Out On The Couch
No matter the degree earned or license held, everyone who works in the mental health field shares an important common interest: preventing suicide. Suicide prevention requires a well-rounded approach, including education on risk factors, properly assessing for safety, increasing patients’ protective factors and support, and providing support for those affected by the suicide of a loved one (Balon, 2007). Surprisingly, most clinical training programs fail to comprehensively educate on the details of suicide assessment (Valente, 1994). The institutions that do include training for suicide assessment usually fail to cover the consequences of a completed suicide, thus failing to acknowledge both the personal and professional consequences on the clinician (Valente, 1994). Consistent research suggests the majority of clinicians––particularly those early in their careers––are completely unprepared for their own emotional responses as well as the reactions of the client’s family (Hendin, Haas, Malsberger, Szanto, & Rabinowicz, 2004). For this reason, among others, clinicians who have lost patients to suicide are left with a myriad of complex emotions without space to effectively process the loss, leading to professional isolation (Campbell & Fahy, 2002). Bound by HIPAA, many clinicians do not have the luxury to openly grieve around their friends and family. This is a simple yet vital part of effective bereavement processing (McAdams & Foster, 2002). Whether the relationship had been forming for weeks, months, or years, a patient’s death has a lasting impact on the clinician (Ford, 2009).
Regardless of professional boundaries between patient and clinician, the human reaction to loss inevitably emerges. A clinician’s grief is generally inescapable upon learning of a patient’s death no matter the cause. In addition to this typical grief, client death by suicide triggers a unique reaction from the clinician due a feeling of personal responsibility (Strom-Gottfried & Mowbray, 2006). For LGBTQ+ affirmative providers, the need for proper training on suicide assessment and the consequences of completed suicide is even greater as such populations are at higher risk of suicide. For therapists and other clinicians working with LGBTQ+ communities, it is particularly important to be aware of the enhanced risks of suicide and to understand how this affects the therapeutic process for both parties involved. Client suicide may not only elicit complicated grief, but it may also trigger suicidal ideation within the providers themselves, particularly those with a history of attempts, ideation, self-injury, or depression. With so many potential multifaceted factors affecting the clinician, it is clear there is a serious need for more understanding and support around client suicide, as it can lead to occupational hazards as well as personal danger.
There is little pleasure in discussing client suicide, as it is a topic riddled with fear, shame, and discomfort. Nevertheless, client suicide occurs more often that most clinicians may expect. This underestimation is likely due to the response of shame and isolation associated with such an event. Roughly five percent of trainee or predoctoral therapists experience client suicide (DeAngelis, 2008). Later, the number jumps dramatically. More than 25 percent of licensed psychotherapists experience a client suicide at some point during their career (Finlayson & Simmonds, 2019). Moreover, on average, about 50 percent of psychiatrists lose a patient to suicide during their tenure (DeAngelis, 2008). For clinicians earlier in their careers, 33 percent report that a patient’s suicide impacted their personal life and 39 percent reported it affected their professional life (Dewar, Eagles, Klein, Gray, & Alexander, 2000). An overwhelming majority of trainees report obsessing over how they could have prevented it, and nine percent even consider changing careers (Dewar et al., 2000). For such little training and even less open discussion on the topic of client suicide, it is a rather prevelant issue. Further dialogue both throughout training and in the general clinical world may help promote awareness and decrease the stigma associated with being a therapist affected by client suicide.
LGBTQ+ risk factors
It is hard to separate LGBTQ+ suicides from others since sexual orientation and gender identity are rarely reported in official records (National LGBT Health Education Center, 2018). Nevertheless, a myriad of studies through self-report and quantitative research show LGBTQ people are at great risk for having suicidal ideation and are more likely to have attempts in the past (National LGBT Health Education Center, 2018). In fact, almost half of LGB youth seriously consider suicide and are five times more likely to have attempted suicide compared to their non-LGB peers (National LGBT Health Education Center, 2018). Bisexual and pansexual youth, as well as those questioning their gender identity, are also more likely to experience depression compared to their lesbian or gay peers (National LGBT Health Education Center, 2018). Approximately 40 percent of LGBTQ+ adolescents and young adults report suicidal ideation, and one third of transgender and gender nonconforming youth reported attempting suicide in the past year (Lang, 2019). 40 percent of transgender and gender nonconforming adults report attempting suicide at least once in their lifetime, and 92 percent report attempting as youth (James et al., 2016). Considering all of these factors, it is absolutely crucial for LGBTQ+ mental health providers to be aware of these risks for their patients as well as their own professional development and wellbeing.
While the death of a client elicits a reaction regardless of cause, client suicide is unique in the way it affects a clinician’s functioning (Coverdale, Roberts, & Louie, 2007). Clinicians who experience client suicide are left with guilt, self-doubt, shame, feelings of incompetence, and fear of judgment from colleagues (Veilleux, 2011). Upon receiving the news of a client’s suicide, clinicians have reported feelings of shock, disbelief, denial, anger, sleep disturbance, appetite changes, and difficulty concentrating (Kleespies, Smith, & Becker, 1990). In fact, research suggests clinicians mirror the reactions of a family member, especially repression and denial (Kapoor, 2004). Perhaps unsurprisingly, clinicians with fewer years of experience are likely to have a more acute response to patient suicide compared to their more experienced colleagues (Gitlin, 2007). However, while the intensity of reaction decreases as experience increases, the type of reactions are often the same regardless of years in practice (Knox, Burkard, Jackson, Schaack, & Hess, 2006). When therapists leave work, they do not turn off as people. It is necessary to recognize that clinicians are human and experience similar feelings and experiences to those of their patients. As we humanize clinicians, we can be more cognizant of how colleagues may be affected and thereby better able to provide support early on.
A clinician is often the person trusted with a patient’s most vulnerable thoughts and painful experiences, and as such, they were expected to lessen the pain with which the patient could no longer cope (Shannon-Karasik, 2017). In most cases, the clinician cannot be responsible for instances outside of their control. As we are reminded: therapy cannot solve all our problems. Of course, there are some cases, although rare, where the therapist missed major red flags (Gorkin, 1985). The more experienced the therapist, the harder it is to acknowledge the possibility of contributing to the loss or knowing they may have been able to prevent it (Gorkin, 1985). For anyone, but especially for more experienced clinicians, this realization is a major hit to the ego. If this type of complex pathological grief becomes a longer-term issue, the therapist is impacted in the way they treat new clients or even their willingness to accept referrals (Gorkin, 1985). Finding a balance between professional and personal responsibility is central to normalizing the reaction to client suicide and creating a field that strengthens, rather than shames, its peers.
Unlike their licensed colleagues, pre-licensed clinicians have access to weekly supervision. Practicing under a supervisor’s license allows the pre-licensed clinician to experience a sense of relief, as the supervisor holds legal responsibility and is required to provide weekly consultation. A supervisor who can validate, normalize, and share responsibility for the loss provides significant support for the clinician and softens the intensity of reactions (Knox et al., 2006). Supervisors who inadvertently dismiss the clinician’s experience of patient suicide, on the other hand, can directly hinder the clinician’s bereavement process (Knox et al., 2006). A large number of clinicians lose a patient to suicide, yet the majority of those clinicians report being met with little to no support from their colleagues or supervisors (DeAngelis, 2001). Lack of support can further lead to feelings of inadequacy and fear of professional punishment (Sacks, Kibel, Cohen, Keats, & Turnquist, 1987). To those who require supervision, nonjudgmental communication and encouragement can positively affect the therapist’s professional development.
Recommendations for Self Care
1. Seek consultation
Talking to someone is vital, as there is an innate human need for nonjudgmental support and validation (DeAngelis, 2008). Support from colleagues and peers is essential for processing effectively and preventing burnout in clinicians following client suicide (Fox & Cooper, 1998). For trainees and other pre-licensed clinicians, quality supervision and training must also be integrated into peer support In order to positively increase professional development (Knox et al., 2006). Because the supervisor plays such a significant role in a young clinician’s development, their responses and reactions to experiences like client suicide will substantially impact the trainee’s advancement for better or worse (Horn, 1994). It is important for trainees to explore feelings related to the suicide in supervision (Ting, Jacobson, & Sanders, 2008). Some may not feel comfortable consulting with their supervisors, whether the relationship is fragmented or previous attempts have been met with responses that are dismissive, shaming, or otherwise unhelpful. For trainees in such cases, it may be appropriate to consult with other colleagues or professors as long as confidentiality of the patient is maintained and no identifying information is shared. If possible, the trainee may be able to seek additional supervision from an outside supervisor contracted with their training site. For licensed mental health professionals or those not requiring supervision for other reasons, consultation groups or advisors may be helpful in lieu of individual supervision. Most consultation groups or advisors usually require some some of fee, but the therapist seeking consultation holds the power in being able to find the right fit rather than being stuck with someone who feels unsafe. Sometimes seeking consultation requires the clinician to go out of their way to an extent that may become infeasible. In such circumstances, personal psychotherapy may be a more practical option for support.
2. Go to therapy
Outside of the professional setting, it is also important to seek support through individual counseling, which may provide a safe space for longer-term processing and safety (McAdams & Foster, 2002). Trainees may be able to access free or low-cost counseling through their educational institution or training site. Licensed clinicians who cannot afford full-fee therapists may find quality low-fee counseling in their area at training sites. Once the right fit has been established, the therapist who experienced the client suicide may benefit from journaling and letter writing exercises that can be processed with their own therapist (Whisenhunt et al., 2017). Writing a timeline of events for better deconstructing the experience may be helpful, too (Gladding, 2011). For those in areas where personal psychotherapy requires a lengthy commute, telehealth may be an appropriate alternative for receiving support from a qualified therapist through confidential video calls. Therapy comes in many shapes and sizes, and finding the right fit sometimes takes a few tries. Dedication to finding someone that feels safe and empathetic of one’s experience is worth the short-term frustration for the sake of preventing long-term issues related to client suicide.
3. Radical acceptance
Radical acceptance means accepting what is, and acknowledging things that are out of your control or in the past (Linehan, 2015). Accepting does not mean liking what happened or being fine with it, but rather recognizing reality instead of avoiding it. Part of using radical acceptance as a way of coping with client suicide is noting therapy has its limits. As therapists, we cannot solve every problem and cannot control the choices of others (DeAngelis, 2008). Accepting the things we cannot change provides space for finding the strength to get ahead of things within our control.
4. Check the facts
It is imperative for clinicians to read up on the research related to client suicide and the effects of grief on the provider. Normalizing the experience to the extent that the clinician better understands their reaction can help decrease feelings of isolation and shame (Sanders et al., 2005). Increasing education around death, suicide, and grief may also increase the chances of prevention in the future. This can help restore some sense of control in an otherwise disempowering situation.
Activating the parasympathetic nervous system through lowering one’s heart rate can help not only with reducing fight-or-flight responses in the moment, but also through increasing the likelihood of positive mood throughout the day (Linehan, 2015). Ideally more intense exercise, even just for 20 minutes, can help with this. However, going for a walk around the neighborhood or doing jumping jacks for five minutes may also do the trick. When emotional responses feel overwhelming, this can be a helpful tool for regulating in the moment.
6. Practice mindfulness
Increasing mindfulness helps with radical acceptance as well as increasing our ability to participate effectively in each moment (Linehan, 2015). Research shows that the practice of observing and describing present thoughts, feelings, and sensations helps to increase emotion regulation and decrease distress (Linehan, 2015). The more this is practiced, the easier it will become to regulate difficult emotions. Practicing mindfulness can be done through a yoga class or breath workshop, meditation recording, or using grounding exercises to notice the world around you. Grounding exercises can be as simple as observing five things you can see, four you can hear, three you can touch, two you can smell, and one you can taste. Mindfulness is a practice, meaning it initially requires significant effort and can increase in ease over time. Simply starting by paying attention to present internal and external experiences is an effective path toward greater mindfulness.
It is important to alternate between processing the loss and distracting from it (Papadatou, 2000). Outside of seeking supervision, training, and individual therapy, it is important to soothe oneself and enjoy positive experiences. For some, this may be playing with their pets, spending time with loved ones, going out to dinner with a friend, watching a funny movie, listening to their favorite music, or taking a bubble bath. It is important that these activities are not centered around the topic of client suicide or the clinician’s experience of it, as this diminishes the point of distracting. For example, the clinician should not spend time with friends talking about the incident or their feelings around it, they should not listen to music that is sad or angry, and they should not watch movies or shows about dying (Linehan, 2015).
8. Avoid negative coping mechanisms
Of course, there are many other tools that may be appealing to some in order to self-soothe. It is strongly recommended to avoid alcohol or drugs, social isolation, lashing out at colleagues or friends, restricting food or binging, and professional withdrawal. While these may provide solace in the moment, they often make things worse.
There needs to be a proactive rather than reactive approach to the effects of client suicide. This, of course, means continued training on the various complexities of assessing for suicidality. Instead of shying away from suicidal or otherwise higher-risk patients, clinicians must be provided with training better suited for working with these specific issues and populations (Knox et al., 2006). Marsha Linehan’s development of Dialectical Behavior Therapy is a perfect example of such a modality, as it was developed for suicidal patients in psychiatric care and has now been adapted for working with patients under the care of all levels of mental health professionals (Linehan, 2015). When trainees are provided with a framework for working with suicidal patients early in their careers, they are more likely to feel secure in their approach and assessments rather than feeling apprehension and self-doubt (Knox et al., 2006).
A proactive approach also means there needs to be more training on coping skills for therapists after client suicide (Sanders, Jacobson, & Ting, 2008). While clinicians are often trained to teach coping skills to their patients, training does not focus on teaching clinicians how to apply those skills to their own experiences (Sanders et al., 2008). Providing education and training on this beforehand increases the chances of successful recovery from such events in the most effective manner. Trainees are more likely to feel as though they have failed as people and as clinicians, leading to a tendency to overanalyze what they could have done differently and avoid suicidal patients altogether (Brown, 1987). Training programs, educational institutions, and supervisors must invoke dialogue with nonjudgmental empathic understanding and instruction on clinical implications, promoting more effective professional development after suicide (Brown, 1987). Educators and supervisors must reiterate the importance of self-care throughout the training process and beyond. The earlier suicide is discussed, the less likely clinicians will reinforce silence around this issue.
Suicide Prevention Resources
Learn more from our continuing education courses
Balon, R. (2007). Encountering patient suicide: The need for guidelines. Academic Psychiatry, 31, 336-337. doi:10.1176/appi.ap.31.5.336
Campbell, C., & Fahy, T. (2002). The role of the doctor when a patient commits suicide. Psychiatric Bulletin, 26, 44-49. doi:10.1192/pb.26.2.44
Coverdale, J. H., Roberts, L. W., & Louie, A. K. (2007). Encountering patient suicide: Emotional responses, ethics, and implications for training. Academic Psychiatry, 31, 329-332. doi:10.1176/appi.ap.31.5.329
DeAngelis, T. (2001). Surviving a patient’s suicide. Monitor on Psychology, 32(10). Retrieved from https://www.apa.org/monitor/nov01/suicide
DeAngelis, T. (2008). Coping with a client’s suicide. GradPSYCH Magazine, 11. Retrieved from https://www.apa.org/gradpsych/2008/11/suicide
Dewar, I. G., Eagles, J. M., Klein, S., Gray, N., & Alexander, D. A. (2000). Psychiatric trainees’ experiences of, and reactions to, patient suicide. Psychiatric Bulletin, 24, 20-23. doi:10.1192/pb.24.1.20.
Finlayson, M., & Simmonds, J. (2019). Workplace responses and psychologists’ needs following client suicide. Omega: Journal of Death & Dying, 79(1), 18-33. doi:10.1177/0030222817709693
Ford, D. (2009). Junior clinical psychologists’ experience of processing the death of a therapy client, from a cause other than suicide: A qualitative study (Unpublished doctoral dissertation). University of Hertfordshire, United Kingson.
Fox, R., & Cooper, M. (1998). The effects of suicide on the private practitioner: A professional and personal perspective. Clinical Social Work Journal, 26(2), 143-157.
Gitlin, M. (2007). Aftermath of a tragedy: Reaction of psychiatrists to patient suicides. Psychiatric Annals, 37, 684-687.
Gladding, S. (2011). The creative arts in counseling (4th ed). Alexandra, VA: American Counseling Association.
Gorkin, M. (1985). On the suicide of one’s patient. Bulletin of the Menninger Clinic, 49, 1-9.
Hendin, H., Haas, A., Maltsberger, J. T., Szanto, K., Rabinowicz, H. (2004). Factors contributing to therapists’ distress after the suicide of a patient. The American Journal of Psychiatry, 161(8), 1442-1446. doi:10.1176/appi.ajp.161.8.1442
Horn, J. (1994). Therapists’ psychological adaption to client suicide. Psychotherapy, 31, 190-195.
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. transgender survey. Washington, DC: National Center for Transgender Equality.
Kapoor, A. (2004). Suicide: The effect on the counselling psychologist. Counselling Psychology Review, 1(3), 28-36.
Kleespies, P. M., Smith, M. R., & Becker, B. R. (1990). Psychology interns as patient suicide survivors: Incidence, impact and recovery. Professional Psychology: Research and Practice, 21, 257-263.
Knox, S., Burkard, A. W., Jackson, J. A., Schaack, A. M., & Hess, S. A. (2006). Therapists-in-training who experience a client suicide: Implications for supervision. Professional Psychology: Research and Practice, 37, 547-557. doi:10.1037/0735-7028.37.5.547
Lang, N. (2019). Nearly 40% of LGBTQ youth have contemplated suicide: Report. Rolling Stone. Retrieved from https://www.rollingstone.com/culture/culture-news/lgbtq-youth-suicide-report-846952/
Linehan, M. M. (2015). DBT skills training manual (2nd ed.). New York, NY: The Guilford Press.
McAdams, C. R., III, & Foster, V. A. (2002). An assessment of resources for counselor coping and recovery in the aftermath of client suicide. Journal of Humanistic Counseling, Education & Development, 41, 232-241.
National LGBT Health Education Center. (2018). Suicide risk and prevention for LGBTQ people. Boston, MA: The Fenway Institute.
Papadatou, D. (2000). A proposed model of health professionals’ grieving process. OMEGA: The Journal of Death and Dying, 41, 59-77. doi:10.2190/TV6M-8YNA-5DYW-3C1E
Sacks, M. H., Kibel, H. D., Cohen, A. M., Keats, M., & Turnquist, K. N. (1987). Resident response to patient suicide. Journal of Psychiatric Education, 11(4), 217-226.
Sanders, S., Jacobson, J. M., & Ting, L. (2008). Preparing for the inevitable: Training social workers to cope with client suicide. Journal of Teaching Social Work, 28(1), 1-17. doi:10.1080/08841230802178821
Shannon-Karasik, C. (2017). Therapists told us what it’s like to lose a patient to an overdose. Vice. Retrieved from https://vice.com/en_us/article/kznw4z/therapists-lose-patient-to-overdose
Strom-Gottfried, K., & Mowbray, N. D. (2006). Who heals the helper? Facilitating the social worker’s grief. Families in Society: The Journal of Contemporary Social Services, 87, 9-15.
Ting, L., Jacobson, J. M., & Sanders, S. (2008). Available supports and coping behaviors of mental health social workers following fatal and nonfatal client suicidal behavior. Social Work, 53(3), 211-221.
Valente, S. M. (1994). Psychotherapist reactions to the suicide of a patient. American Journal of Orthopsychiatry, 64, 614-621.
Veilleux, J. C. (2011). Coping with client death: Using a case study to discuss the effects of accidental, undetermined, and suicidal deaths on therapists. Professional Psychology: Research and Practice, 42(3), 222-228. doi:10.1037/a0023650
Whisenhunt, J. L., DuFresne, R. M., Stargell, N. A., Rovnak, A., Zoldan, C. A., & Kress, V. E. (2017). Supporting counselors after a client suicide: Creative supervision techniques. Journal of Creativity in Mental Health, 12(4), 451-467. doi:10.1080/15401383/2017/1281184