A few days after Christmas, I got a phone call from my mother. My big sister, Amber, had taken her own life with a handgun. During our holiday visit, she seemed depressed, over-apologetic, and not quite herself, but this escalation utterly blindsided us.
I had been involved in her care leading up to that point and I see people in crisis every day. But as I grieved my sister in the days and months that followed, I questioned myself as a clinician: What did I miss? What was my responsibility in this?
A "Perfect Storm" of Despair
Amber was a passionate nurse who worked in rehabilitation and hospice settings in addition to operating her own healthcare business on the side. Like many on nursing's front lines, she burned the candle at both ends, taking care of everyone else -- her patients, her children -- before attending to herself. She was also in the middle of a divorce.
Six months before she took her own life, Amber had been admitted to the psychiatric ward of a health system where I was crisis director at the time. She had broken down and was experiencing rapid thoughts and paranoid delusions. While treating her, we discovered that she'd become dependent on pain medication. According to the law, that meant self-reporting to the medical board of her state and having her RN license suspended.
This was a severe blow: Her identity and self-worth were heavily wrapped in her professional standing and ability to provide for her family. The weeks following her release I saw her undertake the humbling process of an intensive outpatient program (along with meds with side effects like weight loss, nausea, and restlessness) with the goal of being professionally reinstated. Unfortunately, the anger and hopelessness of being both unemployed and feeling inadequate as a mother accelerated her downward spiral.
Looking for Answers in the Aftermath
In the weeks after we lost her, I combed her home in hopes of finding something I'd missed. I found notes laying bare of the utter defeat and despair she was experiencing. I learned that she had applied for mental health disability six times -- and been denied six times -- in an attempt to shore up her finances while she tried to become a licensed nurse again. The last notice of denial was dated the day of her death. In her state, the text of the letter could easily be paraphrased as, "You are worthless."
This systemic failure of my sister's care was easy to spot. Other unconnected dots seemed obvious in retrospect, but had been missed by myself and the fragmented care delivery system that failed her. Did anyone ask if she had access to weapons? As an African-American woman in her 30s, she did not obviously fall into the demographic that commits suicide with a gun. Her psych ward commitment was her first recorded hospitalization, so there was no mental health history to draw from and caregivers missed other opportunities to collaborate.
Answering the Call to Change
Mental illness and substance use disorders often go hand-in-hand. The healthcare industry has not properly prepared frontline caregivers to connect and manage the co-occurrence of mental illness and substance use. Often the Gordian knot of problems is approached with a "point solution" mentality that fails to make whole sense out of either, effectively treating neither. Add the risk of suicide (those suffering from addiction often have problems with impulse control) and you have a volatile brew that requires important systemic changes to reduce risk for those in crisis.
As for my part, one of the ways I have decided to honor my sister's spirit was by becoming more involved in national efforts to prevent suicide. It has been my hope that this awful experience could serve others in the long run in my capacity as a committee member for the National Suicide Prevention Lifeline (1-800-273-TALK ).
Looking closer to home, I have worked with colleagues to improve the way staff assesses and collaborates at intake and beyond to help those at risk of suicide. Everybody in the hospital can now see and share metric risk assessments based on national clinical standards like the Suicide Behavior Questionnaire-Revised (SBQ-R), including a widget that displays a "risk score" to any staff reviewing a patient's electronic medical record (EMR). Safety plans have been included in our therapists' best practices and we've made other strides to connect suicide prevention practices from admissions, to in-facility care, to care after discharge. But most of all, we've undergone a mindset shift: suicidality is not separate from the addictive experience. If it's inseparable from the patient's experience, it should be integrated in care.
If you survey the healthcare landscape, there's no end to improvements that should be made, but over and above that, the biggest change I want to see – for Amber's sake and any other soul that may now be speeding toward the precipice – is to uproot the stigma that stands between help and the people who need it.
We can see how Magic Johnson coming forward with his HIV diagnosis was one of the tipping points that helped Americans, with and without the illness, stop thinking of it as a curse for those living in the shadows. Silence and shame are the common poisons that prove the most lethal of all, whether it's somebody contending with addiction, being bullied online, or made to feel they don't belong because of their gender.
As my story illustrates, even years of training can leave us defenseless against this enemy. I wake up every day with a firm idea of what I must do to honor my sister's memory, but all of us have the power and responsibility to help bring those who struggle quietly at the margins into the light and away from the brink.
Marlon Rollins, PhD, is chief operating officer of Laguna Treatment Hospital, an American Addiction Centers facility. He holds a PhD in educational psychology, as well as an MA in counseling psychology, and is a licensed mental health counselor and a national certified counselor.
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