Paradise Lost: When Clients Commit Suicide

Paradise Lost: When Clients Commit Suicide

by Marian Joyce*
A psychologist describes the trauma of losing a patient to suicide.

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Becky

“May I speak to Becky, please?” I asked the female voice that had answered the phone.

“Who’s calling?”

“Dr. Joyce,” I replied.

“Her therapist?” she asked. I knew I had to protect my client’s confidentiality, so I couldn’t answer that question. I began to feel uneasy.

“I’m sorry," she said softly. "Becky killed herself last night.”

I felt as though underwater, my voice garbled, when I finally managed to say, “Okay, thanks for telling me.”

Becky’s gone? My patient committed suicide? I wandered into my living room, dazed. I stared out the picture window into the courtyard where the heavenly bamboo were growing. I hadn’t noticed how they had reddened, with berries forming, signaling the start of winter. The liquid amber tree was bare, dried leaves cluttering the bed. I need to clean up those dead leaves, I thought.

I looked at the clock. It was 9:45 and I was to meet my husband at our new house at 11:00. On my way over, I began to reflect on my last therapy session with Becky, a mere six days earlier. She had been struggling with depression, but she did not seem more deeply depressed than before, nor did she mention suicide. The only clue I had was a casual comment made towards the end of the session.

“I really don’t know what I’m going to do now. I thought about the Peace Corps,” Becky said. “But I need to be close to a therapist and psychiatrist.”

“Yes. And I wonder if being far away from Matt would also be hard,” I said. Becky was having difficulty recovering from a breakup with Matt.

“Well, that too,” she said. Then she changed the subject.

“I like having more time now that school is over,” she said. “I’ve been reading The Inferno.” I didn’t follow up on her comment and she moved on to a new topic.

At the end of the session, I escorted her to the door and, for some reason, I felt compelled to do “doorknob therapy,” unusual for me. As I opened the door, I said, “Maybe you might try reading something less…less intense than the Inferno?“

And that is when she beamed that smile, forever imprinted on my psyche, as last looks must always be.
And that is when she beamed that smile, forever imprinted on my psyche, as last looks must always be.

“Less intense? You mean, like, Paradise Lost?” A wide, brilliant smile. Then she exited down the hallway.

As I later found out, four days later she walked in on Matt with another woman and then drove herself to the emergency room because she was feeling suicidal. Six hours later, she was discharged and ten hours later she was dead. I’ll bet she flashed that same smile to the hospital staff before they let her go.

My husband, Joe, was already at the 1911 arts and crafts house that we had bought three weeks earlier. We were full of optimism and hope for rescuing this gem from neglect, but we hadn’t yet moved in.

“Marian, where do you want to put the bathroom sink? If we put it here,” Joe said, pointing to the back, “there’ll be more room for the closet. Glynn needs to know.” Glynn was our contractor.

I found myself pondering the ideal location of the sink. I imagined all the alternatives and finally settled on placing the sink towards the back.

Then Joe and Glynn were at it again, arguing about where to put the dishwasher. I tuned them out as I thought about the subtext of Becky’s Inferno/Paradise Lost comments. Had she tried to tell me: “I am bad, a sinner. I want to die and I will probably burn in hell”? How had I missed that reference?

Some people think that being a therapist is easy. “All you do is just sit there and listen,” they often say. But sometimes the client’s thoughts swim deep underwater, like fish that surface only briefly. Blink and you will have missed the sighting. Fortunately, clients will find creative ways to draw my attention to what they want me to hear until I finally “get it.” But I wouldn’t have that opportunity with Becky. I was left with so many unanswered questions: Should I have detected something that last session? Was there something I could have done? Why did she do it?

The 1:00 Spot

The next day I opened my planner and saw Becky’s name in the 1:00 spot. I stared at it for a moment. When I wrote that in, Becky was sitting in the room with me. And now she is gone. What was I supposed to do with her name? Crossing it off seemed disrespectful. I decided to leave it alone.

My 10:00 appointment was Sherry, a woman who had been going through a particularly rough patch lately. At 10:10 when she still hadn’t arrived, I began to panic. Where is she? I could feel my heart pounding. I frantically flipped through my planner to find her phone number.

“Hello,” she said. I sighed with relief.

“Hi, Sherry. It’s Dr. Joyce,” I tried to sound calm. “I had you down for a 10:00. Is everything okay?”

“Yeah, I’m on my way. My mother called just as I was leaving and I couldn’t get her off the phone. I’ll be right there.”

After our session, I hurried out of the office to make my appointment with a seasoned psychologist I had sought out to help me with my cases before Becky’s suicide.

“Well, a lot has happened since I made the appointment,” I said.

“Oh really?” she replied. Then she got out of her chair and stood up. “You don’t mind if I stand while we talk, do you? I have a bad back.”

I didn’t know whether to stand up with her, which felt awkward, or remain seated, which made me feel like I was a child. I chose the latter, and proceeded to look up at her intense gaze and recount the story of my patient’s suicide.
I felt shame as I described Becky’s case, her depression, my treatment plan, her ultimate giving up. I waited for her to offer some words of concern or encouragement.
I felt shame as I described Becky’s case, her depression, my treatment plan, her ultimate giving up. I waited for her to offer some words of concern or encouragement.

“Well, why don’t we go over your case session by session so we can find out what went wrong?” she said instead.

All I heard was “wrong.” Did she mean to say that if I had done things differently, Becky would still be alive? The thought of putting the entire year and a half that I treated Becky under the microscope terrified me.

“We could do that,” I said, but I knew I would never perform that “psychological autopsy” with her.

A few weeks later, some colleagues and I went out for a drink at a rooftop terrace overlooking San Diego bay. I began to relax for the first time in weeks as I watched the planes float by at practically eye level. This respite was suddenly interrupted by an emergency call from a client. I found a private corner and spent a few minutes calming her down.

“Sorry, client in crisis,” I said, returning to the table. “Seems like I’ve had a tough caseload lately.”

“You know, Marian,” Gita said, “that’s why we screen our clients and choose them carefully.” Gita knew about my client’s recent suicide.

“I guess I’m not very good at predicting that stuff,” I finally said.

Afterwards, I stopped by one of my colleague’s offices to get a book she was lending me. I found myself studying an abstract painting on her wall that I had never really looked at before.

“That looks like a nasty dragon,” I said. “I never noticed that before.”

She gave me a very concerned look and said,
“Marian, I think this suicide has traumatized you. You are seeing dragons and danger everywhere.”
“Marian, I think this suicide has traumatized you. You are seeing dragons and danger everywhere.” At first I sighed—she is a classical psychoanalyst and injects meaning into everything—but I could see her point.

“It’s just that I keep blaming myself and I can’t stop visualizing my client’s last moments. I can’t let it go.”

“This is not your fault. You couldn’t have known she was going to do that. We can’t stop someone from killing themselves if they really want to,“ she said.

But I had a hard time believing this. Can’t we stop them? Shouldn’t we know how to do this? Isn’t that just an excuse therapists use to get themselves off the hook?

I was very careful about revealing Becky’s suicide to others. Thinking back on the entire experience, that isolation was the most pernicious aspect of the ordeal.
I now realize that most people could not fathom how wounding it is to lose a patient. The slightest nuance or tone of blame from an esteemed colleague could ruin my day.
I now realize that most people could not fathom how wounding it is to lose a patient. The slightest nuance or tone of blame from an esteemed colleague could ruin my day.

I had shared my experience with a friend from graduate school whom I thought would be understanding. He responded flippantly, “What did you do wrong now, Marian?” I knew his sense of humor. He didn't mean that, but there it was again… my fault.

The Lawsuit

Shortly after the suicide, I contacted my professional liability insurance company to inform them of the suicide. They asked me a few questions regarding Becky’s case: age, employment status, relationship with parents and so on.

At the end, the person said, “It’s very likely the parents will sue you for wrongful death. Given what you have told me, they will need someone to blame. Please write up a summary of the incident and let us know if you are contacted regarding a lawsuit.”

Most therapists I know live in fear of being sued. I was no exception. And, of course, that is exactly what happened. Approximately three months later I received a request for medical records from an attorney representing the family.

“You must release these records, Dr. Joyce,” she said when I called her.

“I will be happy to as soon as I receive a release from the representative of the deceased’s estate,” I replied, referring to the notes from my conversation with the insurance company.

“You know that her parents can get these records. Your refusal is just causing additional emotional distress,” she said.
I had been warned that the attorney would attempt to control me through intimidation. I thought I was ready for this, but I noticed my hand was shaking.
I had been warned that the attorney would attempt to control me through intimidation. I thought I was ready for this, but I noticed my hand was shaking.

“Are you giving me legal advice then, about who holds the privilege?” I said as firmly as I could under the circumstances.

“Alright, then, I will have the parents send you a release,” she finally conceded.

I received the release a day before I was about to leave for vacation, so I wrote to the attorney to say that I would respond to her request when I returned.

When I got back, I was welcomed by more correspondence from the attorney’s office threatening to lodge a complaint with the Board of Psychology. I am able to smile now at my naïveté then, to think that the friendly letter I wrote her before vacation would keep the pit bull from biting.

My insurance company assigned me an attorney before the lawsuit was even filed in order to intercept the badgering correspondence. My attorney arranged to come to my office to meet me in person, dressed very casually in jeans and cowboy boots. It was Friday, but his attire did not inspire confidence.

“So, how long have you been in this office?" he asked me. "I love this part of San Diego.”

"Oh, I've been here for seven years. Yeah, it's great to be so close to the park." He did not seem concerned, which worried me immensely. Perhaps he was trying to set me at ease, but his nonchalant approach was far from reassuring to me.

"Do you want to go over the details of the case?" I said. Why did I feel like the only one ready to work? Don’t you see the danger I am in, I thought. Don’t you understand what is at stake?

"We've got time," he said, "This is sort of a get-to-know you meeting. I already read the report you sent to the insurance company and I think we have a great case. Nothing to worry about."

About a month later, I received a letter, a “90 Day Notice Intent to Sue a Health Care Provider.” My attorney had warned me it was coming, but I was unprepared for the false allegations justifying the lawsuit, written up in a short paragraph, all set in boldface. It didn’t look like a carefully crafted legal document, more like a rushed memo by an employee who would later regret having written it. Like all of the attorney’s previous correspondence, it lacked proper punctuation and spacing—no period after Dr., no comma after however, no spacing between paragraphs. She doesn’t follow the rules, I thought. She doesn’t care about them. This frightened me.

A 90-day waiting period. So I have the summer off, I thought. No more letters in white or gray envelopes or upsetting voicemails from attorneys. It sounded heavenly. I can get a lot of house projects done in 90 days.

I eagerly returned to my current project painting the upstairs bedroom. I opened the can of Benjamin Moore Philadelphia Cream paint and stirred it until smooth and blended. I turned on the radio and the Westerfield trial was on. In February, David Westerfield, a 50-something single man, sexually brutalized and murdered Danielle Van Damm, a 7-year old girl who lived next door to him.

The defense attorney was cross examining Brenda Van Damm, the mother, who had been at a local bar with her friends, drinking, dancing, and smoking marijuana the night of the murder, returning home at 2 am.

“All of the doors were a little bit open,” Brenda said, describing the children’s rooms and then explained that she closed them that night when she returned home.

“Did you look inside?”

“No,” she said quietly.

“Why not?” What is the correct answer to that accusatory question, I thought. It’s going to come out defensive. He’s making her look negligent and wanton, obviously his intent.

“Because when I got—when I went upstairs to tell Damon,” she said, referring to her husband, “that I was home, I asked him how…how the tuck-in went, how everything went that night, if anyone asked for me, and he said that everything had gone fine, that they all had brushed their teeth and been read to and no one asked for me.”

As the defense attorney continued grilling her about her alcohol consumption that night, I felt my stomach tightening, my anger forming. Even if she had been too lax, she wasn’t responsible for her child’s murder. Her husband was home with her daughter. A mother is allowed a night out once in awhile.

I then imagined myself on the stand for the wrongful death of my client:

“Well, Dr. Joyce, did you ask your client if she was suicidal the session before she killed herself?”

“No.”

“And why not?”

“Because she didn’t appear to be more distressed than usual.”

“Than usual? What was her usual distress?”

“She was depressed.”

“And you didn’t think depression was cause enough to inquire about her suicidal thoughts?”

There really was no way to answer these questions. If I said I didn’t detect her distress, I appeared incompetent, but if I said I recognized her distress and did nothing, I was negligent. I’m screwed, I thought. I got down off the step ladder, set the paint brush down, and turned the radio off.

How was I supposed to live with all this uncertainty? I realized that I was deluding myself about a “summer off.” I decided to call my attorney, hoping he could help.

“Did you get the 90-day intent to sue letter?” he asked.

“Yes. It’s a bunch of lies. Where is she getting this stuff?”

“Don’t worry,” he said. “It’s always like this. I told you, you are low on the totem pole of people to sue in this case. It is what it is.” Once again, his cavalier approach was not reassuring

“Hey, have you been watching the Van Dam trial?” I said, changing the subject. “I had to turn it off. I don’t think I can get on the stand like that,” I said.

He laughed. “Relax, Marian. It’s not going to be anything like that. ” I thought of my dentist, needle poised over my gaping mouth: “This won’t hurt a bit.”

That phone call didn’t help, I thought after I hung up the phone. So instead, I popped in a U2 CD, turned up the volume, and went back to cutting in.

The “summons,” an official version of the “intent to sue” letter, arrived in September. I knew that all the allegations were false, but I didn’t trust that the truth would be sufficient.
Six months into my dealings with the legal world, I was beginning to understand that the lawsuit was solely about money, how much the plaintiff’s attorney could get for her clients, how little the insurance company could pay on my behalf.
By then, six months into my dealings with the legal world, I was beginning to understand that the lawsuit was solely about money, how much the plaintiff’s attorney could get for her clients, how little the insurance company could pay on my behalf. “My attorney” was really working for the liability insurance company, not for me.

My attorney planned a lengthy phone appointment to prepare me for my deposition. As usual, he was his upbeat self.

“You just need to answer the questions,” he instructed me. “Don’t offer any information that the attorney doesn’t ask for,” he said.

“What if she asks me something way off-base? Will you make an objection?” I was already feeling tense. I found myself drawing spirals on my notepad.

“I can object, but you still have to answer the question. It’s not like in court, because there’s no judge,” he explained. “Don’t worry, Marian. She’s not going to ask you anything you can’t answer.”

I felt dread after our conversation. I went out to get the mail and I brightened when I saw the envelope from Bradbury and Bradbury, a company that makes exact reproductions of arts and crafts wallpaper. I spread the samples out and compared them. I liked the one with a delicate leaf pattern, and the accompanying border with vines and red berries. I called and ordered ten rolls for the dining room, and then impulsively added three of the rose pattern for the powder room.

When people ask me today how I survived a wrongful death lawsuit, I tell them that I threw myself into the renovation of my home. I wanted desperately to bring this house back to life because I could not resuscitate my client.

At the deposition, I finally saw the pit bull in person. She was a stout middle-aged woman with two inch grey roots on her dyed red hair. The attorneys for the hospital, psychiatrist, and emergency room doctor were there as well, dressed in dark suits. We sat around an oval table. I was at the far end seated in front of the plaintiff’s attorney and the court reporter was to my right.

The plaintiff’s attorney grilled me regarding my credentials for thirty minutes. Then she worked her way line-by-line through the treatment notes.
The plaintiff’s attorney grilled me regarding my credentials for thirty minutes. Then she worked her way line-by-line through the treatment notes. After four hours, we took a lunch break and then she fired off detailed questions about the week of the suicide.

Afterwards, I met my husband for drinks at the Torrey Pines Lodge, a sprawling, gorgeous building in the Arts and Crafts style of architecture, like our house. I gravitated to the fire in the lobby bar.

“I love the wood tones in this trim,” I said, referring to the honey-colored wood on the fireplace. “It’s so warm, not like our dark mahogany.”

“Hey,” Joe said. I knew that “hey” meant he was coming up with an idea, which usually meant more work. “Let’s take down our wainscoting and trim and plane it. Then we can stain it a lighter, warmer tone.”

Normally I would have dissuaded Joe from such a time-consuming project. But I liked the idea of transforming the dark and dirty into something fresh and light.

“Great idea,” I said. “Let’s do it. It’ll make such a difference.”

That project involved sanding, staining and shellacking yards of wood, a project that outlasted the lawsuit.

After much haggling, the attorneys finally agreed on a settlement amount, which was shared among the defendants. Because it was a settlement, there was no admission of guilt by anyone. That should have set my mind at ease, but by then I knew the case was only about the money.

Grief and Healing

About five months later, I attended a course on clinical hypnosis given by a UCLA professor. He was demonstrating a particular projective device in which clients project unconscious material onto an imagined screen.

"I want you to get comfortable and close your eyes," he said in a soothing voice. I opened one eye to see if everyone was following instructions. They were, so I decided to give this a try.

He began to take us down a spiral staircase and count backwards from ten. When he made the suggestion my arm might lift up, it did. Once established that we were in a hypnotic state, he described the screen where my movie would play out.

“You are sitting in a dark movie theatre facing the screen. Let yourself go and watch the movie that unfolds on the screen.”

It took a minute to see anything on my screen. But then cartoon characters started dancing on a stage and then my sister appeared. The next movie was of my husband calling me from a train and then dancing with me once I boarded. Both movies were joyful.

I suppose I could analyze these for deeper meaning, but what happened next took me by surprise. I began to sob. I knew it was about Becky. I hadn’t yet cried like that about her death, about losing my client. I could finally let myself feel sad that she would never get that rewarding job she desired, or be free of her attachment to Matt to find the love of her life, or even be able to bury her parents.

It was only after that pivotal moment under hypnosis, when I wasn’t looking for it, really, that I was at last able to move past the feelings of guilt, blame, shame, and anger at the lawsuit.

The lawsuit settled, the house renovations finished, Joe and I decided to celebrate with a housewarming party.

Guests gushed over the house as they filed in.

“I can’t believe what you did with this house! Wow! How did you get rid of that dark stain?” a friend asked.

Joe and I looked at each other and smiled.

“It was a big job,” Joe said. “I wouldn’t recommend it for everyone.” I thought back to the evening after the deposition in front of the Torrey Pines fire. I guess we would have never done it if I hadn’t had the lawsuit, I thought. Then it struck me: I was beginning to gain some distance and perspective.

The friend from graduate school whose remark months earlier had so unsettled me came up to me.

“I meant to ask you about your lawsuit. Did it work out okay?” he said.

“Yes, it’s all settled. There shouldn’t be any repercussions,” I said.

“I’m really glad to hear that. I often wondered how you were doing. And I don’t think I ever told you I was sorry that you lost your client. I think I was a little afraid of the whole thing, to tell you the truth.”

“Thanks for that.” I said.

Regarding my work, I have once again recovered my enthusiasm, but it is tempered. I now know that anyone is capable of losing hope at times and even though I listen carefully to the subtle messages my clients share with me, sometimes they choose to keep parts of themselves completely concealed. I know my limitations and that I can’t predict or know what a person will do. And I have to live with that uncertainty and with the consequences that may ensue.


 



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Dr. Marian Joyce* is a psychologist and writer in San Diego, Ca. She has been in private practice for twenty years working mainly with adults who have depression and anxiety. After a client committed suicide, Dr. Joyce was devastated and experienced doubt about her ability as a therapist. She is happy to say that she pulled through this dark time, but she often felt alone with her grief. She hopes her story will help other therapists to understand what it is like to lose a client and other clinician survivors to know that they are not alone.

*Dr. Joyce is a pseudonym.

CE credits: 1

Learning Objectives:

  • Learn about the legal implications of a client's suicide.
  • Describe the reactions and feelings that are likely to arise for therapists after a client's suicide.
  • Outline possible precautions for therapists to take to alleviate risks around lawsuits.