Jane G. Tillman, PhD, ABPP

	The APA website offers a page called “

Helping residents cope with a patient suicide

.” Among the useful recommendations is attending APA meeting workshops on the subject, like the one we will offer in Atlanta: Workshop 4122 – “Responding to the Impact of Suicide on Clinicians,” Tuesday, May 17 3:30 pm-5 pm, Georgia World Congress Center, Level 4, Room B404.

What are the effects on the clinician when his/her patient dies by suicide? How to respond? Drs Plakun and Tillman have been offering a workshop on responding to the impact of suicide on clinicians as part of the 

1. How likely is it that a psychiatrist will experience the death of a patient by suicide?

The suicide of a patient has been recognized as an 

 Studies have reported that 25% to 60% of psychiatrists will have a patient die by suicide during his or her career. Estimates suggest that the likelihood is closer to 

Psychiatrists often help patients at high risk, treat those with acute psychiatric illness in the ED or inpatient settings, and manage medications for more seriously disturbed patients. In addition, psychiatrists whose practice primarily involves prescription of medication see a high volume of patients and thus have more risk exposure.

In studies of clinicians who have a patient die by suicide, up to 38% of psychiatrists report severe distress.

The death of a patient by suicide has been shown to have more severe effects on trainees and early career professionals. These young clinicians may not have thought about the possibility of the death of a patient. They may feel vulnerable in terms of their experience and knowledge-base in 

 who are suicidal or more severely disturbed in the area of aggression and impulsivity.

2. What are the known effects of patient suicide on clinicians? 

Reactions to the death of a patient by suicide vary. Some psychiatrists rationalize that, like colleagues in oncology or cardiology, there are some mental illnesses with a fatal trajectory and thus suicide is an expectable outcome. Unlike other medical specialties, however, the patient who dies by suicide has been both the victim and perpetrator of a fatal event.

In studies of clinicians who have a patient die by suicide, up to 38% of psychiatrists report 

 about treatment decisions, failure to hospitalize the patient, concern about negative reactions by the physician’s institution, or fear of a lawsuit.

Other reactions to a patient death by suicide include: traumatic reactions, anger, sadness, serious self-doubt about one’s choice of profession, fear of 

 by colleagues, decisions not to treat more disturbed patients, self-criticism, and experiences of stigma.

 Studies of those bereaved following a suicide show that survivors often 

, stigma, blaming, and anger than those bereaved from other causes of traumatic sudden death.

3. If you or a colleague experience the death of a patient by suicide, how should you respond?

If your patient dies by suicide, there are several tasks to attend to. Pragmatic tasks include notifying your 

 and reviewing the events leading up to the suicide. If you work in a hospital or organization, there are likely sentinel event reviews, risk management reviews, or other meetings designed to identify opportunities to improve care based on case-specific learning. In these meetings it is important to process the event with a stance that avoids either blaming or premature reassurance that the death was inevitable.

In private practice settings, clinicians who lose patients to suicide are often left alone with the event and its difficult emotional aftermath. We recommend that clinicians review the event with a trusted colleague, supervisor, or personal psychotherapist.

If the clinician is part of an organization, then meeting in role-related groups may be useful (eg, residents, attendings, supervisors, administrators). In addition to these groups, it is quite useful to find a way to convene the staff in a peer protected environment to discuss the sense of trauma and painful feelings associated with the event. 

Clinicians often report a sense of increasing isolation following the death of a patient by suicide. If a colleague’s patient 

, then reaching out in the days, weeks, and even months following the event to lend a supportive and compassionate listening stance is often helpful to the colleague.

The clinician must also prepare for the possibility of meeting with the patient’s family. This includes planning carefully how to manage the confidentiality boundary. We recommend offering a non-judgmental space for the family to process their questions and feelings, and that the clinician receive the range of feelings with an empathic stance, while neither accepting or assigning blame for the loss.

Dr Plakun is Associate Medical Director and Director of Biopsychosocial Advocacy at the Austen Riggs Center, and former Harvard Medical School clinical faculty member. He is a Distinguished Life Fellow of the American Psychiatric Association, and leader of its Psychotherapy Caucus. Dr Plakun, who has been honored as the Outstanding Psychiatrist in Clinical Psychiatry by the Massachusetts Psychiatric Society, is a leader in organized psychiatry and an advocate for the value of psychotherapy and other psychosocial treatments. Jane G. Tillman, PhD, ABPP, is Director of the Erikson Institute for Education and Research of the Austen Riggs Center. She is an Assistant Clinical Professor at the Yale Child Study Center and an Instructor in Psychology in the Department of Psychiatry-part time-at the Harvard Medical School. A clinical psychologist and a psychoanalyst, Dr Tillman has a special interest in suicide research.

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	9. Plakun E, Tillman J. Responding to clinicians after loss of a patient to suicide. 

Articles

What are the effects on the clinician who loses a patient? How to respond?

The Impact of Patient Suicide on Clinicians 

[[{"type":"media","view_mode":"media_crop","fid":"30787","attributes":{"alt":"Suicide","class":"media-image","id":"media_crop_6786137626094","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3230","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image"}}]]With the death by suicide of Robin Williams and with the increased incidence of suicides among our active-duty soldiers and among lesbian, gay, bisexual, and transgender youths, there is growing awareness of the public health and social problems of suicide. Research consistently shows that suicide rates are elevated among those in certain professions-especially physicians and nurses.

 One of the early pioneers in suicidology, Edwin Shneidman,

 estimated that for every person who completes suicide, there are 6 survivors who suffer from a significant grief reaction.

Yet, even with reports of increasing suicide rates, suicide remains a statistically rare occurrence. The most recent CDC data show that 39,518 people in the US killed themselves in 2011.

It is a fact that many psychiatrists will lose a patient to suicide.

 Bereavement from suicide is quite similar to bereavement experiences with other traumatic losses, although with suicide a proportion of friends and/or family members will experience stigma, shame, and self-blame.

 Between 30% and 40% of therapists who have lost a patient to suicide report severe distress-including anxiety, stress reactions, and depressive experiences.

In the late 1990s, I became interested in studying the effect of patient suicide on psychotherapists and discovered firsthand how daunting a task this is. Instead of asking psychotherapists to fill out anonymous questionnaires, my methodology was to interview therapists whose patient had committed suicide. Participants were asked to talk in detail about what effect, if any, the patient’s suicide had. After receiving Institutional Review Board approval, I began recruiting participants. Several colleagues declined to participate in this research: some told me they worried about legal repercussions of talking about the suicide; others declined to talk about the pain or perhaps shame that such a discussion might evoke. Others were simply too busy. Over several years, I was able to talk with 12 clinicians and to identify some general themes common to the experience of having a patient commit suicide.

The audiotaped transcripts of the interviews were analyzed and 8 common themes emerged:

• Traumatic responses: dissociation, traumatic intrusion, avoidance, somatic symptoms participants associated with the suicide, and dreams (nightmares) about the patient

• Affective responses: crying, sadness, anger, grief, and fear or anxiety about the consequences

• Treatment-specific relationships: clinicians reviewed and reconstructed some of their work with the patient, particularly their last session, and spoke about contact with the patient’s family

• Relationships with colleagues: this proved to be one of the most complicated experiences and included contacts with the clinician’s personal analyst or psychotherapist, supervisors, peers, trainees, and other institutional staff

• Risk management concerns: many had to do with potential for being sued

• Grandiosity, shame, humiliation, guilt, judgment, and blame were spoken about (using this language) by the clinicians seeking to understand their own ongoing internal response and their projected fear about how others would respond to them as “the person whose patient killed himself or herself”

• A sense of crisis was part of the experience of most clinicians interviewed; trainees were uncertain about their work and choice of a specialty; others felt unsure that they wanted to continue work, feeling that psychotherapy exposed them and their patients to an unsettling vulnerability

• The effect on work with other patients: clinicians spoke about how they were changed for better and, at times, for worse in their work with other patients; some spoke of no longer accepting suicidal patients for treatment, or quickly moving into management and action rather than seeking to deepen the relationship and understand the suicidal patient; a few felt calmer in the face of suicidal crises with patients

For more than 10 years, Eric Plakun, MD, Edward Shapiro, MD, and I have presented a workshop at the American Psychiatric Association on the range of reactions clinicians facing a patient suicide may have and the institutional and professional dynamics that occur following such a suicide. Out of these workshops and after listening to many colleagues speak about their experiences, we developed recommendations for clinicians, trainees, administrators, and peers about how to respond in the event of a suicide.

Patient suicide is now recognized as an occupational hazard for psychiatrists. Training focuses on prevention and intervention with suicidal patients. What is less prevalent is training in “post-vention”-what the clinician should anticipate when a patient does commit suicide. In addition to the personal reactions, clinicians must be prepared to speak with the family of the patient, to manage institutional inquiry procedures, and to engage in various risk management–driven procedures. Often, self-care comes last and may be neglected, which can lead to chronic problems related to stress, anxiety, anger, and depletion. For some clinicians, there is a process of grieving that takes more time than they, or their colleagues, anticipate.

Legal advice often involves not talking about the suicide. Laws about how to invoke peer review protection vary from state to state; thus, understanding how to convene a peer-protected space to speak about the event is important. In addition to a sentinel event review aimed at studying treatment and outcomes, clinicians need a protected space to speak about their feelings and the effect on morale after a patient suicide.

Managing the group process requires a sensitive and skilled leader. Intense affects, anger, blame, and other potentially destructive projective processes must be recognized and interpreted for the group to work productively to understand the complex feelings experienced by various members. Because of the tendency for guilt and shame associated with stigma, scapegoating and blame may be prevalent; a way to acknowledge and work with these feelings is necessary.

Role-related groups may also be important, particularly when the clinician is a trainee and the dynamics of supervisors or others in charge of evaluating the trainee may inhibit more full participation in a group process. In our workshop, we have heard numerous stories of trainees who felt blamed, demoralized, or somehow isolated and alone following the suicide of a patient. Systems anxiety and its transmission across hierarchical structures is important to recognize. Supervisors frequently are not trained in how to support a trainee whose patient has committed suicide. Therefore, thinking together as a group may lead to a more coherent and supportive atmosphere.

It is recommended that the clinician meets with the patient’s family to offer genuine condolences and to provide support. Clinicians must think carefully in advance about how to approach the family. Legal consultation may help the clinician think clearly about how to manage requests for medical records or oth-er confidential information. Offering a judgment-free, empathic, non-defensive space to listen to the family is important. This is not the time for the clinician to turn to the family for support, to divulge personal information that might burden the family, or to slip into blaming or overly explaining speculative hypotheses about the patient’s motivations. The primary purpose of meeting with the family is to support the family.

Dr M is a young psychiatrist who recently completed his training. He has completed several fellowships in child psychiatry and has psychoanalytic training. His specialty is working with young adults and adolescents, many of whom struggle to separate from home and enter the role of adult functioning. Dr M feels very empathic with his patients and is aware of the emotional crises they frequently have. When he was a resident, a fellow trainee had a patient commit suicide. Although he felt sorry for his colleague, he confides that he felt superior to his colleague and took some comfort in that idea.

Over the past 18 months, Dr M has particularly enjoyed working with David. Feeling depressed and suicidal, David took a leave of absence from college after his second semester. Over the course of their work together, David had his ups and downs but soon began to understand his conflicts around separation, his vulnerability to depressive reactions, and his sensitivity to interpersonal rejection. David was at the point where he felt ready to return to college, and Dr M agreed.

The week before he was to return to college, David talked about how he was looking forward to going back to school. He seemed appropriately anxious but also excited. Three days later, Dr M learned that David had hanged himself in the basement of the family home. Dr M was shocked-he racked his brain for any indication in the sessions over the past weeks for an indication that David was depressed or suicidal. Nothing stood out. David reported that he was taking his antidepressant medication and felt it was effective.

Restless and unable to sleep, Dr M kept reviewing every detail of his work with David-he wondered what it was that he had missed. He couldn’t make sense of what had happened, and over the next few days, he felt angry and directed his anger toward a colleague. He had been aware of a gentle competition with this colleague over the years, and now that colleague came to represent judgment, blame, and arrogance. Any thought of the colleague left Dr M feeling angry and bitter.

Contrary to his understanding of what a dedicated physician does, Dr M decided to forego attending the funeral. He called his insurance provider and was advised not to have any contact with the family. However, after consulting with a trusted advisor, Dr M called the family and offered to meet with them. Although this felt like the right thing to do, he was anxious about not following the legal advice he had received. The meeting with David’s family was very painful, the family was uncommunicative, and Dr M left with the feeling that they blamed him for their son’s death. Unspoken guilt seemed to pervade the atmosphere of that meeting.

Over the following weeks, Dr M withdrew from colleagues; had trouble sleeping, with occasional nightmares; and felt ashamed about his past “grandiosity” in thinking he was a good and dedicated physician. This attitude had convinced him that none of his patients would ever commit suicide. He felt chastened by the event, which had challenged his previous professional identity and assumption that competent physicians never lose a patient to suicide.

Unlike the grief he felt following his mother’s death, Dr M’s grief for David was tinged with bitter resentment, shock, and a type of narcissistic injury that surprised him. Several months after David’s suicide, Dr M sought consultation with a psychoanalyst who had previously been helpful.

In the years following David’s suicide, Dr M’s feelings about himself and his work had changed. He felt more aware of the risks of treating certain patients: at times he was prone to over-management or to turning down referrals because the patient sounded too troubled. He resented feeling hypervigilant, and the thought of a lawsuit was frequently on his mind. He wondered how he could handle having another patient commit suicide, yet he realized the risk of having a patient commit suicide was about the same as it had been before David’s death-about 50%.

This vignette illustrates an expected course of turmoil following the suicide of a patient and is an example of the many responses a clinician might have. Many clinicians have a more severe reaction. As an occupational hazard, preparing for the possibility of patient suicide will help the clinician anticipate the types of support that our colleagues or we may need to weather the event. Improved training about the effects may help clinicians and organizations respond effectively when a patient commits suicide.

Dr Tillman is Evelyn Stefansson Nef Director of the Erikson Institute at the Austen Riggs Center in Stockbridge, Mass. She reports no conflicts of interest concerning the subject matter of this article.

 Agerbo E, Gunnell D, Bonde JP, et al. Suicide and occupation: the impact of socio-economic, demographic and psychiatric differences. 

 Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS); 2011. www.cdc.gov/injury/wisqars/index.html. Accessed November 11, 2014.

 Ruskin R, Sakinofsky I, Bagby RM, et al. Impact of patient suicide on psychiatrists and psychiatric trainees. 

 Begley M, Quayle E. The lived experience of adults bereaved by suicide: a phenomenological study. 

 Hendin H, Haas AP, Maltsberger JT, et al. Factors contributing to therapists’ distress after the suicide of a patient. 

 Wurst FM, Kunz I, Skipper G, et al. The therapist’s reaction to a patient’s suicide: results of a survey and implications for health care professionals’ wellbeing. 

 Tillman JG. When a patient commits suicide: an empirical study of psychoanalytic clinicians. 

 Plakun EM, Tillman JG. Responding to clinicians after loss of a patient to suicide. 

As an occupational hazard, preparing for the possibility of patient suicide will help the clinician anticipate the types of support that our colleagues or we may need to weather the event.

Jane G. Tillman, PhD, ABPP

Articles

The Impact of Patient Suicide on Clinicians

Patient Suicide: Impact on Clinicians