When Patients "Die by Suicide"

“Despair is a desperate refusal to be oneself.” 
-Rollo May in Freedom and Destiny (p.237)

“It is only in the face of death that mans self is born.”
-Saint Augustine

“Objectivity means openness, and openness about suicide is not easily gained.
The law has found it criminal, religion calls it a sin, and society turns away from it …
An objective inquiry into this field somehow betrays the impulse of life itself.” 
-James Hillman in Suicide and the Soul (p. 16) 

I wrote this because we don’t talk enough about suicide. In our culture, even in the psychotherapy field, suicide is, in a way, an elephant in the room. An elephant we often don’t acknowledge and are likely uncomfortable to even approach in our thoughts. Most of the time we address suicide in a most inhumane and sterile way that it becomes a mere protocol or complex. 

A Google search on suicide in the Seattle area brings forth little beyond statistics and local concern. Even the Pulitzer Prize-winning newspaper The Seattle Times does not have much content that meaningfully engages discussion about suicide. Yet, in 2020, in Washington state, 1,170 people had died by suicide. That’s about 3 people a day. As “helpful” as statistics are, they merely point towards the need for a more meaningful engagement. The fact remains, suicide is becoming more common and is a fundamental and intimately personal dimension of being a person and living in relationship to life and context.

I do not write this blog post as a “what to do” or a repeat of information that is easily found. My focus is on my experience of being impacted by the suicides of former patients, the experience of those who’re contemplating suicide, and a more desensitized and accepting stance towards the reality of this experience.

Disclaimer: I am not a suicide expert. This blog is not intended to be used as legal or mental health counsel. No explicit details about any particular patient was provided.  All patient stories are either a composite of the experiences of multiple individuals or based on actual events with any identifying information altered to protect patient confidentiality. This post has been reviewed and edited by a lawyer who specializes in mental health law and ethics.
If you are in crisis, do not call me, please call your local crisis line which can typically be reached by dialing 711, or call 911 or head to your nearest emergency room. 
I am not a suicide expert. I screen potential patients for risk and I do not take on patients with high intensity and frequency of suicidal behaviors and ideation.

A Phone Call

This all hit home for me, in a new and profoundly personal way, when I received a call from the partner of a patient. Before even a word was uttered, hearing them wailing on the other end of the line, on a felt level I knew that their partner, my patient, had killed themselves. It was just three hours prior, that day, that we had last spoken with one another. I was likely the last meaningful contact they had. 

The racing thoughts of "Did I do everything I could have?” "Did I give enough space to their experience?” "Did I dwell enough emotionally with his felt experience or let them affect me enough that they might not have felt as alone and hopeless?” "Was being with them too much for me that I was holding them at a distance, despite trying to be warm and empathetic?” “Oh my God am I going to be sued?” “Have I take thorough enough notes?” “Have I missed something paramount to the process?” and lastly "What the fuck am I supposed to do now?" This all happened in about a minute. On top of this, I had another patient calling in 3 minutes.  

I rescheduled patients as best I could, left voicemails with my analyst and supervisor, then reached out to a colleague whom I knew would be monitoring their notifications along with my analysis cohort mates. Before my colleague called, I spent who knows how long feeling like I was being pulled in every direction from questioning myself to grief, emptiness, and paranoia.  

As I learned after, and talk about later, the most helpful bits were not the debriefing the moment or providing reassurance but the simple gesture of holding silence. In moments like that, there’s really not much a person can say, but the little that comes up from the heart can go a long way. I recall my analyst calling me back and spending just 5 minutes on the phone with me. It meant so much to me at the time.

To make things even heavier, just two days prior I had found out that a former patient had killed themselves some months after our relationship had ended. This news came as little surprise, but I was still enveloped with a sense of shock and sadness. My still very vivid impression of this person was that they walked with an aggressively defensive nihilism and a smile that could convince anyone. Behind it all, was an immense loss of something that perhaps never was, but still so longed for. That was too painful to turn towards and feel, let alone acknowledge. For some people, like this person, they will ward off feelings of value, or even care from others, because that value and care is too painful to begin to hope or live again.

The phone call with the news of a patient’s suicide was one of the more shocking and surreal experiences I have ever had in my life. Patient suicide is, I believe, one of the most painful experiences to go through as a psychotherapist. 

Moments of shock or great pain are certainly disruptive, but disruption is also a loosening of a something or idea that has given us security but that may also inhibit us from living and connecting to the experience and values of life and ourselves. Painful experiences are invitations to reassess, what Stolorow would call organizing principles. One can only hope that we are in a caring context and have a caring relationship(s) that helps us sort those things out. I’ve always clung to these words of Kahlil Gibran, 

Your pain is the breaking of the shell that encloses your understanding. Even as the stone of the fruit must break, that its heart may stand in the sun, so must you know pain. -Kahlil Gibran's "On Pain" from The Prophet

Throughout my years of study and personal work around what it means and is like to live, I’ve had a tentative and begrudging consent to the way things are in life. Perhaps even more so crippling, despite having been in therapy, at times, multiple times a week for almost 10 years, a belief that as a therapist I am the instrument that catalyzes help or change. For me, this phone call split open my understanding of helping and confronted my relationship with and posture towards the reality of suffering that is present in life and more importantly walks into my office in a way I could not have imagined. I’m thankful to my analyst for holding the space and my supervisor for letting me be agitated with them and see-through and relate to my loosening understandings.

The Reality of Suicide

A patient’s suicide is not something that I ever seriously foresaw being confronted by. I do not think many therapists do. Yet, for many, suicide is a part of the work. According to the American Psychological Association, 1 in 5 mental health providers have lost a patient to suicide. For those working in an urban environment, if our political climate does not continue its glacial-like trajectory, I foresee that suicide is going to become all the more common. 

Perhaps this unpreparedness is a failure of our education or training to broach the conversation of suicide more, or in a different way. Perhaps it was talked about enough and with a humane sensitivity. But, perhaps my own experience of it (unconsciously) inhibited me from being in the classroom and being able to take it in. I don't really know. 

In our training as therapists, we are taught the necessary steps of assessment and protocol, but never describe and explore the experience of not wanting to go on living, the quality of some peoples relationship to life, of not having something that we’ve so longed for, or losing something that we are so intimately close to in such a tragic way. We do not talk about what it is like to really not want to go on living. Or even more commonly, to not want to be a part of what reality requires, but still not wanting to go live in the woods. 

Yet, death, and wanting to will it, is a-part-of life, and we’ve made it so shameful and embarassing.

Suicide is a-part-of life. Not everyones immediate life, but it is a-part-of the fabric of the human experience. For some, they see death as the only way “out” or to stop the pain. Yet, for them, at the same time, suicide and death is such a shameful thing to even hold in mind or entertain. Yet, death, and wanting to will it, is a-part-of life, and we’ve made it so charged. Rilke puts it, life and death are halves of the same coin. By excluding the one, we also exclude the other. Taking it a step further, authenticity is worked or ground out in the relationship between life and death. It’s only cultivated in relationship, and at times a painful one, with death and a realization of our futility. Thoughts of suicide is a flirtation with death amidst a feeling of inescapable despair. Death thrusts us into relationship and questioning our lives and more importantly what we want to do. However, this opportunity or invitation back into life, or accessing ones self is only made possible amidst support and closeness in relationships.

I am not saying that we should love death but rather that we should love life so generously, without picking and choosing, that we automatically include it (life's other half) in our love. This is what actually happens in the great expansiveness of love, which cannot be stopped or constricted. It is only because we exclude it that death becomes more and more foreign to us and, ultimately, our enemy.  —Rilke's letter to Countess Margot Sizzo-Noris-Crouy in The Dark Interval (2018)

Depression, Meaninglessness, and Suicide

I do not know why I did not foresee this. Iwas just never seriously confronted by it. Which feels silly with my interest in and being un-consentually branded “the existential expert.” It’s part of the “gig” in working with existential/human issues. I have done quite a bit of writing and personal exploration on loneliness and depression, and the broader human experiences as a-part-of life on a daily basis, but the dimension of suicidality and not wanting to go on I’d never been confronted by in such an intense way. I had a feeling for suicide, an awareness of it, and worked with it, but it became something very different and intensely personal when I’d gotten a taste of it. Since then, serious risk of suicidality has been a constant theme and a part of a notable portion of my case-load since all this transpired.

I had a feeling for suicide, an awareness of it, and worked with it, but it became something very different and intensely personal when I’d gotten a taste of it.

I've talked about depression at much greater length in my series on Living With Depression, but briefly, depression is at its most fundamental level, an individual's loss of connection with the value and goodness of life. On a metaphysical level, the individual has lost relationship with their self. It is through the self that we detect and experience life. It is through our feelings and emotions that we get some indication of how something is for us. These emotions, on the most basic level, come back to what we like and dislike. Within those likes are values that support and guide our life. Meaning in life are bundles of values. They enliven us or bring us to life. When we do not have a connection to ourselves, through our emotions, to detect the values of life, it can feel so isolating, alone, cold, cut off, not like ourselves, indifferent, and potentially afraid to interact with others.  Depression is an experienced loss of the value of life.

“The problem of suicide isn’t the possibility itself or its occasional consideration - this is part of human freedom. The problem is whether we have reasons that keep us from taking this step, whether we find enough meaning in life to keep us from departing this life. Meaning and values are the ropes that keep us from falling into the abyss.” —Victor Frankl

It has to be said that the stage or context in which suicidality and suicide takes place, at least here in North America or the Seattle area, is that of a fear of, outright denial, or an avoidance of the reality and prevalence of suicidality. We are a culture that values life. Or more, a particular type of life, perhaps of procedure, method, and results, which may actually be quite devoid of a relationship to one’s person or to values through one’s likes and dislikes. Many of my patients are quite well off, and by all means live a “good” life. Yet, not many weeks or days go by when a reflections comes up of, “What’s this all for?” Frankl said:

“For too long we have been dreaming a dream from which we are now waking up: the dream that if we just improve the socioeconomic situation of people, everything will be okay, people will become happy. The truth is that as the struggle for survival has subsided, the question has emerged: survival for what? Ever more people today have the means to live but no meaning to live for.  From The Unheard Cry for Meaning (p.21)

Many people I know, in both my professional and personal realms, do not have a space or relationship (outside of perhaps, psychotherapy) where they can “let be” and feel their emotional experience. Commonly, folks feel the need to put on a good face, get back to work, and avoid expressing feelings in life and within relationships. Negative beliefs abound, from not believing that one is impacting anyone or anything, to not finding anything meaningful in life, to feeling like one can never amount to anything or change. 

“For some people, life is just not good. It can be either that it never was, is no longer, or they have not had enough goodness.” —Curtis Dueck 

The conditions of existence can be(come) so impoverished, inhospitable, and bleak. We become exposed and left not having the support or connection to rediscover life. How could this not lead to hopeless, powerlessness, and despair? When we cannot find the value of life, amidst immense despair, naturally, thoughts of suicide emerge.

An interesting and meaningful mind-body experiment is holding your breath underwater. Whether in a pool or a sink, at a certain point, there is an instinctual reflex of panic which moves us towards survival. A deeper soul meaning that resonates through our body via adrenaline and into our joints that forces us back into life. That deeper soul meaning, which shows up in the reflex is fueled by and pointed towards a value. In suicide, this reflex is almost completely diminished because the meaning (bundles of values) is not there. Ron Rolheiser summarizes James Hillman’s view quite beautifully that

“The soul can make claims that go against the body and against our physical wellbeing, and suicide is often that, the soul making its own claims.” 

For some people, life is just not good. They look at their work, their income, or how they haven’t gotten a raise as much as their colleagues, their childhood, their current relationship(s) are dragged down by them, lack of prospects in the future, and it's quite frankly bleak and riddled with shame and guilt. For some people, they have never had the experience of closeness, space, choice, or even purpose. Like the word hiraeth, in relationship to depression, there may be a longing or loss of something that simply never was. They have not had enough life, or don’t remember the goodness of life, to be able to say “yes” to life. To consent to it and cultivate it further.

“Death is our friend precisely because it brings us into absolute and passionate presence with all that is here, that is natural, that is love. . . . Life always says Yes and No simultaneously. Death (I implore you to believe) is the true Yea-sayer. It stands before eternity and says only: Yes.” —Rilke's letter to Countess Margot Sizzo-Noris-Crouy in The Dark Interval (2018)

Is It Still Depression … Or Is It Despair?

Not all depressed people are suicidal. The risk of suicide is 25% greater for those who do carry a diagnosis of depression. Depression is such a broad general term. The experience of depression is quite vast. When thoughts of suicide begin to occur, I don’t think we’re still talking about depression. I think we’re talking about despair. To read a lot about this, look at the literature of Kierkegaard. Specifically his books Either/Or, The Concept of Dread, and lastly, the classic The Concept of Anxiety.

Despair is a fancy word for an individual's state when they have given up on the quest for self-creation. The neighbor and predecessor of despair is dread. We all live in a state of dread. Said differently, to be in dread is to be anxious. We’re anxious because we have a choice or freedom. We can choose to live by what’s right for us, from that deep place of resonance with what’s authentic from our self. To choose what is against our self is to choose an external or hollow life and not confront life and answer its questions of us - to create ourselves.

Think about it this way. Many people may feel anxious (dread) to go to work and see that massive inbox of what they have to get done, or face that co-worker who drives them up a wall or threw them under the bus, or better yet, has to go home and be with a partner that they feel little to no relationship, support, closeness, desire, or outright allowance of their emotional life with. Through their relationship with life, it’s giving them an experience. An experience that asks them a question of (generally) how is this for me and what is a meaningful way to respond to this gives me justice and self-value?

In a state of despair individual is so broken down that they no longer feel as though there is ground beneath them, a connection to the goodness of life or relationship, they’re left with a cold emptiness, or like a stiff wind that feels like it blows right through you, a pervasive feeling of estrangement, no energy or motivation to move. It's as if one looks around at all they have and do but is left with an emptiness. Yet, here is a strange paradox, we’re most close to death, and its cold, but in a way, we’re most close to ourself. This is one of the reasons why I chose the image of someone falling, but in water, because in despair we no longer have access to the goodness of life or connection. We’re not able to hear the music of the self which pulls us back into life, because it’s been so drowned out in self-hatred, judgments, and shame.

Rollo May said it so well that despair “is the sweltering furnace which melts out the impurities in the ore. Despair is not freedom itself, but it is a necessary preparation for freedom.” While at the same time, despair is a “desperate refusal to be oneself.” Kierkegaard, whom Rollo May loved, described it as “not willing to be one's self, or still lower, despair at not willing to be a self; or lowest of all, despair at willing to be another than himself.” (Freedom and Destiny, p.237-238). May, and Kierkegaard, believed that the self is spirit, “Man is spirit. But what is spirit? Spirit is the self. But what is the self? The self is a relation which relates itself to its own self.” When there is no acceptance and support, no connection and closeness, or no care from another - how can there be life? But, a little can and could go a long way. Please read on. 

The Double Standard

I think there is a double standard people often hold with those who are depressed. Say we are going to a party and when we arrive all of our friends are there except one. We ask, and someone tells us that the absent friend is feeling anxious and could not come. We are often accepting of someone's anxious feelings. Often times those who are anxious are able to provide a somewhat rational explanation as to why they are feeling anxious, hence making it easier to accept—even if their rationalization is a defense. 

Dont get me wrong, as humans, regardless of inner condition, we’re masterful at providing rationalistic explanations for any direction or justification for our coping or way of dealing with that inner condition. Yet, here is an inference, there is something that is so hard to turn towards and feel. 

With depression, as opposed to anxiety, there is a sense that there is something so very wrong with themselves. I find that depression is met with a sense of sympathy. A sense that we are acknowledging the other, but holding them, and our self-experience of them, at arm's length. Protecting ourselves. As opposed to empathy, where we're taking up relationship with the person and letting them touch us on those very deep and personal levels and feeling.

Most people are terrified at the mention or occurrence of suicide.

Life is meant to move. When we’re with someone who is depressed, there is a felt experience of deadness, drought, dryness, slowness, dis-ability, tiredness, loneliness, isolation, etc. These things, for many people can be so damn hard to endure…and turn towards in compassion.

Helping Starts With Ourselves

As a psychotherapist, we are bound by a code of ethics that require necessary steps in the instance of a risk of suicide. It's painted on the walls and chiseled in granite. Suicide assessment and prevention is a an ongoing required continued education credit that we have to take. We need to know what the signs, markers, or indications are, the protocol to follow, and how to talk with our patients about it. There is no bypassing it. 

Yet, all this has the potential to completely bypass the experience the patient is bringing to us. The fact that they are bringing it up is an indication that they want to live and are moving towards connection to a something in them.

For me, immediately after the experience of having a patient die by suicide, the most helpful responses from others were the most spontaneous, impulsive, or immediate, and the ones with the fewest words. An "Oh. My. God,” “FUCK!” "Mmmm, no words. I'm so very sorry,” "OMG, that is so much!" A bodily slumping or an immediate change in facial expression. Some immediate response with an affect or visual component to it. These were all indications, and I could feel it, that the other was really with me. Being impacted. Feeling along with me.  

"Where all words are too few, every word is too much." —Victor Frankl

Helping begins from the heart, soul, or our experience of a thing. How is what the other is saying or feeling, for me? As I’ve said in my papers on The Humanity of the Psychotherapist and Loneliness, 2020s, & Rollo May, helping has been so cheapened and anxiously redefined into a doing activity rather than a being activity. The highest form of helping is actually care. Care is the recognition of the shared humanity with the other. That we stand on the same common basis of humanity. Care is the necessary source of eros, or love. If we never cared for a thing, ourselves, we would not exist. Someone cannot become aware of themselves apart from being loved by another. Heidegger believed that if we did not care for ourselves, we would disintegrate.

“When we do not care, we lose our being; and care is the way back to being.” -Rollo May in Love and Will (p.289)

“Love isn't a state of perfect caring. It is an active noun like struggle.
To love someone is to strive to accept that person exactly the way he or she is, right here and now.”
-Fred Rogers from The World According to Mister Rogers: Important Things to Remember

In my training in existential analysis (EA), we spend the last day of the basic training in the theory of EA on love. The days prior were focused around Victor Frankl's principles of Logotherapy—that of having a purpose and meaning which we grasp and pulls us forward through life, and dark time, are felt within our body and pull us forward—if we allow them. But, as Frankl and Alfred put it, as did Rollo May, it is love that reaches beyond the horizon of circumstances. And it is in care, the highest form of love, that we are able to reach beyond all defenses. 

“Love goes very far beyond the physical person of the beloved. It finds its deepest meaning in its spiritual being, his inner self. Whether or not he is actually present whether or not he is still alive at all,  ceases somehow to be of importance … love is the only way to grasp another human in the innermost core of his personality” —Viktor Frankl in Mans Search for Meaning (p.38)

It is love that reaches the person. Yet, as I have experienced from some folks, they are terrified of love (or more broadly, connection). But, none the less, you are reaching the person. In the instance of talking about suicide, or being with suicide threats, what is most important is to have a posture of understanding. Not trying to persuade, dissuade, and certainly not to argue or take it personally. Although, all these may happen. Hillman states:

“Whenever treatment directly neglects the experience as such and hastens to reduce or overcome it, something is being done against the soul. For experience is the souls one and only nourishment.” (Suicide and the Soul, p. 20)

Lastly, as therapists, we are in a bind. The patient's family and loved ones can call and contact whoever they would like or is available and there will be a service and a wake to begin and support that process of grief. As therapists, we are bound by confidentiality. In the wake of such shocking events, not having the space, support, or connection, even if just to ourselves, to feel and process what has happened, can and did feel so surreal and isolating. It's so important for us to have these spaces and relationships to process what we are going through. At the least with a supervisor or psychotherapist.

Conclusion

The truth remains: there is nothing we can do that will, with certainty, prevent patients or those we know from ending their lives. Not wanting to live is a-part-of life. For some people, life is simply not good. For some people, their-life has simply not been good. They have lost connection with the value(s) of life and access to the value(s) of their life and who they are. No access or memory to the fundamental value of life, goodness, there is no hope. But, a warm and understanding gesture of care, may be immensely powerful and go a long way. For love reaches beyond defense into the most profound base of the person. It is to plant a seed with no expectation of what will happen, but to know that you’re enacting the fundamental value of life, and that is to relate with another. That has the potential of life.

Remember, hope is a good thing. —Andy from The Shawshank Redemption

My name is Caleb Dodson I’m a private psychotherapist in Seattle, WA and I’m most passionate about bringing kindness to and excavating a sense of humanity in the most challenging experiences to bring about a more full life.