May 17, 2016
*Disclaimer: Names and details have been altered to protect patient privacy.
“Sherry, let me go,” my patient begged.
“Do you mean let you go home or let you go permanently?” I asked, concern unintentionally harshening my voice.
Earlier in the session a client of mine told me she wished she were dead. She’d voiced this sentiment several times throughout the two years we’d been working together. Whenever I’d ask her how worried I should be, she’d assure me she wasn’t doing any harm to herself. “I give you my word, Sherry,” she promised.
But on this damp-to-the-soul October day, *Chen sat on the edge of my couch and made a chilling confession. The night before, three blocks from her Brooklyn apartment she’d purposely stepped in front of a car, then jumped back on the curb even as the driver swerved to avoid her.
Chen, 34, had suffered physical, sexual, and emotional abuse by several family members since the age of 7. But she was resilient; she’d not only put herself through college and graduate school, but excelled, and was now working as an audiologist. And she was becoming increasingly more depressed because her parents, brothers, and cousins, whom she financially supported, had pushed her deep into debt.
There was a huge gap between our first and second therapy sessions. I wasn’t sure I’d see her again. Chen later told me that the “stress and shame” of confiding intimate details of her past led her to delay making another appointment—for eight months.
I was happy she reconnected, but set ground rules for our working together: She could not disappear and she must always be honest.
She’d honored my rules thus far. But on this particular day, as I was absorbing my patient’s admission of wanting to have her body fatally slammed by 4,000 pounds of metal, I agonized over how to proceed. The National Association of Social Workers Code of Ethics calls for us to respect the rights of a patient to decide her fate. But if a patient is deemed a strong suicide risk—as in, not just revealing thoughts, but a plan on how to commit the act—a therapist may have no choice but to break one of the most important tenets of the therapist-patient relationship: confidentiality.
According to the CDC, in 2013, 9.3 million adults reported having suicidal thoughts, with 41,149 moving from ideation to deed. Psychiatrists have numerous assessment scales to gauge suicidal ideation—monitoring factors such as past attempts, family history of suicide, and talk of a specific intent or plan to self-harm. Even with these precautions, the American Psychiatric Association shared that 71 percent of psychotherapists have had at least one client attempt suicide, with 28 percent succeeding.
And mental-health providers can suffer more than just the anguish and grief of losing a patient that they care about: Oftentimes, the surviving families of clients who’ve committed suicide will sue the therapist or psychiatrist. In fact, suicide is the number one cause of lawsuits brought against mental-health providers. Nearly every solo practitioner I’ve spoken to refuses to treat a patient who is considered “chronically suicidal.” This ethically cloudy issue has existed in the profession for decades: In 2000, a study on therapists’ reactions to patient suicides revealed that six of the 26 clinicians interviewed described themselves as “anxious” or “reluctant” to accept suicidal patients into their practice. A new study presented at the 2016 Annual Meeting of the American Psychiatric Association found 73 percent of respondents “fear litigation and retribution following patient suicide.” The rationale for this reluctance to treat potential suicides is that hospitals or clinics with more substantive treatment programs are better equipped to give the level of care necessary for at-risk patients.
I experienced this reluctance myself during an internship at a mental-health outpatient treatment center. During a session, my 23-year-old patient *Bill, heartsick since a breakup three months earlier, expressed a wish to end his life. He hadn’t mapped out a plan yet, but his affect was extremely depressed and he’d begun drinking every night. His mother attended the session as well, watching as I made Bill promise not to harm himself before our next appointment. He also agreed to go to an AA meeting that evening.
I was shaken up, but felt I’d covered my bases and let him leave my office. Twenty minutes later my phone rang. It was the psychiatrist down the hall, with whom I shared the case. Bill had just expressed the same suicidal ideation with her—and she decided to call for an ambulance to take him to a psychiatric hospital.
During his two-week stay at the hospital, I visited twice. Bill expressed alarm for causing everyone “so much trouble,” saying he didn’t believe he’d have actually hurt himself. He very much wanted to resume his weekly visits after he got released.
But the psychiatrist had already terminated him, recommending a colleague to replace her—a move my supervisor recommended for me as well. I should protect myself, she said, laying out a worst-case scenario: You take him back; he commits suicide; his mother sues you. I replied, “The worst-case scenario for me is not taking him back and hearing he kills himself.”
Still, I agonized, and sought other colleagues for their opinions—most of them advised terminating. But ultimately, I had to obey my conscience, which nagged: Can I live with myself if I tell a patient I believe I can help that I don’t feel we are a good fit, and can I refer him or her somewhere else?
Bill’s new psychiatrist and I checked in regularly to coordinate treatment. For the next three years, Bill and I worked together, and after he terminated treatment, he kept in touch periodically. Last month, he emailed to share news of his upcoming wedding, and thanked me for not giving up on him.
As a child of Holocaust survivors, I grew up accustomed to the presence of seemingly impenetrable sadness—sadness I felt it was my mission to ease. Before becoming a therapist nine years ago, I spent 20 months volunteering at a suicide hotline. It was draining work, but there was nothing that satisfied my heart more than when the person on the other end of the line said, “You helped me feel better.” Of course the lifting of spirits was for the moment. Whatever the caller might do the next day or the day after that I’d never know. Or bear responsibility for.
But when I became a therapist, I discovered the constant, low-grade strum of stress in my belly; quick to inflame when a patient expresses unendurable misery, whether during an in-person visit, or by phone or texts. On more than a few occasions, while I’ve been on vacation, I’ve received messages from patients expressing a wish to be dead. I roll over on an Acapulco beach, try to keep sand from getting on my iPhone and attempt to assess the seriousness of that statement and what I can do to at least apply a mental Band-Aid.
While I am grateful The American Association of Suicidology maintains the Clinician Survivor Task Force to help mental-health professionals who have survived a client’s suicide, I pray I am never in need of their services. I pray I can help Chen before she even considers jumping in front of another car.
Chen says, “Sherry, it’s not just the sadness. I’m simply exhausted. I need this to end.”
“Exactly what is it you need to end?”
“How I feel.”
“Chen, I’m very glad you told me about the car incident. Honesty is part of our deal. But now that you’ve told me, we need to do something about it.”
My patient insists, “Sherry, you can’t really stop someone from killing herself if that’s what she wants to do. It wouldn’t be your fault.”
At least Bill was the treatment center’s patient, and I shared responsibility for his case with a team. Chen, though, is a private-practice patient. And even though her family has no knowledge of her being in therapy, thus there’s no risk of a lawsuit, if, God forbid, something were to happen … The emotional cost of losing a patient to suicide would be mine alone—and it’s a cost I don’t feel equipped or willing to pay.
“Just as you say I can’t stop you from feeling a certain way,” I told Chen, “you can’t stop me from giving in to what I would feel if you killed yourself.” My words were semi-jocular, banking on the trust and respect we share together to jolt her.
“Don’t guilt me,” she said, managing a smile.
“Chen, what made you jump back on the curb?”
After a long silence, she answered, “I don’t know.”
“There was a study of people who jumped off the Golden Gate Bridge and survived. The moment after they jumped, they regretted it,” I said.
“I wouldn’t regret not having the flashbacks to the abuse. I wouldn’t regret not having to deal with my family when they call or come over.”
“Chen, those are things we can continue working on. You have said that we’ve made a lot of progress.”
“We have, I’m doing a lot better than when I first came to you. But sometimes I have moments when it doesn’t seem worth it to continue struggling.”
There was a silence as I wrestled with my ethical duty and my instincts about what would best benefit this patient. The second hand ticked twice around the clock peeking out from my stained wooden bookcase. I inhaled deeply. “I don’t see anything to be gained by calling 911 and having you committed. You would be out in a few days and it would be hard for you to trust me again with your truths. But there is only one way I can feel comfortable still working with you.”
“I need you to have a meds consult.”
“Sherry, I’ve told you many times I don’t want to take meds.”
“Yes but now you had this impulsive moment of wrenching pain there could have been no coming back from. I need you to do this—to protect both of us.”
“If I don’t?”
“Chen, I’ve told you that I take anti-depressants.” Joking, I added, “I don’t leave home without them.”
She said, “I want to stay the me I know. I don’t want to become someone else.”
“You won’t. Meds can lighten the grinding pain that made you jump in front of a car, and help us better focus on and nurture the instincts that made you jump back on the curb.”
I reached over and took her hand. “I need you to promise me you will make the appointment and that you will not do anything to harm yourself. If you feel that hopeless, reach out.”
She took my hand, agreed to follow my advice, and we continued the session. Thirty minutes later she walked out, assuring me she’d text me later that day after booking the appointment with the psychiatrist.
What will I do if she doesn’t come back?
Sherry Amatenstein, LCSW, is a New York–based clinical therapist, and the author of three books, among them, THE COMPLETE MARRIAGE COUNSELOR. Her anthology: HOW DOES THAT MAKE YOU FEEL? True Confessions from Both Sides of the Couch will be published in September by Seal Press.