35 Years of Working With Suicidal Patients: Lessons Learned.

Abstract

Abstract Following a personal description of several patients who have committed suicide in my clinical practice and consultation, I summarize the literature on risk assessment for suicide. The form adopted is a set of specific questions that a knowledgeable clinical supervisor might use to help a clinical team examine their clinical decision-making and determine practical guidelines in caring for a suicidal patient. The factors covered include suicidal risk assessment, presence of comorbid and protective factors, immediate emergency interventions on both an outpatient and inpatient basis, and possible short-term and long-term interventions. The training and practical clinical implications of following these guidelines are considered. The checklist, in the form of probing questions, is not intended to foster an adversarial process, but rather to provide a framework in evaluating the assessment and care of suicidal individuals. My professional journey began as a graduate student in clinical psychology at a Veteran's Administration hospital. H. B. was a 45-year-old Caucasian male who was diagnosed as schizophrenic and who had a history of parental neglect, as well as combat-related stress experiences. He was one of my first clinical patients and I had worked with him for several months. While under my care, he killed himself. Over the course of the next 35 years of clinical work, I have been involved with three other psychiatric patients who have died by suicide. Another suicidal patient was being seen by a clinical graduate student whom I was supervising. He was her first patient and he killed himself over the Christmas holidays. In fact, patient suicide is not that unusual in the life of clinicians. As Bongar (2002) has observed, one in six psychology interns and one in three psychiatric residents experience the suicide of a patient at some point during their training. Moreover, with clinical experience the incidence of patient suicide does not greatly diminish. A practicing clinical psychologist will average five suicidal patients per month. One in two psychiatrists and one in six clinical psychologists will experience a patient's suicide in their professional careers (Chemtob, Bauer, Hamada, Pelowski, & Muraoka, 1989). Two other recent clinical consultations are the occasion for the present reflections. I was asked to consult to a Canadian treatment team called the Society of Northern Renewal headed by Dr. William Foote. They were addressing the high suicide rate of Inuit people in the territory of Nunavut. As noted in Dr. Foote's government report (private communication), the Inuit people are twice as likely to commit suicide than other native populations and four times as likely to engage in self-destructive behaviours. A variety of factors, including economic dislocation and deprivation, social isolation, disruption of traditional cultural patterns, and demoralizing social problems (substandard living, overcrowding) and substance abuse contribute to such self-injurious behaviors (Meichenbaum, in press). On top of this array of stressors in the early 1980s in three Inuit communities, a subgroup of 85 male Inuit youth were sexually abused by a self-confessed male pedophile school teacher over a period of six years. One of the consequences of this victimization experience is the very high rate of suicide among the Inuit, especially among the cohort of abused young men. For instance, the suicide rate among Inuit females is 32 per 100,000, 119 per 100,000 for Inuit males, and for the cohort of abused young men ages 19 to 29, the suicide rate is 200 per 100,000 (Foote, 2004, private communication). These suicidal numbers stand in stark contrast to the base rate of suicide of only 12 per 100,000 in the general population. The suicide rate rises to 60 per 100,000 in a psychiatric population (Bongar, 2002). My last consultation where a patient committed suicide was at a psychiatric facility where an adolescent patient was hospitalized on Friday evening by his parents for substance abuse and erratic behaviors. …