To the patient who wants to die: a psychologist’s perspective [PODCAST]

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“I often think about how I can make you see these things about yourself that others see. I think about the ways I can tell you that things will get better even though the darkest of days is upon you right now.

But I know I can’t make you see these things; no one can. I know these things may not be helpful to hear, irrelevant, noisy.

So instead of trying to convince you, dear one, I’m going to be here for you. I’m going to listen to you. I’m going to advocate for you. I’m going to help pull you out of this depression. I’m going to help you live a valued life with chronic pain.

I’m not going anywhere. Please, please stay here too.”

Melissa Geraghty is a psychologist and can be reached on Twitter @mindfuldrg.

She shares her story and discusses her KevinMD article, “To the patient who wants to die: a psychologist’s perspective.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Melissa Geraghty. She’s a clinical health psychologist, and she wrote the KevinMD article “To the patient who wants to die: a psychologist’s perspective.” Melissa, welcome to the show.

Melissa Geraghty: Thank you so much. I’m happy to be here.

Kevin Pho: So we’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Melissa Geraghty: So I decided to go into psychology because I’ve been dealing with chronic pain my entire life. I have well over 30 medical conditions, including the rare neural tube defect tethered cord syndrome. So since high school, really, I knew I wanted to help other people who are struggling with what I’ve been struggling with. So I specialize in chronic pain, complex medical, and eating disorders.

Kevin Pho: So tell me a little bit more about that intersection between psychology, chronic pain, and eating disorders. What are some samples of typical cases you might see?

Melissa Geraghty: Yeah, it’s a very interesting intersection. So I can have someone who has a rare disease, or someone, for example, with Chiari, chronic pain, and lots of other symptoms that it includes as well, and then they might also have difficulties with eating. And so it’s really interesting to see the amount of overlap between the eating disorder world and the chronic pain world. And unfortunately, in my experience, a lot of professionals don’t specialize in either, so I really saw that there was the need to specialize not only in one of these but both of these, because so many of my patients have difficulties with both.

Kevin Pho: So when I have a patient with chronic pain, going to a psychologist actually probably isn’t the first place that patient may go to. They may go to their primary care doctor, they may go to a chronic pain specialist, but I probably wouldn’t think of a psychologist until I met you. So tell me some of the modalities and the treatments that you offer patients with chronic pain.

Melissa Geraghty: So what I found is, unfortunately, properly trained therapists in chronic pain are hard to find. So that’s probably why you wouldn’t think about sending someone to someone like me to begin with. But we’re out there. We’re typically called clinical health psychologists, rehabilitation psychologists, or pain psychologists, and have very specialized training. A lot of us work in hospitals or pain clinics; some are in private practice, like myself. And it really is allowing, helping, and guiding people with chronic pain to learn how to be able to still live their values despite having horrific medical experiences. Being able to navigate the health care world and all of that insurance and such, it’s just very overwhelming. And so while, of course, psychology isn’t going to cure pain, it’s going to help people be able to learn how to deal with their pain better, how to react with others better, and communicate better. So it’s a very helpful addition to the chronic pain team.

Kevin Pho: Let’s speak hypothetically. If I sent a chronic pain patient to you for the first time, just to give an example, what kind of questions would you like to ask that patient, and what kind of things would you want to know during that first initial session?

Melissa Geraghty: Yeah, absolutely. So typically, my intakes with patients, especially with complex medical conditions, can last three sessions, because there’s a lot of medical-based trauma that I’ll talk about, either gaslighting experiences they’ve had, especially with my women chronic pain patients who have been told that some of their conditions are anxiety, and then it’s found out that they have some very serious medical condition. That’s happened to myself before. So we’ll talk a lot about that. We’ll talk about if family members and work colleagues believe in their pain. That’s a big thing, people not believing, it’s not bad enough, or just not understanding the accommodations they need. I’ll also ask questions about suicidal thoughts, depression, anxiety, everything that, of course, can happen when you’re living with unrelenting pain.

Kevin Pho: All right, let’s transition now into that KevinMD article that you wrote. This was back in April. It’s titled “To the patient who wants to die: a psychologist’s perspective.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Melissa Geraghty: Absolutely. So I actually wrote the article the night after one of my patients attempted suicide. And as we know, this past year and a half has been extremely taxing on everyone, and particularly health care professionals. All the therapists I have communicated with have been experiencing heightened caseloads that involve constant crisis and high-acuity patients. And in my well over 10 years of being a therapist, I’ve never had a patient attempt suicide in my care, and this past year and a half, I’ve had quite a few.

And so, like I said, I wrote this after one particular patient had attempted, and it was the first time ever I had to call the police on a patient. And I’m so glad I did; otherwise, she would have died. I remember feeling such desperation and helplessness in that moment, which is why I wrote this article. I felt it was therapeutic for me to just get it out there. And as I was dealing with the police for this particular patient, I was also getting another patient who is at high risk of suicide hospitalized. And I remember, after I was taking care of that, I just broke down and sobbed. I felt so helpless, and it was just a very intense day, and very intense days after that. But thankfully, after a lot of support, that patient who attempted is in a much better place, and she’s grateful that she’s alive.

And again, another reason why I wrote this article: Nearly 1 in 10 suicides are due to chronic pain. My patient was nearly that statistic, and it was a lot. It was a lot.

What’s interesting is that I’ve actually received some negative feedback from the article from those in the chronic pain community, saying that I didn’t understand, or saying that I made blanket statements about chronic pain and suicide. But the article in no way, shape, or form is supposed to be representative of the chronic pain population. And I think it’s important to understand that many people with chronic pain, yeah, they don’t have supportive friends or family like my patient does, and that’s kind of what my article touched on. I think it’s important to recognize that the experience of one does not invalidate the experience of another, right?

When a patient comes to me and they’re suicidal, I don’t share those things that my article talked about, like, “I wish you could see yourself the way your family does and how capable you are.” But of course I think those things, because I’m human, and I really know that person, and I’m honored to be with that patient and them sharing that level of vulnerability. So of course, as a human, I just want to be like, “No, you have to stay here because of this, this, and this, and your family loves you.” But that’s not helpful in those moments when someone is in that severe pain. So I lean in and I sit with them, and they don’t need to hear all those things, why they shouldn’t kill themselves. It’s really about, again, being there, having that space, that dialogue for them.

For every mental health care professional, and health care professionals in general, as we know, it’s been trauma after trauma, crisis after crisis, with no breathers for 18 months. And I think it’s about time that people give health care professionals some grace about what they’re going through as well. We know that doctors are at a higher risk of suicide than the general population. I believe it’s twice the general population. And the main focus, of course, is our patients when we’re on the job, but we’re also human too, and I think people forget that sometimes. I’ve seen a lot of attacks on health care professionals online, and for health care professionals who are trying to be able to process what they’re going through. And again, we’re human, and this was one way for me to begin to process what’s been going on: writing articles like this.

Kevin Pho: So you mentioned that during your professional career, you haven’t had a patient attempt suicide until this past year. Tell me something that you’ve learned from that, and how will that change how you treat patients or how you interact with patients going forward?

Melissa Geraghty: Because I work with high-acuity patients anyway, just given the nature of chronic pain, complex medical, and eating disorders, I’ve had plenty of patients over my years of experience who’ve had suicidal thoughts, some who I’ve had to put inpatient and start that process. But again, yeah, like you said, it’s never been actual attempts. And so now, going forward, I think it is just being able to continue to screen. The thing that’s difficult is, while I have these conversations and have always had these conversations with my patients before, I’ve felt that things have been more unpredictable this past 18 months, where someone may be relatively stable and then, because of external conditions, really quickly, rapidly have those suicidal thoughts, which then can lead to, especially in my teenage patients, the impulsivity to do something about it.

So I think it is more monitoring, even when someone is relatively stable. It’s more getting family members involved, talking about the signs. The really tricky part of this, though, is if someone’s going to attempt, they’re going to attempt. I know there are lots of guidelines and things you can look for, risk factors, of course. But that’s the very difficult thing about this subject: You can look at all those, and someone can still attempt.

I knew my patient who attempted was suicidal. We had been talking about it. She was having difficult thoughts, but she hadn’t had a plan, and she still had lots of things that she was looking forward to. And then one weekend, it was enough for her. Her pain had elevated, and then she attempted. So looking back, there wasn’t anything that was an “Oh, I missed that” kind of thing, because, of course, I explored that, like, “What did I miss?” And I’ve done that with all of my patients who have attempted this past 18 months. But unfortunately, I think it’s these circumstances brought upon us with the pandemic that have changed how things are and look.

Kevin Pho: Absolutely. Now, it’s probable that the majority of your patients are also on significant numbers of medications as well, and I’m sure they see a lot of different specialists as well as their primary care clinician. Now, can you comment on your role as a pain psychologist in the treatment and management plan for a lot of the patients that you see?

Melissa Geraghty: So a lot of the time, unfortunately, I try to contact other team members, but unfortunately, I’m met with radio silence. But when I am able to talk to someone like a patient’s psychiatrist, that’s very useful information, because I often see the patient once or twice a week for 50 to 60 minutes at a time, versus a psychiatrist who may see that person once a month, every few months, depending. So I provide a lot of valuable insight into that person. And so even when there are professionals who don’t call me back, which is quite often, I do still try to leave voicemails, and hope that they get them on their confidential voicemail, of insights that I have about the patient, concerns that they have about their medications or possible reactions they’re having, and so on and so forth.

Kevin Pho: And you mentioned about yourself, when you deal with a lot of these very serious cases, sometimes very intense cases, where do you go for support after dealing with a particularly difficult case?

Melissa Geraghty: Absolutely. My best friend is also a psychologist, so that quite helps. We do a lot of processing and debriefing together. I also have my own pain psychologist, who I’ve known for well over a decade, so that has been very beneficial. I’m spending time with my husband, my pups, and nature, those sorts of things. But regardless of all these things, and allowing myself to express and process the vicarious trauma and the trauma I’ve experienced daily for the last 18 months, it’s still been very difficult. So I’m at the level where I’m burned out, and so I’ve been making sure to talk about that a lot. I’ve put a cap on my caseload. I’m trying to delegate a bit and bring on other team members, particularly with high-acuity patients, so it’s not just me on the team. But it’s been a very, very difficult 18 months.

Kevin Pho: We’re talking to Melissa Geraghty. She is a clinical health psychologist, and she wrote the KevinMD article “To the patient who wants to die: a psychologist’s perspective.” But listen, in the primary care setting, a lot of patients that you see are among our most challenging. Now, from your perspective, can you share any tips that physicians like myself can use in the exam room when we try to manage chronic pain patients or patients with eating disorders?

Melissa Geraghty: The most important thing, despite the time sensitivity oftentimes in those rooms, is allowing that patient to have that space to be vulnerable. Again, a lot of people with these sorts of difficulties have experienced a lot of gaslighting, a lot of just being denied treatment, being told that they’re overexaggerating, all of this stuff. So it is about just leaning and listening and having that eye contact and allowing them to share a bit of their story so that they feel heard and understood.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Melissa Geraghty: Absolutely. So as health care professionals, it’s important that we process the trauma that we are dealing with on a daily basis. Sometimes we can be the worst patients, right? We have the tendency to pile it up and keep moving forward, because that’s what we’ve always done, and that may have worked before. But now we’re dealing with a whole different playing field with this pandemic. The amount of death and high-acuity patients we’re experiencing on a daily basis is paramount. So it’s really important that we are processing all of that grief and trauma, the vicarious trauma that we’ve been experiencing, with our own therapists as well.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Melissa Geraghty: Thank you for having me.

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