Evidence-Based Reviews

Losing a patient to suicide: What we know

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Hendin et al30 found that mental health therapists have described losing a patient as “the most profoundly disturbing event of their professional careers,” noting that one-third of these clinicians experienced severe distress that lasted at least 1 year beyond the initial loss. In a 2004 study, Ruskin et al4 similarly found that one-quarter of psychiatrists and psychiatric trainees noted that losing a patient had a “profound and enduring effect on them.” In her article on surviving a patient’s suicide, Rycroft31 describes a “professional void” following the loss of her patient, in which “the world had changed, nothing was predictable any more, and it was no longer safe to assume anything.” Additionally, many clinicians experience an “acute sense of aloneness and isolation” subsequent to the loss.32

Many clinicians have noted that they considered leaving the field after such a loss,33,34 and it is hypothesized that many may have done so.35-37 Others have noted that, at least temporarily, they stopped treating patients who were potentially suicidal.29,35

Box 1

Clinicians’ grief trajectories after a losing a patient to suicide

Several authors have proposed general models for describing the suicide grief trajectories of clinicians after a suicide loss. Tillman38 identified distinct groups of responses to this event: traumatic, affective, those related to the treatment, those related to interactions with colleagues, liability concerns, and the impact on one’s professional philosophy. She also found that Erikson’s stages of identity39 provided an uncannily similar trajectory to the ways in which those who participated in her research—clinicians at a mental hospital—had attempted to cope with their patients’ deaths, noting that the “suicide of a patient may provoke a revisiting of Erikson’s psychosocial crises in a telescoped and accelerated fashion.”38

Maltsberger40 offered a detailed psychoanalytic analysis of the responses clinicians may manifest in relation to a suicide loss, including the initial narcissistic injury sustained in relation to their patient’s actions; the subsequent potential for melancholic, atonement, or avoidance reactions; and the eventual capacity for the resolution of these reactions.

Al-Mateen et al33 described 3 phases of the clinician’s reaction after losing a patient who was a child to suicide:

  • initial, which includes trauma and shock
  • turmoil, which includes emotional flooding and functional impairments
  • new growth, in which clinicians are able to reflect on their experiences and implications for training and policy.

For each phase, they also described staff activities that would foster forward movement through the trajectory.

In a 1981 study, Bissell41 found that psychiatric nurses who had experienced patient completed suicides progressed through several developmental stages (naïveté, recognition, responsibility, individual choice) that enabled them to come to terms with their personal reactions and place the ultimate responsibility for the suicide with the patient.

After losing a patient to suicide, a clinician may experience grief that proceeds through specific stages (Box 133,38-41). Box 22-4,6,16,24,29,30,33,34,40,42-45 describes a wide range of factors that affect each clinician’s unique response to losing a patient to suicide.

Box 2

Factors that affect a clinician’s response to losing a patient to suicide

There are many factors that make the experience of losing a patient to suicide unique and variable for individual clinicians. These include the amount of a clinician’s professional training and experience, both in general and in working with potentially suicidal individuals. Chemtob et al2 found that trainees were more likely to experience patient suicide loss than more seasoned clinicians, and to experience more distress.4,30,42 Brown24 noted that many training programs were likely to assign the most “extraordinarily sick patients to inexperienced trainees.” He noted that because the skill level of trainees has not yet tempered their personal aspirations, they are likely to experience a patient’s suicide as a personal failure. However, in contrast to the findings of Kleespies,42 Hendin,30 Ruskin et al,4 and Brown24 suggested that the overall impact of a patient’s suicide may be greater for seasoned clinicians, when the “protective advantage” or “explanation” of being in training is no longer applicable. This appears consistent with Munson’s study,43 which found that a greater number of years of clinical experience prior to a suicide loss was negatively correlated with posttraumatic growth.

Other factors affecting a clinician’s grief response include the context in which the treatment occurred, such as inpatient, outpatient, clinic, private practice, etc.44; the presence and involvement of supportive mentors or supervisors16; the length and intensity of the clinical relationship6,29; countertransference issues40; whether the patient was a child33; and the time elapsed since the suicide occurred.

In addition, each clinician’s set of personal and life experiences can affect the way he/ she moves through the grieving process. Any previous trauma or losses, particularly prior exposure to suicide, will likely impact a clinician’s reaction to his/her current loss, as will any susceptibility to anxiety or depression. Gorkin45 has suggested that the degree of omnipotence in the clinician’s therapeutic strivings will affect his/her ability to accept the inherent ambiguity involved in suicide loss. Gender may also play a role: Henry et al34 found that female clinicians had higher levels of stress reactions, and Grad et al3 found that female clinicians felt more shame and guilt and professed more doubts about their professional competence than male clinicians, and were more than twice as likely as men to identify talking with colleagues as an effective coping strategy.

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