Evidence-Based Reviews

Losing a patient to suicide: What we know

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Effects on clinical work

A suicide loss is also likely to affect a clinician’s therapeutic work. Many authors12,52,64-67 have found that this commonly leads therapists to question their abilities as clinicians, and to experience a sharp loss of confidence in their work with patients. The shattered beliefs and assumptions around the efficacy of the therapeutic process, a sense of guilt or self-blame, and any perceived or actual negative judgment from colleagues can dramatically compromise a clinician’s sense of competence. Hendin et al30 noted that even the most experienced therapists expressed difficulty in trusting their own clinical judgment, or accurately assessing risk after a suicide loss.

In addition, the common grief and trauma-related responses to a suicide loss (including shock, numbness, sadness, anxiety, and generalized distress) are likely to result in at least some temporary disruption of a clinician’s optimal functioning. If trauma-related symptoms are more pronounced, the effect and longevity of such impairment may be exacerbated, and are likely to “impair clinical response and therapeutic judgment.”15 In addition, because such symptoms and states may be triggered by exposure to other potentially suicidal patients, they are more likely to impact clinical functioning when the clinician works with suicidal individuals. Thus, the normative responses to a suicide loss are likely to impact a clinician’s work, just as they are likely to impact the personal and occupational functioning of any survivor of suicide loss.

In clinician-survivor discussions and support groups I’ve led, participants have identified many common areas of clinical impact. Perhaps one of the most common early responses reported by clinician-survivors who continued to work with potentially suicidal individuals was to become hypervigilant in relation to any perceived suicide risk, to interpret such risk in such a way as to warrant more conservative interventions than are necessary, and to consequently minimize the patient’s own capacities for self-care.68 Conversely, others reported a tendency to minimize or deny suicidal potential by, for example, avoiding asking patients directly about suicidal ideation, even when they later realized that such questioning was indicated.69

Suicide loss may also lead to more subtle clinical reactions that have been observed not only with suicidal patients, but also in relation to patients who struggle with loss or grief. These include avoidant or even dissociative reactions in relation to their patient’s pain, which in turn can impact the clinician’s ability to “be fully present” or empathic in clinical encounters.50,69 Still, other clinicians noted that they tended to project residual feelings of anger onto their current suicidal patients, or envied patients who seemed to have mastered their grief. Consistent with Maltsberger’s description of “atonement reactions,”40 some clinicians found themselves doing more than should be expected for their patients, even losing their sense of professional boundaries in the process. Anderson70 noted that in pushing herself beyond what she knew were her optimal clinical boundaries, she was “punishing herself” for failing to prevent her patient’s suicide because, as she realized, “doing ‘penance’ was better than feeling helpless and powerless.” And Schultz16 described how therapists may have subsequent difficulty in trusting other patients, especially if patients who completed suicide did not disclose or denied their suicidal intent.

Working toward a supportive solution

In summary, unless clinicians who lose a patient to suicide have more supportive experiences, the combination of confidentiality-related restrictions, confusion about legal/ethical repercussions, unsupportive reactions from colleagues, and unexpected impairments in clinical work are likely to lead to intensified distress, isolation, the perceived need to “hide” the impact in professional settings, and consideration of leaving the profession. However, as I will describe in Part 2 (Current Psychiatry. November 2019), losing a patient to suicide can paradoxically present opportunities for clinicians to experience profound and personal transformation, and postvention protocols can help them navigate the often-complicated sequelae to a patient’s suicide. There is also much we can do to help support a clinician colleague who has lost a patient to suicide.

Bottom Line

For mental health clinicians, losing a patient to suicide is a clear occupational hazard. After a suicide loss, clinicians often experience unique personal and professional challenges, including the impact of the loss on clinical work and professional identity, legal/ethical issues, and confidentiality-related constraints on the ability to discuss and process the loss.

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