This episode contains discussion of suicide and its impact
You can also access this podcast as a video with subtitles HERE.
Losing a patient or colleague to suicide can be devastating. In this episode Dr Rachel Gibbons (psychiatrist, psychoanalyst and group analyst) talks about her personal experience of surviving patient suicide and the work she has done to understand suicide and homicide; its impact on healthcare staff; and what helps.
The Royal College of Psychiatrists has produced a number of resources to support staff when a patient dies by suicide – you can find them here.
If you’ve been affected by the issues in this episode you can get help from a range of organisations.
Samaritans Call 116 123 Email jo@samaritans.org
Campaign Against Living Miserably (CALM) Call 0800 58 58 58 – 5pm to midnight every day or visit the webchat page
Papyrus – for people under 35 Call 0800 068 41 41 – 9am to midnight every day. Text 07860 039967 pat@papyrus-uk.org
I’d love to connect with you so come and find me on LinkedIn, Twitter or Facebook.
Sign up to my weekly newsletter here to get updates about the podcast as well as psychology tips and insights direct to your inbox.
Follow and subscribe so you don’t miss an episode!
Transcript
[music]
Paula: Hi, I’m Dr. Paula Redmond, a clinical psychologist and you’re listening to the When Work Hurts Podcast. On this show, I want to explore the stories behind the statistics of the mental health crisis facing healthcare professionals today, and to provide hope for a way out through compassion, connection, and creativity. Join me as I talk to inspiring clinicians and thought leaders in health care about their unique insights, and learn how we can support ourselves and each other when work hurts.
This week, I’m talking about a tough subject, the impact of patient and colleague suicide on clinicians. We do obviously talk about suicide throughout the episode and feelings around it. If this is something that might be tricky for you, do just take care of yourself. To explore this issue, I spoke to Dr. Rachel Gibbons who is a consultant psychiatrist, psychoanalyst, and group analyst, who has a special interest in the field of suicide. She has a range of leadership positions at the Royal College of Psychiatry, including being Chair of the working group on the effect of suicide and homicide on clinicians, being co-chair of the Patient Safety Group, and vice-chair of the psychotherapy faculty. I started by asking her how she came to be involved in this line of work.
Rachel: I’m a doctor, so a mature medical student. In my training, I didn’t know what type of medicine I wanted to do until I did psychiatry. On the first day, I was asked to sit down and I’ve been on ward rounds in medicine, and they watch out for Mary Robertson. Her ward round goes on for about 12 hours. I said, “Oh no, we’ll have to stand up, walk around.” I had this idea of what a ward round was.
In the first day of psychiatry, I was ushered into a room to sit down, given a pot of tea, and then we spent the whole day discussing patients, seeing patients, thinking about the dynamics of their families. I thought within that first day this is the most fantastic job. I can’t believe there is a job as wonderful as this and that stayed. Absolutely, from that moment on, I was totally determined, committed to being a psychiatrist.
It stayed in my mind, and it still is the most fantastic job. If you’re interested, I’m sure that’s probably true of all different branches of medicine, isn’t it? If you follow your heart, then it’s the most fantastic job ever, and for me, that was psychiatry. As a mature student, what I did is I [unintelligible 00:02:45] trained in adult psychiatry, and adult psychotherapy. It took me quite a long time, I was a mature student anyway.
It came to me becoming a consultant in 2008, after an awful lot of training. I was looking forward to it. With my heart and soul, I think it’d be fair to say, I was very ready for it. I got a job. It was a very competitive time for consultant roles. I fought very hard to get a job that I really wanted in an environment, a mental health organization where I had trained and I loved the colleagues that I trained with, but also people that trained me.
I was delighted to get– Felt like joining a family in a way. I was so pleased. It was an inpatient consultant job. On the first day, it gave me a big lesson in what it means to become a consultant because on my first day of being a consultant, I landed in this new job and I arrived, the introduction, to be introduced, to be told, “Oh, you do know we’re closing, don’t you?”
It was just the start of the bed reductions within psychiatry, where they reduced 30% of the beds over a few years. It’s just the start of that, and the inpatient unit I joined was going to close and that was how I found out. I started as a consultant psychiatrist, and I hoped that I was going to bring something, all the training I’d done that I was going to bring something good and that would help people.
On my second week as a consultant, my first patient died by suicide., a patient that had been on the ward. You claim this and I discharged from the ward. My third week, my second patient died by suicide. Everything was gone and I was drowning at that point. Apart from, I don’t think you would have known I was drowning. If you’ve seen me, I don’t know whether you’d have known that I was drowning. I could recognize it in other people’s faces now but at the time, I couldn’t. I don’t even recognize it in myself. I knew there was something very wrong.
Paula: Did that happen immediately like in a shock way?
Rachel: In a moment I heard about the first death, in the moment, something in me was annihilated. Something was just killed, gone, wiped out, devastated. I think there’s something both about the shock but there’s something also about coming up against suicide, really coming up against suicide. What that means, that is so shocking and disturbing, and puts you up against something about life you really don’t want to know about.
You do know somewhere about it because I think there’s some way when we hear about suicide, there is some part of us that recognizes something but I think there’s another part of you that really, really doesn’t know something, and suicide tells you it within a moment. I think something changed within hearing about the first death, but the second death just came on top of it and just absolutely, “Well, yes, there you go.” Absolutely, this is the way it is.
Paula: What about the organizational response to that? What part did that play?
Rachel: Just to add to it a bit, I had another– I had those two deaths. It was drowning, just starting to emerge a bit, and then I had another impatient death a few months later. In that first year, we had three deaths, three serious incident inquiries, and three Coroner’s Court visits if you like. I don’t know quite how to put words to the organizational response.
Because you’re in such a shocked state yourself, it’s very difficult to objectively assess what the organization’s response was, but certainly what my experience was of the organization’s response, compounding the difficulty, and feeling very much like I was being on trial certainly in the Coroner’s Court. Actually, in a way the Coroner’s Court was less like that than the internal inquiries, and there was one in particular for the inpatient death which really was very difficult indeed.
I think the thing is, particular at that stage of career, you’re very connected to your organization. You imagine it’s going to look after you. I think we all still are, aren’t we? Whenever we’re functioning within an organization, we have expectations that our organization is going to be a bit of paternal or maternal to us and look after us, which is not the case.
In a way, I got that shocking experience of that not being the case, a bit like finding out about the suicides, suddenly feeling totally abandoned by the organization, and the awareness that actually there isn’t someone looking out for me in this wider organizational maternal-paternal way. Actually, there’s a ruthlessness here, maybe about life altogether that gets magnified by the organizational response.
That was also devastating. I think, also it was very difficult about it was that after a suicide, I think it’s very common to feel shame, humiliation, isolation. When you’re going through these organizational processes, you’re feeling that position, that guilty, ashamed position, and feel you deserve to be punished in some way, which certainly doesn’t help. I think by the end of the third one, I was probably a little unhinged actually.
Paula: Would you understand that in relation to your own trauma response?
Rachel: Undoubtedly looking back, I know that I had post-traumatic stress disorder. I know that I did. I know that I was living it inside it. I still have it. I can still feel it and I can still see it in other people but I think in reality, this is what I think, in the health service, I think we’re so traumatized. I think the people that often work within health services are functioning within post-traumatic stress disorders. We’re all triggering each other and then the whole nature of it becomes collateralized to be traumatized.
Paula: How do you think that shows up?
Rachel: I think within the health service, it shows up to do with sadomasochism. Actually, I think that it becomes the brutalization of the environment is a result of trauma, which I think there is in the health environment at the moment, certainly the NHS health environment, but not just that.
Paula Redmond: By sadomasochism, do you mean the patterns of behaviors that we might get into that are continuing to hurt us.
Rachel: It becomes normalized and it becomes extremely difficult, the opposite to kindness and compassion. It becomes normalized to relate to each other. There’s more than aggressive ways. In a way, there’s nothing wrong with aggression. It’s not that. It’s what people talk about bullying. It’s the idea. I don’t quite [unintelligible 00:10:26] buy into bullying because bullying [unintelligible 00:10:28] implies as one victim and one aggressor. With sadomasochism, the nature of describing it like that is that it’s a two-player game.
You can’t have a sadist without having a masochist. A masochist will be a sadist in a different situation. We all behave like that. If we could become overwhelmed with anxiety and stress, we can’t be kind or compassionate. Actually, what we do is we project into other people and we can all be cruel, thoughtless, dismissive, contemptuous. In a way, that’s the heart of a lot of the work that I’ve been doing in different settings is trying to get to the heart of the trauma with the idea that if we can address this, acknowledge it, and address it, then it can relieve some of that disturbance within the whole system, that if we don’t address it, if we keep on denying–
When I started working on suicide, what happened to me as I was absolutely devastated, and managed to [unintelligible 00:11:24] nobody talks about suicide at that point. I got together with a couple of colleagues and we asked Rob Hale, who was the director of Portman and had a big interest in suicide to come and join us, and we formed a group. We met monthly to work through this and to talk about it, to reflect on it, and found that actually by doing that, we started to recover ourselves.
The trouble was, at that time, nobody talked about suicide. This was something we could do. We had to do it secretly really then. Other people didn’t have access to this. This wasn’t something that was widely available. What then happened is everybody’s trauma just stays under the surface and it’s just still there. Nobody talked about suicide. Nobody talked about the trauma of a patient’s suicide on them at that point.
The whole nature of what I’m trying to do or the movement towards is, if we can talk about it, if we can acknowledge this, we can start to mitigate, transform this post-traumatic stress disorder that a lot of us are struggling with into something creative. The idea of post-traumatic growth, that if we don’t engage with our trauma, it becomes destructive to us. It triggers sadomasochism and disturbance in our systems. If we can engage with it and work on it, it can become transformational and transform services, be it therapy really. The whole idea of therapy is the same as that. You get transformation through trauma, or if you can engage with it, work on it, talk about it, engage with your feelings, but it’s not easy thing to do. It’s not an easy thing to do.
Paula: What are the kinds of particular issues around suicide that make it so traumatic and such a tricky thing too?
Rachel: Where do I start with that one? I think the primary headline for me about suicide is to do, broader aspects of this, but it’s to do with that it occurs out of the blue. In my experience, the research I’ve done and looking at everything, all the data, it really does occur out of the blue. It’s incredibly shocking loss event in itself, incredibly shocking loss event. Even if you don’t know someone very closely, it’s an incredibly shocking loss event.
If you do know someone, and you have a love relationship with that person, it’s a very profound, sudden, distressing loss event. Then, you’re left with absolute uncertainty. You do not know and cannot know why someone has died by suicide because they’re not there to discuss it with you. Someone has gone the person who could at least involved in it, get involved in a dialogue or discourse around why it happened isn’t there. You are left in a place of unrelenting, unremitting uncertainty, which is not where human beings can tolerate being at all. We can’t tolerate that.
What we do then is we create a narrative or in any situation where we’re uncertain, we can’t tolerate it. What we’d like to do then and what we just do automatically is create a narrative to provide us with a story about why something’s happened and then we can relax, “Phew, I know now,” even though that story is not based in any reality. This happens with suicide. Suicide, very, very shocking, really, profoundly uncertain.
I think that level of loss and uncertainty really fragments fractures our own mind. In addition to that, it puts us up really hard against death and something about the reality of life that it’s something about what life means. It’s hard to put words into that but it hits us with a very deep philosophical question, I think, suicide. Very hard to digest and compute, and we then create a narrative.
Now, the trouble is, what we do is we create a very simple narrative. I think this is true for clinicians, families, and friends bereaved. It’s across the board. Then, we create a narrative and we create a very simple narrative and it’s the same narrative all the time. We create it with ourselves as the protagonist. We’re the star of the show in this narrative, and we are to blame. We’ve done something. We’ll have something in our mind that we’ve done, and it’s all us. We’ve done this. If we’d have done something different, this wouldn’t have happened.
At least, we’re not uncertain anymore but then we’re left in a terrible position of persecution where we feel we’re responsible for someone else’s death and to blame. I think in this state of mind, it’s to blame rather than responsible where we feel and actually can hold with absolute certainty that we’re to blame for someone else’s death, which is a terrible persecutory state better than being uncertain because I think that leaves you in a fragmented place.
It’s like an encapsulated, delusional state and very, very unbearable. It can take a long time. The trouble is, if we really believe to a delusional level that we’re to blame, then it makes it very difficult to talk to people about it and you see it, because the groups that I run now are involved in running, you can see that people don’t want to say their narrative, because they’re sure that everybody will just say, “Oh my gosh, yes, it is you.”
The other people are going to believe it, so you best hide it and keep it to yourself. For families and friends, it’s unbearable level of uncertainty, that it’s not almost barely survivable. How do you make sense of it? I think probably when people have got past the acute grieving, which some people never get past, but I think some people when they do get past, they spent an awful lot of the time. Maybe I spent an awful lot of my time, but I do actually is thinking about why has this happened? What’s led someone to do this? That’s actually where I spent a lot of my time thinking about that, reading about that, and trying to understand that.
Paula: How can we understand that? What does the data and literature say?
Rachel: What’s very interesting is there’s very, very little about the underlying mental mechanisms that lead to suicide. Very, very little. It’s amazing that we tolerate it and don’t comment on it. Wherein other branches of science, there’s quite stringent rules that you try and prove the null hypothesis. You look at the data and try and prove the null hypothesis. It doesn’t happen with suicide.
People ignore the null hypothesis and they try and go straight to try to prove what their fantasy is about it. They ignore all the data that says something different. I think the data that I have seen and been involved with seems to indicate that it is incredibly difficult to predict any individual suicide. This idea that we can tell, and it’s so difficult to discuss this with people, particularly within mental health.
The data I’ve seen to actually predict this live person sitting in front of me now, if I think about you, let’s say, if this live person sitting in front of me now is going to go on and die by suicide, I don’t think there is any evidence I’ve seen that that’s possible. If we look at the evidence around risk assessment tools, and let’s just hold on to that a bit. The majority of deaths by suicide do not happen within mental health population. Over 73% happened in the population who haven’t been in contact with mental health services.
When we’ve looked at Coroner’s data, quite a lot of those have no known history of mental health problems at all. It’s very hard to keep that in mind by far the majority have not been in contact with mental health services. About 27%, 28% have in the last year and that includes things like IAPT. This includes all different levels of mental health. I think we start having a fantasy of people on the wards or people in their neighbors but it’s not the case. For that group that have been in touch with mental health services and have had a risk assessment, if you like one of these risk assessments, 95% have rated them as low risk or no risk. What people might say is, “Oh, we haven’t got the right tools,” but that is an example of the argument that [unintelligible 00:20:07] I made rather than arguing the null hypothesis which is actually maybe– could it be that predicting individual suicide might be incredibly difficult if not impossible. To me, that makes sense with what I’ve been reading about suicide. What I wanted to go on and say is that the only people that thought about the unconscious mental mechanisms of psychoanalysts and the two that have written about it most recently are Don Campbell and Rob Hale.
Rob Hale was in our group who’ve written a wonderful book called Working in the Dark: Understanding the Pre-suicide State of Mind. They’re really the only people who have tried to understand what leads someone to die by suicide. What they say, and seems to be backed up with a lot of the data now. This is my interpretation of something. What I would say is for everybody with suicide, “Look at it yourself, have a think about it yourself,” is that suicide occurs in response to a loss event.
What precedes many deaths by suicide, many, many, is some significant life event or some significant loss event. That could be some with no mental health history, significant loss event. That could be weeks. It could be days, weeks, months, years even, before someone dies, but let’s say it’s years, someone might say he never got over the death of his mother. There’s some sense that there’s a loss event preceding it and that there’s something about mourning the inability to mourn that event which leads to the death by suicide.
The other thing to say about why I think it’s hard if not impossible to predict is that suicide isn’t acting out what’s called acting out. We all act out. If I get stressed at work and come home, I’ll say I just need a drink. That’s an acting out. I’m doing something almost like it’s a first expression of a feeling or emotion. I might think, “Oh, I’m wanting a drink. Oh, I must be stressed.” By doing it, I know that I start to get some insight into the fact that I feel it. This I think is the case with suicide. The suicide is an acting-out event. People act out when they can’t put their feelings into words.
Often, the first thing they might know about how desperate they’re feeling is that they make a serious attempt on their life, and it’s through the doing that we start to symbolize something. This idea that people could come and tell us that they’re suicidal in an active way, I’m not sure about that. I think maybe in many cases the person themselves knows and anybody else knows that they’re truly suicidal is that they make a serious attempt on their life.
Paula: You said that part of what goes on is an inability to mourn, can you say a bit more about that?
Rachel: Mourning is a major life task. We spend quite a lot of our life mourning to separate, to individuate, become someone separate from our parents, is a mourning process and quite a complex one, but it’s also very dangerous. A lot of people know the [unintelligible 00:23:15] grief cycle about the different feelings that come after a loss event so the first would be denial. The next would be anger, then bargaining. Then sadness and acceptance.
If we just take that as a very relatively crude model of mourning, what we can see afterwards is this period of anger. In a way, having suicidal ideation is a very normal part of mourning. If we’re truthful to ourselves about it, that if we’ve suffered a significant loss event, we might have fleeting suicidal thoughts. The bigger the loss event, the more traumatizing, the more difficult, the more intense those thoughts might be because you might really think I can’t survive that.
If I think if I lost my children, might not want to carry on. Don’t know that I’d survive that. If we think about that, in a way, suicidal ideation is a normal part of mourning. I think in these cases, following these loss events, there’s something that happens in the mourning cycle that leads to this action, if you like, the suicidal thoughts. There is a [unintelligible 00:24:26] I just can’t mourn this. I’ve got to get away from it. Mourning’s very, very painful.
Paula: I’m interested in what you were saying about mental health services. If you work in mental health services, it often feels like your one aim is to prevent suicide, that things are really set up. Nothing else matters as long as you’ve done the risk assessments.
Rachel: Which is part of the sadomasochistic environment because to me, that doesn’t feel right at all because in a way, in all health environments, our role is to care. For me, caring isn’t predicting and preventing suicide. It’s about engaging in a therapeutic, caring, compassionate, containing way with somebody that might then allow some facilitation of them moving through whatever these painful places that they’re in.
If we think about physical medicine rather than psychological, a significant portion of people that die by suicide have got serious physical health problems and not serious mental health problems, but yet, people who work within physical health environments don’t see it as their job to predict and prevent suicide. In some ways, I think it is a bit of disturbance of our current system that that’s what we’re focused on. I think that takes away from compassionate engagement and thinking that our primary task is compassionate engagement in a therapeutic way. If we can do that, it’s very likely to prevent suicide.
If we can help people put their feelings into words, help them with their distress, their losses, then it’s very likely to prevent suicide but chasing after, “Are you going to kill yourself? Please reassure yourself,” that’s driven. The whole thing of predicting and preventing suicide is driven by our own fear of what’s going to happen to us. We’re terrified. We’re functioning in a post-traumatized state where we are terrified
Paula: All sorts of things go on in terms of thresholds being set for services around suicide risk and people not being able to access help unless they are at risk of self-harm or suicide?
Rachel: Yes. It hurts your head.
Paula: I can think about it and say it’s actually a nightmare.
Rachel: It hurts your head, doesn’t it really? People feel trapped in a unbearable place which they know and can recognize as not being the same place to be in but yet, the route out isn’t visible.
Paula: That’s so interesting because those words could apply to patients and professionals too in terms of how we relate to work.
Rachel: I was just associating to someone presenting about– During the pandemic, there was a group who set up a staff mental health service. Mental health staff were referred to this mental health service, and they were found to have secondary-level mental health problems. Many more were referred than they were expecting. What they found was the staff had as serious mental health problems as the patients that they were treating. [unintelligible 00:27:59] picture of the division, isn’t it really?
Paula: That brings on to my next question about colleague suicide and the impact that that has on us. I think there’s an accepted understanding that doctors are at higher risk of suicide than the general population but I’m not sure if that’s accurate.
Rachel: I think the data changes quite a bit and which general population are you thinking about. I think there are different professions with different risks. The colleagues that come to my mind are doctors but not just doctors. They’re nurses. The people that I’ve seen who’ve died by suicide are across the spectrum of mental health, and I think there’s a profound effect. I think there can be in a way an even greater silencing struggle with the colleague suicide. Because of the guilt and sense of responsibility and sense of shame, it’s not a hierarchy of pain but can be harder to mourn or engage with.
I think the organization itself which can function as a system can feel more guilty and therefore find it even harder to actually put in support. I think a lot of the principles are similar as with struggling with a family, a friend who’ve died by suicide or a patient. What I just want to say is what’s very interesting is when I go and talk about suicide, I’ll ask people within the audience to put up their hand if they’ve had a clinical audience, if they have had experience personally of suicide. At least a half or two-thirds have put up their hand. I think this division between clinicians, [unintelligible 00:30:07] we have clinicians and we have patient suicides and then there are family members, and friends is an artificial one. We are family and friends, and suicide affects everybody. What I would like to do with a colleague suicide is put that right up there as well as something we need to think about and not hugely separate it one way or another.
Paula: Interesting to think about how suicides within families can cast a very long multi-generational shadow. and I’ve certainly experienced that in relation to colleague suicide in a couple of places that I’ve worked at where I didn’t know the person but it’s around and it can be felt years later.
Rachel: It’s felt years later because it hasn’t been engaged with consciously. If you don’t engage with it consciously, it gets expressed unconsciously. It’s dangerous. I do talks about that that actually the reflecting and reflective practice is a life or death issue. That actually is a very serious issue. If we don’t engage and think and try and process, what we’ll do is reenact things, and it’ll come back in a disturbed way. There was one case where there was a death of a patient by a suicide on a ward not engaged with. A year later to the day, another patient did almost exactly the same thing but survived, was saved by the staff, and was reparative but I think the profound unconscious processing can’t be underestimated.
Paula: How might that be apparent? What might we see in terms of disturbance in a team?
Rachel: I think we can see profound disturbances because I think the trouble is once people turn away from thinking together and reflecting, then it becomes very difficult to establish this. The more the team doesn’t think together, the more they turn away from each other, the more disturbed their behavior become. In inpatient settings, in mental health ward settings, you can get situations with a lot of violence that actually there’s a real dangerous expression. I think that’s also hard to talk about because people don’t want to think about the dangerous aspect of something. Someone’s died. This is the real edge of something stuff as is homicide which is what I also do some work on. These disturbances get into the system and not only in emotional violence but actually can be in physical violence and reenactment. It really profoundly disturbs the system. Again, going back to where we started a bit about the sadomasochism within our environment, unprocessed trauma.
Paula: Also, my sense particularly within mental health services of a lot of avoidance that can go on in relation to patient risk, and actually it ends up increasing the risk. We want to turn away from the reality of this stuff.
Rachel: Can I just point out something? Even the word risk is an avoidance. What is it we are really saying when we’re talking about patient risk? What does risk mean? Risk means, on the whole, I’m very frightened of you killing yourself or killing somebody else but we can’t say that. We use the word risk. Don’t we? That’s what we mean. We use all sorts of words to allow us to talk about something we’re actually very preoccupied with without us knowing that we’re very preoccupied with it.
Paula: Also, I think it is about us getting into trouble for managing the unmanageable. Like where is the risk? Someone does something and you get–
Rachel: That’s right. I’m very frightened about something terrible happening to me. Where’s the risk? Absolutely. I totally agree with that.
Paula: I’m wondering I’d be curious to hear about the work in homicide that you do as well and the links there.
Rachel: We’ve been running this what we call the suicide group, the consultant psychiatrists. Now, there are other groups being ran. We are actually running one in the heart of the Royal College for all psychiatrists on the effect of patient suicide. What happened after a little while is we started to have presentations of patient homicide in this group, and what you could see is that the consultants that were presenting about patient homicide were really seriously traumatized. That’s not to say in all cases, and it’s not the case people can hear me and say, “Well, I wasn’t affected.” It’s very different. Different in different cases and different with different people but seeing really high levels of trauma with patient homicide. In some cases, you could see the organizational response, never mind it’s trauma of the event. What seemed to be happening in some cases whether the consultants were almost framed for the murder themselves and were treated as though they were the murderer and therefore almost brought into that themselves and made it incredibly difficult to seek help. I think that’s still the case.
We had a group at the Royal College. We started off. We’ve got a homicide working group, and it was almost impossible for the clinicians that have been affected by patient homicide to say anything at all. They could not. They were pretty mute actually. Trying to get, bring this out into the open and to talk about it, I think we’re about eight or nine years behind suicide and one patient homicide, someone was saying, “Far fewer patient homicides than suicide but one patient homicide affects a very, very wide area.” It can be very traumatic for an awful lot of people.
Paula: It’s scary to think about it. Isn’t it? It’s scary just the word homicide and murder. Really terrifying to think that can be part of your working life when you haven’t signed up to that.
Rachel: I don’t know whether we don’t sign up to it. That’s the thing that I was thinking. Maybe there’s a part of us that does sign up to it. There was a consultant I was talking to about who now serves with white sharks in Australia. You think, “Well, maybe there is something of us that does put ourselves unconsciously in these dangerous situations.” Undoubtedly, to work with these powerful human forces, there is something in us that drives us to it, puts us in these situations.
Paula: Is homicide different from the perspective of prevention?
Rachel: Personally, I’m going to speak totally to my own understanding. I think the internal mental mechanisms aren’t wholly [00:37:26] totally different to suicide. I think again the first time someone might know that they’re at risk of enacting a homicide is when they do it. Again, I think we have the same problems and certainly from talking to people that I have heard talk about it, they have had no clue that their patient was going to enact this.
Paula: It’s so terrifying. Isn’t it that thought that we can’t stop people killing each other or themselves?
Rachel: We do know that. This is what I struggle with. It’s like we constantly go back to this but really if you don’t work in mental health, you wouldn’t really think I can predict someone’s capacity to enact a suicide or homicide. You wouldn’t really think that. I don’t think.
Paula: If you don’t, do you feel reassured that that’s someone’s job? There’s people out there who are doing that.
Rachel: I think but I’m not sure that we really believe that they’re going to do it but I think again it’s a bit like a story that if we create that story, that means we don’t have to think about it because if we have to think about it, if we have to move close to think about the unpredictability and the reality first that someone might know about this is that they do it. Then, we could do it. My children could do it. My parents could do it. My husband could do it. My brother could do it. Where does that leave us? If this is part of a human condition, then it can affect all of us which I think we do many, many mental maneuvers to try and prevent engaging with.
Paula: You’ve talked about how talking is really important in this and being able to voice some of this unspeakable stuff. I’m wondering if we can expand on that in terms of their particular ways of talking or spaces.
Rachel: What we’ve been spending a lot of time at the Royal College doing is trying to write guidance for all mental health organizations. We’ve just completed writing guidance for all mental health organizations for the pastoral care of their staff following the suicide of a patient. We’re going to be writing one for pastoral care staff following the homicide of a patient. We have got these recommendations based on research conducted with the Oxford Center for Suicide Research.
With the Oxford Center for Suicide and Research, we also have produced a booklet for clinicians after they’ve had a death by suicide, giving them advice and self-care and recommendations. What we’ve recommended in this, I can tell you what we’ve recommended, and certainly, reflection is a very large part of it, but the trouble is to just say, “Oh, you’ve got to reflect in mental health services.” That’s not going to work. We’re too busy. We are far too busy to be doing whatever this reflection is.
We’re not going to do that. What’s worked with the suicide group that we have at the moment, suicide and homicide group, is it’s run regularly. It’s been run regularly over many, many years. People know it’s there. People drop-in. They drop out. They come. What we find is there’s a core group of people. Others will come once, tell their story, get some relief, go. Some people stay. Some people come a few times. People drop in and out.
There’s something about having systemically enshrined is the word that keeps going to my mind, spaces to reflect that they do need to be in there before this event happened. There’s something about a culture of having these spaces. Whatever you want to call them, we’ve call this one a suicide. What you’re recommending is that all mental health organizations have a suicide group basically. There’s something that goes on, but then you’re going to need somebody who is committed to engaging with that and holding that. That has been developed in some other mental health organizations now by consultant, medical psychotherapists, and psychiatrists holding these groups.
They seem to be working well and seem to be wanted by the mental health environments. Recommending that, what we’re also recommending is for all mental health organizations is to have a suicide lead, someone who is actually responsible organizationally for the pastoral and make a real effort to emphasize the pastoral care because what happens in this situation and within mental health services, something moves from pastoral to suicide prevention and making sure we get these actions put in for the whole system. That’s it.
Rather than actually no, it’s about pastoral care. It’s about pastoral lead, pastoral senior management support because I think, again, there’s something about– Actually, just to receive something from your manager saying, “Look, I’m sorry, this patient died. I hope you’re all right.” There’s something about those basic human caring responses that within current health services, you really need to emphasize, put in almost in a protocol to actually make sure that they happen.
There’s something very important about the relating with families and friends, that this is something that can happen very powerfully after death by suicide, is everybody’s overwhelmed by anxiety and shock, and everybody can fall apart. Everything can fragment, so relationships between families, friends, the organization, the clinicians can become quite fractured. What’s very important and what we’re really putting a lot of emphasis on is that the employment of family liaison officers with all mental health services so to actually have someone who isn’t involved, who can act in a third space and support and accompany the families and friends and communicate for them and help liaise.
What I see with clinicians a lot is they’re so distressed, but they so want to help the families and friends. They so want to, but they’re not in a good state to do that. They’re really not. I think there would be something that would so help them than look after themselves if they knew that someone was looking after the families and friends. Then, they could relax a bit and maybe think about what might be right for them. What you often don’t want, and I’ve seen some really quite difficult situations where this has happened is traumatized clinicians rushing to try and engage with a family without some support and containment.
That’s often not necessarily what the family want. There’s something about, look, stop, think, a reassurance about care for the family, communication, which is very important. We were also thinking about body systems. If you’ve had this experience to be buddied up with someone who’s had it in the past and knows a bit about the processes to help you accompany you, and very, very much about the group, psychological support, and individual psychological input. We’ve got a lot of things we’ve been thinking about in that, but I think they will come to something to do with trying to enshrine something about pastoral and what it actually really means, what’s the fundamental components of looking after ourselves? It’s amazing that you have to actually write those down for people. It’s like, remember to breathe, remember to eat. It is like, look after yourself [unintelligible 00:45:22] try and sit down, talk to somebody, try and go and reflect in a safe place where you feel you can talk through this.
Paula: I think there’s something important about just acknowledging that this is a thing that when a patient dies by suicide, it really hurts and it can be devastating. I think actually that’s just important message in itself because I think there’s a lot of people who’ve experienced that and just haven’t stopped to think about the impacts on them or that they’re allowed to be impacted. Everyone just carries on. You get all the systems, everything and the investigation goes, but there isn’t a real acknowledgement that it’s normal and expected that this is really hard, and then that compounds, doesn’t it? You’ve not only got the shame of, “It’s my fault,” but the shame of, “This is hard and everyone else’s life’s going on as normal, but I’m struggling here.”
Rachel: It can be really devastatingly hard. I think it’s something called disenfranchised grief, is what you’re talking about, which is this idea that actually I haven’t got a right to grieve in a way. There’s a hierarchy in grief. There’s not enough grief to go around, so it’s important the families and the friends have the grief. I haven’t got it right, because if I say that I’m hurt or that I’m grieving as well, somehow that’s going to take something away from the validity of the families and friends’ grief, which is not a sane way to think.
It’s a bit like there’s not enough love to go around, [unintelligible 00:47:13] not enough grief to go around. Well, there is. If you don’t, I think we can again function within a bit of a disturbed system, which is the patient comes first and the patient [unintelligible 00:47:26] which doesn’t really make sense because if we don’t look after the people caring, then they can’t care. It’s a bit like, “Well, what’s more important? The mother or the baby?” The baby’s more important. Unfortunately, if the baby doesn’t have a healthy mother, it’s not going to get very far.
There’s something about that, and if we can try and step back from and really try and engage with that this is what’s fundamentally important, if we can care for the people that are caring, then people will be cared for in a way that is better. If people have a capacity for life, joy– A non-depressed mother is a mother that you want.
Paula: What message would you want to give someone who might be listening to this and has been affected by suicide through their work, and maybe their organization doesn’t have yet all these things in place?
Rachel: We’ve produced a lot of resources. Firstly, you are not on your own. You’re really not on your own and you can feel really on your own and whatever the narrative is you are creating in your mind, I can promise you, you will be creating one where you are to blame, you are not. That is not saying that’s a delusional narrative. It is just to hold onto that. There is also quite a lot of resources now in a way there never was in 2008 and we’ve produced a lot. They are on the Royal College website, and you can download them. They also signpost you to all sorts of other resources.
We’ve got videos of clinicians talking about the effect that suicidal patient has on them. We’ve linked up with the American– There’s the clinician survivors of suicide in the United States, huge organization now. This has raised awareness of the fact that this can be a very powerful trauma for people. There’s a lot of resources out there and a lot of help out there. Do reach out, do communicate about it. It is through the communication, it’s through talking about it, that you will feel better.
[music]
Paula: Thank you for listening. If you enjoy this episode and you’d like to help support the podcast, please do share with others. Post about it on social media, or leave a rating and review. I’d love to connect with you, so do come and find me on LinkedIn or Twitter. You can also sign up to my mailing list to keep up to date with future episodes and get useful psychology advice and tips straight to your inbox. All the links are in the show notes. Thanks again. Until next time, take good care.
[music]
[00:50:40] [END OF AUDIO]
