Rachel Rowan Olive
CW: suicide, iatrogenic abuse and neglect
There is a poem by Clint Smith which opens:
When people say “we have made it through worse before” / all I hear is the wind slapping against the gravestones / of those who did not make it.
I think about it a lot.
Sometimes the moral arc of the universe / does not bend in a direction that will comfort us.
I think about it especially when I’m remembering people who have died by suicide, because mental health is the area where I try hardest to bend that moral arc. And I think about it most of all when I remember the people I knew from mental health services.
In my seven-and-a-half years in the system, I have known five people under my mental health trust who died by suicide. Three of them, we were under the same team at the time. Two, I had stayed in a crisis house with and I found out from media reports later. There are more, fellow advocates or activists under different trusts who were failed or punished for their distress. Most of my friends have major mental health problems, because frankly after all this time in the system I don’t know how to talk to normal people anymore. My old GP said once I move in high-risk circles.
I think I can get my head round what she meant, but I can’t dismiss this as an occupational hazard of being long-term mad. Sometimes, everyone does their best and a patient dies anyway. That is not what happened to the people I knew. Not most of them, anyway. I can’t talk in detail about their deaths publicly because it doesn’t feel fair – to them, to those who were closer to them than I was. But the thing is, at the moment I can’t talk in detail about their deaths anywhere. And I need to.
Mental health clinicians also “move in high-risk circles” for suicide bereavement. There are studies on the effects of this guidance (here and here) on where psychiatrists whose patients die can turn for support, such as the examples here and here. I have no doubt that this is often poorly implemented and little comfort against the shock of someone’s absence, but there is at least a language for that kind of grief, and an acknowledgement that it hurts.
In my experience, patients who find out about another patient’s death don’t have that. Recent work on suicide bereavement discusses losing friends, but there are specific kinds of pain that go with losing a fellow patient. Research on our experience talks about suicide clusters, or imitative suicide, as though we copy death like it’s homework. As though there are no emotions involved. There are issues around suicide-method-related information, which shouldn’t be shared following a death. But there are many, many other ways in which another patient dying by suicide can intensify your own suicidal thoughts.
So here are the things that ran through my head when my fellow patients died, in the hope of starting a conversation about those thought processes, and how to support people with them. Not all of these thoughts are fair or reasonable, but I had them anyway.
Anger. We’re under the same team/trust/NHS. Why didn’t you save them? What went wrong? How can I trust mental health services when they couldn’t keep my friend safe? How can I work with you when you let them die?
This one is particularly knotty because if there is an ongoing investigation or will be an inquest, the team you usually turn to for support might not even be able to acknowledge the death as a suicide. They might not be allowed to discuss it at all.
Fear. They fell through the cracks. Will I fall through them too?
Jealousy. I wish that I had died, and they hadn’t. Because how can I kill myself now, when I’ve just seen the consequences?
Guilt. There is a special kind of survivors’ guilt to surviving your own suicidal crises, influenced by the popular myth that those who survive suicide attempts didn’t really mean it. If we both tried to kill ourselves, and they died, and I didn’t – does that mean I didn’t really mean it? If so, does that mean that my distress is not real and I don’t deserve help? For me, this cycle of self-invalidation is the thing that turbo-charges my own suicidal thoughts.
More guilt. Here I am selfishly feeling jealousy and fear and anger at the system instead of remembering them as they were, as a person.
Then later, in future crises, frustration. Sometimes clinicians blithely assert that things will get better. Don’t say that, I want to shout. I can give you the names of the ones for whom it did not get better.
I do believe it’s possible to get through these feelings – but we have to be able to name them first. While waiting for thorough research and guidance on how to support patients with this, services need to plan how they communicate deaths to fellow patients, and consider carefully-facilitated dedicated sessions to support us. We need to be able to express anger with those services, so it might help to have an external facilitator, from an organisation with experience in suicide bereavement support.
I come back to Smith’s poem. It is possible to hold hope without pretending recovery is guaranteed:
do not say I am hopeless, I believe there is a better future
to fight for, I simply accept the possibility that I may not
live to see it. I have grown weary of telling myself lies
that I might one day begin to believe. We are not all left
standing after the war has ended. Some of us have
become ghosts by the time the dust has settled.