Clinician Suicide: What You Can Do to Save a Life Clinician Suicide: Are We at Risk?

Morton M. Silverman, MD

Clinical Assistant Professor of PsychiatryThe University of Colorado School of MedicineDenver, Colorado

Senior Science Advisor, Suicide Prevention Resource CenterWaltham, MA

Learning Objective #1Summarize the existing literature on the epidemiology and demographics of clinician suicide

Key Questions

• What is the true suicide rate for health care clinicians?

• Is the rate different than in the general population?

• Is the rate different within professional health care specialties?

Centers for Disease Control and Prevention. WISQARS™. Leading Causes of Death Reports, National and Regional, 1999 – 2014. http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html. Accessed June 16, 2016.

10 Leading Causes of Death, United States2014, All Races, Both Sexes Methodological Problems with

Reports of Clinician Suicides

Silverman MM. Physicians and suicide. In: Goldman LS, et al. The Handbook of Physician Health: The Essential Guide to Understanding the Health Care Needs of Physicians. Chicago, IL: American Medical Association; 2000:95-97.

1. Unstandardized and haphazard case finding techniques (eg, obituaries)

2. Inconsistent case definition (eg, employed, retired, etc)3. Difficulty in classifying occupations into clear categories (eg,

psychologists)4. Unmatched comparison groups (eg, age, race, gender,

geographical location)5. Nonrandomized study time intervals (ie, sampling bias)6. Unrepresentative samples and cases (ie, extrapolating small

numbers)7. No investigation of accidental, unintentional, and undetermined

causes of death (ie, unclassified true suicides)8. Paucity of standardized epidemiological and statistical tools and

techniques

Understanding the Statistics

• Standard Mortality Rate (SMR):# MD suicides /100,000 // # general population suicides /100,000

• Proportionate Mortality Rate (PMR):Proportion of MD suicides /MD deaths // proportion of professional group suicides /professional group deaths

• Odds Ratio (OR):# MD suicides /# MDs // # general population suicides /# general population

• Relative Risk (RR):Incidence rate of MD suicides // incidence rate of general population suicides

International and US Studies

Elevated suicide rates inNurses: 9 studiesPsychologists: 3 studiesSocial workers: 2 studies Dentists: 4 studiesPharmacists: 3 studiesVeterinarians: 3 studiesPhysicians: 38 studies

14 studies (females)

Danish Nested Case-Control Study Ages 18–67; 1981–2006

Hawton K, et al. J Affect Disord. 2011;134(1-3):320-326.

Compared to Primary School Teachers (ORs):Nurses: 1.90Physicians: 1.87 (females: 2.31)Dentists: 2.10 (males: 2.30)Pharmacists: 1.9 (females: 2.06)Veterinarians: 1.06

Compared to the Entire Population (ORs):Dentists: 2.50Physicians: 2.08Pharmacists: 2.07Nurses: 2.04Veterinarians: 1.29

Elevated Suicide Risk in US Health Care Professions

National Institute for Occupational Safety and Health (NIOSH)/National Occupational Mortality Surveillance (NOMS). 1995.

• Psychologists OR = 3.2

• Pharmacists OR = 3.1

• Physicians OR = 2.8

• Dentists OR = 1.75

• Social workers OR = 1.35

• Nurses PMR = 149–255

NIOSH/NOMS White Male Suicide Deaths (2010 data – PMRs)

• Physicians 1.87 (#2)

White Females: 2.78 (#1)

• Dentists 1.67 (#3)

• Veterinarians 1.54 (#4)

• Chiropractors 1.50 (#6)

• [Lawyers 1.33 (#9)]

• Pharmacists 1.28 (#14)

Psychologists1981–1990; < 65 years old

Phillips SM. Archives of Suicide Research. 1999;6(1):11-26.

• Based on obituaries published in American Psychologist; 759 death certificates reviewed

No manner of death listed on 71%Suicide listed on 5.5% (42 deaths)

• Results: No increase in suicide rates• Limitations: Operationally defining “psychologists” as

APA members

Suicides may be underreported

Professions not listed on death certificates

• Explanatory Factor(?): Increase in # of women in profession

Psychologists

Kleespies PM, et al. Prof Psychol Res Pr. 2011;42(3):244-251.

• Psychologists have not been included as an occupational category in most epidemiological studies of suicide; Majority of studies consist of uncontrolled case reports

• NIOSH/NOMS study (1984–1988) provides strongest evidence (PMR = 166): white males (PMR = 161); white females (PMR = 212)

• Findings are currently “suggestive, albeit conflicting and flawed,” and should be interpreted with caution, and further systematic research is needed

Psychologists and Suicidal Symptoms

SI = suicidal ideation.Deutsch CJ. Professional Psychology: Research and Practice. 1985;16(2):305-315. Pope KS, et al. Professional Psychology: Research and Practice. 1994;25(3):247-258. Gilroy PJ, et al. Professional Psychology: Research and Practice. 2002;33(4):402-407. Kleespies PM, et al. Prof Psychol Res Pr. 2011;42(3):244-251.

• Deutsch (1985): 264 MA and PhD-level psychotherapists; 2% suicide attempts

• Pope et al (1994): 800 psychologists; 29% SI; 4% suicide attempts

• Gilroy et al (2002): 425 counseling psychologists: 21% passive SI; 18% SI; 3% SI w/ plan

• American Psychological Association survey (2009): 40% to 60% some disruptions due to burnout, anxiety, or depression; 18% reported SI while dealing with personal and professional stressors or challenges

Nurses

Hem E, et al. Psychol Med. 2005;35(6):873-880. Agerbo E, et al. Psychol Med. 2007;37(8):1131-1140. Andersen K, et al. Aust N Z J Psychiatry. 2010;44(3):243-249. Skegg K, et al. Aust N Z J Psychiatry. 2010;44(5):429-434. Hawton K, et al. J Affect Disord. 2011;134(1-3):320-326. Kolves K, et al. J NervMent Dis. 2013;201(11):987-990. Alderson M, et al. Crisis. 2015;[Epub ahead of print].

• Hem et al (2005): 10.4/100,000 [general population = 8.0]

• Agerbo et al (2007): RR = 2.04• Andersen et al (2010): RR = 2.37• Skegg et al (2010): 9.0/100,000 [general population

= 7.0]• Hawton et al (2011): RR = 1.90• Kolves et al (2013): RR = 2.24• Alderson et al (2015): 1999-2014; 9 studies reviewed;

burnout; job demands; no support; emotional exhaustion; psychological distress; increased depression, smoking, substance abuse; knowledge/access to means

Center C, et al. JAMA. 2003;289(23):3161-3166.

Schernhammer ES, et al. Am J Psychiatry. 2004;161(12):2295-2302.

Meta-Analysis of Male Physicians’ Suicide Rate Ratios in 24 Studies Meta-Analysis of Female Physicians’ Suicide Rate Ratios in 13 Studies

Schernhammer ES, et al. Am J Psychiatry. 2004;161(12):2295-2302.

Going by the Numbers

*Male MD suicide rates = female MD suicide rates (in general population M:F = 4:1).Schernhammer ES, et al. Am J Psychiatry. 2004;161(12):2295-2302. Lindeman S, et al. Br J Psychiatry. 1996;168(3):274-279.

• Estimated 300 to 400 MD suicides/year– Estimate 3% of all male MD deaths/year– Estimate 6.5% of all female MD deaths/year

• Male MD rates are slightly higher than male general population rates (1.1–3.4)

• Female MD rates are much higher than female general population rates (2.5–5.7)

Physician Suicide Rate Ratios

Schernhammer ES, et al. Am J Psychiatry. 2004;161(12):2295-2302.

• Relative to General PopulationMale MDs: 1.41 (CI: 1.21–1.65)Female MDs: 2.27 (CI: 1.90–2.73)

• Percentage IncreaseMale MDs: 40% higher than all menFemale MDs: 130% higher than all females

Mean Age at Death by Suicide

Craig AG, et al. Dis Nerv Syst. 1968;29(11):763-772. Rich CL, et al. Am J Psychiatry. 1979;136(8):1089-1090. Pitts FN Jr, et al. Am J Psychiatry. 1979;136(5):694-696. Blachly PH, et al. Bulletin of Suicidology. 1968:1-18. American Medical Association/Council on Scientific Affairs. 1987.

Gender Mean Age Study

Males 48.8 +/- 0.96 Craig et al (1968)

51.3 +/- 0.60 Rich et al (1979)

Females 41.8 +/- 3.07 Craig et al (1968)

47.8 +/- 2.0 Pitts et al (1979)

ALL48.8 Blachly et al (1968)

49.3 AMA/CSA (1987)

MD Method of Suicide(NVDRS; 16 states; 2003–2008)

NS = not significant; NVDRS = National Violent Death Reporting System.Gold KJ, et al. Gen Hosp Psychiatry. 2013;35(1):45-49.

• Firearms 48%• Poisoning 23.5%

• Barbiturates 39.5%• Antipsychotics 28.7%• Benzodiazepines 21.0%• Antidepressants 1.31% (NS)• Opiates 1.15% (NS)

• Blunt trauma 14.5%• Asphyxia 14.0%

Suicide Studies That IdentifyMedical Subspecialty

• Anesthesiologists (8)• Psychiatrists (7)• Otorhinolaryngologists (3)• Ophthalmologists (3)• Pathologists (2)

10/12 studies done in the United StatesLast US study (1980) was based on data from 1967–1972

*Missing Data = 18%; Total = 223.Hawton K, et al. J Epidemiol Community Health. 2001;55(5):296-300.

Relative Risk of Suicide by Specialty(Compared to General Medicine; 1979–1995)

Specialty Number Relative Risk

Community health 7 8.0

Anesthesia 13 6.8

Radiotherapy 1 5.0

Psychiatry 9 4.8

Public health 2 4.5

General practice 84 3.6

Radiology 3 3.2

OB/GYN 2 2.6

Surgery 6 2.1

Emergency 0 0

General medicine 4 BASELINE

Common Risk Factors

• Occupational strain and stress

• Long working hours (eg, sleep deprivation)

• Poor help-seeking for mental disorders

• Stigma

• Psychiatric disorders

• Perfectionism

• Economy

• Role transitions

• Access to and knowledge of pharmaceuticals, dosing, and lethality

Problems in Year Before Death (United Kingdom)

Hawton K, et al. J Psychosom Res. 2004;57(1):1-4.

• 71% Occupational

– Lawsuits, feeling overloaded, working long hours, not able to cope (paperwork)

• 63% Mental health

• 40% Relationships

• 29% Financial

• 23% Family and friends

• 17% Alcohol and other drugs

• 11% Physical health

• [Gold KJ, et al. Gen Hosp Psychiatry. 2013;35(1):45-49. (United States) – “job problems” OR = 3.12]

Psychiatric Disorders Associated with Physician Suicide

Blachly PH, et al. Bulletin of Suicidology. 1968:1-18. AMA Council on Scientific Affairs. Conn Med. 1986;50(1):37-43. Clayton PJ, et al. J Affect Disord. 1980;2(1):37-46. Welner A, et al. Arch Gen Psychiatry. 1979;36(2):169-173. Pitts FN, et al. Am J Psychiatry. 1979;136(5):694-696. Murray RM. Lancet. 1974;1(7868):1211-1213. Hawton K, et al. J Psychosom Res. 2004;57(1):1-4. Gold KJ, et al. Gen Hosp Psychiatry. 2013;35(1):45-49.

• Major depressive disorder

• Bipolar affective disorder

• Alcohol and/or other drug abuse

• Anxiety disorders, including panic disorder

• Previous suicide attempt

Depression in the Medical Profession

Welner A, et al. Arch Gen Psychiatry. 1979;36(2):169-173. Clayton PJ, et al. J Affect Disord. 1980;2(1):37-46. Frank E, et al. Am J Psychiatry. 1999;156(12):1887-1894. Wieclaw J, et al. OccupEnviron Med. 2006;63(5):314-319. Center C, et al. JAMA. 2003;289(23):3161-3166.Valko RJ, et al. Dis Nerv Syst. 1975;36(1):26-29. Kirsling RA, et al. Psychol Rep. 1989;64(3 Pt 1):951-959. Gold KJ, et al. Gen Hosp Psychiatry. 2013;35(1):45-49.

• Higher rates in medical students (15%–30%), interns (30%), and residents vs general population

• Lifetime rates of depression in female physicians: 39% vs 30% in age-matched PhD females (both higher than general population)

• Lifetime rates of depression in male physicians (13%) similar or slightly elevated compared to males in general population

Conclusion

Center C, et al. JAMA. 2003;289(23):3161-3166.

More decisively addressing depression and suicidal behaviors in physicians may have a

multiplier effect beyond improved mental health and productivity, fewer suicides, and better physical health. It may also improve

their mentoring and training of medical students and residents, as well as improving

the mental health care of their patients.

Bottom Line

All the studies that controlled for demographic covariates found that health-related occupations have elevated suicide risk:

PhysiciansDentistsNursesSocial workers

**Not enough multivariate studies addressing Psychologists

Clinician Suicide: What You Can Do to Save a Life

Michael F. Myers, MD

Professor of Clinical PsychiatrySUNY Downstate Medical CenterBrooklyn, New York

Learning Objective #2Develop a clinical skill set that informs state-of-the-art diagnosis and treatment of suicidal clinicians

“The Perfect Patient”: Myth vs Reality

• A fellow clinician• You feel honored that they’ve chosen you • Smart• Educated• Articulate• Honest, open, forthcoming• Being health professionals, you both speak the same

language• Someone who will pay your fees• Not too sick• Will be grateful for your care• Less likely to sue

The Suicidal Clinician: Referral Context

ED = emergency department.

• Self-referral – by telephone, e-mail, in-person at work site

• Referral by others – primary care physician, emergency MD, professional colleague or friend, family member, patient

• Setting – private office, ED, inpatient medical/surgical unit, couple therapy situation

• State physician health program

• Residential treatment program

The Suicidal Clinician: Presentation

• Denial and minimization of symptoms

• Resistance to accepting patient role – underlying terror, shame, guilt

• Mistrust of treating clinician

• Fear of loss of autonomy, privacy, prescribed medication, hospitalization, loss of professional license, loss of job (or position if trainee)

• Fearing the consequences, suicidal history, thinking, behaviors, plans, means may not be volunteered and lied about upon inquiry

• Not comfortable with or suspicious of collateral information and signing release for previous medical records

The Suicidal Clinician: Psychiatric Disorders

Silverman MM. Physicians and suicide. In: Goldman LS, et al. The Handbook of Physician Health: The Essential Guide to Understanding the Health Care Needs of Physicians. Chicago, IL: American Medical Association; 2000.

• Major depressive disorder

• Bipolar disorder

• Alcohol use and other substance use disorder

• Anxiety disorders

• Borderline personality disorder

The Suicidal Clinician: Additional Psychiatric Disorders

MDD = major depressive disorder.Myers MF. Drivers of suicidal behaviors in physicians. In preparation.

• Burnout

• Substance/medication induced depressive disorder (especially in clinicians who have been self-medicating)

• Posttraumatic stress disorder

• Other personality disorders

• “Double depression”

• Comorbid conditions: MDD and substance use disorder, anxiety disorder and unrelenting and progressive medical disorder, bipolar disorder and narcissistic personality disorder, MDD and traumatic brain injury

• Adjustment disorders with overwhelming stress, loss, threat, public humiliation

The Suicidal Clinician: Risk Considerations

Myers MF. Physician suicide and resilience: diagnostic, therapeutic and moral imperatives. World Medical Journal. 2011;57(3):90-97.

• Previous history of a depressive episode

• Previous suicide attempt

• Family history of mood disorders, including suicide

• Professional isolation

• Lawsuits and medical license investigations

• Poor treatment adherence

• Treatment refractory psychiatric illness

The Suicidal Clinician: Risk Considerations Updated

Tucker RP, et al. J Affect Disord. 2016;189:365-378.

• Undiagnosed and untreated bipolar I or II disorder

• Rapid cycling bipolar disorder

• Comorbid conditions

• Impulsivity

• Unrecognized emergent psychosis

• Severe sleep deprivation and circadian rhythm disruption

• Acute suicidal affective disturbance

Another Risk Factor in Medically Trained Clinicians

• We know how to kill ourselves – knowledge of biochemistry, physiology, pharmacology, anatomy, and toxicology

• Access to surgical instruments, syringes, IV tubing, insulin, KCl, fentanyl and other narcotics, pharmaceutical samples

• Self-prescribing vs falsified writing of Rx for family members

The Suicidal Clinician: Interview Imperatives

• Consider the dyadic context of one clinician (you) assessing and treating another clinician (your patient)

• Reflect upon transference and countertransference dynamics when one clinician treats another

• A warm, compassionate, empathic, and nonjudgmental style is essential

• Be comprehensive and thorough, ie, rigor = understanding

• Pay attention to your gut feelings in the face of discordance

• Your doubts, uncertainty, and mistrust should give you pause

• ALWAYS assess with a biopsychosocial construct Suicide Risk Formulation: A Guide for Psychiatrists. Produced by the American Association of Suicidology [AAS] with a grant from Noven Therapeutics, LLC. 2009. Content provided by: L Berman, PhD, T Lineberry, MD, MM Silverman, MD.

Determination of Risk

Psychiatric Examination

Risk Factors Protective

Factors Specific Suicide

Inquiry

Modifiable Risk Factors

Risk Formulation

Risk Assessment vs Formulation

Berman AL, et al. Suicide Life Threat Behav. 2014;44(4):432-443.

• Risk Assessment involves collecting data regarding the presence vs absence of criteria or, in the case of suicide, risk factors and protective factors (akin to ingredients)

• Risk Formulation involves some understanding of how risk factors combine, interact, fuel, and are buffered by protective factors or otherwise form “a recipe” for heightened risk for suicidal behavior– Further, formulation of level of risk requires

judgment/intuition

Other Things to Keep in Mind

MSE = mental status exam.Berman AL. Managing Medicolegal Risk when Treating Suicidal Patients. Presented at: 2015 International Academy of Suicide Research/American Foundation for Suicide Prevention International Summit on Suicide Research; October 11, 2015; New York, NY.

• Do not rely solely on your patient’s self-report

• Do not assume if no suicidal ideation then no risk

• The majority of patients who die by suicide DENY having SI when last asked before their death

• There is no research evidence in support of the proposal that active SI predicts greater risk for death by suicide than does passive SI

• There is no substitute for a detailed MSE, collateral information, clinical intuition, experience, and consultation

The Suicidal Clinician: Joiner Triad

Joiner TE. Why People Die by Suicide. Cambridge, MA: Harvard University Press; 2005.

• Thomas Joiner’s conceptualizations of what drives individuals to kill themselves are helpful in understanding suicide in clinicians

• He has described 3 inner feeling states1. Perceived burdensomeness – a sense that one is

a burden on others

2. Failed belongingness – a sense that one does not belong to a valued social group

3. Learned fearlessness – the acquired capability to enact lethal self-injury

“Learned Fearlessness”

Joiner TE. Why People Die by Suicide. Cambridge, MA: Harvard University Press; 2005.

“…the kind of exposure to pain and fear that people also might learn through such experiences as mountain climbing,

performing surgery, fighting in wars or being afflicted with anorexia”

Stigma is Ubiquitous

Myers MF. Stigma and the Ailing Physician. Part 3. www.psychcongress.com/blogs/michael-myers-md/stigma-and-ailing-physician-part-3. Accessed June 17, 2016.

• Enacted stigma is exterior and refers to discrimination against people with a psychiatric illness because of their perceived unacceptability or inferiority

• Felt stigma is interior and refers to both the fear of enacted stigma and a feeling of shame associated with having a mental illness

• Both types of stigma can be at play when a symptomatic health professional decides to seek treatment

• Both types of stigma threaten self-esteem, security, identity, and life chances

Treating Suicidal Clinicians

Myers MF, et al. The Physician As Patient: A Clinical Handbook for Mental Health Professionals. Arlington, VA: American Psychiatric Publishing, Inc.; 2008.

• Suspicion of suicidal thinking and planning• Artful thorough and dynamic suicidal risk assessment

and formulation in the context of trust and mutual respect

• Document, document, document• Detailed inquiry of means/method – stockpiled

medications, self-prescribed medications, Internet ordering of medications, medications stolen/diverted from the workplace, firearms

• Hospitalize for safety – this should be judicious and in consultation with others

• Close follow-up after discharge

Treating Suicidal Clinicians (continued)

Myers MF. Physician suicide: what you can do to save a life. Brian Buss Lecture. Presented at: 43rd Annual Winter Conference of the Oregon Psychiatric Physicians Association; February 13, 2016; Portland OR.

• Obtain old records of Rx – speak to previous treating professionals

• Collaborative information (especially loved ones) – push for this

• Second and third opinions – especially a good psychopharmacologist

• Work closely with your state physician health program if your patient is involved

• Practice biopsychosocial treatment model

Treating Suicidal Clinicians (continued)

• If split treatment, insure regular contact with psychotherapist and document all communication and any change in status, medication, or psychotherapy modality change

• Watch for emerging or masked bipolar illness in treatment-resistant depressed MDs

• Insure that any comorbid substance use disorder is being properly treated

Treating Suicidal Clinicians (continued)

CBT = cognitive-behavioral therapy; DBT = dialectical behavior therapy; CAMS = Collaborative Assessment and Management of Suicidality.

• Pay attention to transference and countertransference issues that are ubiquitous when one clinician treats another

• Always remember that your patient is a hurting individual who just happens to be a clinician – do not lower your high standards – do not be seduced into taking short cuts in care

• Refer for evidence-based psychotherapies – CBT, DBT, CAMS, and more

Treating Suicidal Clinicians (continued)

• Watch for dangerous symptoms – intractable sleep disturbance, rapid cycling, agitation, and emerging subtle psychotic symptoms – act fast and appropriately!

• Be kind, compassionate, thorough, and clear when you need to be firm, paternal and “physicianly” – never forget the terror, desperation and shame that lurks behind symptomatic behavior in ill clinicians

Wise Words from the Trenches…

Stated by Dr. ‘Mark’ after the suicide death of his psychiatrist brother. (Myers MF. Videotape. When Physicians Die By Suicide. 1998.)

“If given the opportunity to treat a fellow health professional, psychiatrists should double their

compassion and double their skepticism”

More Wise Words…

Jamison KR. To Know Suicide: Depression Can Be Treated, but It Takes Competence. The New York Times. August 15, 2014.

• “Distinguishing between bipolar depression and major depressive disorder, for example, can be difficult, and mistakes are common. Misdiagnosis can be lethal. Medications that work well for some forms of depression induce agitation in others. We expect well-informed treatment for cancer or heart disease; it matters no less for depression.

• Because I teach and write about depression and bipolar illness, I am often asked what is the most important factor in treating bipolar disorder. My answer is competence. Empathy is important, but competence is essential.”

• Copies of DVD “Suicide Risk Formulation: A Guide for Psychiatrists” are available by contacting:Amy Kulp, MS, Interim Executive Director, American Association of Suicidology, 5221 Wisconsin Avenue, NW, Washington, DC 20015. Telephone: 202-237-2280

Clinician Suicide: What You Can Do to Save a Life

Carla Fine, MS

Independent Author and Speaker

Learning Objective #3Describe what it is like to lose a physician family member to suicide and what is most helpful for family members who have been bereaved by a physician suicide

There is a Wall of Silence Surrounding Suicide Loss

Suicide is not spoken about openly or easily,

especially in the medical community. There is

a wall of silence surrounding this mysterious

topic, probably because the pain is so private

and the act so public.

Suicide Loss is Shattering

The suicide of someone you love is

shattering. You think that you have lost your

mind, that you are crazy, that you won’t be

able to live through the next hour, let alone

the rest of your life.

Survivors Never Stop Looking for Answers

As survivors, we live and relive the suicide of

our loved ones. We turn every detail in every

way possible, always looking for the time

when we could have stepped in and stopped

what was happening.

No Time to Say Goodbye

I wrote my book No Time to Say Goodbye:

Surviving the Suicide of a Loved One

because I want the voices of those of us

whose loved ones have killed themselves to

be heard. Only by letting go of the silence,

can we start to remember their lives and not

just their deaths and the way they died.

The Word “Normal” is Erased from Our Vocabulary

Suicide transforms us and changes us

forever. We will never go back to “normal”—

that word is erased from our vocabulary. Our

world becomes divided into before and after.

Suicide and Death are Two Separate Entities

Survivors also understand that suicide and

death are two separate entities: first you have

to get through the suicide before you mourn

the death. And at the beginning—and for

survivors the beginning is at least the first

three years—all we can think about is the

suicide.

Suicide Loss is Isolating

Dr. Edward Dunne describes how the act of

suicide hits like a meteorite—it crashes into a

family or community and each person is left

to circuit in his or her own individual orbit of

grief.

Suicide Questions Our Very Foundations and Beliefs

Suicide breaks all the rules. People we know

and hold dear have defied the course of

nature and determined when and how they

will die. The question, “Why do we die?” has

always been an unanswerable mystery; with

suicide, the question reshapes into, “Why did

my loved one choose to die?”

The Medical Community Avoids the Subject of Clinician Suicide

Close friends of Harry who were doctors—people who deal with death more frequently than others—avoided me and avoided Harry’s existence, or so it seemed to me.

This silence surprised and confused me. Only by addressing the topic of clinician suicide openly and publicly can we begin to shatter the stigma of suicide in the medical community as well as help survivors to heal.

Living without Answers or Resolution

How is it possible to live without resolution?

To never know what really happened?

Survivors live in the land of uncertainty. We

have to learn to adjust our lives to never

having definitive answers, to never having

permanent resolution, to never having clarity.

We Never Know When We May Have Saved Them Earlier

There were probably times during my long

marriage when I had said the right words or

done the right thing to stop Harry from ending

his life, that I had almost certainly saved him

on several occasions over the years without

knowing it, as most survivors probably did

with their loved ones.

Suicide Makes Us Instant Philosophers and Poets

Those of us who have lost a loved one to

suicide become instant philosophers and

poets; we think about what keeps us alive—

or wanting to be alive—like we used to think

about where to go on vacation or what car to

buy.

Asking for Help is Very Difficult

For survivors, reaching out for support after

the suicide of a loved one is more difficult

than you may think. You can barely function,

let alone make a deliberate thought-out

decision to ask for help.

Suicide Support Groups are the Key to Healing

Suicide support groups, in-person or on Internet

chatlines, are very important to survivors. The

defining part of losing a loved one to suicide is the

isolation and alienation you feel from all that was

once familiar. To share stories with people who

know exactly what you have been through gives

you the lifeline of connection.

Networking with Other Survivors is Essential

If there is only one piece of advice that I

could give to a suicide survivor it would be to

find some kind of support network to meet

and exchange experiences with other people

who have “been there” as well.

Survivors Know When Therapists are Uncomfortable Speaking about Suicide

When a survivor goes to a therapist who is uncomfortable

with the subject of death or suicide or both, we know it right

away. Our radar is finely tuned.

The focus of any therapy must be on the survivor. Questions

about the “why” or the “cause” of the suicide just reinforce

the guilt and blame we already feel about our failure to keep

our loved one alive.

The Voice of the Survivor Informs the Study of Suicide

Survivors can inform the work of researchers

and clinicians by describing behaviors that, in

the wake of suicide, are now considered

symptoms. We can recount details of our loved

one’s demeanor that may shed new light on the

decision or process one goes through before

ending his or her life.

The Help We Receive Determines Our Healing

Many of us who have lost loved ones to suicide make it through because we had the good fortune to be helped by sensitive and sympathetic first responders, counsellors, and therapists.

You are the professionals we look to for help in navigating the chaos that follows a death by suicide. We also depend on you for practical and emotional support and guidance, as well as the ability to answer our questions openly and without judgment.

How Best to Help Survivors of Suicide Loss

1. Advise survivors to protect their health and the health of their family members during this time.

2. Urge them to seek out other survivors to help break the isolation and alienation that makes them feel so different and strange.

3. Counsel survivors to surround themselves with people they feel comfortable with, who don’t judge them or turn away and change the subject when they mention the topic of suicide.

How Best to Help Survivors of Suicide Loss

4. Explain how a sensitive, knowledgeable, and sympathetic mental health professional can sometimes make all the difference.

5. Acknowledge and accept their reality that they have changed and will never be the same.

Conclusion

By erasing the stigma that surrounds suicide,

the secrecy of mourning our loved one’s

death will begin to diminish and allow us to

heal. In letting go of the silence, we also let

the many others out there who are touched

by suicide know that they are not alone in

their grief and pain.

From One Survivor to Another

Thank you very much. I deeply hope that Harry’s interrupted and too short life will serve to help others, especially in the medical community, and the legacy of his suicide will shed much needed light on the topic of suicide and those who are touched by it every day.

www.carlafine.com