Article and Publication Information

Annotation

Alexander, P.

A psychotherapist's reaction to his patient's death.

Suicide and Life-Threatening Behavior, 7(4), pp. 203-210, 1977, Winter.

3/00 eb >3/26/00<

This article is in two parts: an essay written shortly after the suicide of a psychotherapy patient and a postscript analysis of the death of a patient. The essay is a poignant and somewhat emotional description of the events surrounding the suicide followed by therapeutic considerations of a suicidal patient. The author focuses on three main points: the importance of being in touch with one's own anger toward the suicidal patient; the need to vary one's approach toward the dependent patient as he/she encounters different emotional phases; and the importance of promptly involving significant friends and relatives.

The postscript analysis examines the author's own anger toward his client and the tendency to repress and/or project that anger. Included are brief summaries of several articles on psychotherapists' responses to : "sudden deaths" of patients; the dying patient; and the suicide of a patient. The information is sketchy at best and gives few suggestions for how to manage these situations. The main theme that is emphasized is that some psychotherapists tend to avoid expressing mourning for the dead patient. If there has been enough contact and/or intimacy, the death represents a significant loss that is similar to that of a caretaker or family member and requires consideration in the resolution process.

Stern, E. M.

Three instances of the emergence of grief.

Psychotherapy Patient, 2(1), pp. 3-14, 1985, Fall. [Therapist survivor-case, pp. 9-14]

3/00 eb >3/26/00<

This case study highlights the effect on a clinic when a significant staff member of a medical clinic unexpectedly commits suicide. The leadership of the clinic attempted to minimize the suicide in order to quickly resume optimal functioning. No opportunity was presented for the group to process their feelings. Feelings of incompetence, guilt, helplessness, and grief prevented the group from being able to integrate the event and resume functioning. A team of mental health professionals helped the leadership to disseminate available information, quell rumors, and facilitate the staff's appropriate mourning. Organizational dysfunction and the steps required to mitigate the effect of suicide in a work group is discussed in some detail.

Young, J. J., Ursano, R. J., Bally, R. E., & McNeil, D. S.

Consultation to a clinic following suicide. American Journal of Orthopsychiatry, 59, pp. 473-476, 1989.

3/00 eb >3/26/00<

This is a very poignant case study written 12 years after the unexpected suicide of a patient in psychotherapy with the author. He discusses his own initial shock and sense of helplessness as well as the flood of grief and fury. His need to reconstruct the victim's course of therapy and his possible role in the suicide is an important recovery process. Although he leaves the reader with a sense that believes he is not "the master of another's fate," there are lingering, unanswered questions that create an enigma surrounding authentic recovery.

Gorkin, M.

On the suicide of one's patient. Bulletin of the Menninger Clinic, 49, pp. 1-9, 1985.

4/00 ms >4/2/00<

Dr. Gorkin discusses the many aspects of adjusting to the suicide of a patient as well as the pathological developments to be worked through. Dr. Gorkin also recommends several clinic and hospital procedures that may better enable therapists to cope with such a loss.

Dr. Gorkin uses his own experience with a patient who committed suicide to look at the therapist's feelings of shock, sense of failure, aggression, guilt, depression, and grief.

The purpose of the article is to highlight some potential risks for the therapist who does not work through a patient's suicide because he fails to mourn the loss of the patient.

Carter, R. E.

Some effects of client suicide on the therapist. Psychotherapy: Theory, Research, and Practice, 8, pp. 287-289, 1971.

4/00 ms >4/2/00<

This article is based on the author's thinking about his experience with a client who committed suicide. Carter discusses the initial phase where attention should be given to the therapist's need for factual information and simple support, understanding and sympathy from peers and her/his supervisor. The resolution phase is characterized by a process of working through the therapist's role in the client's suicide. The therapist's grief and mourning must first be lived through before the question of his/her role can be dealt with objectively.

Feldman, D.

A social work student's reaction to client suicide. Social Casework, 68, pp. 184-187, 1987.

4/00 ms >4/2/00<

Shock and disbelief were the student's first reactions followed by rage at herself and the social work school for never acknowledging that this could happen in therapy. Sharing her experience with fellow students and friends proved helpful. She experienced depression and felt that she needed both human support and an intellectual grasp of the situation to gain control.

The student was encouraged to continue to express her feelings to her supervisor regarding the suicide of the client. This author also recommends that group process can be very helpful to those who feel marked or blamed by others to dispel the fantasy.

Chemtob, C. M., Hamada, R. S., Bauer, G., Kinney, B., & Torigoe, R. Y.

Patients' suicide: Frequency and impact on psychiatrists. American Journal of Psychiatry, 145, pp. 224-228, 1988.

4/00 ms >4/2/00<

This article is based on a national survey of randomly selected psychiatrists. The survey revealed that 51% ( N=131) of the 259 respondents had had a patient who committed suicide. The impact of a patient's suicide on the therapist is clear and substantial. Psychiatrists reported feeling anger and guilt, experiencing loss of self-esteem, and having intrusive thoughts about the suicide. Many psychiatrists also reported experiencing posttrauma symptoms. This survey argues strongly for establishing structured support mechanisms to assist psychiatrists when a suicide occurs and more explicitly structuring training programs to prepare psychiatrists for this common occupational hazard.

Brown, H. N.

The impact of suicide on therapists in training. Comprehensive Psychiatry, 28, pp. 101-113, 1987.

{Balon, R. Letter. 28, p. 362, 1987. [a response to the article]}

4/00 xx >4/2/00<

Most reports about the impact of patient suicide on trainees refer to psychiatric residents. The results of a survey of all mental health professionals in August 1983 showed that patient suicide during training is not a rare event for many mental health professionals.

The impact on any therapist following the suicide of a patient is powerfully shocking and disturbing. The author discusses several particular explanations for the reaction from trainees. (1) Trainees have a uniformly deep investment in being helpful. (2) The trainee feels he or she has failed as a person. (3) The trainee is likely to feel that he or she has failed if suicide occurs. Discouragement and depression become inevitable.

Growth through this crisis will be strongly influenced by trainee preparation and reactions, plus important sustaining relationships within the training program.

Marshall, K.

When a patient commits suicide. Suicide and Life-Threatening Behavior, 10, pp. 29-40, 1980.

4/00 jm >4/2/00<

Eastside Community Mental Health Center, located in Bellevue, Washington, presents organizational and personnel requirements for training staff members to work therapeutically with suicidal persons as well as recover from an actual suicide. A generally supportive and non-blaming atmosphere may be most important, allowing staff the freedom and safety to openly share without fear of judgment. To ensure the necessary emotional objectivity for debriefing, Eastside recommends at least one mental health professional from outside the treatment group. In addition to these external resources, staff members must have prior training and experience working with suicidal people and feelings.

When providing extensive basic training for working therapeutically with suicidal persons, Eastside helps each staff person gain clarity on their personal philosophy regarding suicide as well as their personal responsibility towards their patients. In addition, the agency teaches guidelines for therapeutic work with suicidal patients and procedures to follow if there is a successful suicide.

A clinical example demonstrates Eastside's process, moving through three phases: the "resuscitation phase," dealing with anger, distress, and immediate reactions to the question of reponsibility; the "rehabilitation phase," focusing on guilt, grieving, and further fact finding; and lastly, the"renewal phase," discussing lessons learned, detaching from the suicide, and preparing for work with future clients.

Holden, L.D.

Therapist response to patient suicide: Professional and personal. Journal of Continuing Education in Psychiatry, 39(5), 23-32, May, 1978.

4/00 jm >4/9/00<

Holden's study, awarded the William Menninger Memorial Award for original research, examines the reactions of 29 staff psychotherapists at Timberland Psychiatric Hospital in Dallas, Texas to a patient's suicide. Through an anonymous questionnaire, 28 psychotherapists' responses revealed 43% (12 respondents) had at least one patient suicide, while 3 respondents had a second patient suicide. These therapists averaged 13 years of clinical experience.

Twelve of the 15 patients committed suicide shortly after terminating therapy. Averaging 2.7 years of intensive, long-term, individual psychotherapy, the client population was 60% women and an average age of 34, with diagnoses of borderline, obsessiveness and anxiety, among others. Ten patients agreed to a no-harm contract, bringing the efficiency of such agreements into question.

Not surprisingly, therapists' reactions to the news of a patient's suicide included a number of affective states from shock to pain to anger, combined with defenses of denial, withdrawal, and projections, demonstrating the deep personal pain any person, therapist or not, might feel when losing someone. The longer-term impact on the therapist resembles a complicated bereavement, with guilt, self-doubt, relief, anger, and sadness, sometimes to depressive levels. Frequently used was intellectualization, when therapists attempted analysis of their patients' feelings, attempted identifying contributing factors as well as obsessing over intervention, guilt over patient management, or questioning missed cues during treatment.

Professional and/or personal competence suffered temporarily in approximately 66% of respondents. Reflection, balanced by sharing the experience with other staff members, helped therapists feel less guilty, less alone, and less burdened with the loss and more assured of their efforts.

Litman, R.

When patients commit suicide. American Journal of Psychotherapy, 19, 570-576, 1965. (Reprinted in E. S. Shneidman, N. L. Farberow, & R. E. Litman (Eds.), The psychology of suicide (pp. 475-482). New York: Science House, 1970.)

>6/14/00<

This article draws from a research study composed of an in-depth interview of 200 psychotherapists after one of their clients had completed suicide. The conclusions include the full range of emotional and intellectual responses regarding this often taboo subject area. It identifies the cultural aspects underpinning most therapists' general tranquil attitudes towards death. However, it goes on to delineate how these attitudes may alter upon a direct concrete encounter with death. Therefore, exploring the theoretical, philosophical and scientific attitudes one has and how they may impact the healing process on two levels, both as a human being and as a therapist is often overlooked. Litman's comprehensive study is a stepping stone for further discussion and recommended reading for all clinicians whether or not they have had a client complete suicide.

Kolodny, S., Binder, R. L., Bronstein, A. A., & Friend, R. L.

The working through of patients' suicides by four therapists. Suicide and Life-Threatening Behavior, 9, 33-46, 1979. (Reprinted in A. S. Cook, A. S., & K. A. Oltjenbruns (Eds.), Dying and grieving: Lifespan and family perspectives (pp. 457-471). New York: Holt, Rinehart and Winston, 1989.)

>6/14/00<

This article details the poignant, honest, and heartfelt accounts of four therapist survivors of client suicide and the value of their year-long group meetings to process the various ways it impacted each of them. A vital reading for all therapists regarding this potential event which enables enlightenment, increased sensitivity vs. any denial of what all therapists fear most. Thus, this article also promotes the ability to be a supportive colleague when the "almost inevitable" happens to someone you know. The authors' joint recommendations include individual mourning, group sharing to offset the shame and isolation one can experience, plus the rationale for training opportunities to all professionals working with depressed and or suicidal folks. The latter is especially useful in promoting continued awareness and self mastery of assessment tools and countertransference issues.