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Studies have found that 1 in 2 psychiatrists,1-4 and 1 in 5 psychologists, clinical social workers, and other mental health professionals,5 will lose a patient to suicide in the course of their career. This statistic suggests that losing a patient to suicide constitutes a clear occupational hazard.6,7 Despite this, most mental health professionals continue to view suicide loss as an aberration. Consequently, there is often a lack of preparedness for such an event when it does occur.
This 2-part article summarizes what is currently known about the unique personal and professional issues experienced by clinician-survivors (clinicians who have lost patients and/or loved ones to suicide). In Part 1, I cover:
- the impact of losing a patient to suicide
- confidentiality-related constraints on the ability to discuss and process the loss
- legal and ethical issues
- colleagues’ reactions and stigma
- the effects of a suicide loss on one’s clinical work.
Part 2 will discuss the opportunities for personal growth that can result from experiencing a suicide loss, guidelines for optimal postventions, and steps clinicians can take to help support colleagues who have lost a patient to suicide.
A neglected topic
For psychiatrists and other mental health professionals, the loss of a patient to suicide is certainly not uncommon.1-5 Despite this, coping with a patient’s suicide is a “neglected topic”8 in residency and general mental health training.
There are many published articles on clinicians experiencing suicide loss (for a comprehensive bibliography, see McIntosh9), and several authors10-19 have developed suggestions, guidelines, and detailed postvention protocols to help clinicians navigate the often-complicated sequelae to such a loss. However, these resources have generally not been integrated into clinical training, and tend to be poorly disseminated. In a national survey of chief residents, Melton and Coverdale20 found that only 25% of residency training programs covered topics related to postvention, and 72% of chief residents felt this topic needed more attention. Thus, despite the existence of guidelines for optimal postvention and support, clinicians are often left to cope with the consequences of this difficult loss on their own, and under less-than-optimal conditions.
A patient’s suicide typically affects clinicians on multiple levels, both personally and professionally. In this article, I highlight the range of normative responses, as well as the factors that may facilitate or inhibit subsequent healing and growth, with the hope that this knowledge may be utilized to help current and future generations of clinician-survivors obtain optimal support, and that institutions who treat potentially suicidal individuals will develop optimal postvention responses following a suicide loss. Many aspects of what this article discusses also apply to clinicians who have experienced a suicide loss in their personal or family life, as this also tends to “spill over” into one’s professional roles and identity.
Grief and other emotional effects
In many ways, clinicians’ responses after a patient’s suicide are similar to those of other survivors after the loss of a loved one to suicide.21 Chemtob et al2 found that approximately one-half of psychiatrists who lost a patient to suicide had scores on the Impact of an Event Scale that were comparable to those of a clinical population seeking treatment after the death of a parent.
Continue to: Jordan and McIntosh have detailed...
Jordan and McIntosh22 have detailed several elements and themes that differentiate suicide loss and its associated reactions from other types of loss and grief. In general, suicide loss is considered traumatic, and is often accompanied by intense confusion and existential questioning, reflecting a negative impact on one’s core beliefs and assumptive world. The subsequent need to address the myriad of “why” questions left in its wake are often tinted with what Jordan and Baugher23 term the “tyranny of hindsight,” and take the form of implicit guilt for “sins of omission or commission” in relation to the lost individual.
Responses to suicide loss typically include initial shock, denial and numbness, intense sadness, anxiety, anger, and intense distress. Consistent with the traumatic nature of the loss, survivors are also likely to experience posttraumatic stress disorder symptoms such as intrusive thoughts, avoidance, and dissociation. Survivors also commonly experience significant guilt and shame, and this is likely to be socially reinforced by the general stigma associated with suicide as well as the actual blaming and avoidance responses of others.24-27
Clinicians’ unique reactions
For clinicians, there are additional components that may further complicate or exacerbate these reactions and extend their duration. First and foremost, such a loss affects clinicians on both personal and professional levels, a phenomenon that Plakun and Tillman13 have termed a “twin bereavement.” Thus, in addition to the personal grief and trauma reactions entailed in losing a patient to suicide, this loss is likely to impact clinicians’ professional identities, their relationships with colleagues, and their clinical work.
Clinicians’ professional identities are often predicated on generally shared assumptions and beliefs that, as trained professionals, they should have the power, aptitude, and competence to heal, or at least improve, the lives of patients, to reduce their distress, and to provide safety. In addition, such assumptions about clinicians’ responsibility and ability to prevent suicide are often reinforced in the clinical literature.28,29
These assumptions are often challenged, if not shattered, when patients take their own lives. A clinician’s sense of professional responsibility, the guilt and self-blame that may accompany this, self-doubts about one’s skills and clinical competence, the fear of (and actual) blame of colleagues and family members, and the real or imagined threat of litigation may all greatly exacerbate a clinician’s distress.11
Continue to: Hendin et al found...
Hendin et al30 found that mental health therapists have described losing a patient as “the most profoundly disturbing event of their professional careers,” noting that one-third of these clinicians experienced severe distress that lasted at least 1 year beyond the initial loss. In a 2004 study, Ruskin et al4 similarly found that one-quarter of psychiatrists and psychiatric trainees noted that losing a patient had a “profound and enduring effect on them.” In her article on surviving a patient’s suicide, Rycroft31 describes a “professional void” following the loss of her patient, in which “the world had changed, nothing was predictable any more, and it was no longer safe to assume anything.” Additionally, many clinicians experience an “acute sense of aloneness and isolation” subsequent to the loss.32
Many clinicians have noted that they considered leaving the field after such a loss,33,34 and it is hypothesized that many may have done so.35-37 Others have noted that, at least temporarily, they stopped treating patients who were potentially suicidal.29,35
Box 1
Several authors have proposed general models for describing the suicide grief trajectories of clinicians after a suicide loss. Tillman38 identified distinct groups of responses to this event: traumatic, affective, those related to the treatment, those related to interactions with colleagues, liability concerns, and the impact on one’s professional philosophy. She also found that Erikson’s stages of identity39 provided an uncannily similar trajectory to the ways in which those who participated in her research—clinicians at a mental hospital—had attempted to cope with their patients’ deaths, noting that the “suicide of a patient may provoke a revisiting of Erikson’s psychosocial crises in a telescoped and accelerated fashion.”38
Maltsberger40 offered a detailed psychoanalytic analysis of the responses clinicians may manifest in relation to a suicide loss, including the initial narcissistic injury sustained in relation to their patient’s actions; the subsequent potential for melancholic, atonement, or avoidance reactions; and the eventual capacity for the resolution of these reactions.
Al-Mateen et al33 described 3 phases of the clinician’s reaction after losing a patient who was a child to suicide:
- initial, which includes trauma and shock
- turmoil, which includes emotional flooding and functional impairments
- new growth, in which clinicians are able to reflect on their experiences and implications for training and policy.
For each phase, they also described staff activities that would foster forward movement through the trajectory.
In a 1981 study, Bissell41 found that psychiatric nurses who had experienced patient completed suicides progressed through several developmental stages (naïveté, recognition, responsibility, individual choice) that enabled them to come to terms with their personal reactions and place the ultimate responsibility for the suicide with the patient.
After losing a patient to suicide, a clinician may experience grief that proceeds through specific stages (Box 133,38-41). Box 22-4,6,16,24,29,30,33,34,40,42-45 describes a wide range of factors that affect each clinician’s unique response to losing a patient to suicide.
Box 2
There are many factors that make the experience of losing a patient to suicide unique and variable for individual clinicians. These include the amount of a clinician’s professional training and experience, both in general and in working with potentially suicidal individuals. Chemtob et al2 found that trainees were more likely to experience patient suicide loss than more seasoned clinicians, and to experience more distress.4,30,42 Brown24 noted that many training programs were likely to assign the most “extraordinarily sick patients to inexperienced trainees.” He noted that because the skill level of trainees has not yet tempered their personal aspirations, they are likely to experience a patient’s suicide as a personal failure. However, in contrast to the findings of Kleespies,42 Hendin,30 Ruskin et al,4 and Brown24 suggested that the overall impact of a patient’s suicide may be greater for seasoned clinicians, when the “protective advantage” or “explanation” of being in training is no longer applicable. This appears consistent with Munson’s study,43 which found that a greater number of years of clinical experience prior to a suicide loss was negatively correlated with posttraumatic growth.
Other factors affecting a clinician’s grief response include the context in which the treatment occurred, such as inpatient, outpatient, clinic, private practice, etc.44; the presence and involvement of supportive mentors or supervisors16; the length and intensity of the clinical relationship6,29; countertransference issues40; whether the patient was a child33; and the time elapsed since the suicide occurred.
In addition, each clinician’s set of personal and life experiences can affect the way he/ she moves through the grieving process. Any previous trauma or losses, particularly prior exposure to suicide, will likely impact a clinician’s reaction to his/her current loss, as will any susceptibility to anxiety or depression. Gorkin45 has suggested that the degree of omnipotence in the clinician’s therapeutic strivings will affect his/her ability to accept the inherent ambiguity involved in suicide loss. Gender may also play a role: Henry et al34 found that female clinicians had higher levels of stress reactions, and Grad et al3 found that female clinicians felt more shame and guilt and professed more doubts about their professional competence than male clinicians, and were more than twice as likely as men to identify talking with colleagues as an effective coping strategy.
Continue to: Implications of confidentiality restrictions
Implications of confidentiality restrictions
Confidentiality issues, as well as advice from attorneys to limit the disclosure of information about a patient, are likely to preclude a clinician’s ability to talk freely about the patient, the therapeutic relationship, and his/her reactions to the loss, all of which are known to facilitate movement through the grief process.46
The development of trust and the sharing of pain are just 2 factors that can make the clinical encounter an intense emotional experience for both parties. Recent trends in the psychodynamic literature acknowledge the profundity and depth of the personal impact that patients have on the clinician, an impact that is neither pathological nor an indication of poor boundaries in the therapy dyad, but instead a recognition of how all aspects of the clinician’s person, whether consciously or not, are used within the context of a therapeutic relationship. Yet when clinicians lose a patient, confidentiality restrictions often leave them wondering if and where any aspects of their experiences can be shared. Legal counsel may advise a clinician against speaking to consultants or supervisors or even surviving family members for fear that these non-privileged communications are subject to discovery should any legal proceedings ensue. Furthermore, the usual grief rituals that facilitate the healing of loss and the processing of grief (eg, gathering with others who knew the deceased, sharing feelings and memories, attending memorials) are usually denied to the clinician, and are often compounded by the reactions of one’s professional colleagues, who tend not to view the therapist’s grief as “legitimate.” Thus, clinician-survivors, despite having experienced a profound and traumatic loss, have very few places where this may be processed or even validated. As one clinician in a clinician-survivors support group stated, “I felt like I was grieving in a vacuum, that I wasn’t allowed to talk about how much my patient meant to me or how I’m feeling about it.” The isolation of grieving alone is likely to be compounded by the general lack of resources for supporting clinicians after such a loss. In contrast to the general suicide “survivor” network of support groups for family members who have experienced a suicide loss, there is an almost complete lack of supportive resources for clinicians following such a loss, and most clinicians are not aware of the resources that are available, such as the Clinician Survivor Task Force of the American Association of Suicidology (Box 312).
Box 3
Frank Jones and Judy Meade founded the Clinician Survivor Task Force (CSTF) of the American Association of Suicidology (AAS) in 1987. As Jones noted, “clinicians who have lost patients to suicide need a place to acknowledge and carry forward their personal loss … to benefit both personally and professionally from the opportunity to talk with other therapists who have survived the loss of a patient through suicide.”12
Nina Gutin, PhD, and Vanessa McGann, PhD, have co-chaired the CSTF since 2003. It now supports clinicians who have lost patients and/or loved ones, with the recognition that both types of losses carry implications within clinical and professional domains. The CSTF provides a listserve, opportunities to participate in video support groups, and a web site (www. cliniciansurvivor.org) that provides information about the clinician-survivor experience, the opportunity to read and post narratives about one’s experience with suicide loss, an updated bibliography maintained by John McIntosh, PhD, a list of clinical contacts, and a link to several excellent postvention protocols. In addition, Drs. Gutin and McGann conduct clinician-survivor support activities at the annual AAS conference, and in their respective geographic areas.
Continue to: Doka has described...
Doka47 has described “disenfranchised grief” in which the bereaved person does not receive the type and quality of support accorded to other bereaved persons, and thus is likely to internalize the view that his/her grief is not legitimate, and to believe that sharing related distress is a shame-ridden liability. This clearly relates to the sense of profound isolation and distress often described by clinician-survivors.
Other legal/ethical issues
The clinician-survivor’s concern about litigation, or an actual lawsuit, is likely to produce intense anxiety. This common fear is both understandable and credible. According to Bongar,48 the most common malpractice lawsuits filed against clinicians are those that involve a patient’s suicide. Peterson et al49 found that 34% of surviving family members considered bringing a lawsuit against the clinician, and of these, 57% consulted a lawyer.
In addition, an institution’s concern about protecting itself from liability may compromise its ability to support the clinician or trainee who sustained the loss. As noted above, the potential prohibitions around discussing the case can compromise the grief process. Additionally, the fear of (or actual) legal reprisals against supervisors and the larger institution may engender angry and blaming responses toward the treating clinician. In a personal communication (April 2008), Quinnett described an incident in which a supervising psychologist stomped into the grieving therapist’s office unannounced and shouted, “Now look what you’ve done! You’re going to get me sued!”
Other studies29,50,51 note that clinician-survivors fear losing their job, and that their colleagues and supervisors will be reluctant to assign new patients to them. Spiegleman and Werth17 also note that trainees grapple with additional concerns over negative evaluations, suspension or termination from clinical sites or training programs, and a potential interruption of obtaining a degree. Such supervisory and institutional reactions are likely to intensify a clinician’s sense of shame and distress, and are antithetical to postvention responses that promote optimal personal and professional growth. Such negative reactions are also likely to contribute to a clinician or trainee’s subsequent reluctance to work with suicidal individuals, or their decision to discontinue their clinical work altogether. Lastly, other ethical issues, such as contact with the patient’s family following the suicide, attending the funeral, etc., are likely to be a source of additional anxiety and distress, particularly if the clinician needs to address these issues in isolation.
Professional relationships/colleagues’ reactions
Many clinician-survivors have described reactions from colleagues and supervisors that are hurtful and unsupportive. According to Jobes and Maltsberger,52 “the suicide death of a patient in active treatment is commonly taken as prima facie evidence that the therapist, somehow or another, has mismanaged the case,” and thus the clinician often faces unwarranted blame and censure from colleagues and supervisors. Hendin et al30 noted that many trainees found reactions by their institutions to be insensitive and unsupportive, one noting that the department’s review of the case “felt more like a tribunal or inquest.” In a personal communication (April 2008), Quinnett noted that many clinicians he interviewed following a suicide loss reported a pattern of isolation and interpersonal discomfort with their colleagues, who implicitly or explicitly expressed concerns about their competence. He described how a respected colleague received “no understanding, no support, only abuse” from her supervisors. Such responses, while perhaps surprising from mental health professionals, probably reflect the long-standing cultural attitude of social condemnation of suicide, and of those who are associated with it.
Continue to: Negative reactions from professional colleagues...
Negative reactions from professional colleagues are most likely to occur immediately after the suicide loss and/or during the course of a subsequent investigation or psychological autopsy. Castelli-Dransart et al53 found that the lack of institutional support after a clinician experiences a suicide loss contributed to significantly higher stress responses for impacted clinicians, and may lead to a well-founded ambivalence about disclosure to colleagues, and consequent resistance to seeking out optimal supervision/consultation or even personal therapy that could help the clinician gain clarity on the effects of these issues. Many mental health professionals have described how, after the distressing experience of losing a patient to suicide, they moved through this process in relative isolation and loneliness, feeling abandoned by their colleagues and by their own hopes and expectations for support.
Stigmatization. In clinical settings, when a patient in treatment completes suicide, the treating clinician becomes an easy scapegoat for family members and colleagues. To the extent that mental health professionals are not immune from the effects and imposition of stigma, this might also affect their previously mentioned tendency to project judgment, overtly or covertly, onto the treating clinician.
Stigma around suicide is well documented.25 In The Surgeon General’s Call to Action to Prevent Suicide,54 former Surgeon General David Satcher specifically described stigma around suicide as one of the biggest barriers to prevention. Studies have shown that individuals bereaved by suicide are also stigmatized, and that those who were in caregiving roles (parents, clinicians) are believed to be more psychologically disturbed, less likable, more blameworthy, and less worthy of receiving support than other bereaved individuals.25,55-63 These judgments often mirror survivors’ self-punitive assessments, which then become exacerbated by and intertwined with both externally imposed and internalized stigma. Hence, it is not uncommon for suicide survivors to question their own right to grieve, to report low expectations of social support, and to feel compelled to deny or hide the mode of death. Feigelman et al26 found that stigmatization after a suicide loss was specifically associated with ongoing grief difficulties, depression, and suicidal thinking.
In my long-term work with clinician-survivors, I’ve come to believe that in addition to stigma around suicide, there may also be stigma projected by colleagues in relation to a clinician’s perceived emotional vulnerability. A traumatized clinician potentially challenges the notion of the implicit dichotomy/power imbalance between professionals and the patients we treat: “Us”—the professional, competent, healthy, and benevolent clinicians who have the care to offer, and “Them”—our patients, being needy, pathological, looking to us for care. This “us/them” distinction may serve to bolster a clinician’s professional esteem and identity. But when one of “us” becomes one of “them”—when a professional colleague is perceived as being emotionally vulnerable—this can be threatening to the predicates of this distinction, leading to the need to put the affected clinician firmly into the “them” camp. Thus, unwarranted condemnations of the clinician-survivor’s handling of the case, and/or the pathologizing of their normative grief reactions after the suicide loss, can seem justified.
Stigma associated both with suicide and with professional vulnerability is likely to be internalized and to have a profound effect on the clinician’s decisions about disclosure, asking for support, and ultimately on one’s ability to integrate the loss. When this occurs, it is likely to lead to even more isolation, shame, and self-blame. It is not surprising that many clinicians consider leaving the profession after this type of experience.
Continue to: Effects on clinical work
Effects on clinical work
A suicide loss is also likely to affect a clinician’s therapeutic work. Many authors12,52,64-67 have found that this commonly leads therapists to question their abilities as clinicians, and to experience a sharp loss of confidence in their work with patients. The shattered beliefs and assumptions around the efficacy of the therapeutic process, a sense of guilt or self-blame, and any perceived or actual negative judgment from colleagues can dramatically compromise a clinician’s sense of competence. Hendin et al30 noted that even the most experienced therapists expressed difficulty in trusting their own clinical judgment, or accurately assessing risk after a suicide loss.
In addition, the common grief and trauma-related responses to a suicide loss (including shock, numbness, sadness, anxiety, and generalized distress) are likely to result in at least some temporary disruption of a clinician’s optimal functioning. If trauma-related symptoms are more pronounced, the effect and longevity of such impairment may be exacerbated, and are likely to “impair clinical response and therapeutic judgment.”15 In addition, because such symptoms and states may be triggered by exposure to other potentially suicidal patients, they are more likely to impact clinical functioning when the clinician works with suicidal individuals. Thus, the normative responses to a suicide loss are likely to impact a clinician’s work, just as they are likely to impact the personal and occupational functioning of any survivor of suicide loss.
In clinician-survivor discussions and support groups I’ve led, participants have identified many common areas of clinical impact. Perhaps one of the most common early responses reported by clinician-survivors who continued to work with potentially suicidal individuals was to become hypervigilant in relation to any perceived suicide risk, to interpret such risk in such a way as to warrant more conservative interventions than are necessary, and to consequently minimize the patient’s own capacities for self-care.68 Conversely, others reported a tendency to minimize or deny suicidal potential by, for example, avoiding asking patients directly about suicidal ideation, even when they later realized that such questioning was indicated.69
Suicide loss may also lead to more subtle clinical reactions that have been observed not only with suicidal patients, but also in relation to patients who struggle with loss or grief. These include avoidant or even dissociative reactions in relation to their patient’s pain, which in turn can impact the clinician’s ability to “be fully present” or empathic in clinical encounters.50,69 Still, other clinicians noted that they tended to project residual feelings of anger onto their current suicidal patients, or envied patients who seemed to have mastered their grief. Consistent with Maltsberger’s description of “atonement reactions,”40 some clinicians found themselves doing more than should be expected for their patients, even losing their sense of professional boundaries in the process. Anderson70 noted that in pushing herself beyond what she knew were her optimal clinical boundaries, she was “punishing herself” for failing to prevent her patient’s suicide because, as she realized, “doing ‘penance’ was better than feeling helpless and powerless.” And Schultz16 described how therapists may have subsequent difficulty in trusting other patients, especially if patients who completed suicide did not disclose or denied their suicidal intent.
Working toward a supportive solution
In summary, unless clinicians who lose a patient to suicide have more supportive experiences, the combination of confidentiality-related restrictions, confusion about legal/ethical repercussions, unsupportive reactions from colleagues, and unexpected impairments in clinical work are likely to lead to intensified distress, isolation, the perceived need to “hide” the impact in professional settings, and consideration of leaving the profession. However, as I will describe in Part 2 (
Bottom Line
For mental health clinicians, losing a patient to suicide is a clear occupational hazard. After a suicide loss, clinicians often experience unique personal and professional challenges, including the impact of the loss on clinical work and professional identity, legal/ethical issues, and confidentiality-related constraints on the ability to discuss and process the loss.
Related Resources
- American Association of Suicidology Clinician Survivor Task Force. www.cliniciansurvivor.org.
- Gutin N. Helping survivors in the aftermath of suicide loss. Current Psychiatry. 2018;17(8):27-33.
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59. Jordan JR. Is suicide bereavement different? A reassessment of the literature. Suicide Life Threat Behav. 2001;31(1):91-102.
60. McIntosh JL. Control group studies of suicide survivors: a review and critique. Suicide Life Threat Behav. 2003;23(2):146-161.
61. Range LM. When a loss is due to suicide: unique aspects of bereavement. In: Harvey JH, ed. Perspectives on loss: a sourcebook. Philadelphia, PA: Brunner/Mazel; 1998:213-220.
62. Sveen CA, Walby FA. Suicide survivors’ mental health and grief reactions: a systematic review of controlled studies. Suicide Life Threat Behav. 2008;38(1):13-29.
63. Van Dongen CJ. Social context of postsuicide bereavement. Death Stud. 1993;17(2):125-141.
64. Bultema JK. The healing process for the multidisciplinary team: recovering post-inpatient suicide. J Psychosoc Nurs. 1994;32(2):19-24.
65. Cooper C. Patient suicide and assault: their impact on psychiatric hospital staff. J Psychosoc Nurs Ment Health Serv. 1995;33(6):26-29.
66. Foster VA, McAdams CR III. The impact of client suicide in counselor training: Implications for counselor education and supervision. Counselor Educ Supervision. 1999;39(1):22-33.
67. Little JD. Staff response to inpatient and outpatient suicide: what happened and what do we do? Aust N Z J Psychiatry. 1992;26(2):162-167.
68. Horn PJ. Therapists’ psychological adaptation to client suicidal behavior. Chicago, IL: Loyola University of Chicago; 1995.
69. Gutin N, McGann VM, Jordan JR. The impact of suicide on professional caregivers. In: Jordan J, McIntosh J, eds. Grief after suicide: understanding the consequences and caring for the survivors. New York, NY: Routledge; 2011:93-111.
70. Anderson GO. Who, what, when, where, how, and mostly why? A therapist’s grief over the suicide of a client. Women Ther. 2004;28(1):25-34.
Studies have found that 1 in 2 psychiatrists,1-4 and 1 in 5 psychologists, clinical social workers, and other mental health professionals,5 will lose a patient to suicide in the course of their career. This statistic suggests that losing a patient to suicide constitutes a clear occupational hazard.6,7 Despite this, most mental health professionals continue to view suicide loss as an aberration. Consequently, there is often a lack of preparedness for such an event when it does occur.
This 2-part article summarizes what is currently known about the unique personal and professional issues experienced by clinician-survivors (clinicians who have lost patients and/or loved ones to suicide). In Part 1, I cover:
- the impact of losing a patient to suicide
- confidentiality-related constraints on the ability to discuss and process the loss
- legal and ethical issues
- colleagues’ reactions and stigma
- the effects of a suicide loss on one’s clinical work.
Part 2 will discuss the opportunities for personal growth that can result from experiencing a suicide loss, guidelines for optimal postventions, and steps clinicians can take to help support colleagues who have lost a patient to suicide.
A neglected topic
For psychiatrists and other mental health professionals, the loss of a patient to suicide is certainly not uncommon.1-5 Despite this, coping with a patient’s suicide is a “neglected topic”8 in residency and general mental health training.
There are many published articles on clinicians experiencing suicide loss (for a comprehensive bibliography, see McIntosh9), and several authors10-19 have developed suggestions, guidelines, and detailed postvention protocols to help clinicians navigate the often-complicated sequelae to such a loss. However, these resources have generally not been integrated into clinical training, and tend to be poorly disseminated. In a national survey of chief residents, Melton and Coverdale20 found that only 25% of residency training programs covered topics related to postvention, and 72% of chief residents felt this topic needed more attention. Thus, despite the existence of guidelines for optimal postvention and support, clinicians are often left to cope with the consequences of this difficult loss on their own, and under less-than-optimal conditions.
A patient’s suicide typically affects clinicians on multiple levels, both personally and professionally. In this article, I highlight the range of normative responses, as well as the factors that may facilitate or inhibit subsequent healing and growth, with the hope that this knowledge may be utilized to help current and future generations of clinician-survivors obtain optimal support, and that institutions who treat potentially suicidal individuals will develop optimal postvention responses following a suicide loss. Many aspects of what this article discusses also apply to clinicians who have experienced a suicide loss in their personal or family life, as this also tends to “spill over” into one’s professional roles and identity.
Grief and other emotional effects
In many ways, clinicians’ responses after a patient’s suicide are similar to those of other survivors after the loss of a loved one to suicide.21 Chemtob et al2 found that approximately one-half of psychiatrists who lost a patient to suicide had scores on the Impact of an Event Scale that were comparable to those of a clinical population seeking treatment after the death of a parent.
Continue to: Jordan and McIntosh have detailed...
Jordan and McIntosh22 have detailed several elements and themes that differentiate suicide loss and its associated reactions from other types of loss and grief. In general, suicide loss is considered traumatic, and is often accompanied by intense confusion and existential questioning, reflecting a negative impact on one’s core beliefs and assumptive world. The subsequent need to address the myriad of “why” questions left in its wake are often tinted with what Jordan and Baugher23 term the “tyranny of hindsight,” and take the form of implicit guilt for “sins of omission or commission” in relation to the lost individual.
Responses to suicide loss typically include initial shock, denial and numbness, intense sadness, anxiety, anger, and intense distress. Consistent with the traumatic nature of the loss, survivors are also likely to experience posttraumatic stress disorder symptoms such as intrusive thoughts, avoidance, and dissociation. Survivors also commonly experience significant guilt and shame, and this is likely to be socially reinforced by the general stigma associated with suicide as well as the actual blaming and avoidance responses of others.24-27
Clinicians’ unique reactions
For clinicians, there are additional components that may further complicate or exacerbate these reactions and extend their duration. First and foremost, such a loss affects clinicians on both personal and professional levels, a phenomenon that Plakun and Tillman13 have termed a “twin bereavement.” Thus, in addition to the personal grief and trauma reactions entailed in losing a patient to suicide, this loss is likely to impact clinicians’ professional identities, their relationships with colleagues, and their clinical work.
Clinicians’ professional identities are often predicated on generally shared assumptions and beliefs that, as trained professionals, they should have the power, aptitude, and competence to heal, or at least improve, the lives of patients, to reduce their distress, and to provide safety. In addition, such assumptions about clinicians’ responsibility and ability to prevent suicide are often reinforced in the clinical literature.28,29
These assumptions are often challenged, if not shattered, when patients take their own lives. A clinician’s sense of professional responsibility, the guilt and self-blame that may accompany this, self-doubts about one’s skills and clinical competence, the fear of (and actual) blame of colleagues and family members, and the real or imagined threat of litigation may all greatly exacerbate a clinician’s distress.11
Continue to: Hendin et al found...
Hendin et al30 found that mental health therapists have described losing a patient as “the most profoundly disturbing event of their professional careers,” noting that one-third of these clinicians experienced severe distress that lasted at least 1 year beyond the initial loss. In a 2004 study, Ruskin et al4 similarly found that one-quarter of psychiatrists and psychiatric trainees noted that losing a patient had a “profound and enduring effect on them.” In her article on surviving a patient’s suicide, Rycroft31 describes a “professional void” following the loss of her patient, in which “the world had changed, nothing was predictable any more, and it was no longer safe to assume anything.” Additionally, many clinicians experience an “acute sense of aloneness and isolation” subsequent to the loss.32
Many clinicians have noted that they considered leaving the field after such a loss,33,34 and it is hypothesized that many may have done so.35-37 Others have noted that, at least temporarily, they stopped treating patients who were potentially suicidal.29,35
Box 1
Several authors have proposed general models for describing the suicide grief trajectories of clinicians after a suicide loss. Tillman38 identified distinct groups of responses to this event: traumatic, affective, those related to the treatment, those related to interactions with colleagues, liability concerns, and the impact on one’s professional philosophy. She also found that Erikson’s stages of identity39 provided an uncannily similar trajectory to the ways in which those who participated in her research—clinicians at a mental hospital—had attempted to cope with their patients’ deaths, noting that the “suicide of a patient may provoke a revisiting of Erikson’s psychosocial crises in a telescoped and accelerated fashion.”38
Maltsberger40 offered a detailed psychoanalytic analysis of the responses clinicians may manifest in relation to a suicide loss, including the initial narcissistic injury sustained in relation to their patient’s actions; the subsequent potential for melancholic, atonement, or avoidance reactions; and the eventual capacity for the resolution of these reactions.
Al-Mateen et al33 described 3 phases of the clinician’s reaction after losing a patient who was a child to suicide:
- initial, which includes trauma and shock
- turmoil, which includes emotional flooding and functional impairments
- new growth, in which clinicians are able to reflect on their experiences and implications for training and policy.
For each phase, they also described staff activities that would foster forward movement through the trajectory.
In a 1981 study, Bissell41 found that psychiatric nurses who had experienced patient completed suicides progressed through several developmental stages (naïveté, recognition, responsibility, individual choice) that enabled them to come to terms with their personal reactions and place the ultimate responsibility for the suicide with the patient.
After losing a patient to suicide, a clinician may experience grief that proceeds through specific stages (Box 133,38-41). Box 22-4,6,16,24,29,30,33,34,40,42-45 describes a wide range of factors that affect each clinician’s unique response to losing a patient to suicide.
Box 2
There are many factors that make the experience of losing a patient to suicide unique and variable for individual clinicians. These include the amount of a clinician’s professional training and experience, both in general and in working with potentially suicidal individuals. Chemtob et al2 found that trainees were more likely to experience patient suicide loss than more seasoned clinicians, and to experience more distress.4,30,42 Brown24 noted that many training programs were likely to assign the most “extraordinarily sick patients to inexperienced trainees.” He noted that because the skill level of trainees has not yet tempered their personal aspirations, they are likely to experience a patient’s suicide as a personal failure. However, in contrast to the findings of Kleespies,42 Hendin,30 Ruskin et al,4 and Brown24 suggested that the overall impact of a patient’s suicide may be greater for seasoned clinicians, when the “protective advantage” or “explanation” of being in training is no longer applicable. This appears consistent with Munson’s study,43 which found that a greater number of years of clinical experience prior to a suicide loss was negatively correlated with posttraumatic growth.
Other factors affecting a clinician’s grief response include the context in which the treatment occurred, such as inpatient, outpatient, clinic, private practice, etc.44; the presence and involvement of supportive mentors or supervisors16; the length and intensity of the clinical relationship6,29; countertransference issues40; whether the patient was a child33; and the time elapsed since the suicide occurred.
In addition, each clinician’s set of personal and life experiences can affect the way he/ she moves through the grieving process. Any previous trauma or losses, particularly prior exposure to suicide, will likely impact a clinician’s reaction to his/her current loss, as will any susceptibility to anxiety or depression. Gorkin45 has suggested that the degree of omnipotence in the clinician’s therapeutic strivings will affect his/her ability to accept the inherent ambiguity involved in suicide loss. Gender may also play a role: Henry et al34 found that female clinicians had higher levels of stress reactions, and Grad et al3 found that female clinicians felt more shame and guilt and professed more doubts about their professional competence than male clinicians, and were more than twice as likely as men to identify talking with colleagues as an effective coping strategy.
Continue to: Implications of confidentiality restrictions
Implications of confidentiality restrictions
Confidentiality issues, as well as advice from attorneys to limit the disclosure of information about a patient, are likely to preclude a clinician’s ability to talk freely about the patient, the therapeutic relationship, and his/her reactions to the loss, all of which are known to facilitate movement through the grief process.46
The development of trust and the sharing of pain are just 2 factors that can make the clinical encounter an intense emotional experience for both parties. Recent trends in the psychodynamic literature acknowledge the profundity and depth of the personal impact that patients have on the clinician, an impact that is neither pathological nor an indication of poor boundaries in the therapy dyad, but instead a recognition of how all aspects of the clinician’s person, whether consciously or not, are used within the context of a therapeutic relationship. Yet when clinicians lose a patient, confidentiality restrictions often leave them wondering if and where any aspects of their experiences can be shared. Legal counsel may advise a clinician against speaking to consultants or supervisors or even surviving family members for fear that these non-privileged communications are subject to discovery should any legal proceedings ensue. Furthermore, the usual grief rituals that facilitate the healing of loss and the processing of grief (eg, gathering with others who knew the deceased, sharing feelings and memories, attending memorials) are usually denied to the clinician, and are often compounded by the reactions of one’s professional colleagues, who tend not to view the therapist’s grief as “legitimate.” Thus, clinician-survivors, despite having experienced a profound and traumatic loss, have very few places where this may be processed or even validated. As one clinician in a clinician-survivors support group stated, “I felt like I was grieving in a vacuum, that I wasn’t allowed to talk about how much my patient meant to me or how I’m feeling about it.” The isolation of grieving alone is likely to be compounded by the general lack of resources for supporting clinicians after such a loss. In contrast to the general suicide “survivor” network of support groups for family members who have experienced a suicide loss, there is an almost complete lack of supportive resources for clinicians following such a loss, and most clinicians are not aware of the resources that are available, such as the Clinician Survivor Task Force of the American Association of Suicidology (Box 312).
Box 3
Frank Jones and Judy Meade founded the Clinician Survivor Task Force (CSTF) of the American Association of Suicidology (AAS) in 1987. As Jones noted, “clinicians who have lost patients to suicide need a place to acknowledge and carry forward their personal loss … to benefit both personally and professionally from the opportunity to talk with other therapists who have survived the loss of a patient through suicide.”12
Nina Gutin, PhD, and Vanessa McGann, PhD, have co-chaired the CSTF since 2003. It now supports clinicians who have lost patients and/or loved ones, with the recognition that both types of losses carry implications within clinical and professional domains. The CSTF provides a listserve, opportunities to participate in video support groups, and a web site (www. cliniciansurvivor.org) that provides information about the clinician-survivor experience, the opportunity to read and post narratives about one’s experience with suicide loss, an updated bibliography maintained by John McIntosh, PhD, a list of clinical contacts, and a link to several excellent postvention protocols. In addition, Drs. Gutin and McGann conduct clinician-survivor support activities at the annual AAS conference, and in their respective geographic areas.
Continue to: Doka has described...
Doka47 has described “disenfranchised grief” in which the bereaved person does not receive the type and quality of support accorded to other bereaved persons, and thus is likely to internalize the view that his/her grief is not legitimate, and to believe that sharing related distress is a shame-ridden liability. This clearly relates to the sense of profound isolation and distress often described by clinician-survivors.
Other legal/ethical issues
The clinician-survivor’s concern about litigation, or an actual lawsuit, is likely to produce intense anxiety. This common fear is both understandable and credible. According to Bongar,48 the most common malpractice lawsuits filed against clinicians are those that involve a patient’s suicide. Peterson et al49 found that 34% of surviving family members considered bringing a lawsuit against the clinician, and of these, 57% consulted a lawyer.
In addition, an institution’s concern about protecting itself from liability may compromise its ability to support the clinician or trainee who sustained the loss. As noted above, the potential prohibitions around discussing the case can compromise the grief process. Additionally, the fear of (or actual) legal reprisals against supervisors and the larger institution may engender angry and blaming responses toward the treating clinician. In a personal communication (April 2008), Quinnett described an incident in which a supervising psychologist stomped into the grieving therapist’s office unannounced and shouted, “Now look what you’ve done! You’re going to get me sued!”
Other studies29,50,51 note that clinician-survivors fear losing their job, and that their colleagues and supervisors will be reluctant to assign new patients to them. Spiegleman and Werth17 also note that trainees grapple with additional concerns over negative evaluations, suspension or termination from clinical sites or training programs, and a potential interruption of obtaining a degree. Such supervisory and institutional reactions are likely to intensify a clinician’s sense of shame and distress, and are antithetical to postvention responses that promote optimal personal and professional growth. Such negative reactions are also likely to contribute to a clinician or trainee’s subsequent reluctance to work with suicidal individuals, or their decision to discontinue their clinical work altogether. Lastly, other ethical issues, such as contact with the patient’s family following the suicide, attending the funeral, etc., are likely to be a source of additional anxiety and distress, particularly if the clinician needs to address these issues in isolation.
Professional relationships/colleagues’ reactions
Many clinician-survivors have described reactions from colleagues and supervisors that are hurtful and unsupportive. According to Jobes and Maltsberger,52 “the suicide death of a patient in active treatment is commonly taken as prima facie evidence that the therapist, somehow or another, has mismanaged the case,” and thus the clinician often faces unwarranted blame and censure from colleagues and supervisors. Hendin et al30 noted that many trainees found reactions by their institutions to be insensitive and unsupportive, one noting that the department’s review of the case “felt more like a tribunal or inquest.” In a personal communication (April 2008), Quinnett noted that many clinicians he interviewed following a suicide loss reported a pattern of isolation and interpersonal discomfort with their colleagues, who implicitly or explicitly expressed concerns about their competence. He described how a respected colleague received “no understanding, no support, only abuse” from her supervisors. Such responses, while perhaps surprising from mental health professionals, probably reflect the long-standing cultural attitude of social condemnation of suicide, and of those who are associated with it.
Continue to: Negative reactions from professional colleagues...
Negative reactions from professional colleagues are most likely to occur immediately after the suicide loss and/or during the course of a subsequent investigation or psychological autopsy. Castelli-Dransart et al53 found that the lack of institutional support after a clinician experiences a suicide loss contributed to significantly higher stress responses for impacted clinicians, and may lead to a well-founded ambivalence about disclosure to colleagues, and consequent resistance to seeking out optimal supervision/consultation or even personal therapy that could help the clinician gain clarity on the effects of these issues. Many mental health professionals have described how, after the distressing experience of losing a patient to suicide, they moved through this process in relative isolation and loneliness, feeling abandoned by their colleagues and by their own hopes and expectations for support.
Stigmatization. In clinical settings, when a patient in treatment completes suicide, the treating clinician becomes an easy scapegoat for family members and colleagues. To the extent that mental health professionals are not immune from the effects and imposition of stigma, this might also affect their previously mentioned tendency to project judgment, overtly or covertly, onto the treating clinician.
Stigma around suicide is well documented.25 In The Surgeon General’s Call to Action to Prevent Suicide,54 former Surgeon General David Satcher specifically described stigma around suicide as one of the biggest barriers to prevention. Studies have shown that individuals bereaved by suicide are also stigmatized, and that those who were in caregiving roles (parents, clinicians) are believed to be more psychologically disturbed, less likable, more blameworthy, and less worthy of receiving support than other bereaved individuals.25,55-63 These judgments often mirror survivors’ self-punitive assessments, which then become exacerbated by and intertwined with both externally imposed and internalized stigma. Hence, it is not uncommon for suicide survivors to question their own right to grieve, to report low expectations of social support, and to feel compelled to deny or hide the mode of death. Feigelman et al26 found that stigmatization after a suicide loss was specifically associated with ongoing grief difficulties, depression, and suicidal thinking.
In my long-term work with clinician-survivors, I’ve come to believe that in addition to stigma around suicide, there may also be stigma projected by colleagues in relation to a clinician’s perceived emotional vulnerability. A traumatized clinician potentially challenges the notion of the implicit dichotomy/power imbalance between professionals and the patients we treat: “Us”—the professional, competent, healthy, and benevolent clinicians who have the care to offer, and “Them”—our patients, being needy, pathological, looking to us for care. This “us/them” distinction may serve to bolster a clinician’s professional esteem and identity. But when one of “us” becomes one of “them”—when a professional colleague is perceived as being emotionally vulnerable—this can be threatening to the predicates of this distinction, leading to the need to put the affected clinician firmly into the “them” camp. Thus, unwarranted condemnations of the clinician-survivor’s handling of the case, and/or the pathologizing of their normative grief reactions after the suicide loss, can seem justified.
Stigma associated both with suicide and with professional vulnerability is likely to be internalized and to have a profound effect on the clinician’s decisions about disclosure, asking for support, and ultimately on one’s ability to integrate the loss. When this occurs, it is likely to lead to even more isolation, shame, and self-blame. It is not surprising that many clinicians consider leaving the profession after this type of experience.
Continue to: Effects on clinical work
Effects on clinical work
A suicide loss is also likely to affect a clinician’s therapeutic work. Many authors12,52,64-67 have found that this commonly leads therapists to question their abilities as clinicians, and to experience a sharp loss of confidence in their work with patients. The shattered beliefs and assumptions around the efficacy of the therapeutic process, a sense of guilt or self-blame, and any perceived or actual negative judgment from colleagues can dramatically compromise a clinician’s sense of competence. Hendin et al30 noted that even the most experienced therapists expressed difficulty in trusting their own clinical judgment, or accurately assessing risk after a suicide loss.
In addition, the common grief and trauma-related responses to a suicide loss (including shock, numbness, sadness, anxiety, and generalized distress) are likely to result in at least some temporary disruption of a clinician’s optimal functioning. If trauma-related symptoms are more pronounced, the effect and longevity of such impairment may be exacerbated, and are likely to “impair clinical response and therapeutic judgment.”15 In addition, because such symptoms and states may be triggered by exposure to other potentially suicidal patients, they are more likely to impact clinical functioning when the clinician works with suicidal individuals. Thus, the normative responses to a suicide loss are likely to impact a clinician’s work, just as they are likely to impact the personal and occupational functioning of any survivor of suicide loss.
In clinician-survivor discussions and support groups I’ve led, participants have identified many common areas of clinical impact. Perhaps one of the most common early responses reported by clinician-survivors who continued to work with potentially suicidal individuals was to become hypervigilant in relation to any perceived suicide risk, to interpret such risk in such a way as to warrant more conservative interventions than are necessary, and to consequently minimize the patient’s own capacities for self-care.68 Conversely, others reported a tendency to minimize or deny suicidal potential by, for example, avoiding asking patients directly about suicidal ideation, even when they later realized that such questioning was indicated.69
Suicide loss may also lead to more subtle clinical reactions that have been observed not only with suicidal patients, but also in relation to patients who struggle with loss or grief. These include avoidant or even dissociative reactions in relation to their patient’s pain, which in turn can impact the clinician’s ability to “be fully present” or empathic in clinical encounters.50,69 Still, other clinicians noted that they tended to project residual feelings of anger onto their current suicidal patients, or envied patients who seemed to have mastered their grief. Consistent with Maltsberger’s description of “atonement reactions,”40 some clinicians found themselves doing more than should be expected for their patients, even losing their sense of professional boundaries in the process. Anderson70 noted that in pushing herself beyond what she knew were her optimal clinical boundaries, she was “punishing herself” for failing to prevent her patient’s suicide because, as she realized, “doing ‘penance’ was better than feeling helpless and powerless.” And Schultz16 described how therapists may have subsequent difficulty in trusting other patients, especially if patients who completed suicide did not disclose or denied their suicidal intent.
Working toward a supportive solution
In summary, unless clinicians who lose a patient to suicide have more supportive experiences, the combination of confidentiality-related restrictions, confusion about legal/ethical repercussions, unsupportive reactions from colleagues, and unexpected impairments in clinical work are likely to lead to intensified distress, isolation, the perceived need to “hide” the impact in professional settings, and consideration of leaving the profession. However, as I will describe in Part 2 (
Bottom Line
For mental health clinicians, losing a patient to suicide is a clear occupational hazard. After a suicide loss, clinicians often experience unique personal and professional challenges, including the impact of the loss on clinical work and professional identity, legal/ethical issues, and confidentiality-related constraints on the ability to discuss and process the loss.
Related Resources
- American Association of Suicidology Clinician Survivor Task Force. www.cliniciansurvivor.org.
- Gutin N. Helping survivors in the aftermath of suicide loss. Current Psychiatry. 2018;17(8):27-33.
Studies have found that 1 in 2 psychiatrists,1-4 and 1 in 5 psychologists, clinical social workers, and other mental health professionals,5 will lose a patient to suicide in the course of their career. This statistic suggests that losing a patient to suicide constitutes a clear occupational hazard.6,7 Despite this, most mental health professionals continue to view suicide loss as an aberration. Consequently, there is often a lack of preparedness for such an event when it does occur.
This 2-part article summarizes what is currently known about the unique personal and professional issues experienced by clinician-survivors (clinicians who have lost patients and/or loved ones to suicide). In Part 1, I cover:
- the impact of losing a patient to suicide
- confidentiality-related constraints on the ability to discuss and process the loss
- legal and ethical issues
- colleagues’ reactions and stigma
- the effects of a suicide loss on one’s clinical work.
Part 2 will discuss the opportunities for personal growth that can result from experiencing a suicide loss, guidelines for optimal postventions, and steps clinicians can take to help support colleagues who have lost a patient to suicide.
A neglected topic
For psychiatrists and other mental health professionals, the loss of a patient to suicide is certainly not uncommon.1-5 Despite this, coping with a patient’s suicide is a “neglected topic”8 in residency and general mental health training.
There are many published articles on clinicians experiencing suicide loss (for a comprehensive bibliography, see McIntosh9), and several authors10-19 have developed suggestions, guidelines, and detailed postvention protocols to help clinicians navigate the often-complicated sequelae to such a loss. However, these resources have generally not been integrated into clinical training, and tend to be poorly disseminated. In a national survey of chief residents, Melton and Coverdale20 found that only 25% of residency training programs covered topics related to postvention, and 72% of chief residents felt this topic needed more attention. Thus, despite the existence of guidelines for optimal postvention and support, clinicians are often left to cope with the consequences of this difficult loss on their own, and under less-than-optimal conditions.
A patient’s suicide typically affects clinicians on multiple levels, both personally and professionally. In this article, I highlight the range of normative responses, as well as the factors that may facilitate or inhibit subsequent healing and growth, with the hope that this knowledge may be utilized to help current and future generations of clinician-survivors obtain optimal support, and that institutions who treat potentially suicidal individuals will develop optimal postvention responses following a suicide loss. Many aspects of what this article discusses also apply to clinicians who have experienced a suicide loss in their personal or family life, as this also tends to “spill over” into one’s professional roles and identity.
Grief and other emotional effects
In many ways, clinicians’ responses after a patient’s suicide are similar to those of other survivors after the loss of a loved one to suicide.21 Chemtob et al2 found that approximately one-half of psychiatrists who lost a patient to suicide had scores on the Impact of an Event Scale that were comparable to those of a clinical population seeking treatment after the death of a parent.
Continue to: Jordan and McIntosh have detailed...
Jordan and McIntosh22 have detailed several elements and themes that differentiate suicide loss and its associated reactions from other types of loss and grief. In general, suicide loss is considered traumatic, and is often accompanied by intense confusion and existential questioning, reflecting a negative impact on one’s core beliefs and assumptive world. The subsequent need to address the myriad of “why” questions left in its wake are often tinted with what Jordan and Baugher23 term the “tyranny of hindsight,” and take the form of implicit guilt for “sins of omission or commission” in relation to the lost individual.
Responses to suicide loss typically include initial shock, denial and numbness, intense sadness, anxiety, anger, and intense distress. Consistent with the traumatic nature of the loss, survivors are also likely to experience posttraumatic stress disorder symptoms such as intrusive thoughts, avoidance, and dissociation. Survivors also commonly experience significant guilt and shame, and this is likely to be socially reinforced by the general stigma associated with suicide as well as the actual blaming and avoidance responses of others.24-27
Clinicians’ unique reactions
For clinicians, there are additional components that may further complicate or exacerbate these reactions and extend their duration. First and foremost, such a loss affects clinicians on both personal and professional levels, a phenomenon that Plakun and Tillman13 have termed a “twin bereavement.” Thus, in addition to the personal grief and trauma reactions entailed in losing a patient to suicide, this loss is likely to impact clinicians’ professional identities, their relationships with colleagues, and their clinical work.
Clinicians’ professional identities are often predicated on generally shared assumptions and beliefs that, as trained professionals, they should have the power, aptitude, and competence to heal, or at least improve, the lives of patients, to reduce their distress, and to provide safety. In addition, such assumptions about clinicians’ responsibility and ability to prevent suicide are often reinforced in the clinical literature.28,29
These assumptions are often challenged, if not shattered, when patients take their own lives. A clinician’s sense of professional responsibility, the guilt and self-blame that may accompany this, self-doubts about one’s skills and clinical competence, the fear of (and actual) blame of colleagues and family members, and the real or imagined threat of litigation may all greatly exacerbate a clinician’s distress.11
Continue to: Hendin et al found...
Hendin et al30 found that mental health therapists have described losing a patient as “the most profoundly disturbing event of their professional careers,” noting that one-third of these clinicians experienced severe distress that lasted at least 1 year beyond the initial loss. In a 2004 study, Ruskin et al4 similarly found that one-quarter of psychiatrists and psychiatric trainees noted that losing a patient had a “profound and enduring effect on them.” In her article on surviving a patient’s suicide, Rycroft31 describes a “professional void” following the loss of her patient, in which “the world had changed, nothing was predictable any more, and it was no longer safe to assume anything.” Additionally, many clinicians experience an “acute sense of aloneness and isolation” subsequent to the loss.32
Many clinicians have noted that they considered leaving the field after such a loss,33,34 and it is hypothesized that many may have done so.35-37 Others have noted that, at least temporarily, they stopped treating patients who were potentially suicidal.29,35
Box 1
Several authors have proposed general models for describing the suicide grief trajectories of clinicians after a suicide loss. Tillman38 identified distinct groups of responses to this event: traumatic, affective, those related to the treatment, those related to interactions with colleagues, liability concerns, and the impact on one’s professional philosophy. She also found that Erikson’s stages of identity39 provided an uncannily similar trajectory to the ways in which those who participated in her research—clinicians at a mental hospital—had attempted to cope with their patients’ deaths, noting that the “suicide of a patient may provoke a revisiting of Erikson’s psychosocial crises in a telescoped and accelerated fashion.”38
Maltsberger40 offered a detailed psychoanalytic analysis of the responses clinicians may manifest in relation to a suicide loss, including the initial narcissistic injury sustained in relation to their patient’s actions; the subsequent potential for melancholic, atonement, or avoidance reactions; and the eventual capacity for the resolution of these reactions.
Al-Mateen et al33 described 3 phases of the clinician’s reaction after losing a patient who was a child to suicide:
- initial, which includes trauma and shock
- turmoil, which includes emotional flooding and functional impairments
- new growth, in which clinicians are able to reflect on their experiences and implications for training and policy.
For each phase, they also described staff activities that would foster forward movement through the trajectory.
In a 1981 study, Bissell41 found that psychiatric nurses who had experienced patient completed suicides progressed through several developmental stages (naïveté, recognition, responsibility, individual choice) that enabled them to come to terms with their personal reactions and place the ultimate responsibility for the suicide with the patient.
After losing a patient to suicide, a clinician may experience grief that proceeds through specific stages (Box 133,38-41). Box 22-4,6,16,24,29,30,33,34,40,42-45 describes a wide range of factors that affect each clinician’s unique response to losing a patient to suicide.
Box 2
There are many factors that make the experience of losing a patient to suicide unique and variable for individual clinicians. These include the amount of a clinician’s professional training and experience, both in general and in working with potentially suicidal individuals. Chemtob et al2 found that trainees were more likely to experience patient suicide loss than more seasoned clinicians, and to experience more distress.4,30,42 Brown24 noted that many training programs were likely to assign the most “extraordinarily sick patients to inexperienced trainees.” He noted that because the skill level of trainees has not yet tempered their personal aspirations, they are likely to experience a patient’s suicide as a personal failure. However, in contrast to the findings of Kleespies,42 Hendin,30 Ruskin et al,4 and Brown24 suggested that the overall impact of a patient’s suicide may be greater for seasoned clinicians, when the “protective advantage” or “explanation” of being in training is no longer applicable. This appears consistent with Munson’s study,43 which found that a greater number of years of clinical experience prior to a suicide loss was negatively correlated with posttraumatic growth.
Other factors affecting a clinician’s grief response include the context in which the treatment occurred, such as inpatient, outpatient, clinic, private practice, etc.44; the presence and involvement of supportive mentors or supervisors16; the length and intensity of the clinical relationship6,29; countertransference issues40; whether the patient was a child33; and the time elapsed since the suicide occurred.
In addition, each clinician’s set of personal and life experiences can affect the way he/ she moves through the grieving process. Any previous trauma or losses, particularly prior exposure to suicide, will likely impact a clinician’s reaction to his/her current loss, as will any susceptibility to anxiety or depression. Gorkin45 has suggested that the degree of omnipotence in the clinician’s therapeutic strivings will affect his/her ability to accept the inherent ambiguity involved in suicide loss. Gender may also play a role: Henry et al34 found that female clinicians had higher levels of stress reactions, and Grad et al3 found that female clinicians felt more shame and guilt and professed more doubts about their professional competence than male clinicians, and were more than twice as likely as men to identify talking with colleagues as an effective coping strategy.
Continue to: Implications of confidentiality restrictions
Implications of confidentiality restrictions
Confidentiality issues, as well as advice from attorneys to limit the disclosure of information about a patient, are likely to preclude a clinician’s ability to talk freely about the patient, the therapeutic relationship, and his/her reactions to the loss, all of which are known to facilitate movement through the grief process.46
The development of trust and the sharing of pain are just 2 factors that can make the clinical encounter an intense emotional experience for both parties. Recent trends in the psychodynamic literature acknowledge the profundity and depth of the personal impact that patients have on the clinician, an impact that is neither pathological nor an indication of poor boundaries in the therapy dyad, but instead a recognition of how all aspects of the clinician’s person, whether consciously or not, are used within the context of a therapeutic relationship. Yet when clinicians lose a patient, confidentiality restrictions often leave them wondering if and where any aspects of their experiences can be shared. Legal counsel may advise a clinician against speaking to consultants or supervisors or even surviving family members for fear that these non-privileged communications are subject to discovery should any legal proceedings ensue. Furthermore, the usual grief rituals that facilitate the healing of loss and the processing of grief (eg, gathering with others who knew the deceased, sharing feelings and memories, attending memorials) are usually denied to the clinician, and are often compounded by the reactions of one’s professional colleagues, who tend not to view the therapist’s grief as “legitimate.” Thus, clinician-survivors, despite having experienced a profound and traumatic loss, have very few places where this may be processed or even validated. As one clinician in a clinician-survivors support group stated, “I felt like I was grieving in a vacuum, that I wasn’t allowed to talk about how much my patient meant to me or how I’m feeling about it.” The isolation of grieving alone is likely to be compounded by the general lack of resources for supporting clinicians after such a loss. In contrast to the general suicide “survivor” network of support groups for family members who have experienced a suicide loss, there is an almost complete lack of supportive resources for clinicians following such a loss, and most clinicians are not aware of the resources that are available, such as the Clinician Survivor Task Force of the American Association of Suicidology (Box 312).
Box 3
Frank Jones and Judy Meade founded the Clinician Survivor Task Force (CSTF) of the American Association of Suicidology (AAS) in 1987. As Jones noted, “clinicians who have lost patients to suicide need a place to acknowledge and carry forward their personal loss … to benefit both personally and professionally from the opportunity to talk with other therapists who have survived the loss of a patient through suicide.”12
Nina Gutin, PhD, and Vanessa McGann, PhD, have co-chaired the CSTF since 2003. It now supports clinicians who have lost patients and/or loved ones, with the recognition that both types of losses carry implications within clinical and professional domains. The CSTF provides a listserve, opportunities to participate in video support groups, and a web site (www. cliniciansurvivor.org) that provides information about the clinician-survivor experience, the opportunity to read and post narratives about one’s experience with suicide loss, an updated bibliography maintained by John McIntosh, PhD, a list of clinical contacts, and a link to several excellent postvention protocols. In addition, Drs. Gutin and McGann conduct clinician-survivor support activities at the annual AAS conference, and in their respective geographic areas.
Continue to: Doka has described...
Doka47 has described “disenfranchised grief” in which the bereaved person does not receive the type and quality of support accorded to other bereaved persons, and thus is likely to internalize the view that his/her grief is not legitimate, and to believe that sharing related distress is a shame-ridden liability. This clearly relates to the sense of profound isolation and distress often described by clinician-survivors.
Other legal/ethical issues
The clinician-survivor’s concern about litigation, or an actual lawsuit, is likely to produce intense anxiety. This common fear is both understandable and credible. According to Bongar,48 the most common malpractice lawsuits filed against clinicians are those that involve a patient’s suicide. Peterson et al49 found that 34% of surviving family members considered bringing a lawsuit against the clinician, and of these, 57% consulted a lawyer.
In addition, an institution’s concern about protecting itself from liability may compromise its ability to support the clinician or trainee who sustained the loss. As noted above, the potential prohibitions around discussing the case can compromise the grief process. Additionally, the fear of (or actual) legal reprisals against supervisors and the larger institution may engender angry and blaming responses toward the treating clinician. In a personal communication (April 2008), Quinnett described an incident in which a supervising psychologist stomped into the grieving therapist’s office unannounced and shouted, “Now look what you’ve done! You’re going to get me sued!”
Other studies29,50,51 note that clinician-survivors fear losing their job, and that their colleagues and supervisors will be reluctant to assign new patients to them. Spiegleman and Werth17 also note that trainees grapple with additional concerns over negative evaluations, suspension or termination from clinical sites or training programs, and a potential interruption of obtaining a degree. Such supervisory and institutional reactions are likely to intensify a clinician’s sense of shame and distress, and are antithetical to postvention responses that promote optimal personal and professional growth. Such negative reactions are also likely to contribute to a clinician or trainee’s subsequent reluctance to work with suicidal individuals, or their decision to discontinue their clinical work altogether. Lastly, other ethical issues, such as contact with the patient’s family following the suicide, attending the funeral, etc., are likely to be a source of additional anxiety and distress, particularly if the clinician needs to address these issues in isolation.
Professional relationships/colleagues’ reactions
Many clinician-survivors have described reactions from colleagues and supervisors that are hurtful and unsupportive. According to Jobes and Maltsberger,52 “the suicide death of a patient in active treatment is commonly taken as prima facie evidence that the therapist, somehow or another, has mismanaged the case,” and thus the clinician often faces unwarranted blame and censure from colleagues and supervisors. Hendin et al30 noted that many trainees found reactions by their institutions to be insensitive and unsupportive, one noting that the department’s review of the case “felt more like a tribunal or inquest.” In a personal communication (April 2008), Quinnett noted that many clinicians he interviewed following a suicide loss reported a pattern of isolation and interpersonal discomfort with their colleagues, who implicitly or explicitly expressed concerns about their competence. He described how a respected colleague received “no understanding, no support, only abuse” from her supervisors. Such responses, while perhaps surprising from mental health professionals, probably reflect the long-standing cultural attitude of social condemnation of suicide, and of those who are associated with it.
Continue to: Negative reactions from professional colleagues...
Negative reactions from professional colleagues are most likely to occur immediately after the suicide loss and/or during the course of a subsequent investigation or psychological autopsy. Castelli-Dransart et al53 found that the lack of institutional support after a clinician experiences a suicide loss contributed to significantly higher stress responses for impacted clinicians, and may lead to a well-founded ambivalence about disclosure to colleagues, and consequent resistance to seeking out optimal supervision/consultation or even personal therapy that could help the clinician gain clarity on the effects of these issues. Many mental health professionals have described how, after the distressing experience of losing a patient to suicide, they moved through this process in relative isolation and loneliness, feeling abandoned by their colleagues and by their own hopes and expectations for support.
Stigmatization. In clinical settings, when a patient in treatment completes suicide, the treating clinician becomes an easy scapegoat for family members and colleagues. To the extent that mental health professionals are not immune from the effects and imposition of stigma, this might also affect their previously mentioned tendency to project judgment, overtly or covertly, onto the treating clinician.
Stigma around suicide is well documented.25 In The Surgeon General’s Call to Action to Prevent Suicide,54 former Surgeon General David Satcher specifically described stigma around suicide as one of the biggest barriers to prevention. Studies have shown that individuals bereaved by suicide are also stigmatized, and that those who were in caregiving roles (parents, clinicians) are believed to be more psychologically disturbed, less likable, more blameworthy, and less worthy of receiving support than other bereaved individuals.25,55-63 These judgments often mirror survivors’ self-punitive assessments, which then become exacerbated by and intertwined with both externally imposed and internalized stigma. Hence, it is not uncommon for suicide survivors to question their own right to grieve, to report low expectations of social support, and to feel compelled to deny or hide the mode of death. Feigelman et al26 found that stigmatization after a suicide loss was specifically associated with ongoing grief difficulties, depression, and suicidal thinking.
In my long-term work with clinician-survivors, I’ve come to believe that in addition to stigma around suicide, there may also be stigma projected by colleagues in relation to a clinician’s perceived emotional vulnerability. A traumatized clinician potentially challenges the notion of the implicit dichotomy/power imbalance between professionals and the patients we treat: “Us”—the professional, competent, healthy, and benevolent clinicians who have the care to offer, and “Them”—our patients, being needy, pathological, looking to us for care. This “us/them” distinction may serve to bolster a clinician’s professional esteem and identity. But when one of “us” becomes one of “them”—when a professional colleague is perceived as being emotionally vulnerable—this can be threatening to the predicates of this distinction, leading to the need to put the affected clinician firmly into the “them” camp. Thus, unwarranted condemnations of the clinician-survivor’s handling of the case, and/or the pathologizing of their normative grief reactions after the suicide loss, can seem justified.
Stigma associated both with suicide and with professional vulnerability is likely to be internalized and to have a profound effect on the clinician’s decisions about disclosure, asking for support, and ultimately on one’s ability to integrate the loss. When this occurs, it is likely to lead to even more isolation, shame, and self-blame. It is not surprising that many clinicians consider leaving the profession after this type of experience.
Continue to: Effects on clinical work
Effects on clinical work
A suicide loss is also likely to affect a clinician’s therapeutic work. Many authors12,52,64-67 have found that this commonly leads therapists to question their abilities as clinicians, and to experience a sharp loss of confidence in their work with patients. The shattered beliefs and assumptions around the efficacy of the therapeutic process, a sense of guilt or self-blame, and any perceived or actual negative judgment from colleagues can dramatically compromise a clinician’s sense of competence. Hendin et al30 noted that even the most experienced therapists expressed difficulty in trusting their own clinical judgment, or accurately assessing risk after a suicide loss.
In addition, the common grief and trauma-related responses to a suicide loss (including shock, numbness, sadness, anxiety, and generalized distress) are likely to result in at least some temporary disruption of a clinician’s optimal functioning. If trauma-related symptoms are more pronounced, the effect and longevity of such impairment may be exacerbated, and are likely to “impair clinical response and therapeutic judgment.”15 In addition, because such symptoms and states may be triggered by exposure to other potentially suicidal patients, they are more likely to impact clinical functioning when the clinician works with suicidal individuals. Thus, the normative responses to a suicide loss are likely to impact a clinician’s work, just as they are likely to impact the personal and occupational functioning of any survivor of suicide loss.
In clinician-survivor discussions and support groups I’ve led, participants have identified many common areas of clinical impact. Perhaps one of the most common early responses reported by clinician-survivors who continued to work with potentially suicidal individuals was to become hypervigilant in relation to any perceived suicide risk, to interpret such risk in such a way as to warrant more conservative interventions than are necessary, and to consequently minimize the patient’s own capacities for self-care.68 Conversely, others reported a tendency to minimize or deny suicidal potential by, for example, avoiding asking patients directly about suicidal ideation, even when they later realized that such questioning was indicated.69
Suicide loss may also lead to more subtle clinical reactions that have been observed not only with suicidal patients, but also in relation to patients who struggle with loss or grief. These include avoidant or even dissociative reactions in relation to their patient’s pain, which in turn can impact the clinician’s ability to “be fully present” or empathic in clinical encounters.50,69 Still, other clinicians noted that they tended to project residual feelings of anger onto their current suicidal patients, or envied patients who seemed to have mastered their grief. Consistent with Maltsberger’s description of “atonement reactions,”40 some clinicians found themselves doing more than should be expected for their patients, even losing their sense of professional boundaries in the process. Anderson70 noted that in pushing herself beyond what she knew were her optimal clinical boundaries, she was “punishing herself” for failing to prevent her patient’s suicide because, as she realized, “doing ‘penance’ was better than feeling helpless and powerless.” And Schultz16 described how therapists may have subsequent difficulty in trusting other patients, especially if patients who completed suicide did not disclose or denied their suicidal intent.
Working toward a supportive solution
In summary, unless clinicians who lose a patient to suicide have more supportive experiences, the combination of confidentiality-related restrictions, confusion about legal/ethical repercussions, unsupportive reactions from colleagues, and unexpected impairments in clinical work are likely to lead to intensified distress, isolation, the perceived need to “hide” the impact in professional settings, and consideration of leaving the profession. However, as I will describe in Part 2 (
Bottom Line
For mental health clinicians, losing a patient to suicide is a clear occupational hazard. After a suicide loss, clinicians often experience unique personal and professional challenges, including the impact of the loss on clinical work and professional identity, legal/ethical issues, and confidentiality-related constraints on the ability to discuss and process the loss.
Related Resources
- American Association of Suicidology Clinician Survivor Task Force. www.cliniciansurvivor.org.
- Gutin N. Helping survivors in the aftermath of suicide loss. Current Psychiatry. 2018;17(8):27-33.
1. Alexander D, Klein S, Gray NM, et al. Suicide by patients: questionnaire study of its effect on consultant psychiatrists. BMJ. 2000;320(7249):1571-1574.
2. Chemtob CM, Hamada RS, Bauer G, et al. Patients’ suicides: frequency and impact on psychiatrists. Am J Psychiatry. 1988;145(2):224-228.
3. Grad OT, Zavasnik A, Groleger U. Suicide of a patient: gender differences in bereavement reactions of therapists. Suicide Life Threat Behav. 1997;27(4):379-386.
4. Ruskin R, Sakinofsky I, Bagby RM, et al. Impact of patient suicide on psychiatrists and psychiatric trainees. Acad Psychiatry. 2004;28(2):104-110.
5. Bersoff DN. Ethical conflicts in psychology, 2nd ed. Washington, DC: American Psychological Association; 1999.
6. Chemtob CM, Bauer GB, Hamada RS, et al. Patient suicide: occupational hazard for psychologists and psychiatrists. Prof Psychol Res Pr. 1989;20(5):294-300.
7. Rubin HL. Surviving a suicide in your practice. In: Blumenthal SJ, Kupfer DJ, eds. Suicide over the life cycle: risk factors, assessment, and treatment of suicidal patients. Washington, DC: American Psychiatric Press; 1990:619-636.
8. Kaye NS, Soreff SM. The psychiatrist’s role, responses, and responsibilities when a patient commits suicide. Am J Psychiatry. 1991;148(6):739-743.
9. McIntosh JL. Clinicians as survivors of suicide: bibliography. American Association of Suicidology Clinician Survivor Task Force. http://pages.iu.edu/~jmcintos/Surv.Ther.bib.htm. Updated May 19, 2019. Accessed August 26, 2019.
10. Douglas J, Brown HN. Suicide: understanding and responding: Harvard Medical School perspectives. Madison, CT: International Universities Press; 1989.
11. Farberow NL. The mental health professional as suicide survivor. Clin Neuropsychiatry. 2005;2(1):13-20.
12. Jones FA Jr. Therapists as survivors of patient suicide. In: Dunne EJ, McIntosh JL, Dunne-Maxim K, eds. Suicide and its aftermath: understanding and counseling the survivors. New York, NY: W.W. Norton; 1987;126-141.
13. Plakun EM, Tillman JG. Responding to clinicians after loss of a patient to suicide. Dir Psychiatry. 2005;25:301-310.
14. Prabhakar D, Anzia JM, Balon R, et al. “Collateral damages”: preparing residents for coping with patient suicide. Acad Psychiatry. 2013;37(6):429-30.
15. Quinnett P. QPR: for suicide prevention. QPR Institute, Inc. http://pages.iu.edu/~jmcintos/postvention.htm. Published September 21, 2009. Accessed August 26, 2019.
16. Schultz, D. Suggestions for supervisors when a therapist experiences a client’s suicide. Women Ther. 2005;28(1):59-69.
17. Spiegelman JS Jr, Werth JL Jr. Don’t forget about me: the experiences of therapists-in-training after a patient has attempted or died by suicide. Women Ther. 2005;28(1):35-57.
18. American Association of Suicidology. Clinician Survivor Task Force. Clinicians as survivors of suicide: postvention information.
19. Whitmore CA, Cook J, Salg L. Supporting residents in the wake of patient suicide. The American Journal of Psychiatry Residents’ Journal. 2017;12(1):5-7.
20. Melton B, Coverdale J. What do we teach psychiatric residents about suicide? A national survey of chief residents. Acad Psychiatry. 2009;33(1):47-50.
21. Valente SM. Psychotherapist reactions to the suicide of a patient. Am J Orthopsychiatry. 1994;64(4):614-621.
22. Jordan JR, McIntosh JL. Is suicide bereavement different? A framework for rethinking the question. In: Jordan JR, McIntosh JL, eds. Grief after suicide: understanding the consequences and caring for the survivors. New York, NY: Routledge; 2011:19-42.
23. Jordan JR, Baugher B. After suicide loss: coping with your grief, 2nd ed. Newcastle, WA: Caring People Press; 2016.
24. Brown HB. The impact of suicide on therapists in training. Compr Psychiatry. 1987;28(2):101-112.
25. Cvinar JG. Do suicide survivors suffer social stigma: a review of the literature. Perspect Psychiatr Care. 2005;41(1):14-21.
26. Feigelman W, Gorman BS, Jordan JR. Stigmatization and suicide bereavement. Death Stud. 2009;33(7):591-608.
27. Goffman E. Stigma: notes on the management of spoiled identity. New York, NY: Simon & Schuster; 1963.
28. Goldney RD. The privilege and responsibility of suicide prevention. Crisis. 2000;21(1):8-15.
29. Litman RE. When patients commit suicide. Am J Psychother. 1965;19(4):570-576.
30. Hendin H, Lipschitz A, Maltsberger JT, et al. Therapists’ reactions to patients’ suicides. Am J Psychiatry. 2000;157(12):2022-2027.
31. Rycroft P. Touching the heart and soul of therapy: surviving client suicide. Women Ther. 2004;28(1):83-94.
32. Ellis TE, Patel AB. Client suicide: what now? Cogn Behav Pract. 2012;19(2):277-287.
33. Al-Mateen CS, Jones K, Linker J, et al. Clinician response to a child who completes suicide. Child Adolesc Psychiatric Clin N Am. 2018;27(4):621-635.
34. Henry M, Séguin M, Drouin M-S. Mental health professionals’ response to the suicide of their patients [in French]. Revue Québécoise de Psychologie. 2004;25:241-257.
35. Carter RE. Some effects of client suicide on the therapist. Psychother Theory Res Practice. 1971;8(4):287-289.
36. Dewar I, Eagles J, Klein S, et al. Psychiatric trainees’ experiences of, and reactions to, patient suicide. Psychiatr Bull. 2000;24(1):20-23.
37. Gitlin M. Aftermath of a tragedy: reaction of psychiatrists to patient suicides. Psychiatr Ann. 2007;37(10):684-687.
38. Tillman JG. When a patient commits suicide: an empirical study of psychoanalytic clinicians. Inter J Psychoanal. 2006;87(1):159-177.
39. Erikson EH. Identity and the life cycle. New York, NY: International Universities Press, Inc.; 1959.
40. Maltsberger JT. The implications of patient suicide for the surviving psychotherapist. In: Jacobs D, ed. Suicide and clinical practice. Washington, DC: American Psychiatric Press; 1992:169-182.
41. Bissell BPH. The experience of the nurse therapist working with suicidal cases: a developmental study [dissertation]. Boston, MA: Boston University School of Education; 1981.
42. Kleespies PM. The stress of patient suicidal behavior: Implications for interns and training programs in psychology. Prof Psychol Res Pract. 1993;24(4):477-482.
43. Munson JS. Impact of client suicide on practitioner posttraumatic growth [dissertation]. Gainsville, Florida: University of Florida; 2009.
44. Hodgkinson PE. Responding to in-patient suicide. Br J Med Psychol. 1987;60(4):387-392.
45. Gorkin M. On the suicide of one’s patient. Bull Menninger Clin. 1985;49(1):1-9.
46. Fuentes MA, Cruz D. Posttraumatic growth: positive psychological changes after trauma. Mental Health News. 2009;11(1):31,37.
47. Doka KJ. Disenfranchised grief: new Directions, challenges, and strategies for practice. Champaign, IL: Research Press; 2002.
48. Bongar B. The suicidal patient: clinical and legal standards of care, 2nd ed. Washington, DC: American Psychological Association; 2002.
49. Peterson EM, Luoma JB, Dunne E. Suicide survivors’ perceptions of the treating clinician. Suicide Life Threat Behav. 2002;32(2):158-166.
50. Kolodny S, Binder RL, Bronstein AA, et al. The working through of patients’ suicides by four therapists. Suicide Life Threat Behav. 1979;9(1):33-46.
51. Marshall KA. When a patient commits suicide. Suicide Life Threat Behav. 1980;10(1):29-40.
52. Jobes DA, Maltsberger JT. The hazards of treating suicidal patients. In: Sussman MB, ed. A perilous calling: the hazards of psychotherapy practice. New York, NY: Wiley & Sons; 1995:200-214.
53. Castelli-Dransart DA, Gutjahr E, Gulfi A, et al. Patient suicide in institutions: emotional responses and traumatic impact on Swiss mental health professionals. Death Stud. 2014;38(1-5):315-321.
54. US Public Health Service. The Surgeon General’s call to action to prevent suicide. Washington, DC: Department of Health and Human Services; 1999.
55. Armour M. Violent death: understanding the context of traumatic and stigmatized grief. J Hum Behav Soc Environ. 2006;14(4):53-90.
56. Calhoun, LG, Allen BG. Social reactions to the survivor of a suicide in the family: a review of the literature. Omega (Westport). 1991;23(2):95-107.
57. Dunne EJ, McIntosh JL, Dunne-Maxim K, eds. Suicide and its aftermath: understanding and counseling the survivors. New York, NY: WW Norton & Co; 1987.
58. Harwood D, Hawton K, Hope J, et al. The grief experiences and needs of bereaved relatives and friends of older people dying through suicide: a descriptive and case-control study. J Affect Disord. 2002;72(2):185-194.
59. Jordan JR. Is suicide bereavement different? A reassessment of the literature. Suicide Life Threat Behav. 2001;31(1):91-102.
60. McIntosh JL. Control group studies of suicide survivors: a review and critique. Suicide Life Threat Behav. 2003;23(2):146-161.
61. Range LM. When a loss is due to suicide: unique aspects of bereavement. In: Harvey JH, ed. Perspectives on loss: a sourcebook. Philadelphia, PA: Brunner/Mazel; 1998:213-220.
62. Sveen CA, Walby FA. Suicide survivors’ mental health and grief reactions: a systematic review of controlled studies. Suicide Life Threat Behav. 2008;38(1):13-29.
63. Van Dongen CJ. Social context of postsuicide bereavement. Death Stud. 1993;17(2):125-141.
64. Bultema JK. The healing process for the multidisciplinary team: recovering post-inpatient suicide. J Psychosoc Nurs. 1994;32(2):19-24.
65. Cooper C. Patient suicide and assault: their impact on psychiatric hospital staff. J Psychosoc Nurs Ment Health Serv. 1995;33(6):26-29.
66. Foster VA, McAdams CR III. The impact of client suicide in counselor training: Implications for counselor education and supervision. Counselor Educ Supervision. 1999;39(1):22-33.
67. Little JD. Staff response to inpatient and outpatient suicide: what happened and what do we do? Aust N Z J Psychiatry. 1992;26(2):162-167.
68. Horn PJ. Therapists’ psychological adaptation to client suicidal behavior. Chicago, IL: Loyola University of Chicago; 1995.
69. Gutin N, McGann VM, Jordan JR. The impact of suicide on professional caregivers. In: Jordan J, McIntosh J, eds. Grief after suicide: understanding the consequences and caring for the survivors. New York, NY: Routledge; 2011:93-111.
70. Anderson GO. Who, what, when, where, how, and mostly why? A therapist’s grief over the suicide of a client. Women Ther. 2004;28(1):25-34.
1. Alexander D, Klein S, Gray NM, et al. Suicide by patients: questionnaire study of its effect on consultant psychiatrists. BMJ. 2000;320(7249):1571-1574.
2. Chemtob CM, Hamada RS, Bauer G, et al. Patients’ suicides: frequency and impact on psychiatrists. Am J Psychiatry. 1988;145(2):224-228.
3. Grad OT, Zavasnik A, Groleger U. Suicide of a patient: gender differences in bereavement reactions of therapists. Suicide Life Threat Behav. 1997;27(4):379-386.
4. Ruskin R, Sakinofsky I, Bagby RM, et al. Impact of patient suicide on psychiatrists and psychiatric trainees. Acad Psychiatry. 2004;28(2):104-110.
5. Bersoff DN. Ethical conflicts in psychology, 2nd ed. Washington, DC: American Psychological Association; 1999.
6. Chemtob CM, Bauer GB, Hamada RS, et al. Patient suicide: occupational hazard for psychologists and psychiatrists. Prof Psychol Res Pr. 1989;20(5):294-300.
7. Rubin HL. Surviving a suicide in your practice. In: Blumenthal SJ, Kupfer DJ, eds. Suicide over the life cycle: risk factors, assessment, and treatment of suicidal patients. Washington, DC: American Psychiatric Press; 1990:619-636.
8. Kaye NS, Soreff SM. The psychiatrist’s role, responses, and responsibilities when a patient commits suicide. Am J Psychiatry. 1991;148(6):739-743.
9. McIntosh JL. Clinicians as survivors of suicide: bibliography. American Association of Suicidology Clinician Survivor Task Force. http://pages.iu.edu/~jmcintos/Surv.Ther.bib.htm. Updated May 19, 2019. Accessed August 26, 2019.
10. Douglas J, Brown HN. Suicide: understanding and responding: Harvard Medical School perspectives. Madison, CT: International Universities Press; 1989.
11. Farberow NL. The mental health professional as suicide survivor. Clin Neuropsychiatry. 2005;2(1):13-20.
12. Jones FA Jr. Therapists as survivors of patient suicide. In: Dunne EJ, McIntosh JL, Dunne-Maxim K, eds. Suicide and its aftermath: understanding and counseling the survivors. New York, NY: W.W. Norton; 1987;126-141.
13. Plakun EM, Tillman JG. Responding to clinicians after loss of a patient to suicide. Dir Psychiatry. 2005;25:301-310.
14. Prabhakar D, Anzia JM, Balon R, et al. “Collateral damages”: preparing residents for coping with patient suicide. Acad Psychiatry. 2013;37(6):429-30.
15. Quinnett P. QPR: for suicide prevention. QPR Institute, Inc. http://pages.iu.edu/~jmcintos/postvention.htm. Published September 21, 2009. Accessed August 26, 2019.
16. Schultz, D. Suggestions for supervisors when a therapist experiences a client’s suicide. Women Ther. 2005;28(1):59-69.
17. Spiegelman JS Jr, Werth JL Jr. Don’t forget about me: the experiences of therapists-in-training after a patient has attempted or died by suicide. Women Ther. 2005;28(1):35-57.
18. American Association of Suicidology. Clinician Survivor Task Force. Clinicians as survivors of suicide: postvention information.
19. Whitmore CA, Cook J, Salg L. Supporting residents in the wake of patient suicide. The American Journal of Psychiatry Residents’ Journal. 2017;12(1):5-7.
20. Melton B, Coverdale J. What do we teach psychiatric residents about suicide? A national survey of chief residents. Acad Psychiatry. 2009;33(1):47-50.
21. Valente SM. Psychotherapist reactions to the suicide of a patient. Am J Orthopsychiatry. 1994;64(4):614-621.
22. Jordan JR, McIntosh JL. Is suicide bereavement different? A framework for rethinking the question. In: Jordan JR, McIntosh JL, eds. Grief after suicide: understanding the consequences and caring for the survivors. New York, NY: Routledge; 2011:19-42.
23. Jordan JR, Baugher B. After suicide loss: coping with your grief, 2nd ed. Newcastle, WA: Caring People Press; 2016.
24. Brown HB. The impact of suicide on therapists in training. Compr Psychiatry. 1987;28(2):101-112.
25. Cvinar JG. Do suicide survivors suffer social stigma: a review of the literature. Perspect Psychiatr Care. 2005;41(1):14-21.
26. Feigelman W, Gorman BS, Jordan JR. Stigmatization and suicide bereavement. Death Stud. 2009;33(7):591-608.
27. Goffman E. Stigma: notes on the management of spoiled identity. New York, NY: Simon & Schuster; 1963.
28. Goldney RD. The privilege and responsibility of suicide prevention. Crisis. 2000;21(1):8-15.
29. Litman RE. When patients commit suicide. Am J Psychother. 1965;19(4):570-576.
30. Hendin H, Lipschitz A, Maltsberger JT, et al. Therapists’ reactions to patients’ suicides. Am J Psychiatry. 2000;157(12):2022-2027.
31. Rycroft P. Touching the heart and soul of therapy: surviving client suicide. Women Ther. 2004;28(1):83-94.
32. Ellis TE, Patel AB. Client suicide: what now? Cogn Behav Pract. 2012;19(2):277-287.
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