Should a clinician attend a patient`s funeral?

Addiction counselor and social worker Dinny McClintock, director of adult services at Hope House in Albany, N.Y., says she has lost “numerous” patients to drug overdose, suicide and cancer over the years. She wrote in Addiction Professional six years ago about the first time a patient of hers died, and the mother asked her to go to the funeral after she found McClintock's business card in her son’s wallet.

“This was handled so badly by my co-workers, who didn’t acknowledge my emotions,” McClintock recalls. “For human service workers, we can be very inhumane.”

She says her supervisor questioned whether it was appropriate for her to attend the funeral. “It was viewed as if I had too much transference, and not recognizing that we’re supposed to form these intimate relationships with people,” she says. “I at least needed someone to say, ‘This must be tough for you.’”

By contrast, last year a former patient who had been out of treatment for a long time but had stayed in touch with McClintock died from an overdose. She didn’t feel comfortable going to the funeral, but afterwards, when she heard from the mother, she detected that in fact the family had wanted her to be there.

“Maybe I should have handled it differently,” she says. “You can’t always do it right.”

Marvin Ventrell, executive director of the National Association of Addiction Treatment Providers (NAATP), believes going to a patient's funeral is not the counselor’s role. “I don’t know that there’s any blanket rule that a therapist could not attend a funeral,” he says. “But heart surgeons perform life-saving heart surgery, and sometimes the patients die. They don’t go to the funerals.”

Ventrell doesn’t think counselors should be prohibited from attending, however. “The response needs to be compassionate,” he says. “I would advise that you tell the counselor, ‘I’m not sure that’s the best idea, but clearly this is important to you, you wouldn’t be human if this didn’t affect you.’” The message needs to be one of support and communication, he says.

At the Marworth treatment facility in Pennsylvania, because so many patients come from long distances for residential treatment, it may not be feasible for staff to attend funerals, says medical director Margaret Jarvis, MD. But frequently, staff members will talk to family members on the phone. In the event that a funeral were local, the staff would be able to go, she says.

“I can’t imagine that anybody here would have a problem with the counselor going to the funeral,” Jarvis says. “They would just say, ‘If it would make you feel better, go ahead.’”

Don't bury feelings

Because of recent increases in opioid overdose deaths across the country, counselors are “feeling a little fried, very tired, and kind of scared for the people we care about,” says McClintock. “People are going to die, and even if they don’t die from their addiction, they’re going to die because that’s how life goes.”

If patients are told that they need to be able to process loss and grief, isn’t that what counselors should do themselves? McClintock describes a past workplace where a pet cat was thrown down a landing. “I had to take the cat to the vet and have him put to sleep,” she says. “Even with this cat, nobody was able to process it, nobody was able to say that they missed the cat.” For some of the employees, the cat’s death was “extremely upsetting,” she says. After this, McClintock became overly worried about another pet at the agency, an iguana. “I became almost irrational that this pet has to go, if we can’t guarantee an animal’s safety,” she says.

Clinicians are “too afraid of appearing unprofessional by having feelings,” says McClintock. This can hurt their work even in areas not related to deaths. For example, on one occasion McClintock's house was robbed. “I’m thinking I’m going to work with 72 felons. This is grist for the mill, to be explaining to them that you can’t just rob somebody’s house and not have any effect on them,” she recalls. Her supervisor was concerned that this would not be an appropriate thing to say, but trusted her to give it a try. Afterwards, a few patients told her they had never thought of robbery “from the other side,” she says. “That’s all I wanted—not for me, but for them.”

It is important to stay in touch with feelings, even the bad ones. And when someone dies, it’s appropriate to be sad, says McClintock.

“Some people are so numb to it all; there have been so many losses,” she says. “But you have to take the risk, you have to connect.”

The best way for counselors working with a high-risk population to do this is to “have people in your life who are supportive and caring if you have a loss,” McClintock says.

More Online: A hard reality: Some patients will die

Dangers of drug-free treatment

Headline after headline reads of young people who have died from opioid overdoses, often after going to multiple rounds of treatment in drug-free programs. At a September briefing with the American Society of Addiction Medicine (ASAM) on new medication-assisted treatment guidelines for opioid use disorders, Don Flattery talked about his 26-year-old son Kevin, who died from an opioid overdose a year ago after many cycles of treatment and relapse.

“Painfully I have learned about evidence-based treatment, and the most significant lesson was about medication-assisted treatment,” said Flattery, who is a member of the Virginia Governor’s Task Force on Prescription Drug and Heroin Abuse. He tells everyone he can to “avoid abstinence-only facilities, which are only contributing to opioid overdose deaths.”

However, “People think they’re saving the lives of young people by not letting them have buprenorphine or methadone, and it’s the same attitude that’s been around since the 1970s,” says Shirley Beckett Mikell, consultant to NAADAC, the Association for Addiction Professionals. “It’s the attitude that people can white-knuckle it and come through, and they ask why should we get a young person dependent on medication. But they are already dependent—that’s why they went to treatment in the first place.”

Marworth medical director Margaret Jarvis, MD, says many treatment programs are feeling “helpless” about overdose deaths post-discharge. “These are not places that aren’t doing a good job—they are providing what would be considered quality care—but what is missing is the medications,” she says.

Another aspect of patient deaths from overdoses is being judgmental. “There’s this voyeuristic need to know what the exact circumstances were,” says counselor Dinny McClintock. “It doesn’t matter. I don’t care how he died. The fact is that he’s dead and I’ll miss him.”

Counselors who say that “he did it to himself if it was an overdose” seek to distance themselves from death, McClintock says. “It becomes very shame-based.” It also shows a lack of understanding of addiction, she says.

Professionals working in the field need to understand that this is a fatal disease, says Jarvis. “We’ve always talked about jails, institutions, and deaths, but the number of deaths now are really whacking us upside the head,” she says. “To not acknowledge how hard this is, is asking for trouble.”

Alison Knopf is a freelance writer based in New York.