Losing a patient to suicide with Dr. Nina Gutin

Wednesday, March 11, 2020

Lorenzo Norris, MD, interviews Nina J. Gutin, PhD, a psychologist with a private practice in Pasadena, Calif., about losing patients and loved ones to suicide.

Dr. Gutin wrote two evidence-based reviews on the topic late last year. The reviews were published in Current Psychiatry.

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Take-home points

  • When mental health clinicians lose a patient to suicide, the sequelae can include stigma, potential legal consequences, impact on future clinical work, and restraints on processing the loss because of confidentiality concerns.
  • The American Association of Suicidology founded the Clinician Survivor Task Force (CSTF), which provides consultation, support, and education to mental health professionals to help them respond to the personal/professional loss from the suicide of a patient or loved one.
  • Mental health institutions can benefit from protocols on how to respond to a potential completed suicide, so clinicians and families are not left in a vacuum of uncertainty and blame.
  • After a patient suicide, clinicians need an anonymous or safe space to talk about the patient and the suicide without breaking confidentiality. This can be an online forum, such as the one sponsored by the CSTF, or an institution can identify a supportive colleague who has suffered a similar loss.
    • The CSTF forum allows clinicians to remain anonymous.

Summary

Several domains require attention after the loss of a patient from suicide:

  • Confidentiality restrains the ability to talk about the details of the loss, which stymies grief and learning from the event. Restraints of confidentiality pertain to individual clinicians and clinical teams. On a team, it might feel as if the clinicians are unable to process the loss as a group and talk about important details.
  • Legally, clinicians worry about potential lawsuits, and “psychological autopsies” can lead to retraumatization. Clinicians might struggle with how – or whether – to talk to a patient’s family after suicide. Some lawyers advise compassion over caution. In collaboration with lawyers who advise what can be disclosed, a clinician can speak with a family, and this compassion toward families might decrease the risk of a lawsuit.
  • Clinicians should be prepared for a patient suicide to affect their clinical work. A clinician might become hypervigilant about suicide risk and overreact, or they might experience denial about the risk and avoid asking questions about suicide.
  • Ethically, suicide is an “occupational hazard” of working in the mental health field. Blaming clinicians for patient suicide hampers the depth of working with people with mental illness by causing some clinicians to avoid “high-risk” patients.
  • The stigma around death by suicide extends to the survivors of the loss. When clinicians express vulnerability about loss, it can be interpreted as guilt. Clinicians are expected to keep going no matter what, which is unrealistic. Grief over a patient’s death should be neither pathologized nor shamed.
  • Guilt and blame are the flip sides of each other; both express the complexity and ambiguity of these kinds of losses.
  • Institutions should have “postvention” protocols in place to respond to the likely event of a completed suicide. Guidelines can address what needs to be covered in a review of the case while also supporting clinicians, so they don’t feel like it’s a tribunal. Clinicians should be warned of the normal sequelae of a client suicide, and institutions can make accommodations based on the expected impact of suicide on a clinician’s work. Institutions can provide support by connecting clinicians who have also lost clients to suicide to dispel the belief that they are alone in their loss and to mitigate self-blame.
  • The CSTF provides support through in-person and online support groups, and postvention protocols for institutions. It also and maintains a bibliography of research on clinician survivorship.

References

Gutin NJ. “Losing a patient to suicide: What we know.” Current Psychiatry. 2019 Oct 18(10):14-6,19-22,30-2.

Gutin NJ. Losing a patient to suicide: Navigating the aftermath. Current Psychiatry. 2019 Nov 18(11):17-18,20,22-4.

American Association of Suicidiology. Clinicians as Survivors: After a Suicide Loss.

Owen JR et al. Suicide symposium: A multidisciplinary approach to risk assessment and the emotional aftermath of patient suicide. MedEdPORTAL. 2018 Nov 28;14:10776.

Myers MF and Fine C. Touched by suicide: Bridging the perspectives of survivors and clinicians. Suicide Life Threat Behav. 2007 Apr;37(2):119-26.

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Show notes by Jacqueline Posada, MD, associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

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Podcast Participants

Lorenzo Norris, MD
Lorenzo Norris, MD, is host of the MDedge Psychcast, editor in chief of MDedge Psychiatry, and assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He also serves as assistant dean of student affairs at the university, and medical director of psychiatric and behavioral sciences at GWU Hospital. Dr. Lorenzo Norris has no conflicts of interest.
Renee Kohanski, MD
Renee Kohanski, MD, is a board-certified psychiatrist with additional training in forensic psychiatry. She has been a board examiner for the American Board of Psychiatry and Neurology, and she has practiced within community mental health and departments of corrections. Currently, she is the sole proprietor of RK Psychiatry Associates. She can be seen and heard as a national commentator on general issues as they may relate to psychiatry. Dr. Renee Kohanski has no conflicts of interest.