Humans in Healthcare #30 | A system in crisis

A system in crisis: how emphasis on efficiency can lead to tragedy

By Elena Herrera, PsyD

About six years ago, I was working at a university counseling center. I loved this job and the students on the campus. I took this job because of the promise of exciting opportunities for my career: training future psychologists and working with campus partners to support a specific subgroup of students. One of the responsibilities of our clinical staff was “crisis coverage.” This was by far the least favorite task of our staff.

We were each required to have one day of being on call. We took each student who came in, assessed their situation, and offered resources. Sometimes that meant providing immediate follow-up with one of our staff or referring them to other supports. We prioritized those students who met “crisis” criteria, such as being a danger to themselves or others, had experienced an assault, struggled with severe substance abuse, or were displaying acute psychiatric symptoms such as mania or psychosis. There was room for flexibility, of course, but we tried to keep the focus on helping those students in a true mental health crisis and offer additional resources for students who weren’t in that category.

On one particular day, it seemed that the line of students never got shorter. I couldn’t use the bathroom for several hours, let alone manage a bite of food. I met with a student I’ll call Andy. He reported feeling anxious. When I assessed him, he was very verbose. He was fixated on his girlfriend who hadn’t returned his calls. He was an exchange student, so contact was limited by the phone. There was no danger to himself or others. He was not in crisis, but he was upset and confused. I noticed that he had been set up already with an off-campus provider, so I reminded him of that and encouraged him to talk to that therapist. Because there were many more students to see, and he was not meeting the crisis threshold, I had to send him on his way. I felt bad but also relieved, because I needed to get him out of my office and see the next student in crisis. 

I didn’t think about this student at all until about a week later I got an after-hours call from my supervisor while I was home. I was stunned to hear that this student I mentioned above had been found dead that day by his roommates. It appeared to be a suicide. I was shocked and frozen. My supervisor hurried to reassure me that it wasn’t my fault, but she let me know that the procedure was to review notes from anyone who had contact with him, which was me. She said that based on my note and what I told her, I was in the clear.

The aftermath

The next day, it happened to be my turn for crisis coverage. No questions were asked, and it was assumed I would do my job as planned, so I did. I didn’t expect that several students would come on that day, friends of this deceased student who were shocked, sad, and confused. My supervisor was aware of this, and she tried to get others to come and help out. Because there were so many students coming in, I had to see the students grieving their friend despite my supervisor’s half-hearted attempt to mitigate that. She didn’t send me home, but she probably should have. I insisted that I was fine, but I wasn’t. I was incredibly overwhelmed, and I found myself panicking and shaking internally when students described their guilt and shock. Somehow, I made it to the end of the day, but I was wiped out. I cried, blamed myself, and felt guilty. I also felt angry at the whole situation and my supervisor. Later, when my colleagues found out that this happened, they joined in my anger and outcry that I should have been sent home and supported. I agreed, but there was nothing to be done.

Reflections

Years have passed, and I’m not angry anymore. I can understand the system that creates this kind of seemingly cold and callous behavior. As a supervisor, she had to think about staff coverage and minimizing liability. She couldn’t bother with what was ethically or morally right. Efficiency and making sure all students got seen on the same day was her responsibility. I understand that. However, this system is set up to fail. It builds resentment among staff, creates tension, and increases risk. A shocked, overwhelmed staff member should not see students in need. In my panicked state, I could have missed something with a student, and another potential tragedy could have occurred.

The sad thing is that this is just one aspect of the job that creates this toxic environment. Systems like this are grounded in ways that lead to burnout due to the overwhelming number of patients to be seen with too little staff, or staff that are feeling ineffective and under appreciated. It’s a never-ending cycle. I left the center after a few years. While I loved the students I worked with, I couldn’t do my job as I wanted to. They deserved better, and so I did. I've forgiven myself for the student’s death, but I’ve never forgotten.

About Dr. Herrera

Dr. Elena Herrera is a bilingual, licensed psychologist in California and Oregon and owner of West Coast Psychology Specialists. Her practice serves couples, with a special emphasis on men in tech and engineering as well as therapists and other health professionals. Dr. Herrera has worked in community mental health, and college counseling, and has provided clinical training for future psychologists for almost two decades.

Elena is open to writing and consulting opportunities regarding mental health topics, employee wellbeing, and relationships.

To connect with Elena, find her on social media on LinkedIn and X and check out her professional services at West Coast Psychology