Death can represent the culmination of a longer – dying - process, often the case in the somatic part of the clinic, but also in psychiatric care. Death then makes itself gradually known through a changing body: in the patient's more pronounced facial features, how the jaws are pushed in, the nose becomes more distinct, and the eyes sink in. The conversation gradually fades and eventually contact is limited to holding the patient`s hand. Suicides most often has a much more surprising character though. A most tragic event coming out of the blue. Even when it is the culmination of a long process of suffering, one is usually not prepared for its violent character and irreversible impact – it shocks and startles those in its proximity, including the professionals.
"I was working [as psychiatrist] at the outpatient clinic. There was this man that I was treating. He came on a Friday and told me that he had bought tickets for a concert [...] He wanted to send me a link because it was a good concert: "Okay. Agreed! Bye." After 12 hours, he shot himself - shot himself! I didn't see him. It was VERY traumatizing. How did I miss it? Maybe I could have prevented it, because I was the last person he spoke to? It was VERY difficult. […] I had to take medication to sleep. I blamed myself, because I was the last one. And I talked to his wife after that. She also said to me "how did you not know"? Leah, psychiatrist.
A professional career in mental health care can be viewed as a long series of relationships, each having its beginning and end, implying both attachment and separation. A multitude of relationships that often run in parallel, some long, others short, draining – or highly rewarding. It is relationship-intensive work – professional practice in which using oneself is constitutive for getting the job done – as the Cycle of care implies establishing a relation through “empathetic attachment”, a short or long phase of “active involvement”, and an ending with “felt separation” (Skovholt & Trotter-Mathison, 2016). Leah`s experience illustrates how unpredictable and strongly felt separation by suicide can be – inducing confusion, and feelings of guilt, shame and anger, making the professional temporarily into a self-medicating patient.
Her story is part of a recent study (Moen, 2024), which explores what it does to health professionals to exercise coercion as part of their work. Both those “heads-on” and those “hands-on” regarding use of coercion were subject to in-depth interviews and invited to take part in free-associative writing exercises about their experiences. Psychiatrists and psychologists – those with the mandate to administer use of coercion in Norway, as well as nurses and nursing assistants – those actually and physically undertaking the coercive measures. Death was explicitly and implicitly part of all the accounts, as coercion is often about preventing a premature death, evident in Grace`s story:
“As a psychiatrist in training I was given quite a lot of responsibility for keeping that patient alive […] tube feeding was the only option at that time, and the poor (anorectic) patient pulled out the tube, right. And it had to be put down and I had to do it. And I did it in a way with a clear conscience for all intents and purposes. I knew there was no alternative, but it was terrible. The person is crying, you push something into the body of the patient that she does not want […] But the alternative was, in a way, that the patient did not survive.”
Death can represent the culmination of a longer – dying - process, often the case in the somatic part of the clinic, but also in psychiatric care, like possibly with Grace`s patient. Death then makes itself gradually known through a changing body: in the patient's more pronounced facial features, how the jaws are pushed in, the nose becomes more distinct, and the eyes sink in. The conversation gradually fades and eventually contact is limited to holding the patient`s hand. Suicides most often has a much more surprising character though. A most tragic event coming out of the blue. Even when it is the culmination of a long process of suffering, one is usually not prepared for its violent character and irreversible impact – it shocks and startles those in its proximity, including the professionals.
It can be argued that a suicide leaves “a check” to those left behind – obviously those closest to the deceased – family and friends, but also the professionals involved. In that sense, the suffering that “caused” death doesn’t evaporate, but take on new forms, often as an “invoice” full of questions, making the recipient feeling guilty of answers. In somatic medicine, there is more often a shared recognition between healthcare personnel and relatives that serious conditions can end fatally. In mental health care, it seems much more difficult to get the same message across. The impression left from public debate is that death in mental health care is always avoidable – in contrast to the inevitable deaths in somatic medicine?
Benjamin, also a psychiatrist, lost a patient to suicide and felt unduly blamed – that he was made guilty of an answer, and that there was an expectation that he would accept “the check”:
"Of course, they were a little angry and they thought it was our fault that this had gone wrong [...] And you become the idiot, right. It was our inability to understand completely obvious things that made it go the way it did, and I think that I don't agree with that ((almost whispering here)), right, but ((laughing)) you can't make a debate on that basis. It would be pouring gasoline on fire [...] I think that the question of guilt was considerably more complex […] we have to do what is expected of us in relation to the role - be empathetic to the best of our ability and understanding, apologize for what happened, it is a shame that it happened, but it is not quite the same as saying that it was we who could have prevented it. Maybe right there and then, but not prevent it. I don't think so..."
Benjamin`s inner dialogue appears as an alternation between accusation and defense – not unlike what happens in a courtroom, but in this case the psychiatrist is both prosecutor and defense counsel. Unlike for the accused in other hearings and trials that eventually come to an end, for the “gatekeepers” in mental health care, there is a constant supply of potential life-and-death situations for which one can be held accountable in one's inner court.
Negative capability
All the above stories are illustrations of how death in different ways can invade the therapeutic space - experiences that can make or break the professional. Whether Leah, Grace and Benjamin become part of the group that feels pushed out of their role, profession, or even life, due to encountering death at work, depends on their resilience – the ability to bounce back. A key element of which is “negative capability” – the tolerance of the individual for chaos and uncertainties, the ability to be patient and not act on impulse.
However, resiliency is a relation concept and relates to a large extend on the degree of reverie in the immediate professional surroundings - whether there is present a capacity of individuals or organizations to contain unbearable experiences that have not yet been translated into meaning. A containing capacity in which the affected professional can “digest” the emotionally disturbing “unthought” (Bion, 1962; Bollas, 1987). Is there a colleague, a supervisor or a therapist that does not turn away, but is able to accommodate and process detrimental feelings of guilt and shame that may hit the psychiatrists as a wave? That is the pressing question. Some hospitals have established collegial support in the event of a suicide, or other ways of processing a loss through therapeutic conversations.
At other times, what is called for is a communal space that offers negative capability and reverie, in which the situation`s existential and emotional significance is recognized and honored. In secular society (Taylor, 2007), like our own, even it is no longer a given what is regarded sacred, or in what language we can address it, the birth of a child or the loss of a human life represent something “more” than what the medical or managerial jargons can account for. In ethnically and religiously diverse Nordic societies, with a growing number of people not feeling affiliated with any particular faith, there is no longer a shared language for death and dying, an Ars Moriendi resembling that of the Middle Ages (Leget, 2007) – a common language and a shared frame of understanding guiding both those about to die and those about to be left behind. However, the “more” is still making itself evident, calling for attention in manners that respect the diverse notions about life and death present among both patients and professionals in mental health care.
A unit at a psychiatric hospital had lost a patient to suicide. The young patient had been in the ward for a long time and the staff were left with grief and haunting questions. The head of the department asked me as the hospital chaplain to help arrange for a memorial, and at the same time explained that the deceased was pronounced non-religious and that the staff represented different views of life. It was important that the gathering reflected this and was not perceived of as a religious ceremony. Together we established a space and time for remembrance that was found to be a meaningful, respectful and helpful way of recognizing the loss. Poetry, music, lighting of candles, use of silence, and words shared by health professionals in memory of the deceased patient, provided a space for grief in the context of work.
However, research suggests that it is not a given that grieving and weeping mental health care professionals (Johnson & Katz, 2006) will find room for processing “felt separations”, like in the case of a suicide. Studies show that clinical units – even in those parts of healthcare where deaths often occur, but also in those where one would think that talking about the most difficult would come more easy – varies regarding openness about death (Glaser & Strauss, 1965). Health professionals may establish social defenses against the complexity and overwhelming emotional challenges that can accompany their work, including encounters with the death of others (Menzies-Lyth, 1958).
Social defenses may appear in the form of linguistic practices that function as “rules” for what can be stated (Candrian, 2014), expressed in comments such as "you must be thick– skinned" and "you can't be a parsley leaf if you're going to function in a place like this” (Moen, 2018). The implicit regulations are perhaps what makes it possible to persevere in a field that is distinctly emotionally demanding? However, limiting what can be talked about and expressed come with a cost. Standardizations of what can and cannot be said can have a limiting effect on development and change, as they “prevent important conversations from taking place and key questions from being asked” (Candrian, 2014, p 66).
What questions are never asked and what kind of conversations never take place? At what price? Those are key questions for any workplace, not least relation-intense contexts that comes with “felt separations”. Do the linguistic practices actualized in the event of a suicide in psychiatry facilitate the emotional and existential concerns actualized? In the event of an "unnatural" death in a ward, the police and health authorities will be involved, and legal language will necessarily become dominant, but does it eventually reside for other frames of understanding the situation, or does it work as an effective “lid” on existential feelings and questions, the grief and despair, that may linger with mental health professionals after losing a patient to suicide?
Death in mental health care is already to a much greater extent than in somatic care framed by a morally charged language. Thus, feeling-rules and moral-rules. In the culture, the latter is expressed in contradictory attitudes towards suicide (Critchley & Hume, 2015). On the one hand, being able to end a suffering life by one`s own hand, is by many viewed as the ultimate expression of autonomy and self-determination. On the other hand, there is the traditional condemnation of taking one's own life, throughout history expressed in a theological, moral, and legal language. Today it is expressed in a much more friendly, but often just as absolute, zero-vision health language, where the premise is that suicide can be avoided, that it can be prevented through treatment, which leaves a blinding spotlight on the psychiatrist in charge.
A pressing question is whether psychiatry has within its repertoire a language that does not leave the professionals exclusively in the grip of diagnostic or moral frame of understanding, but that provide enough room for the complexity that accompanies working with patients who constantly challenge the boundaries between life and death. Is there room in psychiatrists` education and practice for an ongoing conversation about shared existential basic conditions, such as freedom and responsibility, vulnerability and finality, hope and meaninglessness – and thus occasion for what the Roman Stoic thinker Seneca names meditatio mortis:
“Nothing can be of so much use to you, in your search for moderation in all things, than to think frequently of the shortness of one's life span and its uncertainties. Whatever you do, cast your eyes on death” (Epistle 114.27 in Seneca, 2018)
Forbidden death
There may be good reasons why the conversation about death does not have such good conditions among the living. The American author and psychiatrist Irvin Yalom, who has worked extensively with seriously ill cancer patients, says that taking death into account can be compared to staring at the sun (Yalom, 2008). In the face of both the sun's sharp rays and the relentless reality of death, we often turn away after a short time and turn our attention to something else. Both the sun and death have an intensity that can dazzle us, but, according to Yalom, both can also shed valuable light on life. In light of the fact that life has an end, it can become clearer that I also have my time and my set of opportunities, that I too must make choices. In one sense, we can therefore, paradoxically, say that human beings come into being in the face of death. There may therefore be good reasons to break the silence about death – also in the therapy room.
However, when we often choose to remain silent about death, it can also be understood from a cultural-historical perspective in addition to the existential, outlined above. Over the past hundred years, death has moved away from home. The fact that a person is going to die in a hospital or in a nursing home is something new. If we go back a hundred years in time, death took place to a greater extent in the framework of the life that had been lived. Death was not more welcome or pleasant, but more ordinary and more in sight. The French historian Philippe Ariès discusses Western attitudes to death throughout history (Ariès, 1976). When he comes to our time, he uses the term "forbidden death”. Implied is that death has not only been moved away from the ordinary, out of conversation, out of sight for most people, but that it has also been made into a taboo – a part of life we are reluctant to face and address.
Having a job that involves encounters with death in a society where death is “forbidden”, can be experienced as particularly socially stressful. Implicitly and explicitly, health professionals working with dying and death convey that they feel partially alienated from people outside the clinic due to their own exposure to death (Moen, 2018). They may take long verbal detours in social contexts so as not to reveal what they are working with daily. This can be hard work, as in Norway, the question – "and what do you do for a living" – is often one of the first we ask each other. When I ask health professionals working with death and dying – including in mental health care – if they feel that people outside the clinic understand their work, most respond that they don’t, some having experienced that the other person becomes uncomfortable and does not know how to respond, when death is brought into the exchange – that the conversation dies.
Those who work as “gatekeepers” between life and death stand out in a positive way, as helpers in the most difficult situations. The reward can be hero status: "What are you made of that can stand in this job? I would never have been able to do that." However, being made a hero or a saint, ascribed other qualities than an ordinary person, can also be stressful – and contribute to it being more difficult to embrace oneself as a vulnerable and fallible human being. Regardless of the response being positive or negative, death being part of one`s work in one way or another, in a society in which death is “forbidden”, may evoke feeling like a social anomaly (Douglas, 2003). A sense of not fitting social categories due to representing a "discredited aspect" of life, making for an enhanced sense of visibility (Goffman, 1968).
Unreasonable guilt
The guilt that potentially emerges in relation to deaths in the clinic relate in part to specific situations where the professional has made choices that have had unforeseen effects. However, there is also a sense of guilt that cannot be linked to specific choices or actions, but which seemed reinforced in situations that calls for action, but where one is deprived of opportunities to act, like when faced with the irreversibility of death, it leaves us powerless and with a sense of guilt. Esther, psychiatric nurse, shared a story that may illustrate the point:
"The suicide that has made the most impression [...] I felt in my soul because I had seen him, but I had not seen him. That's the feeling I'm sitting with there, that you see a person and say, “good morning”, but you're not there anyway and I thought – could I have done something? Could I have said something else in that setting that would have made him not feel so lost, but I will never get an answer to that. It's a thought I've had myself, because I felt myself, I had a bad conscience because I'd seen him, but I hadn't seen him anyway, I felt."
The only "mistake" that may explain Esther`s sense of guilt was that she had her shoes on that day, with her feet placed in a situation simultaneously calling for action and depriving her of the possibility to act. Thus, perhaps actualizing what the German existential philosopher Martin Heidegger denotes as “existential guilt”, which relates to taking up a place in the world, evoked by our “existent potentiality-for-being” (Heidegger, 2010, p 264ff)?
There is also another type of guilt that can manifest itself in the face of the death of the other person – namely the one conveyed by Herbert, a palliative physician, who has experienced countless deaths:
"The interesting thing for me is that most deaths don't do much to me – really not [...] It's rare for a patient to get under my skin, it happens once in a while, but not often. So, I sometimes really wonder if I'm being particularly compassionate or not — and I don't know ((whispers))"
When Herbert worries that death rarely does anything to him, it should not necessarily, I think, as he suggests, be written on the account of lack of empathy, but it can be related to the paradoxical fact that death, which is something we all share, can nevertheless evade as a point of identification in the encounter with the dying. As far as we know, no one experiences the end of their own life, and therefore has no inner representation of death, as Freud pointed out. Death as a physical phenomenon is beyond the reach of experience for the living. According to Heidegger, the death of the other person is thus primarily a reminder that I am not dying, that my own death is still in the future.
It may also serve as an explanation for why Dina, who was also a palliative doctor and had faced the death of others countless times, did not feel that it had turned her life upside down. In her case, it was the divorce from her husband and the break with the religious community in which she had grown up that brought her into a deep crisis. She recounted, not unlike what patients in mental health care can tell, about a feeling that the world she knew was no longer valid, which entailed an existential threat, which gave rise to a fundamental anxiety in her. She experienced a threat of non-being, which first dazzled her and then shed light on her life: “I saw things in a totally different way”, thus sounding like someone that had encountered death, but survived.
Concluding remarks
Death, like the sun, will continue to dazzle us. The question is whether it will also enlighten us – put Life and lives in perspective. This requires that we more often break the silence about it – both in the therapy room and in collegial conversations (Barnett, 2008). Openness about death can be experienced as both counter-intuitive and counter-cultural, as discussed in the previous pages. Hence, it may require both personal courage and intentional organizational facilitation to challenge partly unconscious “conspiracies of silence”.
I have scratched the very surface of a phenomenon that none of us can quite wrap our arms around. The case has been made that finitude is a dimension of life that can leave us speechless. We have identified our own instinctive defense against death as a basic condition, but also how the social defenses established through linguistic practices both at the meso-level and macro-level – in the collegium and in the ward culture, and in society at large – may affect the mental health care professional`s experience of working as “gatekeeper” between life and death at the micro-level.
Relationship-intensive work on the border between life and death can be enormously meaningful, but it also makes us vulnerable to occupational hazards. As made evident above, encounters with the death of the other can move, unsettle or traumatize the psychiatrist. Thus, encountering the death of others may become a question to be or not to be, also for the professional. It is not the fear of one's own physical death that becomes most pressing, but the encounter with the death of the other person may actualize a threat to the practitioner as a social and moral person – coming with a risk of being associated with a “discredited” part of life and, or, induced with unreasonable guilt.
Life is "tangled up in blue" (Dylan, 1975). This is true for both patients and psychiatrists. When the therapist is confronted with the possibility and impossibility of death in the clinic – through a patient`s mental illness that gradually undermines his or her life, or a sudden suicide – the professional may be confronted with the most fundamental questions of all, those about suffering, meaninglessness, and loneliness, about freedom and responsibility. The sense of meaninglessness and despair may “spill over” and the professional is suddenly living the questions of the patient – Why should I get up today? Why is life worth living?
Hence, within the Cycle of Care there needs to be a place for self-care for the practitioner – a phase of “re-creation” (Skovholt & Trotter-Mathison, 2016) – during which questions can be lived and wounds mended, and where both sentences in Per Olov Enquist's famous quote are taken serious: "One day we shall die. But all the other days we shall live." Self-care is a sine qua non if the mental health care professional is to be in it for the long run. Taking care of oneself is not merely an individual responsibility but calls for organizational recognition and facilitation. It requires leadership that takes seriously the fact that it takes two minds to process the most difficult thoughts—including unthought, difficult emotional experiences related to death—with mental healthcare professionals being no exception. □
References
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