Evidence-Based Reviews

Losing a patient to suicide: What we know

Current Psychiatry. 2019 October;18(10):14-16,19-22,30-32

References

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. http://cliniciansurvivor.org. Published May 16, 2016. Accessed January 13, 2019.
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.

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

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Losing a patient to suicide: What we know

References

Clinicians’ unique reactions

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