounded by the shrapnel of another death. Grief started as an undiscovered country and has gradually become the more familiar ground. There is nothing noble or heroic here — this is what it means to be a doctor, and more generally, what it means to be human.
