After finishing our psychotherapy session, I walked alongside Ethan to the waiting room. One month short of his 17th birthday, he’d spent the hour avoiding talk of his unpleasant past. Instead, he’d waxed hopeful about college and a more intellectually stimulating future. He’d asked me to read a few of his freshly written poems. Instead, as usual, I asked him to read his words to me.
“Oh, the horror of merging elements! Indigo shall never mix soundly with Red!” I wondered aloud about whether Ethan’s poem might be referring to his struggles mixing in with other youth. He gave me a Mona Lisa smile. His poetry was dense; he used words like lassitude, regality, and effluent. No wonder he didn’t blend in well with other high-school students.
Once in the waiting room, Ethan did something he’d never done before. He turned to face me and reached out for a handshake. I reached back. His grip was soft, his skin cold and clammy.
“Thank you,” he said. His eyes met mine, another unusual move for him. His discomfort with direct social contact quickly resurfaced, and his gaze dropped back to the floor.
“Sure, Ethan,” I said. “Happy to help. See you next time.”
There was no next time. Three days later, Ethan was dead of a self-inflicted gunshot wound.
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Twenty-eight years later, I can still feel Ethan’s clammy handshake. I still see his eyes meeting mine. I can hear his words, “Thank you,” as they hung in the air that day. I can easily do the math: had he lived, Ethan would be 44 years old now.
As occasionally happens, I recently conducted an unscheduled personal review of my work with Ethan, following a presentation about suicide and suicidality. This time, suddenly awake at 5 a.m., my brain had paired my work with Ethan with my publication of a new book on strengths-based approaches to working with suicide. I mentally walked back through key moments and painful memories. Dark thoughts followed. Who was I to present myself as an expert on suicide? After all, I’d failed Ethan. By the time I’d dragged myself out of bed, I was once again convinced that I should have known Ethan was imminently suicidal. I’d returned to a place of professional self-blame and condemnation.
Every morning, I have the good fortune of breakfast, coffee, and conversation with my coauthor and wife, Rita. Coffee helps. Talking helps. Sunlight helps. On bleak mornings like this one, Rita asks questions and provides reassurance to straighten out my crooked thinking. She helps reorient me to what I already know: scientific research has demonstrated that clinicians can’t predict suicide accurately. Suicide isn’t 100 percent preventable.
Having breakfast with my own personal clinical psychologist helps give me intellectual distance, which in turn offers welcome perspective. Conversations with Rita sometimes lead me to examine my self-doubt through various theoretical lenses. My imaginary Adlerian friends tell me I suffer from an inferiority neurosis. My CBT friends wax empathic about the intransigent nature of core cognitive beliefs; they recommend a cognitive-coping model for dealing with early-morning automatic thoughts (Note: I only hang out with real or imaginary CBT friends who are capable of empathy). My psychodynamic friends try to take me deeper. I resist. They analyze my resistance; I respond with more resistance. My solution-focused friends tell me a distracting joke and walk me to the nearest bakery, while nudging me to do more of whatever already helps me feel better. My family systems colleagues roll their eyes and ask, “Who told you you’re supposed to be a superhero?”
Having lived so long as a youngest and only boy in my family of origin, I confess to my family systems colleagues that they might have a point, but I’m not ready to dismiss my long-held hero wishes as simply a fictional family fantasy. I have two Captain America action figures in my office, and I want to keep them. Without my superhero fantasies, I’m an imperfect, aging mortal—and most days, that’s a reality I’d rather not embrace completely.
The Prevention Myth
I’d worked with Ethan for about 20 sessions. Stocky, socially awkward, and intellectually gifted, he often avoided telling me much of anything, but his unhappiness was palpable. He didn’t fit in with classmates or connect with teachers. Ethan felt like a misfit at home and out of place at school. Nearly always, he experienced the grinding pain of being different, regardless of the context.
But aren’t we all different? Don’t we all suffer grinding pain, at least sometimes? What pushed Ethan to suicide when so many others, with equally difficult life situations and psychodynamics, stay alive?
One truth that reassures me now, and I wish I’d grasped back in the 1990s, is that empirical research generally affirms that suicide is unpredictable. This reality runs counter to much of what we hear from well-meaning suicide-prevention professionals. You may have heard the conventional wisdom: “Suicide is 100 percent preventable!” and, “If you educate yourself about risk factors and warning signs, and ask people directly about suicidal thoughts or plans, you can save lives.”
Although there’s some empirical evidence for these statements (i.e., sometimes suicide is preventable, and sometimes you can save lives), the general idea that knowledge of suicide risk, protective factors, and warning signs will equip clinicians to predict individual suicides is an illusion. In a 2017 large-scale meta-analysis covering 50 years of research on risk and protective factors, Joseph Franklin of Vanderbilt University and nine other prominent suicide researchers conducted an exhaustive analysis of 3,428 empirical studies. They found very little support for risk or protective factors as suicide predictors. In one of many of their sobering conclusions, they wrote, “It may be tempting to interpret some of the small differences across outcomes as having meaningful implications, . . . however, we note here that all risk factors were weak in magnitude and that any differences across outcomes . . . are not likely to be meaningful.”
Franklin and his collaborators were articulating the unpleasant conclusion that we have no good science-based tools for accurately predicting suicide. I hope this changes, but at the moment, I find comfort in the scientific validation of my personal experience. For years, I’ve held onto another suicide quotation for solace. In 1995, renowned suicidologist Robert Litman wrote, “When I am asked why one depressed and suicidal patient dies by suicide while nine other equally depressed and equally suicidal patients do not, I answer, ‘I don’t know.’”
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About halfway through our 20 sessions, Ethan orchestrated a fake suicide attempt. He was discovered, ostensibly unconscious, in the garden shed with an empty pill bottle. After the fact, we discovered that he’d dumped the pills down the toilet, and was feigning unconsciousness.
At the time, having a client fake a suicide was new terrain for me. With 28 years of hindsight, I see it now as a kind of suicide rehearsal. After Ethan’s fake suicide attempt, I met his parents in the hospital emergency room. While there, I consulted with the ER doctor. We were stunned and puzzled that Ethan would pretend to be unconscious and near death. In our next session, when I directly asked Ethan about the feigned suicide, he too was mystified. “I don’t know why I did that,” he said. “If I told you I knew why, I’d be lying.”
Ten sessions later, Ethan seemed much improved. His peer relationships were somewhat better. His parents wanted him to join a church youth group. Ethan didn’t like church, but he’d agreed to give it a try. He’d been writing poetry and spoke admiringly about his English teacher. He’d brought me a stack of his poetry and shared new poems. Ethan looked better and more hopeful than I’d ever seen him.
In my superhero fantasies, I sometimes think that, like Peter Parker, I’ve got an intuitive Spidey sense. Looking back, Ethan had several classic suicide risk factors, including depression, feelings of social alienation, and a fake suicide attempt. Also, as researchers have reported, when depression lifts, as Ethan’s had, suicide risk can increase, partly because of increased energy to act on suicidal impulses; and there’s substantial evidence that, for some patients, suicide risk increases after hospitalization. I should have been more suspicious. Ethan may have given me his poetry and shaken my hand as a final goodbye, but at the time, my Spidey sense didn’t tingle; there was no intuitive knowing. I had no idea what was coming.
The Loudest Thoughts
Early Wednesday morning, our home phone rang. It was Ethan’s older brother. “Dr. John,” he said. “I’m sorry to call you at home.” There was a brief pause. “Ethan killed himself yesterday. My parents wanted you to know.”
I went numb. At the same time, my thoughts raced. I was to blame. What had I missed? I saw an image of that last handshake with Ethan. Also, would I get sued? Another part of me automatically said, “Oh no. I’m so sorry.”
“The funeral is Saturday.” Ethan’s brother waited.
Censoring my self-condemnation took effort. After a short silence, I repeated, “I’m so sorry.”
His brother continued, “If you don’t mind, my parents and I would like you to come to the Mass. In the end, we think you were probably his best friend.”
The call was mercifully short. I wish I could remember and share everything that raced through my mind, partly to help normalize the experience for others. My guess is that most people, upon first hearing of a client’s or loved one’s suicide, experience their own particular array of intense reactions. I know I was awash in a painful, disjointed, and disorganized mix of responses. I was touched to hear that I might’ve been Ethan’s best friend, but I felt devastated: if I was that close to him, then I should have been able to save him.
Amid this jumble of reactions, I heard Ethan’s brother say that the family wanted me at the funeral. I heard him say that they wanted me to come to their house afterward to help celebrate Ethan’s life. “Yes, of course,” I agreed. “I want to be there. Just tell me where and when.” I wrote down the information, told my wife what had happened, noticed my mounting litigation anxiety, and left for the Abnormal Psychology class I was scheduled to teach that morning.
- - - -
Small Catholic churches make anonymity difficult. I was greeted at the entrance, said quick hellos, offered condolences, and slipped into a pew in the back. I remember struggling to focus on the particulars of the service because internal events inside my brain were so loud. At some point, I noticed the priest was preparing to offer communion.
As a child, I’d taken communion in my grandmother’s Catholic Church. Since then, I hadn’t felt Catholic enough to take communion. At Ethan’s funeral, I faced a conundrum: I wanted to join in a meaningful social and spiritual support ritual, yet I wasn’t absolutely certain that taking communion for that purpose was technically permissible. In the end, I stood up, made my way to the front of the church, took communion, and returned to my seat. Although my behavior may not have represented great religious integrity, it felt good and important to be with Ethan’s family in their traditional way of grieving.
After the service, I followed Ethan’s parents to their home. We ate cake. They showed me his computer and more stacks of his poetry. A grief counselor was there. I still hear her voice. I know this sounds terribly judgmental, but her comments about death, dying, grief stages, and descriptions of what’s normal seemed shallow and trite. Her voice irritated me. At the same time, I felt grateful for her presence. She provided useful psychoeducation to the mourners at a time when I didn’t feel up to the task. As I left, I couldn’t resist the impulse to give her a heartfelt hug.
Balms for the Wound
When clients die by suicide, mental health professionals are often coached to proceed with caution. Underneath the sadness, disbelief, and sorrow for Ethan’s family, a voice in my head kept warning me of liability. When children and teens die by suicide, parents and family members often blame therapists. Although Ethan’s brother didn’t do that, I couldn’t help worrying about the legal risks.
Recently, I attended an American Psychological Association (APA) webinar on suicide, featuring David Jobes, a leading suicide researcher and developer of Collaborative Assessment and Management of Suicidality (CAMS). Jobes and the representative from the APA Insurance Trust shared four tips on what to do if a patient dies by suicide: be kind and compassionate, manage your trauma and grief (and get your own therapy), go to the funeral (unless the survivors are really mad at you), and don’t be afraid to express your regrets and sorrow, because there’s good evidence that being human (rather than a detached professional) reduces litigation. Although this list includes great advice for avoiding liability, it’s even better advice for doing the ethical and right thing during an exceptionally challenging time. All I can add to these suggestions is that it’s useful to be in a supervision or peer consultation group. It also helps to marry a mental health professional.
If you’re reading this, you may have a suicide and loss story of your own, or you may face one in the future. Death by suicide usually leaves an aftermath of guilt, anger, sadness, shock, disorientation, and numbness. While suicide can’t always be predicted or prevented—the research is clear about this—therapists are often tasked with doing exactly that. One Australian research group has recommended discontinuing the practice of categorizing suicide risk as mild, moderate, and high—because we’re more than likely to be wrong.
What can we do to help, instead? We can work collaboratively with clients to reduce their misery and help them change negative thinking patterns, enhance social connections, find greater meaning in life, seek out more validating life circumstances, and generally take better care of themselves. When clients are willing and able, we may experience some measure of success. When suicide seems imminent, we can direct clients toward higher levels of care, despite the fact that data are mixed on the outcomes for hospitalizing clients due to suicidality. But in the end, when someone dies by suicide, we are not to blame, even though we may feel blameworthy. By definition, suicide is an act that’s chosen by an autonomous human being.
Trauma and vicarious trauma alter your sense of time. That was certainly the case for me. I was emotionally and intellectually disoriented. I needed support. Being alone to reflect on what happened was occasionally useful. Being with people who reassured me of my competence and worthiness was essential.
Before and after Ethan’s suicide, I was in a peer supervision group that met bimonthly. When I shared the story of Ethan’s suicide with my colleagues, there was empathic murmuring, but mostly silence. Finally, an older psychologist spoke up and asked me several pointed questions about how I’d handled the case. Eventually, he pronounced without equivocation that I’d followed all the customary psychotherapy practices. He said, “You did everything you could.” My relief was immense. Later, I consulted with the psychiatrist who’d been working with Ethan. We talked about our respective shock and sadness, and we provided mutual comfort to each other for not having been able to prevent Ethan’s death.
Positive judgments and support from my peers helped shore me up in places where I felt weak. Hearing “you did all you could” from friends, family, and colleagues was a balm for my emotional wounds. For you, it may be different. I’m not advocating a blanket approach of seeking reassurance as the solution for all suicide survivors. What I’m saying is this: don’t dismiss the importance of interpersonal support as one way to help you cope with your emotional distress.
But here’s the irony: after all these years, I still believe my peers, friends, and wife were too reassuring. Part of me is still convinced that I should’ve done better for Ethan.
And here’s another part of the suicide dialectic. Right alongside my guilt—the feeling that I could’ve done better—is the certainty that I did very good work with Ethan. The idea that I should’ve, or could’ve, saved his life is a superhero fantasy. The reality is that I worked hard, and I was unable to prevent him from dying.
My personal struggles between feeling guilty and feeling competent aren’t universal. You may or may not feel guilty for a long time after a suicide death. You may have other strong emotional reactions, such as anger or sadness. I’m sharing my continued long-term guilt because I want as many people as possible to know at least these two things about what’s normal in the aftermath of suicide.
First, when people really want to die by suicide, they can almost always find a way to make it happen. People will die despite having a caring and skilled psychotherapist, despite excellent healthcare, and despite being surrounded by supportive family and friends. Sometimes, people who choose death by suicide have been struggling with deep, unresolvable, long-term emotional or physical pain. In such cases, it’s possible to understand their choice to die as relief from suffering.
Second, if someone close to you dies by suicide, it’s perfectly normal to feel guilt and regret. And you won’t be the only person hit by guilty feelings. According to the International Association of Suicide Prevention, on average, each suicide affects approximately 135 people. Hardly anyone within the gravitational field of a recent suicide escapes negative emotional fallout. Your guilt may persist despite reassurance from others, but feeling guilty doesn’t mean you’re to blame. Your lingering feelings are one sign—among many—of how much you cared.
After 28 years of waking up after Ethan’s suicide, I’ve concluded that for many psychotherapists, self-condemnation is all too easy. In the aftermath of a client’s suicide, we’re especially vulnerable to experiencing emotional storms of guilt, shame, regret, and possibly even suicidal thoughts of our own. Clearly, dealing with our own vulnerabilities is essential to providing competent care and maintaining our mental health. If you ever find yourself wondering whether it might be time to seek professional help, you might consider that thought an empathic message from within indicating that, yes, it’s an excellent time to reach out for help.
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A third character stands on my office bookshelf between my two Captain America action figures. His name is Sigmund Freud. Aside from his sexist views and narrow cultural orientation, his furrowed brow, melancholic spirit, cocaine addiction, and attraction to the death instinct, he reminds me that the history of psychotherapy includes not only grand successes, but also discouraging failures, and a wide range of modest outcomes. My Freud action figure manages to analyze the delusions out of my superhero fantasies. Do I wish I could save the planet? Yes, I do. Do I wish I could have saved Ethan, and every desperate client who feels the tragic tug toward suicide? Of course. As psychotherapists, I think we all want to save as many clients as possible, but we’re faced with great—and sometimes insurmountable—challenges.
I suspect, in the days after writing this article, that I’ll once again be summoned by my pesky brain, during a dark morning awakening, to rereview the case of Ethan. This time, I have a new plan. I’ll greet Ethan with gratitude for what he’s taught me, and for what he’s enabled me to teach others. I’ll remember Freud’s words, “The voice of reason is small, but very persistent.” Then, I’ll get up and pursue intimacy and connection with a passion. And if you happen to be grieving a suicide or a psychotherapy failure, I hope you’ll consider joining me in my new plan. When it comes to coping with suicide deaths, we need to let go of our superhero expectations and support one another as dedicated, fallible professionals and human beings.
John Sommers-Flanagan, PhD, is a professor of counseling at the University of Montana, a clinical psychologist, and author or coauthor of more than 100 publications, including nine books and many professional training videos. His books, cowritten with his wife, Rita, include Clinical Interviewing and Suicide Assessment and Treatment Planning: A Strengths-Based Approach. More at: johnsommersflanagan.com.
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