Is There No Place For Me?

Vanessa McGann  

The world of the suicide survivor has been neglected if not ignored by the therapeutic community.  When one considers that suicide is one of the leading causes of death for many age groups, that at least 45,000 people kill themselves in the United States annually, and that they in turn leave five to seven close relations to mourn their death, this fact becomes a curiosity.  When one considers that therapists are likely to be treating suicide survivors as well as suicidal individuals, potentially having lost a patient to suicide themselves, this curiosity becomes an enigma.  Why has the topic of suicide survival been so neglected?  Why is the literature for treatment of suicide survivors so scarce? As a psychologist experiencing the death of my sister to suicide, or more importantly the mental health community’s reaction to me mourning it, I have made some observations which may help to illuminate these phenomena.

About a week before my sister took her life she lent (or I guess in retrospect gave) me a memoir about a female schizophrenic entitled, “Is There No Place On Earth For Me?”  Edwin Schneidman has written that when someone ends their life, their “skeletons in the closet” are often transferred to their loved ones.  This must be true because, for the past year, I have asked the question, “Is there no place for me?” almost incessantly.  However, my question arises not because I am suffering from a chronic mental illness, but because I am mourning a suicide.  While this task in our culture is difficult enough, I have found that it is particularly and painfully difficult to be a clinician mourning a suicide; indeed, a clinician mourning a suicide at best loses her bearings and at worst loses her home.  In this past year, I have had a multitude of experiences that were confusing, alienating and ultimately enraging, all stemming from contact with the mental health community.   In the past year, I often felt as if I had two choices: to repress these experiences, to literally forget them, or to flee the field.  I suspect this is a common reaction of clinicians who lose a client or family member to suicide.  It is a reaction that is understandable yet regrettable, for it does not serve to educate, enlighten or change the field.

In many ways, my sister’s death came as no surprise.  When people asked why, I felt I knew the reasons.  And when people asked why now, I felt I understood the timing. And when people told me not to blame myself, I said I felt I had done all that I could.  Don’t get me wrong:  I still felt awful.  I still felt overwhelmed.  I still saw flashes of her lying there and I still wanted her back.  I still needed help and guidance.  But perhaps because I was without the need to question my motives or actions, or those of my sister, perhaps because I was not so filled with confusion and guilt, I found myself able to focus on the quality of support I received from those around me. 

What I would like to do is take you on a journey through some of the thoughts and experiences I’ve had since my sister’s death.  There are a few things I’d like to say before I revisit the past year.  The first is that, though I focus now on disappointments and abandonments, there were moments and people who, (clinicians among them), for whatever reasons, were able to stay with me and support me deeply.  The second is that I am aware I came to this with my own history, needs and reactions, and that the interactions I will describe are both two sided and complex. The third is that I don’t want my telling to be heard as retribution or revenge, though I do want to be a voice of change.  It has taken me a while to realize this, but I do not think that I am crazy, nor do I think that I chose bad therapists, supervisors or friends.  Instead, I think that death, particularly death by choice, leaves behind not just strong feelings in the bereaved but strong feelings in those trying to help them, feelings which we are too quick to split off, attribute to others, and avoid.

What I propose to do is twofold:  I would like to describe some reactions that the mental health and suicide community have had toward me since my sister’s death and then follow with a discussion of why these experiences might have occurred.  I do not think the flavors of these reactions are unique to the mental health community; however, for reasons I will discuss later, they may be more common and stronger among therapists.  I also do not think some or most of these reactions are necessarily “wrong” either clinically or socially.  What seemed hurtful or distressing to me might have, at different time or to another person, felt comforting. But taken together, these reactions suggest to me a defensive pattern which can and often do leave suicide survivors feeling doubly guilty for their feelings, abandoned in reaction to their need, and insane for their difficulty coping.

Here are some of my experiences:

Upon hearing the news of my sister’s suicide, both my therapist and supervisor suggested I take one week off.  When I said I felt this would be too little, they told me that if I felt the need to take an additional week off, I should call my patients back and tell them I needed more time. 

When I went in to see my supervisor, his first reaction to the news was to tell me about his own analyst’s reaction when he himself had lost a patient to suicide on internship: “Son of a bitch is probably better off.”

As I felt increasing difficulty functioning in the weeks ahead, I discussed decreasing my hours with my supervisor.  This was met with interpretations about my identification with my low functioning sister.  I went so far as to review my caseload person by person with him to see who might be ready to terminate.  He concluded I should raise my fees and see many of them more times a week.

After calling my therapist to tell him I needed him to share my sister’s suicide note with me, I printed what was clearly a copy and brought it to his office.  He returned it after one day in order to “respect my autonomy.” 

After telling the leader of a study group of my sister’s suicide and telling him I would be taking a leave of absence, he asked to be paid for the session I had missed the morning after I had found my sister’s body. (Incidentally, I would like to note that I had had the wherewithal after finding her to call in advance and cancel, though I agree it was not 24 hours notice.)

I then emailed my study group to tell them I had had a death in my family and would not be returning for many months.  This was a group of interpersonal psychoanalytic candidates.  Not one of them emailed back to express condolences. 

Two months after my sister’s death, my husband was rightfully concerned about my well being.  With the strong urging, if not insistence of his own therapist, my husband demanded I go for a consultation regarding my own therapy and that we go together for marriage counseling. 

After telling this marriage and family counselor about my need for a weekend to myself, the man made the following intervention (in what I can only assume was his attempt to be neutral and balanced): “I can see how you [referring to my husband] would be scared about your wife’s desire to spend time by herself because of your fears for her, and I can see how you [referring to me] must be wondering if there is something toxic about you since the death of your sister.”  (As my husband is witness, he really did say that!)

Social interactions with friends in the field were also difficult to say the least.  One close colleague, taking me out for a cup of coffee two days after my sister’s memorial, acted incredibly and undeniably hostile to me.  When I finally asked if she were angry, she replied, “Now is not the time to tell you how hurt I am by you,” and proceeded to list for a half an hour the many ways I had wronged her as a friend. 

Another dear psychologist friend, after being wonderfully supportive for two weeks through emails and calls, called to ask if I wanted patient referral.  I called back to say I thought it might be too much and I have never heard from her again.  That was a year ago.  

And, when I finally decided that a practical solution to my sense of being overwhelmed was to find my own full time office to allow me more space and time, instead of being understanding, my office mate and friend reacted as if I were a selfish, unreasonable and cruel person who was in fact abandoning her.  Interestingly, her last comment to me was, “Please don’t call me because it makes me feel very bad about myself to hear from you.”

A former supervisor’s reaction, echoed by countless others in the field when he heard the news was: “Oh, so you are dealing with the guilt.”  With so many assuming that I was feeling guilty, I started to wonder if they thought I had done something wrong. 

At another time, I called a “bereavement specialist” to see if she would validate my feeling that mental health professionals tended to pathologize my grief.  I didn’t get very far because she insisted on trying to get me into one of her groups rather than answer my questions as one professional to another. This was after I had clearly informed her that I had my own therapist and that I was not seeking professional help.  The irony was not lost on me. 

In order to make sense of it all, I was also encouraged to call a friend of my parents who early on had been involved in my sister’s treatment.  He told me coldly that he “didn’t understand my agenda” for calling him.

Unfortunately, I could go on.

My anger at these interactions was interpreted variously as displaced anger at my sister, father or mother or as an avoidance of my mourning.  Increasingly, the focus of therapy and supervision was to look at what was going wrong in the therapeutic/supervisory relationship in terms of what I was projecting and what we were enacting historically.  Difficulty with my professional friends was seen as my “help rejection,” as my difficulty clearly expressing my needs, and as a symbolic representation of my tortured internal world.  The focus also became whether or not I should stay in these relationships or face more loss.  The focus was not on how my environment was actually responding to and meeting my needs.  Most distressing, the focus was not on giving me room to mourn my sister. 

At a certain point, this all became too much.  Feeling crazy, alone and unsupported, I went to the only place left to me:  the floor of Barnes and Noble, in front of the self help section for suicide survivors.  It was there, without the aid of my supervisor, therapist, friends and colleagues,  where I began to see a pattern in what was going on, and I began to stop blaming myself for my anger and difficulty coping.

The first thing I noticed was that the books were not written by clinicians.  There were memoirs and testimonials.  Some were written by “experts” but these experts were experts through experience first and training later.  Furthermore, many of the books described the process of going to professionals to be alienating, pathologizing and retraumatizing rather than healing.   Thus, these people started their own groups run not by clinicians but by fellow survivors.  I realized that the suicide survivor community was organized in a similar fashion to AA, containing the idea that only fellow survivors could help each other. 

In Barnes and Noble, I recalled two different but related phenomena which were important in my healing.  The first was the memory of a graduate school testing professor who had clandestinely taken a session from the curriculum to tell us of her own experience losing a patient to suicide and the alienation among her colleagues which followed.  She was telling us about it because she knew that some of us might lose someone to suicide and wanted us to feel less alone at that time.  I remembered her talking about the rage, not only toward her dead patient, but toward her cold, blaming and neglectful colleagues as well.  Related to this was the memory of a friend who during graduate school lost a patient to suicide and the way she felt our training institution had ignored her feelings, left her unsupported, and let her down.  I began to feel that my struggles over the last few months had less to do with my own deficits than with the community around me.

I then remembered the many articles I read about the communities’ response to mental health outreach after September 11th.  In short, these family members and firefighters were saying to clinicians: we don’t want your intrusive help, interpretations or input.  There is something about your reaction to our grief which is making us worse and not better.  Leave us alone.  This gave me solace. 

I began to pour over the accounts of suicide survivors with an ear not for what they were feeling about their loved one, but about those around them, particularly therapists.  The following was particularly striking:

“Immediately after Tim’s [the brother’s] death I experienced another abrupt and traumatic separation – from my therapist.  He didn’t call me after Tim’s death.  He was aware of the event because his son had been in Tim’s class.  I wanted him to call and express condolences, if not as someone who was concerned about me then at least as a professional with a client who had undergone a major life trauma.  I did not hear from him until our next scheduled therapy session.  I expressed my feelings and he stated that he wasn’t sure whether I wanted to talk to him about it.  Several days later, I tried to jump out of the car while mother was driving me.  She brought me to his office.  He was angry with both of us for not making an appointment and began to tell my mother about things which I had discussed with him in session.  His tone was angry and he raised his voice.  I never saw him after that.  The relationship was irreparably damaged; the incident supported my theory that things weren’t permanent.” (Dunne, p.102)

I would like now to talk about these reactions and to attempt to deconstruct why they may have been occurring. 

First, why did my supervisor feel that a one week respite from my clinical work was enough time?  Why did he need to tell me at the outset that my sister was probably better off?  Why was he so unwilling to see me cut back on my practice and reduce my hours?  I believe it had something to do with the way he saw himself in me and identified with me.  In order to allow the idea that this event had profoundly affected me, he would have to admit that he himself might be vulnerable to damage.  Indeed, he told me about how he had always seen himself as an ox, how he had always ploughed ahead, and how when life had been difficult for him, he had always found solace in his work.  To see me fall apart was, I believe, an act which was not just distressing to him because of his care, concern, or feelings for me, but it was an act which might allow him to experience the devastation of what I was going through.  At one point in our struggles I said to him, “If one of your children had killed themselves as a teenager, would you have taken only one week off?”  This question, though blunt, appeared to reach him.  It was as if for the first time there was no filter between us.  He looked at me and he answered, “No.”

Related to this was the sense of denial on the part of my community.  To this day, my supervisor and therapist say that they literally have difficulty “keeping in mind” the concept that I have had a loss, the fact that my sister killed herself, and what I have gone through.  Early on, when I encountered expectations from others that I felt to be unreasonable, or when I felt judgment from others as to how I was coping, I would (I admit manipulatively) remind them of what I had memorized for my licensing exam: “Statistically,” I would say, “I am now 4 to 5 times more likely to kill myself.” This again seemed to jostle people, to remind them anew because they needed the reminding, that I had gone through a major life trauma.

Another reason my supervisor may have interacted with me the way he did was in order to “contain” me.  This can also be seen in my therapist’s quick return of the suicide note, the study group leader’s demand for payment, and, in the example above, in the sister’s therapist’s adherence to the frame.  We are taught early on in our training that experiences which are overwhelming to our clients must be held and managed by us so that they may take them back in a metabolized form.  We must not bend the frame, lest our clients sense that we cannot handle them in our usual manner.  I in no way think this concept is wrong, but I think it can be and often is misused.  What constitutes the frame is often fluid and it is my contention that, when emotions are running high, clinicians often use their concept of the frame in order to hide or withdraw from a meaningful encounter.   Were my supervisor to react with shock and concern, let alone ask me how I felt about how much time off I felt I needed, for him it might lend credence to my feelings that I “might not make it.”  However, for me it might signal that he was willing to face the impact of my trauma.  Were my therapist to keep my sister’s suicide note, for him it might feel that he was “not respecting my autonomy”, whereas for me it might feel as if he were helping to share my pain.  And again in the above example, were the therapist to welcome the sister and mother without lecturing them on breaking the frame, he might feel as if he were encouraging them to act out of control.  The problem there is that this teenager did just attempt to jump out of a moving car, and his adherence to the frame led her to quit treatment. 

Throughout my readings I have come across countless other examples of therapists acting with a formality and rigidity (and frankly sometimes bizarreness) which I am sure they would defend as “containing” or professional.  Yet it is easy to see these behaviors as stemming from countertransference anxieties in which the therapist is tacitly rejecting the client and avoiding the pain. Unfortunately, for me, as well as many survivors, it comes across as cold and inhuman.  The irony regarding people in the field trying to “contain” my anxieties was that the effect it produced was the opposite.  It consistently made me much more distressed and much more likely to feel alone. 

Another reaction encountered time and time again was blame, as if I were directly responsible for my sister’s death, implicit in the reaction: “oh, so you are dealing with the guilt.”  Surely, most suicide survivors deal with feelings of guilt as part of their reaction to the loss.  But this assumption and the overemphasis that this theme was given was mind boggling.  The dictum “without memory and desire” was not to be found among mental health practitioners when dealing with my sister’s suicide.  This was perhaps most painfully illustrated to me by the couple’s counselor who inferred that I was feeling toxic in regard to the death of my sister.  One potential reason for this emphasis on guilt may have to do with therapists grappling with their own responsibility to their clients.  Victoria Alexander, in her book In the Wake of Suicide writes: “To recognize that a population of people might need some help in dealing with the aftermath of suicide in their lives would be to acknowledge that efforts at prevention too often fail, and that acknowledgement comes hard.  The instinct to preserve a life is much stronger than the desire to address a death, especially one that is intentional.” 

Related to my sense that people were blaming me was my sense that I was being abandoned.  Silence from my friends was deafening and much more common from my friends in the mental health profession than from my friends outside the field.  Consciously, I think people were trying to “give me space” and not bring up any painful feelings.  However, as I pointed out whenever I had the chance, “space” was not my problem; I already had plenty of that.  I noticed another difference between my lay friends and my friends in the field:  My sister died in early October and I would say I received phone calls from people up until November.  Three months later, after New Year’s, feeling much too isolated, I began to ask my friends for more support.  Whereas my friends outside the field heard this request and apologized for their absence, friends in the field tended to become defensive.  They made attempts to point the blame at me with comments such as “actually, I’ve been thinking about my anger at you for not returning my initial phone calls.” Or, “Do you think I have been reacting to subtle ways in which you have been trying to alienate me?”  Again, while there is a possibility that I was asking more of my clinician friends or even that I was more unconsciously hostile to them, there is also the possibility that they were more threatened to acknowledge that they had, on some level, abandoned me in the face of my abandonment.  

When I was not personally avoided, the topic of my sister was avoided.  Ironically, it reminded me of the common misperception that inquiring about suicidal feelings would create suicidality in a patient.  It seemed that mental health colleagues felt that to ask me how I was doing would upset me unnecessarily rather than offer me relief. My understanding was actually that they were avoiding their own upset, avoiding their own symbolic inability to help my sister, and avoiding their inability to help me.  The result was a painful enactment of what at times seemed like endless strings of loss. 

Victoria Alexander writes in her introduction about this avoidance: “I began to wonder why there was so much attention to preventing suicide and so little to the repercussions in other lives when it occurs.  The silence on the subject was unsettling; it seemed to confirm the freakishness of my loss and my fear that I would always be alone with it…I  had the sense that there was something so shameful here that noone wanted to touch it, least of all those in mental health”. 

This brings me to yet another observation, that of the mental health community’s tendency to pathologize me, not for the death of my sister but for the level of my grief.  Every time I cried, every time I fell apart, every time I got angry or distressed, I got the message, often not subtly, that I was not managing as well as I should.  If I had a nickel for every interpretation given to me regarding the pathological antecedents of my grief reaction, I believe I could create a fund to research suicide survival.  Take, for instance, my husband’s therapist’s insistence on a consultation and marriage counseling.  Rather than seeing the jar as half full, that under the circumstances I was doing just what I needed to do, there was a way in which clinicians needed to dig deeper, to become active, to find hidden meaning, to be clever and to fix.  Rather than stand still and bear witness, they chose to meddle, and in that meddling they created new wounds through their subtle judgments and criticisms. 

Worst of all, I experienced at times tremendous hostility from my supervisor, therapist and peers.  This was the most crazy-making because it was so unexpected and it was always most adamantly denied.  I believe this hostility came when they were most vulnerable.  The hostility came when they could not deny my pain, not remove themselves or distance themselves from my need.  The hostility came when they felt helpless to help me and unable to explain the unexplainable.  I’ve been to meetings and conventions where survivors give each other furtive but comforting glances.  “You are not crazy” they say.  I hope in this paper I have made clear that, at least half of the time, they are referring not to their internal states but to their perceptions of the world outside.

Finally, I would like to discuss briefly what could be done.  A former supervisor and friend asked what he thought was a rhetorical question: “Vanessa, you lost your sister.  What can anybody do?”  But I answered him: “Plenty.  They can call, they can ask, they can listen.”  I meant this quite literally.  There are things fellow clinicians who have not directly experienced a suicide can do.  I do not believe you have to be a suicide survivor in order to help or understand a suicide survivor.  I do not believe the split between survivors and clinicians is necessary or healthy.  I do not believe clinician survivors need to go through the amount of guilt, isolation and confusion that they currently go through or that our experience is due solely to our own internal struggles.

Quickly, here are some things people did which helped me.  First, they gave me choices: A colleague and friend said: “I’ve called you a bunch of times and haven’t heard back.  I don’t know if my calls are annoying or helpful.  Should I keep calling?”   Another colleague called and said: “I have a patient to refer who I think you would work very well with but I don’t know if you are up to it.  Are you interested?”  Or even just “A bunch of us are getting together, do you want to come?”  In other words, instead of assuming I wanted my space, they asked. 

Second, they expressed open ended interest without preconceived notions.  They asked questions like: “Has it affected your work?”  “What is it like with your patients?” Or even just: “How are you doing?”  They responded without interpreting, were open to what I told them and, while perhaps not taking all my feelings at face value, did not feel the need to deny or contradict my feelings.  Third and finally, if they acted in a way I felt was defensive or hostile, they had the ability to catch themselves, reflect and apologize rather than react defensively. 

I think our field can change but it will not happen by itself.  I would not be giving this paper if it wasn’t for Nina Gutin, who bravely presented at an analytic conference on her loss and I happened to see a summary of that talk in the Division 39 newsletter.  We are not alone.  It is not a coincidence that AFSP calls their walk “Out of the darkness”.  I think, in order to make changes, for ourselves as well as the survivor community at large, clinician survivors have to fight stigma, come out of the closet, and end our shame.  The task force, with its many voices, is a piece of that and a beginning.

A woman with whom I was leading a survivor group opened by saying to those gathered: “I am so sorry you have to be here but I am so glad you’ve come.”  Is there a place for me?   I’ve lost friendships probably not worth keeping and deepened others.  I’ve been working it out with my therapist and supervisor.  We all know ourselves better now.  I’m trying not to be such an idealist and I know I’ve grown in unexpected ways.  I would trade the knowledge gained in a minute to have my sister back.  There is no silver lining but I figure that while I’m under this cloud, I may as well continue to try to make a place for myself.  I owe myself and my sister that.