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The loss of a client to suicide is a painful personal and professional experience for mental health providers. Whether trainee or experienced professional, the affected clinician often reports feeling overwhelmed and unprepared for the experience of client suicide, together with significant emotional distress and diminished work performance. In this article, we present a brief overview of the literature on the impact of client suicide and ideas for coping with the psychological and professional issues that typically arise. We also provide suggestions for managing the associated practical and administrative tasks, as well as resources for obtaining professional support and guidance in the wake of this tragic event.
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Client Suicide: What Now?
Thomas E. Ellis, The Menninger Clinic and Baylor College of Medicine
Amee B. Patel, The Menninger Clinic
The loss of a client to suicide is a painful personal and professional experience for mental health providers. Whether trainee or
experienced professional, the affected clinician often reports feeling overwhelmed and unprepared for the experience of client suicide,
together with significant emotional distress and diminished work performance. In this article, we present a brief overview of the literature
on the impact of client suicide and ideas for coping with the psychological and professional issues that typically arise. We also provide
suggestions for managing the associated practical and administrative tasks, as well as resources for obtaining professional support and
guidance in the wake of this tragic event.
Athird-year psychiatry resident knocks softly
and asks if you have a moment. He looks shaken,
which is out of character for this competent and
well-liked young professional. One of my
patients, Michael,he begins, as tears well up.
He's deadhung himself last night in his
garage.He says his supervisor had little to say,
other than, These things happen; surgeons lose
patients and sometimes we do, too.A Morbidity
and Mortality conference is scheduled for the
next day, adding to his stress. The resident, now
breaking down completely, sobs, I feel so
ashamed. I really don't think I'm cut out for this.
THE loss of a loved one to suicide is known to have
profound and lasting effects on surviving family
members and significant others (Mishara, 1995). Howev-
er, one member of the survivor group sometimes lost in
the casualty count is the professional helper. Mental
health professionals experience client suicides thousands
of times each year. It is estimated that, of the more than
30,000 suicides annually in the United States, one-third
had received mental health services during the year
preceding their deaths, one-fifth within the last month
(Luoma et al., 2002). In Eastern Europe and Asia, where
mental health resources are more limited and suicide
rates are higher (Hendin, 2008; WHO, 2009), primary
care physicians may experience the patient suicides after
being required to function as mental health providers
(Xiao et al., 2008). Chemtob, Bauer, Hamada, Pelowski &
Muraoka (1989) dubbed client suicide an occupational
hazardfor psychiatrists and psychologists after finding
that 22% of practicing psychologists and 51% of
psychiatrists reported losing a patient to suicide at some
point during their careers. Other studies (e.g., Menning-
er, 1991) suggest that the incidence may be even higher.
Moreover, the loss of a client to suicide is surprisingly
common among psychology and psychiatry trainees.
Ruskin, Sakinofsky, Bagby, Dickens & Sousa (2004)
found that half of 120 graduates of a psychiatry residency
program reported the suicide of a patient, with 62% of
those suicides occurring during training. In the psychol-
ogy arena, Kleespies, Smith & Becker (1990) found that
one in six survey respondents had lost a client to suicide
during the internship training year. In this context, it is not
surprising that 97% of therapists endorse client suicide as
their greatest fear (Pope & Tabachnick, 1993).
To say that client suicide is common, however, is not to
suggest that it is inconsequential. To the contrary, results
of an assortment of studies of the impact of client suicide
are highly consistent, with descriptors ranging from
stressful to career-threatening. Affected clinicians com-
monly use words such as shock,”“disbelief,and
profound sadness,to describe their emotional reactions
(Hendin, Lipschitz, Maltsberger, Haas & Wynecoop,
2000). In addition to a sense of loss, common reactions
include guilt, self-doubt, and anxiety about possible
litigation. Both short-term and long-term behavioral
changes are described, ranging from increased vigilance
in clinical work to avoidance of suicidal clients altogether.
Keywords: suicide; clinician; stress; self-care; coping
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In addition to these reactions, clinicians also report
feeling seriously unprepared (e.g., Grad & Michel, 2005).
This is not surprising in light of data showing that training
for working with suicidal patients is typically inadequate,
and training programs rarely have policies and procedures
in place to prepare trainees for a client's suicide (Ellis &
Dickey, 1998). The purpose of this paper is to provide
practical guidance for clinicians who experience the death
of a client by suicide. We will begin with a brief overview of
the literature on the impact of client suicide on the clinician
and a brief discussion of observed coping responses. This
will be followed by a detailed discussion of how clinicians
might address emotional and procedural needs following
the suicide of a client.
Impact of Client Suicide
When I got the call that Susan had committed
suicide, I refused to believe it. . . . Once the truth
sank in, my next feelings were of panic and fear,
followed at various times by confusion, shame,
doubt, sadness, and relief, to name just a few
emotionsIexperienced.WhenIputdownthe
phone, I realized I had no idea what to do next. . . .
No one had ever taught me what to do when (or if)
this ghastly event were to occur. (Weiner, 2005, p. 1)
A substantial body of literature has accumulated
documenting the impact of losing a client to suicide,
consisting mainly of case reports (e.g., Alexander, 2007;
Biermann, 2003), autobiographical essays (e.g., Carter,
1971; Fox & Cooper, 1998), and empirical studies (e.g.,
Chemtob, Hamada, Bauer, Kinney & Torigoe, 1988;
Chemtob, Hamada, Bauer, Torigoe & Kinney, 1988;
Hendin et al., 2000). While each contributes a unique
perspective, they share a common thread of agreement
that the death of a client by suicide is an emotional,
sometimes even traumatic, experience for the therapist.
In a study of U.S. psychologists, Chemtob et al. (1988)
found stress symptoms at a level comparable to the impact
of losing a family member in almost half of a group of
affected psychologists. Such reactions often involve shock,
disbelief, grief, guilt, anger, and self-doubt (Hendin,
Lipschitz, Maltsberger, Haas & Wynecoop, 2000; Hendin,
Haas, Maltsberger, Szanto & Rabinowicz, 2004). Affected
individuals also report increased irritability, sleep distur-
bance, and difficulty managing life events (Alexander,
Klein, Gray, Dewar & Eagles, 2000). In addition to
personal reactions, clinicians sometimes also experience
professional difficulties, including emotional burnout,
questions about professional identity and competence,
and anxiety about public or legal fallout (Fox and Cooper,
1998; Sanders, Jacobson & Ting, 2005; Tillman, 2006).
They may change professional procedures, including
increased peer consultation, changes in record-keeping
procedures, increased use of hospitalization, and greater
selectivity of populations served (McAdams & Foster,
2000; Menninger, 1991). Similar findings have been
demonstrated among psychiatrists in the United King-
dom (Alexander et al., 2000), Canada (O'Reilly, Truant &
Donaldson, 1990), New Zealand (Little, 1992), and
Thailand (Thomyangkoon & Leenaars, 2008).
Several studies have used the Impact of Events Scale
(IES; Horowitz, Wilner & Alverez, 1979) to evaluate
clinician response. Findings indicate that 25% to 50% of
clinicians experience clinically significant levels of intru-
sion, avoidance, and overall distress immediately follow-
ing client suicide, with a small percentage of clinicians
continuing to report significant distress for months (e.g.,
Chemtob et al., 1988; Chemtob et al., 1988; Ruskin et al.,
2004; Yousef, Hawthorne & Sedgwick, 2002). Kleespies,
Penk & Forsyth (1993) found that one of the longer-
lasting effects of losing a client to suicide was heightened
anxiety later on when working with suicidal clients. Effects
on cognitive processes are also noteworthy, as the affected
therapist often reports wracking my brainin an effort to
solve the mystery of the suicide. Horn (1994) describes
the clinician as preoccupied following the event, some-
times experiencing intrusive thoughts, images, and even
dreams related to suicide (see also Chemtob et al., 1988).
The emotional and cognitive effects described are
consistent with symptoms of PTSD or acute stress
disorder, but the current research of symptoms among
professionals who have experienced client suicide stops
short of labeling psychiatric disorders. That said, the IES
has been demonstrated as a reliable and valid screening
measure for PTSD (e.g., Sundin & Horowitz, 2002).
Self-doubts regarding professional competency are
common, and depressive rumination may also be present
(Hendin et al., 2000). Despite sharing much in common
with others who have had the same experience, clinicians
often describe an acute sense of aloneness and isolation as
they process the loss (Alexander, 2007; Anderson, 2005).
Some therapists may have preexisting cognitive vulnera-
bilities, such as perfectionism or a self-blaming attribu-
tional style, that predispose them to strong emotional
reactions. Such vulnerabilities will be addressed later in
the paper as we discuss ideas for coping with a client's
suicide (see Table 1 for examples).
Finally, treatment providers also report significant
anxiety about being sued because of a client suicide
(e.g., Ellis & Dickey, 1998; Hendin et al., 2004). Moreover,
providers who work in agency or hospital settings are
often required to undergo case reviews to assess adher-
ence to procedure and liability for the institution.
Therapists are particularly susceptible to increased
distress and impairment when they feel as if their
278 Ellis & Patel
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institution is blaming them or if a lawsuit is likely (Hendin
et al.). Stress related to litigation concern is probably
exacerbated by overestimation of the likelihood of
successful malpractice lawsuits (discussed below under
Administrative and Procedural Issues).
Individual Differences Among Clinicians
Virtually all clinicians experience some level of
emotional turmoil and self-doubt following client suicide;
some experience significant impairment as well. A variety
of factors may affect the severity of a clinician's reaction to
a client's suicide.
Experience
This is the most studied variable impacting clinicians
reactions to client suicide, primarily highlighting trainee
status as a risk factor for greater distress and/or
impairment (e.g., Kleespies, Penk & Forsyth, 1993;
Knox, Burkard, Jackson, Schaack & Hess, 2006; Ruskin,
Sakinofsky, Bagby, Dickens & Sousa, 2004). Trainees and
novice therapists often have greater optimism regarding
the therapeutic process, may overestimate the influence
that they have on their clients, and may not yet have
developed a healthy sense of boundaries. Moreover,
lacking experience and extensive training, trainees and
younger clinicians may rely more on their own personal
qualities to help their clients, such that client suicide may
be viewed as a more personal failure (Brown, 1987;
Maltsberger, 1992). Further increasing the vulnerability
of trainees is the often inadequate training they receive
for working with suicidal clients and relative absence of
preparation for the possibility of client suicide (Ellis,
Dickey & Jones, 1998; Ellis & Dickey, 1998). On the other
hand, the association with years of experience posttrain-
ingislessclear.Hendin et al. (2000) found that
experienced therapists reported no less distress following
a client's suicide than less experienced therapists, whereas
Kleespies et al. (1993) found that more intrusive thoughts
were reported among providers earlier in training.
Chemtob et al. (1988) found a negative correlation
between experience and impact of client suicide among
psychologists but not psychiatrists.
Relationship With the Client
Length of therapy and greater intensity within the
therapeutic alliance have been associated with increased
therapist distress (Chemtob et al., 1989; Litman, 1965).
Horn (1994) notes that the type of relationship is less
Table 1
Varieties of Reactions to Client Suicide
Automatic Thoughts Emotions and Behaviors Possible Cognitive Distortions Alternate Thoughts
I must have done something
wrong. It's my fault this
person is dead.
Guilt, self-blame, feeling
of inadequacy
Arbitrary inference
Personalization
If I wasn't powerful enough to
prevent his/her suicide, I wasn't
powerful enough to causeit either.
My colleagues/ supervisors
will think I am incompetent.
If I were more experienced/
attentive/skeptical this
wouldn't have happened.
Shame, feeling of
inferiority, withdrawal
Mind reading
Negative
comparison
Arbitrary inference
My colleagues/supervisors are
likely to be supportive. Experienced
clinicians lose clients, too. I have no
proof that doing things differently
would have led to a different outcome.
I am a failure. I'm incompetent
and not qualified for this work.
Depression, despair Overgeneralization
Dichotomous
thinking
Even if I made mistakes, it doesn't
make me a failure. Competent
professionals all make mistakes
and learn from them.
Why do I feel so bad? I should
be stronger. I'm such a neurotic!
Shame
Failure to
self-nurture
Shoulds
Emotional invalidation
This is a normal reaction to an
abnormal experience. I would never
tell a client or friend to just get over it.
I'll surely be sued. If I am sued,
my career will be over.
Anxiety, worry, avoidance Fortune-telling
Magnification
Lawsuits are more the exception
than the rule. But I can get information
and support, just in case. Being sued
is difficult but seldom ends a career.
I can't face the family. They
surely must blame me for this.
Shame, avoidance Mind reading
Fortune-telling
Avoiding the family could actually
make things worse. Contacting the
family may be helpful for both of us.
He/she sabotaged treatment.
What a hostile thing to do!
Anger, resentment,
sense of betrayal
Personalization My client was in pain. I don't have
to make this about me.
Suicides are par for the course.
No need to reflect; just move on.
Detachment, numbness Minimization
Intellectualization
This is a serious event. Denial and
avoidance won't help me to grow
as a therapist.
279Client Suicide
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predictive of the grief reaction than intensity of attach-
ment; thus, a close therapeutic relationship, while
lowering risk for the client, actually may increase risk
for the clinician should he or she lose that client to
suicide.
Treatment Context
Other factors that may come into play include whether
the individual was a current or former client, individual
client or member of a group, and an outpatient or
inpatient. The extant literature is predominantly focused
on the experience of treatment providers who have a one-
to-one, usually outpatient, relationship with the client
over the course of several sessions. There has been little
emphasis on the experience of group therapists when a
group member completes suicide (Gafford, 2008),
despite the additional demands on the group leader to
provide support and therapy for grieving group members.
Likewise, although the inpatient therapist is protected
somewhat by the fact that responsibility is shared among a
team, a suicide on an inpatient psychiatric unit requires
providers to manage their own grief while simultaneously
supporting colleagues and continuing treatment for the
patient group (Hodgkinson, 1987). A recent study
described the unique context of school counselors who
lost a student client to suicide and continued to have
responsibility for suicide prevention, intervention,
and postintervention protocols within their schools
(Christianson & Everall, 2009).
Cognitive Factors
Very little is known about the cognitive characteristics
of clinicians that may predispose them to strong reactions
to client suicide. However, it is reasonable to consider
cognitive processes, such as interpretations of the event
and attributions regarding causes, to understand individ-
ual differences. Consistently, treatment providers re-
spond to client suicide by reexamining progress notes,
exploring their feelings about the client, and considering
possible mistakes or errors in judgment (Hendin et al.,
2000; Holden, 1978; Valente, 1994). Such responses are
often reinforced by standard procedures following client
suicide, such as mortality reviews, psychological autopsies,
and strategizing with respect to possible legal proceed-
ings. For some, this process can be constructive, even
therapeutic (Kleespies et al., 1993), whereas individuals
prone to rumination may be inclined to become more
distressed (Hendin et al., 2000).
We can also can look to cognitive-behavioral therapy
(CBT) and theory and ask which cognitive distortions
(Burns, 1980) or maladaptive beliefs (A. Ellis, 2003) might
create vulnerability to adverse outcomes with clients.
Experience suggests that adverse reactions to client
suicide are often associated with high, even perfectionis-
tic, performance standards together with a strong sense of
responsibility and tendency toward self-blame when
things go wrong. Table 1 attempts to capture such themes
in various forms, derived from such generalized beliefs as,
I should/must succeed with all of my clients,”“It is my
fault when I fail,and IfIfail,itmeansIam
incompetent(A. Ellis, 2003). These will be recognized
as beliefs that can produce a variety of countertransfer-
ence problems in psychotherapy; they tend to be more
common among therapists in training and those with
fewer years of experience, but can be found in experi-
enced therapists as well. Consistent with CBT theory and
research, changes in such cognitions likely would be
associated with reduced vulnerability to adverse client
outcomes such as suicide. Possible directions for such
changes are described below.
Protective Factors
The literature consistently outlines two factors that
seem to aid therapists in managing the aftermath of client
suicide. First, many of the studies discussed above
highlight the importance of social support, peer consul-
tation, and a sense of collegial support (e.g., Chemtob et
al., 1988; Chemtob et al., 1988; Menninger, 1991). For
example, discussion with case supervisors was identified
by Kleespies et al. (1993) as the most helpful and most
frequently used activity following a client suicide. Never-
theless, it is not uncommon for clinicians to isolate and
avoid interactions with colleagues following client suicide
(Ting, Sanders, Jacobson & Power, 2006). Second,
specific training in treating suicidal clients and managing
suicidal behavior can serve as a protective factor by
increasing therapist confidence and competence in
managing these events (Oordt, Jobes, Fonseca & Schmidt,
2009) and by helping clinicians to be more prepared
should a client suicide occur (Ellis & Dickey, 1998).
Finally, despite the stress and pain incurred, it is not
uncommon for clinicians who lose a client to suicide to
report professional and personal growth in the long run.
For example, respondents to a national survey of
psychologists by Chemtob et al. (1988) reported an
assortment of adjustments to their clinical practices,
including increased focus on suicide cues, increased use
of consultation, and more conservative record keeping.
Personal growth is commonly reported as well. Hendin
et al. (2004) noted that the less distressed clinicians in
their study were inclined to view the experience as an
opportunity for learning rather than occasion for self-
condemnation. Indeed, clinicians sometimes emerge
from the process with a greater appreciation of the limits
of their influence and changed perspectives on their
relationships with clients and the reality of death. They
often report feeling older but wiser,a mix captured well
by a participant in Brown's (1989) study: The experience
280 Ellis & Patel
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has made me a better therapist, but as a person, I'd just as
soon pass on it(p. 430).
How Clinicians Cope
Coping responses to stressful events are, of course,
highly individual, and such is the case for clinicians
responses to client suicide. Kapoor (2008) presents an
excellent review of the literature on therapist coping with
client suicide, which can be dichotomized roughly into
adaptive and maladaptive responses. Most prominent is
the natural inclination to talk about the experience with
colleagues and/or loved ones. Such support-seeking
produces many potential benefits, ranging from comfort
and reassurance to technical review of clinical interven-
tions. Social interaction also facilitates the grief process
through its various stages, from the early sense of shock
and unreality, through a variety of emotional reactions,
and ultimately (one hopes) to a sense of greater
understanding and acceptance.
A general rule of thumb is to resist any temptation (or
pressure) to conduct a technical review immediately after
the patient's death, and instead to attend to the emotional
needs of the clinician to recover from the initial shock
and begin processing the loss. During this support
phase,the emphasis is on ventilation, reassurance,
respite, and restoration of morale (Kleespies, 1993, refers
to this stage as resuscitation,to be followed by
rehabilitationand renewal). Opinions regarding the
time needed for this initial stage range from days to
months; but it is important to note that, as a general rule,
it is not reasonable to expect clinical objectivity from the affected
clinician soon after the event. Efforts to critically review
assessment or treatment at this stage are likely to trigger
emotional reactions ranging from defensiveness to self-
blame. The clinician should, of course, thoroughly
document the facts of the case as soon as possible, while
memory is still fresh, but delay the formal case review until
emotional equilibrium has been restored. At that point,
the clinician is in a position not only to participate in a
review process, but also to attend openly to any lessons
learned.
Clinicians and supervisors are well advised to remain
vigilant for indications of maladaptive coping responses.
Although increased caution with at-risk clients is a
common and sometimes appropriate response, overcom-
pensation sometimes occurs in the form of excessive use
of hospitalization or arbitrary reduction of privileges for
hospital patients. Maladaptive responses may also take the
form of avoidance reactions, as when the clinician quickly
resumes work at full pace and resists any efforts to address
issues, emotional or clinical. On the other hand, it is not
uncommon to encounter clinicians who resolve to stop
working with clients with histories of or risk factors for
suicidal behavior. Indeed, one occasionally hears of a
clinician, especially in training or early career, who
decides to leave the field altogether.
On occasion, maladaptive reactions to work stress,
including client suicide, can reach clinical proportions.
Commonly referred to as burnout(e.g., Kahill, 1988;
Maslach, 2003), early warning signs include increased
tardiness or absenteeism from work, social withdrawal,
irritability, and loss of motivation. Especially at-risk are
professionals who are stylistically overinvolved at work,
have a poor sense of boundaries, tend to take responsi-
bility for their clientsbehavior, and lack skills for self-care
and stress management (Gitlin, 2006; Horn, 1994). In
cases of client suicide, insistence on sorting through this
experience on my own,rather than accepting support
and consultation from others, may be a red flag. Such
solitary coping may be accompanied by a sense of
aloneness, depressed mood, increased substance use,
and other indications of clinically significant dysfunction
that require therapeutic intervention.
What to Do
The immediate aftermath of a client suicide can be a
challenge unlike any the clinician has ever experienced.
In the midst of the shock and admixture of strong
emotions, from grief to self-recrimination, remains the
need to continue functioning professionally and inter-
personally. Colleagues are often unsure what to say or
how to offer support, while administrators are anxious
about following procedures so as to satisfy regulatory
agencies and minimize the probability of a successful
lawsuit. The situation is further complicated if the media
becomes involved in instances where a suicide was carried
out publicly or involved a public figure. Hence, a few
guidelines may prove useful.
Priorities vary, depending on the situation, and cover a
wide range of (sometimes competing) needs; these include
legal and administrative issues, the well-being of the
deceased client's family, issues involving clinical review
and training, and the emotional well-being of the clinician
himself or herself. These needs can be considered in three
broad categories: administrative/procedural, personal/
emotional, and clinical/professional development.
Administrative and Procedural Issues
For clinicians working in service organizations, notifi-
cation of the appropriate administrative and supervisory
staff, as well as clinical team members, should occur
immediately. Such reporting serves many purposes.
Hospitals generally have policies and procedures in
place for such sentinel events,including matters such
as addressing the needs of other patients who may have
known the patient and initiating review processes (see
below) that are often mandated by regulatory agencies to
occur soon after the incident. Also of importance,
281Client Suicide
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notification of supervisors creates the opportunity to
temporarily relieve the affected clinician(s), which can
provide a valuable window for attending to emotional
needs and starting the recovery process. Clear and timely
communication also reduces the risk of rumors and
misunderstandings among staff and clients.
Another important administrative need is completion
of the medical record. This includes documentation of
any contacts with or services provided to the patient,
communications with family members, and the manner of
learning of the patient's death. Such documentation,
recorded while memories are still fresh,provides an
accurate record for future review proceedings and for any
legal proceedings that might follow. It is critical at this
point that the clinician resist any inclination to modify
prior records or in any way falsify his or her account of
events surrounding the patient's death, as such actions
carry with them potentially serious ethical and legal
implications.
It is at this stage that the question of legal counsel often
arises: Should I contact an attorney for advice on how to
handle this situation in order to minimize my chances of
being sued and represent me in case I am sued?The
answer to this question depends upon the individual and
the particulars of the situation. For example, many
organizations such as hospitals and universities have
attorneys on staff or on retainer, such that involving
legal counsel is relatively routine. For private practi-
tioners, the process is less straightforward. Nevertheless,
risk management advice is generally on the side of
caution. Bongar (1991), for example, does not mince
words here:
. . . only the most naïve mental health profes-
sional would not consider consulting an attorney
immediately following a patient's suicide. . . . We
strongly urge psychologists to consult immedi-
ately with an attorney who is expert in matters of
mental health and the law, allowing the attorney,
for example, to help examine professional
liability coverage and to assist in notification of
the insurance carrier (an often mandatory duty).
(p. 193)
While prudence is clearly warranted, clinicians should
not assume that a lawsuit is inevitable in cases of client
suicide. For example, Ruskin, Sakinofsky, Bagby, Dickens &
Sousa (2004) found that, of 120 psychiatrists and psychiatric
trainees who experienced a patient's suicide, only 9%
reported being sued, with only 2 of these going to trial.
Simon (2006) reported that suicide accounted for 17% of
claims reported by the professional liability insurance
program of the American Psychiatric Association, and
that the plaintiff's success rate in these cases was only 2 or 3
out of every 10 litigated claims(p. 547). Indeed, Bongar &
Stolberg (2009) commented, The fear of being sued
probably has more widespread and deleterious effects on
clinicians than actual lawsuits(p. 10).
One reason for the relative infrequency of lawsuits
following suicide is that case law in the United States has
established that suicide cannot be reliably predicted (e.g.,
Pokorny, 1983) and that competent mental health
practitioners, similar to surgeons and other professionals,
occasionally make mistakes. The main vulnerability for
practitioners is negligence, in which the clinician fails to
make a risk assessment or fails to act on the basis of that
assessment. Although consulting legal counsel is prudent,
the clinician can take some comfort in knowing that
plaintiff's attorneys rarely accept cases in which there is
clear evidence of caring and reasonable services to the
client (Simpson & Stacy, 2004).
Contact With the Family
Clinicians and administrators often struggle with
whether to interact with the family, assuming that the
family will be angry with them and fearing that anything
you say can and will be held against you in a court of law.
On the other hand, clinicians who do contact the family
often report that, contrary to their fears, the family
express thanks to the clinician for trying to help their
loved one and even inquire about how the clinician
himself or herself is managing. Hendin et al. (2000)
reported that 19 of 26 affected clinicians saw family
members after suicides, and that, in almost all cases . . .
relatives were not critical of the therapist and often
expressed gratitude for the help that had been provided
(p. 2026).
In this context, it is essential to appreciate the
devastating impact of suicide on the family (Cerel, Jordan
& Duberstein, 2008) and not to lose sight of the
substantial resource that a therapist or agency represents
to the grieving family. Meeting with the family or
attending the funeral are often presented as options to
consider seriously (e.g., Spiegelman & Werth, 2005), not
only as ways to ensure that one is not abandoning the
family, but also as means of facilitating the clinician's
recovery. Simply offering condolences and expressions of
concern can be of tremendous comfort to the family.
Indeed, family members may fear that the clinician
blames them and may need reassurance that they are not
responsible for their loved one's death.
Two issues merit consideration here: First, family
survivors of a member's suicide are at increased risk
themselves for maladaptive coping behaviors and suicide
(Campbell, 2006). Contact with a mental health profes-
sional can be an opportunity for recognition and early
intervention, thereby preventing the emergence of a
282 Ellis & Patel
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more severe, debilitating condition. Although it is
generally inappropriate for the clinician to provide
treatment to the family (Hendin et al., 2000), referral to
other providers or (importantly) to local suicide survivor
organizations can be tremendously useful. For a referral
database, the reader is referred to the American Associ-
ation of Suicidology (AAS): http://www.suicidology.org/
web/guest/support-group-directory.
Second, a family that feels abandoned or treated coldly
by the person or persons who treated their loved one is
more likely to sue. This principle has been demonstrated
in general medical as well as mental health settings
(Taylor, 2006). In a fascinating discussion of the issue,
Campbell (2006) quotes a prominent malpractice attor-
ney as follows:
While some defense counsel or professional
groups may advise against [contact with the
family], in my experience a physician's sympa-
thetic and concerned communication with a
grieving family generally goes a lot further toward
avoiding a claim than inciting one. When a
physician either fails or refuses to communicate
with the family of the deceased . . . their frequent
(and natural) assumption is that he or she may
have something to hide. . . . Even in a situation
where the physician may be at fault, caring
communication with the family may prevent a
claim that a lack of such contact may significantly
encourage. (p. 472)
Emotional Needs of the Clinician
Although it is tempting in a stressful situation to
maintain a nose to the grindstonestance (in this case,
proceeding immediately with a clinical review process to
determine what went wrong), it is critical at this
juncture to recognize research findings on the emotional
impact of client suicide and the possible implications for
(a) the clinician's well-being and (b) objective exploration
of the event. In short, a dispassionate, accurate analysis of
this event is not likely in the context of emotional turmoil.
As noted above, there is no set rule regarding about the
time needed for regaining emotional equilibrium. Each
case is unique, but a general framework may be useful.
The first need to be addressed is typically that for social
support. Similar to one's needs following any emotionally
stressful event, social support serves a variety of purposes,
including the need to reality test (Can this really be
happening?), obtain guidance (What should I do?),
express emotions in a safe environment, and examine
thoughts and perceptions (such as judgments about
competence). Such support may be obtained from one's
supervisor, mentor, peers, or significant other. Whether one
is the recipient or provider of this support, it is important to
keep in mind that the agenda here is emotional, not
technical; although is may be difficult to resist the temptation
to critically examine one's intervention in search of the fatal
mistake,the primary mindset should be one of self-
nurturance and acceptance. Logical analysis can come later.
Clinicians who lose a client to suicide also should avail
themselves of the great array of informational resources
available. Reading first-person accounts of other clinicians
who have had similar experiences (e.g., Alexander, 2007;
Berman, 1995; Gorkin, 1985; Grad & Michel, 2005) can be
of immense value. Another valuable resource is provided
by the AAS (www.suicidology.org). An AAS task force
maintains a website and listserv for clinician-survivors,
where it is possible to dialogue with clinicians at various
stages of recovery. Also available on the site are personal
accounts from clinicians and a bibliography of readings
on the topic of client suicide. Additionally,
some psychological and psychiatric associations provide
resources or networks for clinician-survivors.
The question of seeking psychotherapy to deal with a
client suicide depends on the individual and the
circumstances. Ellis & Dickey (1998) found that more
than 40% of training programs responding to a survey
encouraged trainees to seek therapy following a client
suicide, and that 5% of psychology internships and 8% of
psychiatry residency programs actually required it. In-
dications for entering therapy following client suicide are
consistent with those often associated with professional
burnout (Kahill, 1988; Maslach, 2003): difficulty fulfilling
job roles and responsibilities, increased use of alcohol or
other substances, chronic physical illness, depressed
mood, alienation from co-workers, sleep or appetite
disturbance, etc. If the situation with the client involved
countertransference issues or inappropriate boundaries
(whether too loose or too tight), therapy can be an
appropriate place to address those issues as well.
Whether or not one enters therapy, CBT self-help
strategies can be helpful. For example, thought listing
might be useful in detecting cognitive distortions, such as
I'm incompetent and it's my fault that this person died.
Supervisors of trainees should be especially vigilant for
such attributions and provide reassurance that (a) the
occurrence of a suicide does not necessarily mean that
improper treatment occurred, (b) even if errors were
made, all clinicians make errors, (c) suicides are caused
by myriad influences, and (d) all things considered,
therapist behavior is actually a relatively minor influence
over client behavior. Indeed, it is not an overstatement to
counsel that Mental illness sometimes can be fatal.
Similarly, it behooves clinicians to monitor their moods
and behaviors for reactions stemming from maladaptive
attitudes and beliefs. Table 1 lists an assortment of
reactions and possible cognitive errors with respect to
client suicide. Stressful events may activate latent schemas
283Client Suicide
Author's personal copy
that are not ordinarily apparent and which surface only
when a key issue (e.g., competence or control) is
challenged or threatened (Beck, 1996). As is often
suggested in cognitive therapy, problem emotional and
behavioral reactions (such as those listed in the second
column of Table 1) should be viewed as indication that
thought monitoring and examination are in order.
Identifying any associated distortions can set the stage
for cognitive restructuring, with potential emotional
benefit. Examples of more adaptive interpretations of a
client's suicide are shown in the last column of Table 1.
We should hasten to note that none of this is to suggest
that all strong reactions to client suicide are associated
with irrational thinking or cognitive distortions. Indeed,
strong sadness and thoughts—“This person's death is a
tragedyor It's possible I made mistakes and had better
conduct a thorough review”—though distressing, may be
appropriate and adaptive. It is axiomatic that automatic
thoughts are sometimes true and, as such, should be
addressed through focused problem solving.
Last but not least in considering the emotional well-
being of the clinician is the important role that clinical
supervisors and administrative superiors can play
(Schultz, 2005). Studies of the impact of client suicide
on clinicians consistently point to the value of support
from peers and supervisors in coping with this experience
(Hendin et al., 2000), and this is especially true for
trainees (Kleespies et al., 1993; Spiegelman & Werth,
2005). Providing time for conversation, relief from duties,
and protection from insensitive review processes are
examples of interventions that can greatly facilitate the
recovery process for the affected clinician.
Clinical Review
Systematic clinical review following client suicide (or
any adverse event) is essential to gaining a clarified
understanding of the event; it allows errors to be detected
and corrected and ensures that opportunities for quality
improvement are not missed. Peer review procedures are
in place in most service organizations; private practi-
tioners, on the other hand, must exercise significantly
greater initiative to arrange for review by more eyes than
his or her own, but is a worthwhile endeavor nevertheless.
The best timing for such a review is less obvious:
Specifically, how much time should be allowed to pass
before sitting down with a critical eye, actively seeking to
determine what can be changed to reduce chances of
client suicides in the future? Obviously, this takes us into
the most frightening area for the clinician, and to ask the
clinician to summon up this kind of openness while still in
the throes of shock and grief usually is asking too much.
As noted above, a distressed clinician is often a defensive
clinician, and defensiveness is unlikely to produce the
most accurate analysis.
On the other hand, a lengthy pause between the
occurrence of client suicide and critical analysis of its
context is sometimes not feasible. For example, The Joint
Commission (formerly Joint Commission on the Accred-
itation of Healthcare Organizations) stipulates that a root
cause analysis must be completed within 45 days of a
sentinel event (G. Garland, personal communication,
December 21, 2009). State agencies and malpractice
liability insurance companies also may require reporting
within relatively short time frames. Possible effects of time
and conversations about an event on the accuracy of
memory also must be taken into consideration.
Regardless of the timing, there remains a real danger
that a suicide review becomes a pro forma process more
invested in protecting the feelings of the clinician and
other involved providers and/or the reputation of a
practice or institution than aggressively seeking opportu-
nities for improving services. Recognizing this normal
inclination to remain loyal to one's associates, some
suggest that reviews should eschew interviews altogether
and limit information gathering strictly to the clinical
record, conducted by independent reviewers with no ties
to the organization (P. Quinnett, personal communica-
tion, August 17, 2005).
Most review procedures, however, follow medicine's
Morbidity and Mortality (M&M) review process in
obtaining information from multiple sources, including
personnel involved in the patient's care and discussing
this material in a confidential setting. Stelovich (1999)
provides a detailed outline of a review process implemen-
ted by Harvard Pilgrim Health Care, a health mainte-
nance organization. It employs an interactive process
between a local team of providers involved in the patient's
care, who provide information via clinical records and
participation in a review meeting, and a corporate review
committee that reviews the information, summarizes it,
and produces recommendations. Goals for this process
include not only evaluating quality of care and determin-
ing whether there are deficiencies in need of correction,
but also consideration of the emotional impact of the
event on employees and providing support through the
review process itself. M&M reviews are generally regarded
as nondiscoverablein court proceedings (S. Simpson,
personal communication, January 23, 2010).
Regardless of the process followed, a suicide review
should include several basic categories of information.
These include a case summary, consisting of the client's
initial assessment, diagnosis, and treatment plan; a
summary of the client's treatment following initial
assessment; chronology of events leading up to the
suicide; a brief account of the suicide itself; and any
noteworthy events following the client's suicide, including
any interactions with family members or other significant
others. As noted by Stelovich (1999), the review should
284 Ellis & Patel
Author's personal copy
also include a detailed examination of activities specifi-
cally associated with assessment of risk, interventions and
justification for them, and the adequacy of the associated
documentation.
Discussion
While it is unclear whether bereavement related to
suicide differs in kind or intensity from other forms of
bereavement (Ness & Pfeffer, 1990), it is safe to say that
the loss of a client to suicide qualifies as a significant, often
painful event for the clinician. Because suicide is chosen
by the victim, it is more easily personalized by those who
knew him or her: How could he have done such a thing?
What did I miss? Where did I fail? To the clinician, yet
another layer of significance surfaces, for the loss is both
personal and professional. As explicated by Maltsberger
(1992):
. . . for the psychotherapist, the person is the
principal therapeutic tool. Brown (1987) ob-
served that this is especially true for trainees who
in the beginning of their work know so little
about psychological practice that it often seems
to them they bring only themselves to the
encounter with the patient. Thus it is that the
loss of a patient to suicide raises questions of
professional adequacy that cannot be separated
from questions of personal adequacy. (p. 173)
It is interesting that the enthusiasm of the suicide
survivor movement (e.g., Dunne, McIntosh & Dunne-
Maxim, 1987) does not seem to have been fully mirrored
among mental health professionals. Indeed, the very
stigma that often causes families to feel ashamed and
blameworthy for the death of their loved one seems to
apply to professionals as well, though perhaps in less
obvious form. Recent publications (such as Weiner, 2005)
and initiatives such as those of the AAS are hopeful signs
that this stigma is beginning to diminish.
As we hope this paper has demonstrated, the impact
and implications of this event for clinicians are real and
significant. The legacy of a client's suicide can be long and
severe. However, it is also clear that, with proper
attention, the impact can be mitigated. Action on several
fronts is worth considering:
Appropriate preparation for working with suicidal
clients remains paramount, not only to reduce
questioning of competence by the clinician and his
or her colleagues, but also as a means of reducing
the occurrence of client suicide in the first place.
Clinicians in training are particularly vulnerable and
should not only receive training in suicide risk
assessment and intervention, but also preparation
for the possibility that a client might die by suicide,
with written instructions on procedures to follow if
this should happen.
Preparation for working with suicidal individuals
includes not only knowledge and skills, but also
development of appropriate attitudes. A realistic
sense of the extent and limits of one's responsibil-
ities with respect to a client is part of understanding
(and conveying) what one can and cannot expect
from a therapeutic relationship. Ellis (2004) has
discussed this complex issue in terms of three
models: a Therapist Responsibility Model, a Client
Responsibility Model, and a (preferable) Collabora-
tive Model. The first two models place unrealistic
burdens on one or the other of the two parties and
place the therapist at risk of taking too much or too
little responsibility for client outcomes. The Collab-
orative Model reflects shared responsibility and
acknowledges limitations of the influence of the
therapist. Appropriate modeling by supervisors can
be a highly effective means of developing appropri-
ate attitudes in trainees.
Managers, supervisors, and mentors can play key
roles in preparing for and responding to client
suicides, not only by working to lower the chances of
a suicide's occurring, but also by having established
and well-known policies and procedures in place
should a suicide occur. Such procedures should be
designed to strike a balance between, on one hand,
protecting the clinician and restoring his or her
morale and, on the other hand, ensuring that a
thorough review reveals any errors that were made
and opportunities for improvements are not missed.
Clinicians and supervisors should recognize the
right (and responsibility) to engage in self-care
activities following a client's suicide. These include
personal and technical support-seeking, as well as
utilization of established tools of cognitive therapy to
reveal and modify beliefs and attitudes that may add
unnecessary suffering to what is already a significant
burden. Moreover, supervisors should actively guide
supervisees and trainees toward self-care and re-
duced workloads, rather than expecting them
already to know how to manage their grief and
professional concerns.
Recent years have seen increased emphasis on stress
management and self-care for mental health professionals
(e.g., Norcross, 2000). However, suicide remains an
unwelcome topic in many circles, and clinicians are not
immune to the stigma associated with it. The loss of a
client to suicide challenges the coping resources of the
mental health professional on several levels, and how to
proceed in the aftermath is anything but self-evident.
Empirical and anecdotal evidence suggest that it
285Client Suicide
Author's personal copy
behooves clinicians, supervisors, and administrators to
anticipate client suicide and prepare for its occurrence
through advanced clinical training and development of
appropriate policies and procedures. Such steps might be
considered an integral aspect of an overall approach to
quality clinical services and meaningful clinician self-care.
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Accepted: December 20 2010
Available online 15 April 2011
287Client Suicide
... Research suggests short-term consequences of client suicide may include emotions of shock, disbelief, confusion, and denial, as well as feelings of distress, depression, and anger at the client/society, guilt, shame, a profound sense of responsibility, failure, and feelings of incompetence [11,12]. Post-traumatic distress symptoms, such as intrusive thoughts, avoidant behavior toward potential suicidal clients, sleep disturbances, irritability, difficulty managing life events, and emotional burnout, have been suggested to affect about 50% of MHPs following client suicide [13,14]. Long-term consequences of client suicide may involve feelings of self-doubt and inadequacy, sensitivity to signs of suicidal risk, vigilance and caution when dealing with at-risk patients, concern over one's competence to treat patients, as well as feelings of anxiety, depression, or helplessness when doing so [14][15][16]. ...
... Post-traumatic distress symptoms, such as intrusive thoughts, avoidant behavior toward potential suicidal clients, sleep disturbances, irritability, difficulty managing life events, and emotional burnout, have been suggested to affect about 50% of MHPs following client suicide [13,14]. Long-term consequences of client suicide may involve feelings of self-doubt and inadequacy, sensitivity to signs of suicidal risk, vigilance and caution when dealing with at-risk patients, concern over one's competence to treat patients, as well as feelings of anxiety, depression, or helplessness when doing so [14][15][16]. Individual differences regarding the impact of client suicide on MHPs have 2 of 10 been associated with differences in gender, age, previous exposure to suicide, or coping strategies [10,14,17,18]. ...
... Long-term consequences of client suicide may involve feelings of self-doubt and inadequacy, sensitivity to signs of suicidal risk, vigilance and caution when dealing with at-risk patients, concern over one's competence to treat patients, as well as feelings of anxiety, depression, or helplessness when doing so [14][15][16]. Individual differences regarding the impact of client suicide on MHPs have 2 of 10 been associated with differences in gender, age, previous exposure to suicide, or coping strategies [10,14,17,18]. Interestingly, however, it remains unclear to what extent MHPs' attitudes toward (client) suicide are associated with the impact of client suicide. ...
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Previous research has revealed that mental health professionals (MHPs) often experience significant short- and long-term impacts in the aftermath of client suicide. Individual differences are significant, yet what factors explain these differences remain unclear. The current study aimed to investigate to what extent MHPs’ attitudes toward (client) suicide could predict the short- and long-term impacts of client suicide. A total of 213 MHPs, aged between 18 and 75, reported on a client suicide and their attitudes toward (client) suicide using self-report questionnaires. The results indicate that MHPs who believe it is one’s “rightful choice” to die by suicide report less and MHPs who believe “suicide can and should be prevented” report more impact of client suicide. Predictability and preventability of client suicide proved strongly, positively correlated; yet, neither predicted the impact of client suicide. Taken together, these findings highlight the importance of MHPs’ attitudes toward (client) suicide with respect to clients and MHPs (self-)care.
... Client suicide is used to refer to cases where a mental health practitioner (MHP) is exposed, affected, or bereaved by a client's suicide (Ellis & Patel, 2012). Unfortunately, client suicides are not uncommon in clinical practice. ...
... Incidence rates vary depending on the geographical area of interest, with 30-80% of MHPs in Belgium, the U.S., Ireland, and Australia, as well as approximately 98% of MHPs in Slovenia who indicate to have lost a client to suicide (Finlayson & Simmonds, 2018;Grad, Zavasnik, & Groleger, 1997;Greenberg & Shefler, 2014;Landers, O'Brien, & Phelan, 2010;Rothes, Scheerder, Van Audenhove, & Henriques, 2013). To no surprise, 97% of clinicians claim client suicide to be their greatest fear (Ellis & Patel, 2012), as client suicide can have far-reaching consequences for psychologists, psychiatrists, nurses, general practitioners, and social workers, alike. ...
... Feelings of distress, depression, anger at the client and/or agency/society, guilt, shame, a profound sense of responsibility, failure, and feelings of incompetence soon follow (Ting, Sanders, Jacobson, & Power, 2006). Research suggests about 50% of psychologists and social workers who have experienced client suicide go on to display post-traumatic stress symptoms such as intrusive thoughts, avoidant behavior toward potential suicidal clients, sleep disturbances, irritability, difficulty managing life events, and emotional burnout (Chemtob, Hamada, Bauer, Kinney, & Torigoe, 1988;Dransart, Gutjahr, Gulfi, Didisheim, & S eguin, 2014;Ellis & Patel, 2012;Ting et al., 2006). As such, client suicide seems to elicit symptomatology comparable to what we see when one loses a parent (Chemtob et al., 1988;Greenberg & Shefler, 2014). ...
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Objective Client suicide, used to refer to situations where a mental health practitioner (MHP) is exposed, affected, or bereaved by a client’s suicide, is known to have a profound impact on MHPs. The current study investigated (1) the short- and long-term impact of client suicide and (2) to what extent gender, years of experience, therapeutic background, and exposure to suicidality predicted impact. Methods An international sample of 213 mental health practitioners completed an online survey on the impact of client suicide. Results and Conclusion Overall, results indicate MHPs are significantly affected by client suicide. A two-factor model in which impact of client suicide was predicted by two latent variables, MHP Characteristics and Exposure to Suicidality, explained 43% of short-term, 69% of long-term emotional, and 60% of long-term professional impact. Whereas MHP characteristics did not significantly predict any of the three impact variables (ps >.05), Exposure to Suicidality significantly predicted all three outcome variables (ps <.001). Interestingly, lived experience or exposure to suicidality of friends/family members predicted more impact, while exposure to suicidality at work predicted less impact of client suicide. Implications for both research and clinical practice are discussed. • HIGHLIGHTS • MHPs are significantly affected by client suicide; • Previous exposure to suicidality predicts the impact of client suicide; • MHP characteristics do not predict the impact of client suicide.
... These were further illustrated by validated scales reporting effects over time including reactive changes that clinicians made to their practice (Chemtob, Hamada, Bauer, Torigoe, & Kinney, 1988;Hendin, Lipschitz, Maltsberger, Haas, & Wynecoop, 2000;Spencer, 2007). The findings have been summarized in narrative (Ellis & Patel, 2012) and systematic reviews (S eguin, Bordeleau, Drouin, Castelli-Dransart, & Giasson, 2014;Talseth & Gilje, 2011). All note diverse clinician attitudes toward the level and type of support required afterwards, encouraging further research to underpin training and postvention guidance. ...
... For some, the fear of blame was linked to litigation (Foggin et al., 2016); for others, it was colleagues' perceptions of their competence (Joyce & Wallbridge, 2003). This supports existing consensus that losing a patient to suicide is an intensely challenging experience and may explain high reported levels of post-incident self-scrutiny, as well as the sense of being unworthy or undeserving of formal support (Chemtob et al., 1988;Ellis & Patel, 2012;McAdams & Foster, 2000;Midence et al., 1996;S eguin et al., 2014;Spiegelman & Werth, 2005). ...
... Consequently, they may exacerbate feelings of guilt and self-blame and detract from clinicians' self-care (Norcross, 2000;Strobl et al., 2014). This is broadly consistent with previous research across various healthcare professions, which generally finds organizational support wanting and calls for improvements to better prepare clinicians and facilitate recovery following patient suicide (Ellis & Patel, 2012;Grad & Michel, 2005;Leaune et al., 2019;Sanders et al., 2005;Schneidman, 1971;Sherba, Linley, Coxe, & Gersper, 2019). ...
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Objective: To provide a conceptual overview of how medical doctors and nurses experience patient suicide. Method: A systematic search identified ten qualitative papers for this interpretive meta-synthesis. Constructs were elicited and synthesized via reciprocal translational analysis. Results: Findings comprised four inter-related themes: (1) Intrinsic but taboo: patient suicide perceived as inevitable yet difficult to discuss. (2) Significant emotional impact: clinicians deeply affected, with resilience important for mitigating impact. (3) Failure and accountability: intense self-scrutiny, guilt and shame, with blame attributed differently across professions. (4) Legacy of patient suicide: opportunities for growth but lack of postvention guidance. Conclusions: Patient suicide affects clinicians profoundly. Further research should evaluate postvention procedures to inform effective guidance and support, acknowledging professional differences.HighlightsPatient suicide profoundly affects doctors and nurses as "suicide survivors."Despite common themes, professions differed in blame attributions.Organizations must develop postvention responses to meet clinicians' pastoral needs.
... However, most studies focus exclusively on psychiatrists, although some also include a few psychologists. In their review of research literature, Ellis and Patel (2012) found a great consistency within the reported findings, identifying emotional reactions centred on grief (shock, disbelief, profound sadness, loss, guilt, anger, isolation), symptoms of trauma (including emotional burnout, intrusive thoughts, images and dreams about suicide, avoidance, and heightened anxiety when working with suicidal clients), and depressive rumination and distress lasting for months, often related to doubts about responsibility. Most-helpful coping strategies were talking with a supervisor, colleagues, friends and family. ...
... In the research reviewed above grief has been consistently identified among all types of professionals following the death of their clients/patients, regardless of the cause of death (e.g. Anderson et al., 2015;Ellis & Patel, 2012;Kasket, 2006). However, although grief is the single most common response to client death, there is a range of reactions (emotional, cognitive and behavioural), and a great deal of variability between and within each professional group. ...
... Research has identified both negative impacts on professionals (including trauma and burnout; e.g. Dwyer et al., 2012;Ellis & Patel, 2012), and positive ones (growth; e.g. Anderson et al., 2015;Foster & Vacha-Haase, 2013;Kent et al., 2012). ...
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Background and objective: Caring for critically-ill and dying patients is widely recognised as a central stressor in oncology and palliative-care staff. Past research in this area has mostly focused on medical staff, and the impact of patient deaths on other professionals has received only limited attention. This study aimed to explore how psychotherapists experience and cope with the death of the cancer patients in their care, and whether these experiences promote personal and/or professional growth. Methods: an exploratory sequential mixed-methods design was adopted. Participants were psychotherapists working with adult cancer- and palliative-care patients within UK hospices. In the qualitative phase, seven semi-structured interviews were conducted and examined using thematic analysis. In the quantitative phase, 28 participants completed an online questionnaire designed to evaluate the incidence within the target population of the themes identified in the qualitative phase. Findings: Grief appeared as hospice psychotherapists' main immediate response to client deaths. Participants used coping strategies aiming to facilitate emotional closure, and to foster emotional and cognitive processing. These strategies included conducting personal rituals, receiving support from colleagues and clinical supervision. Several factors hindering these coping strategies were identified, but the vast majority were shared by only a small minority of participants (e.g. feeling disenfranchised in their grief for clients). Repeated exposure to client death caused participants to feel emotionally and physically drained (and for some leading to greater fear of illness and dying). It also affected their outlook on life positively, leading to personal growth. Participants managed the negative long-term impact of their work using self-care strategies, which included working in cancer- and palliative-care settings on a part-time basis, and engaging in creative and future-oriented activities promoting a sense of hope, possibilities, and growth. Conclusion and implications: Although many hospice psychotherapists repeatedly experience grief following the deaths of their clients, most appear able to manage the immediate and long-term impacts of their work. Working in proximity to illness and death is seen as deeply challenging but at the same time as promoting personal growth, and to enhance and bring meaning to hospice psychotherapists' lives. Furthermore, the mixed-methods design adopted here provides evidence that while the qualitative methods employed produced rich data, the addition of a simple quantitative survey allowed to put these in perspective about the wider group of hospice psychotherapists. I argue that this finding supports the call, prevalent in the mixed-methods research literature, to question the segregation of qualitative and quantitative methods.
... However, most studies focus exclusively on psychiatrists, although some also include a few psychologists. In their review of research literature, Ellis and Patel (2012) found a great consistency within the reported findings, identifying emotional reactions centred on grief (shock, disbelief, profound sadness, loss, guilt, anger, isolation), symptoms of trauma (including emotional burnout, intrusive thoughts, images and dreams about suicide, avoidance, and heightened anxiety when working with suicidal clients), and depressive rumination and distress lasting for months, often related to doubts about responsibility. Most-helpful coping strategies were talking with a supervisor, colleagues, friends and family. ...
... In the research reviewed above grief has been consistently identified among all types of professionals following the death of their clients/patients, regardless of the cause of death (e.g. Anderson et al., 2015;Ellis & Patel, 2012;Kasket, 2006). However, although grief is the single most common response to client death, there is a range of reactions (emotional, cognitive and behavioural), and a great deal of variability between and within each professional group. ...
... Research has identified both negative impacts on professionals (including trauma and burnout; e.g. Dwyer et al., 2012;Ellis & Patel, 2012), and positive ones (growth; e.g. Anderson et al., 2015;Foster & Vacha-Haase, 2013;Kent et al., 2012). ...
Thesis
Background and objective: Caring for critically-ill and dying patients is widely recognised as a central stressor in oncology and palliative-care staff. Past research in this area has mostly focused on medical staff, and the impact of patient deaths on other professionals has received only limited attention. This study aimed to explore how psychotherapists experience and cope with the death of the cancer patients in their care, and whether these experiences promote personal and/or professional growth. Methods: an exploratory sequential mixed-methods design was adopted. Participants were psychotherapists working with adult cancer- and palliative-care patients within UK hospices. In the qualitative phase, seven semi-structured interviews were conducted and examined using thematic analysis. In the quantitative phase, 28 participants completed an online questionnaire designed to evaluate the incidence within the target population of the themes identified in the qualitative phase. Findings: Grief appeared as hospice psychotherapists' main immediate response to client deaths. Participants used coping strategies aiming to facilitate emotional closure, and to foster emotional and cognitive processing. These strategies included conducting personal rituals, receiving support from colleagues and clinical supervision. Several factors hindering these coping strategies were identified, but the vast majority were shared by only a small minority of participants (e.g. feeling disenfranchised in their grief for clients). Repeated exposure to client death caused participants to feel emotionally and physically drained (and for some leading to greater fear of illness and dying). It also affected their outlook on life positively, leading to personal growth. Participants managed the negative long-term impact of their work using self-care strategies, which included working in cancer- and palliative-care settings on a part-time basis, and engaging in creative and future-oriented activities promoting a sense of hope, possibilities, and growth. Conclusion and implications: Although many hospice psychotherapists repeatedly experience grief following the deaths of their clients, most appear able to manage the immediate and long-term impacts of their work. Working in proximity to illness and death is seen as deeply challenging but at the same time as promoting personal growth, and to enhance and bring meaning to hospice psychotherapists' lives. Furthermore, the mixed-methods design adopted here provides evidence that while the qualitative methods employed produced rich data, the addition of a simple quantitative survey allowed to put these in perspective about the wider group of hospice psychotherapists. I argue that this finding supports the call, prevalent in the mixed-methods research literature, to question the segregation of qualitative and quantitative methods.
... Research suggests about 20% of psychologists and 50% of psychiatrists experience client suicide (Chemtob et al., 1989), though incidence rates vary depending on the geographical area (e.g., Finlayson & Simmonds, 2018;Greenberg & Shefler, 2014;Rothes et al., 2013). Unsurprisingly, 97% of clinicians claim client suicide to be their greatest fear (Ellis & Patel, 2012). ...
... Looking at the long-term impact of client suicide, MHPs are likely to be subject to both far-reaching personal and professional consequences. Long-term emotional consequences may include depressive rumination, self-doubt, inadequacy, loneliness, isolation from their peers, sensitivity to signs of suicidal risk, and concern over one's competence to treat (Alexander et al., 2000;Ellis & Patel, 2012;Hendin et al., 2000). Long-term professional consequences may include more attentiveness to legal matters of the profession, increased hours of supervision and intervision, vigilance and cautious when dealing with at-risk patients, or in general, for one to adopt a more conservative approach when treating suicidal clients (Alexander et al., 2000;Rothes et al., 2013;Ting et al., 2006). ...
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Client suicide refers to cases where a mental health practitioner is exposed, affected, or bereaved by a client's suicide and is known to have a profound impact on MHPs. The current study investigated the role of coping styles in understanding short- and long-term impact of client suicide. An international sample of 213 mental health practitioners who experienced a client suicide completed a survey on coping strategies (i.e., Brief-COPE) and the impact of traumatic events (i.e., impact of event scale-revised, long-term emotional impact scale and professional practice impact scale). Results indicate coping strategies explain 51% of the short-term, 64% of the long-term emotional and 55% of the long-term professional differences in impact of client suicide. Moreover, while an Avoidant coping style predicted more impact of client suicide, Positive coping and Humor predicted less impact of client suicide. Social Support coping did not predict impact of client suicide. Implications for both research and clinical practice are discussed.
... 26 Prematurely focusing on administrative and legal issues may adversely affect clinicians, and the complex emotional reactions associated with a recent patient suicide loss can impair clinicians' abilities to carry out critical case reviews. 23,27 Guidelines also recommend making more intensive services available to clinicians (ie, consultation, education, support, and resources offered by the American Association of Suicidology Clinician Survivor Task Force 24 ), but not presuming that they will be required. 25 Only after sufficient time for bereavement has passed should efforts be made to enhance clinical training and patient services, 28 including the provision of suicide prevention training and considering what may have "gone wrong" via psychological autopsy or critical case review. ...
Article
Introduction: The loss of a patient to suicide has an enormous impact on clinicians, but few studies have examined its effects. Method: In this retrospective study, we compared clinicians who have and have not experienced a patient suicide using a survey of 2157 outpatient clinicians from 169 New York clinics to determine differences in their suicide prevention knowledge, practices, training, and self-efficacy. Results: Approximately 25% of the clinician respondents lost patients to suicide; psychiatrists, nurses/nurse practitioners, and those with more years of experience were disproportionately affected. After controlling for these demographic/professional differences, clinicians who had experienced patient suicide reported feeling that they had insufficient training, despite actually having more suicide prevention training, greater knowledge of suicide prevention practices, and feeling more comfortable working with suicidal patients than clinicians who had not lost a patient to suicide. There were no differences in self-efficacy or utilization of evidence-based clinical practices. Conclusions: Controlling for demographic/professional differences, clinicians who experienced a patient suicide had more training, knowledge, and felt more comfortable working with suicidal patients. It is critical that sufficient training be available to clinicians, not only to reduce patient deaths, but also to help clinicians increase their comfort, knowledge, skill, and ability to support those bereaved by suicide loss.
... This is in line with studies that found that while men reported more avoidant reactions and behaviors, women reported more emotional reactions (Jacobson et al., 2004;Ting et al., 2008). Length of the relationship with the suicidal patient was associated with over-caution (Ellis & Patel, 2012;Gaffney et al., 2009;Gulfi et al., 2015;Henry et al., 2004). ...
Article
Objective This study examines the association between a patient's suicide and the therapist's suicide risk assessment (SRA) and suicide risk management (SRM) of patients, following the occurrence. Method SRA values range from “absence of suicidality” to “immediate suicidal intent to die”. SRM consists of therapists’ written recommendations. Rates of the various SRA and SRM values in therapists’ evaluations were assessed 6-months prior to the suicide and at the two three- and six-month time-points thereafter. Results Of the 150 soldiers who died by suicides, 30 (20%) visited 50 military therapists in the 6 months preceding their deaths. Using Wilcoxon signed rank test, lower SRA rates of “threatens suicide” were found 2 months after a patient's suicide. Regarding SRM, the mean rates for “recommendations for psychotherapy treatment” were higher at the two (p = 0.022) and the 3 month time-points (p = 0.031) after a suicide. Conclusions The SRA findings may indicate therapists’ fear of treating suicidal patients, causing them to overlook patients’ non-prominent suicide-risk indicators. In SRM, the higher rate of recommendations for additional therapy sessions rather than military release or referrals to other therapists may relate to over-caution and attempts to control the patient's therapy ensuring it's done properly.
... For counsellors and psychotherapists, the concept of grief after a client dies can also be applied (Veilleux, 2011). The experience of grief itself may be intensified if the death was as a result of suicide (McAdams III & Foster, 2000), and may further be heightened if the counsellor or psychotherapist is newly qualified (Ellis & Patel, 2012). ...
Article
Mental health problems have been established as one of the leading causes of the global burden of disease. Approximately a quarter of all people worldwide will experience a mental disorder during their lifetime. With depression and anxiety becoming the leading causes of mental ill health globally, the numbers of people reporting mental health complaints are set to grow. The dramatic increase in reporting and diagnosis of mental health disorders has been in parallel to a decline in the ability to cope with mental health symptoms and a rise in the incidence of self‐harm and suicidal ideation. While mental health assessment and diagnoses are usually the responsibility of general practitioners (family doctors) or psychiatrists, the frontline provision of mental health care is often delegated to counsellors and psychotherapists. Publicly funded counselling and psychotherapy services vary across the globe, but are commonly under‐resourced and lacking in adequate funding. This may lead to insufficient clinical supervision and compressed time to complete continuing professional development, which are both vital for new counsellors and psychotherapists to feel confident in providing care, and to learn new skills. Newly qualified counsellors and psychotherapists may also experience emotional, physical, and mental exhaustion or ‘burn‐out’. This position paper aims to critically appraise available cross‐cultural literature on the experiences of ‘burn‐out’ by newly qualified counsellors and psychotherapists, globally. Finally, we make recommendations for how best to support the mental health and psychological well‐being of newly qualified practitioners.
... When queried about how SRAs affect them, participants endorsed feelings of agitation, exhausting emotional arousal, and debilitating neuroticism, all leading to disproportional resource investments in their suicidal clients. Given the grim understanding that client suicide is inevitable within a psychologist's career (Chemtob et al., 1989) and that reactions from said client suicide are harmful to the practitioner (Ellis & Patel, 2012), it is understandable that psychologists worry about these experiences. Two of the five participants who lost a client to suicide expressed sentiments similar to those of other psychologists such as guilt, betrayal, anxiety, and withdrawal (Skodlar & Welz, 2013). ...
Article
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Psychologists conduct suicide risk assessments (SRAs) regularly to identify and prevent clients’ self-harm and risk of death, although little is known about their experiences of the process. In this phenomenological study, five registered psychologists (master’s and doctoral level) were interviewed to explore the essence of their SRA experiences. Psychologists reported weaving tenets of assessment and therapy throughout their SRAs, relying on their clinical intuition, and investing deeply in their suicidal clients. Also, psychologists reported feeling significant anxiety working with suicidal clients, revealing the ways in which the fear of client suicide guides and motivates their SRA practices. While they have an empathic view of suicide, they believe in preventative intervention. They reported feeling pressure from clients and colleagues to conduct ethical and useful SRAs despite receiving what they consider to be insufficient and ineffectual graduate SRA training. Results from this study offer a qualitative foundation for future research on the ethics, training, and practice of SRA.
Article
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Suicide by a patient of a psychology intern or psychiatry resident is not uncommon. These trainees often experience significant emotional distress as a result. This national survey of psychology internships and psychiatry residency programs provides information on the nature and extent of suicide related training and procedures that programs follow in the aftermath of suicide by a patient of a trainee. The levels of activity in both areas are generally less than might be desired, although considerable variability exists.
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The risk of suicide is significantly elevated in people with depression and related disorders. For this reason, many of the Asian countries represented in the Strategies to Prevent Suicide (STOPS) project have developed training programmes aimed at improving the ability of primary care professionals to recognize and treat depression. Some of the countries have also looked at ways of optimizing the clinical outcomes of pharmacological and psychological treatments and, more importantly, of streamlining the systems within which they are delivered so that more at-risk individuals receive needed care. Most of these projects are relatively small in scale and – like similar projects in Europe or the United States of America – have not yet convincingly demonstrated their effectiveness. A more co-ordinated, systematic approach is needed if the strategies to improve the treatment of depression and related disorders are to achieve their potential in terms of suicide prevention in Asia.
Article
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AIMS AND METHOD A survey of 89 psychiatric trainees in a regional rotational training scheme was carried out to investigate the impact immediately after a patient's suicide and at the time of the study. Main outcome measures used were the Impact of Events Scale and a rating scale of the impact on personal and professional life. RESULTS Twenty-three trainees out of 53 who returned questionnaires reported at least one suicide. Initial reactions included shock, self-blame, guilt, grief and fear of negligence. Impact on personal and professional life was moderately severe. Over half of the trainees were ‘clinically stressed’ in the immediate aftermath, with no statistically significant reduction over time. CLINICAL IMPLICATIONS The impact of a patient suicide can be profound. It can be experienced as a stressful event but can also lead to positive changes in clinical practice. Greater availability of training and support as well as further research in this area are recommended.
Article
Patient suicide and patient suicide attempts are frequently unexpected, sudden, and violent. They can have a significant emotional impact on the treating clinician, particularly if the clinician is still in a training status (cf. P. M. Kleespies et al, 1993). An estimated 40% of psychology trainees have a patient suicide (11.3%) or a patient suicide attempt (29.1%) during their training years. A concept of systematic response called psychological resynthesis (H. L. Resnick, 1969) is proposed for psychology interns and training programs that must cope with the aftermath of a patient suicide or a serious patient suicide attempt. Suggestions for suicide education and the preparation of trainees for the "occupational hazard" of patient suicidal behavior are discussed as part of a health-promotive approach to the training and clinical work environment.
Article
This study enhances and replicates an earlier study (Kleespies, Smith, & Becker, 1990) on the incidence and impact of patient suicidal behavior on psychology interns/trainees, using a much larger sample, a broader spectrum of patient suicidal behaviors, and more adequate comparison groups. The findings indicate that more than 1:4 interns/trainees needed to deal with a patient suicide attempt, and that 1:9 had to cope with a patient suicide completion. Stress level followed a graduated increase in impact with increasing severity of patient suicidal behavior (ie., from suicidal ideation to suicide attempt to suicide completion). Trainees who had a patient suicide were distinguished from those who experienced patient suicide ideation by significantly greater feelings of shock, disbelief, failure, sadness, self-blame, guilt, shame, and depression. Results are discussed in terms of the importance of developing mechanisms to assist trainees in anticipating and working through the strong psychological impact of losing a patient through a self-inflicted death.