83 Therapists as survivors of suicide loss

When a patient in an inpatient or outpatient setting—whether in therapy or after ending it—commits suicide, this act provokes a lot of distressful feelings in their therapist. Besides very personal reactions of shock, grief and regret, therapists often feel guilt, failure and incompetence connected to their professional performance. They are afraid of being blamed by their colleagues and/or of legal litigation from the family of the deceased. If they work in an institution they fear how the management will react to this event. Therapists need help and support, preferably in a form of standardized procedure, which is also presented in this chapter.

The emotions were far too numerous to be documented here, but the one that stands out in my mind is the pervasive feeling I had of being alone. I was going to be standing on my own, a virtual child in the very adult world of psychology.

Spiegelman and Werth (2005, p. 38)

How can you be strong and meet the community needs when you want to disappear into some dark hole and weep a river of tears?

Fleming (1997, p. 133)

If a patient who is, or used to be, in any kind of therapy commits suicide, the event makes his/her therapist a suicide survivor. Even though suicide is characterized as being both an occupational and predictable hazard (Chemtob et al. 1989; Valente 2003), it has nevertheless proven to be an ordeal for the therapists (Kleespies et al. 1990), what's more, quite damaging (Farberow 2001; Dexter-Mazza and Freeman 2003), and with a tremendous and long-lasting effect on every caregiver. Litman, in one of the first articles on the topic (1965), believes that a client's suicide represents a crisis for the therapist, both professionally and personally. He claims that the professional role serves the caregiver as a defensive and reparative function to help overcome the pain which they feel as a human being. The longer therapists practice their clinical work, the more likely it is that they will experience this anxiety-provoking event; studies show that 97 per cent of clinicians fear a client's suicide (Pope and Tabachnik 1993). The numbers of caregivers who confirm having survived their patient's suicide vary according to studies, from 22 per cent (Dexter-Mazza and Freeman 2003) to 47 or 50 per cent (Cryan et al. 1995; Hendin et al. 2000), to as much as 68 per cent (Alexander et al. 2000). It is even more disturbing if a patient's suicide happens in the formative years of a trainee, whether they be a future psychiatrist, clinical psychologist, psychiatric registered nurse, or other health professional. Some authors found that patient suicide happens to one-third of residents (Ellis et al. 1998), while others claimed up to 61 per cent (Pilkinton and Etkin 2003), representing a large number of future professionals only just starting their working career.

Every suicide has a profound effect on the immediate environment. Not only family and friends, but many others who were in personal or professional contact with the suicidal person, can be seriously affected. Therapists, consultants, supervisors, nurses, social workers, family physicians, and many other caregivers involved will most likely be disturbed, frightened and influenced by the patient's fatal decision. If a patient dies of a cardiovascular or some other malignant disease, the death is both expected and accepted, and the various caregivers see little or no personal involvement in it. Suicide, though often strongly connected to the outcome of certain diseases (such as depression), can easily be interpreted as the therapist's unfinished business and responsibility. In comparison to other deaths, suicide is perceived as an unnatural and avoidable death, one which the therapist was closely connected to and should have been able to prevent. This is a standpoint strongly held by the family, society and, especially, by therapists themselves. Litman (1965) refers to this as a ‘taboo area of psychology’, which is probably the crucial reason why the topic was almost untouched for so many years. While suicide has been studied since the beginning of humankind, only within the past 50 years has attention been turned towards bereaved relatives of a family in which a suicide has occurred. Therapists as suicide survivors were neglected to an even greater extent throughout the development of suicidological research, even though the majority of patients who commit suicide had been in some kind of therapy (Gitlin 1999; Valente 2003).

Why so much avoidance to explore the subject? Brown (1987a, b) mentions four possible explanations:

The first written statement about the therapist's own reactions to a patient's suicide was by Freud, who articulated the suppressed feelings after the event had occurred to him (Litman 1965). For a long time afterwards there were few personal reflections from therapists and almost no studies on the topic. There are many reasons for this: suicide provokes strong feelings of failure in therapists and their supervisors or consultants; there is a fear of reactions from the patient's family, including legal litigation; and there is a belief among therapists and within their environment that they will be able to deal with the problem themselves (Grad and Michel 2005). However, therapists are neither prepared for, nor immune to, the disruptive impact of suicide on their professional belief system and on their professional standing (Brown 1987b; Dewar et al. 2000; Valente 2003).

‘There is a terrible sense of failure at having let down those who have put their trust in you’ (Alexander et al. 2000, p. 1572). When a patient commits suicide, the therapist can be notified about the disastrous event in many different, sometimes disturbing ways: some receive the news from the family of the patient, some are informed first thing when coming to work, some come across the obituary, and some only find out about the suicide when the patient does not show up for the therapy session. Regardless of how the information is received, it first provokes shock and disbelief in the therapist, just as it does in anyone close to the deceased suicidal person (Chemtob et al. 1988a; Kleespies 1993; Grad 1996; Hendin et al. 2000, 2004).

In most of the studies, therapists reported that they had experienced various emotional reactions on a very personal level. Their most frequently experienced feelings were: grief, feelings of betrayal and anger towards the patient, guilt, fear of blame, embarrassment, self-doubt, inadequacy, shame (Michel 1997; Grad et al. 1997; Grad and Zavasnik 1998; Hendin et al. 2000; Grad and Michel 2005), anger towards the patient or the consultant (Chemtob et al. 1989), denial and avoidance, fear of being accused of negligence (Yousaf et al. 2002), fears of litigation and retribution from the psychiatric community (Gitlin 1999), and, especially in younger therapists who were still in training, anxiety (Kleespies 1993). All these reactions were connected to many factors regarding therapy and the bond between the therapist and the patient, such as: how long and how closely the therapist had worked with the patient; the therapist's degree of professional commitment (Litman 1965); how much anger and hostility was involved in the relationship (Jones 1987); the level of predictability of suicide; the method and location of suicide; the emotional involvement with the patient (Valente 1994); the therapist's countertransference with the patient; the setting in which they were working with the patient (private or institutional); whether the therapist was the only one responsible for the patient or whether the patient's treatment was the responsibility of a team; whether the therapist was at the beginning of their career or an experienced one; whether the therapist had constant supervision for that specific therapy or not (Grad 1996). It is also very important whether the therapist, their consultant and the whole team have an explanation for the patient's suicide. Motto (1979), in one of the pioneering articles on the topic, stresses two issues: first, the importance of the therapist's own current life cycle (they can be faced with thier own mortality for the first time, or once again after some time), and second, the therapist's theoretical, philosophical and clinical backgrounds at the time of a patient's suicide. It is equally important to know that the therapist's personality (Hendin et al. 2004), his\her therapist's personalites own previously experienced losses and his\her therapist's personalites age and gender (Grad et al. 1997) play a significant role in determining his\her therapist's personalites feelings and reactions ‘after’.

Similar emotional reactions of a therapist after a patient's suicide were reported in most of the studies and thus seem to be quite expected and universal. On the affective level the most frequent and painful feelings therapists experienced were guilt, sadness and incompetence (Kolodny et al. 1979; Jones 1987; Grad et al. 1997; Hendin et al. 2000; Valente 2003; Hendin et al. 2004), which were closely connected to the cognitive feelings of fear of blame, litigation and loss of professional standing (Chemtob et al. 1988b). Both grief and guilt reflected the close relationship with the patient, but also the fear that the relatives (feeling guilty as well) would sue the therapist or the institution. This generalized fear may provoke unfavourable and unhelpful reactions from the administrative staff, additionally burdening the therapist.

Many studies proved that experiencing the suicide of a patient is more difficult when the therapist is still in training (Ellis and Dickey 1998; Yousaf et al. 2002; Dexter-Mazza and Freeman 2003; Ruskin et al. 2004). It is true that the trainee has limited legal responsibilities, but otherwise they function as a competent and fully responsible therapist who treats the patient on their own. The trainee's emotional reactions are similar to those described by the more experienced therapists, only more severe and with long-lasting effects. Trainees are not adequately prepared for such an event happening to them and they are not warned of the impact it might have on them (Pilkinton and Etkin 2003). They are poorly prepared to deal with suicidal patients. Furthermore, there is a substantial difference between informational or knowledge competence with regard to risk factors and the demographics of suicide and the actual ability to effectively manage or treat the suicidal patients (Dexter-Mazza and Freeman 2003). As trainees are not yet permanently and closely intertwined into a clinical team, with which they work at the time of suicide, they can feel less support from the colleagues when the tragic event occurs. It has been proved that the impact of a patient's suicide was more severe for those trainees who perceived less social integration in their professional network (Ruskin et al. 2004).

There were some differences found between male and female therapists (Grad and Michel 1994; Grad et al. 1997) when experiencing a patient's suicide. While female respondents (75 per cent) predominantly preferred to vent their feelings, their male colleagues helped themselves either by going on with work as usual (30 per cent) or talking about their feelings (30 per cent). As most leading positions in mental health in Western settings are held by men, it is possible that they prefer the working routine to stay unchanged after suicide in their environment occurs. Which then implicitly influences the people, men and women, working underneath them, having to deal with the situation in a similar fashion.

Experiencing and surviving a patient's suicide entails, along with many negative outcomes, some beneficial ones as well (Courtenay and Stephens 2001). One beneficial (or formative) outcome has been described by therapists as learning from the experience to develop more thorough and comprehensive risk assessment skills in the formative years. One of the studies (Hendin et al. 2004) has found that the less distressed therapists had a greater capacity to view their misfortunes as learning opportunities rather than as occasions for self-reproach. Negative outcomes were many: the therapists felt isolated, disillusioned, and vulnerable, they were lacking confidence and/or they became afraid of clinical contact.

Most of the described feelings and behaviour patterns were obtained from the respondents inside the psychiatric and psychological field; however, the reactions described by the general practitioners,who had treated suicidal patients were very similar. Compared to psychotherapists, family doctors did not differ in feelings of grief; they also became more cautious with other patients after experiencing a patient's suicide, and they spoke less with colleagues and friends about the event than did psychotherapists. They also differed significantly in other ways: they reported feeling a lesser amount of guilt, they used the supervisor's help less frequently, and they had more difficulties in revealing their feelings after the event to their colleagues (though this is probably indicative of the attitudes and culture in both groups) (Grad and Zavasnik 1998).

Whenever the suicide of a patient occurs, therapists are in need of post-traumatic debriefing and various other procedures, some self-chosen and some prescribed. The procedure should give the therapist the space and time they need for support, understanding and a forum for expressing and accepting their different feelings.

Brown (1987a) proposes a few steps: any therapist working with suicidal patients should have been prepared in advance for the possibility of experiencing a completed suicide of one of their patients. Afterwards, it is necessary to share the responsibility, talk about one's own feelings and fears, perform the psychological autopsy and agree on the procedure concerning the relatives.

Basically there are three different needs to be fulfilled after a patient's suicide (Ellis and Dickey 1998): administrative needs that monitor the occurrence of adverse patient events in order to improve quality; educational needs that take care of the level of suicide-related training (Midence et al. 1996) and provide supervision to each trainee; and emotional needs that support any therapist in distress after the trauma of patient suicide.

It seems that while administrative and possibly also educational needs are often fulfilled, the emotional needs can become a problem both from the side of the institution and that of the therapist. This might be the reason why there are many different suggestions in the literature on how to organize help. All the respondents in the different studies agreed that therapists should have had a chance to express themselves afterwards and that any support was helpful and appreciated (Courtenay and Stephens 2001). However, the proposed procedures about how to achieve this varied. Some authors claimed that even the participation in the study and the interview helped the participants to further process their feelings (Kleespies et al. 1993). Most respondents in the range of studies mentioned that talking to family and friends, to the close team of colleagues, individual colleagues and to consultants or supervisors was most helpful (Chemtob et al. 1989; Grad et al. 1997; Grad and Zavasnik 1998; Alexander et al. 2000; Valente 2003). This can be done in special supervisor–therapist meetings or group meetings, where the therapist can tell their story about the patient; alternatively, it can be done by writing a narrative—whichever suits them best (Valente 2003). Some authors propose ‘away days’ (Walmsley 2003). Reviews of the case or psychological autopsies can be helpful if they are geared towards learning rather than blaming (Alexander et al. 2000). At the same time, however, other authors think that institutional responses and case reviews are rarely helpful (Hendin et al. 2000). One message that is clearly useful is that therapists' fantasies of having ultimate control over patient's lives should be limited (Gitlin 1999).

When suicide occurs in any institution, it provokes many fears, not only among clinicians, but among the management as well. This often results in some legal, disciplinary proceedings, which may add to, rather than diminish, the already existing distress of the medical staff and the therapist. We are living in a ‘blame culture’ (Alexander et al. 2000), where scapegoating and witch hunting are not rare even in academic circles. If psychological autopsies add to self-doubts and distress of the therapist (Goldstein and Buongiorno 1984) and evolve in public shaming, they seem to be counterproductive. In this respect, publicity in the media—especially sensationalist reporting—is additionally distressing for the therapist (Alexander et al. 2000).

Some authors found that outside counsellors, who have been drafted in to assist, are considered unhelpful (Courtenay and Stephens 2001); others, meanwhile, have proposed that an independent institution come in to help in the case of a patient's suicide (Hendin et al. 2000). In light of these contradictory statements, it is obvious that planning any help in advance that would be universally useful is a difficult, if not impossible, job. Perhaps it is wiser to prepare a framework of procedures and then listen to the survivor's needs or the needs of the team that experienced the patient's suicide to fill the framework with their contents.

Proposing any particular protocol that would be useful for every therapist and every team of different caregivers would be a daring act. The therapist's bereavement after a patient has committed suicide is too individual and too personal to fit into a framework of rigid procedures.

In consideration of the above, every protocol should nevertheless include:

Both parts are equally important, but deciding how to combine them is a matter for each individual therapist and institution (Grad 2005). Indeed, when a therapist (similarly to the bereaved relative) works through the feelings and thoughts after the loss of a patient, he may gain in wisdom and experience on how to treat well but also how to accept different consequences better.

Experiencing a patient's suicide is a rite of passage for each therapist: ‘to survive it is testimony to one's hardiness, endurance, and being a real physician’ (Gitlin 1999, p. 1630).

It is necessary to think about ‘before and after’. Rule number one is to offer good training programmes for the trainees in psychiatry, psychology and nursing that prepare future clinicians for the real work with a suicidal patient. If they do experience a patient's suicide (and they probably will, as this is an inevitable occupational hazard of working with selected suicidal population), every institution should prepare a flexible postvention protocol to support and serve the individual needs of the therapist and diminish their feelings of being socially isolated from their colleagues. The best solution would be to achieve a balance between prescribed, compulsory, formal procedures, which will serve administrative and educational needs of the therapist and the institution, and the self-chosen, more informal ones that offer the therapists the most appropriate and convenient form to accept this difficult experience in their professional life.