Psychotherapist reactions to the suicide of a patient

The impact of adolescent suicide on clinicians: a mixed-methods study

BACKGROUND

Clinician reactions to client suicide may include shock, grief, guilt, self-doubt, shame, anger, and fears of blame and medico-legal consequences. Clinicians will often differ in their reactions to the suicide and the type of supports required. Adolescent suicide-specific literature is limited.

AIMS

We sought to explore clinician reactions and perceptions of support following child and adolescent suicide.

METHODS

One hundred and fifteen staff working for a Child and Adolescent Mental Health Service were invited to complete an online survey with quantitative and qualitative components, and an in-depth semi-structured interview. Results were presented to teams for reflection and further feedback.

RESULTS

Eight clinicians participated in the semi-structured interview, and 33 in the online survey. Thirteen were the primary clinician, and 21 were part of a multi-disciplinary team when a client suicided. Respondents were predominantly female, from a range of disciplines. Fifty per cent of primary clinicians found the support good to very good. The rest were neutral. However, 26% of team members found support poor to very poor. Clinicians reported questioning their clinical effectiveness and chosen vocation. Some reported a need to disconnect or withdraw to preserve motivation and empathy for the work. They received significant support from their team, and teams were very anxious for the well-being of primary clinicians.

CONCLUSIONS

Health services must find ways of helping staff feel that their sense of vocation is valued and nurtured. These strategies will likely include fostering team cohesiveness and mutual support and allowing opportunities to temporarily step back and recover after challenging experiences.

After a patient dies by suicide: an illustrative case for trainee psychiatrists and trainers

One of the most challenging experiences psychiatrists will face in their careers may well be the death of a patient by suicide. This is likely to happen at least once during a psychiatrist's career, and often more. It can be an intensely complex and painful event with a wide range of emotional responses. Reflecting on the death and accessing good support helps clinicians process the emotional impact. It can also increase their resilience in the longer term by giving them a greater understanding of both their own and their patients' limitations, and in this way strengthen their capacity for compassion as clinicians. Using an illustrative case study, this article provides an insight into the experience of losing a patient to suicide and signposts to sources of support.

Clinician Response to a Child Who Completes Suicide

Although suicide is a leading cause of death for children and adolescents, there is a dearth of literature on clinician responses to suicides in that age group. However, most psychiatrists experience the death of a patient by suicide, with resulting grief reactions including shock, isolation, rumination, self-doubt, and impact on clinical decision making. The impact is more pronounced in trainee clinicians. Postvention is the clinical, administrative, legal, and emotional processes following a suicide. These processes are discussed in detail, with recommendations for policies and training that assist clinicians with this tragic, but common, professional crisis.

Psychiatric trainees' experiences of, and reactions to, patient suicide

Aims and Method

This survey is the first UK study of trainee psychiatrists' experiences of patient suicide. One hundred and three senior and specialist registrars in psychiatry working in Scotland completed the questionnaire, representing an 81% response rate.

Results

Almost half (47%) had experienced suicide of a patient in their care or otherwise known to them (e.g. through on-call experiences). Although only 28% recalled previous training on issues to consider following a suicide, all of these doctors found this to be of value. Many reported that patient suicide had a deleterious impact on their personal and professional lives. The most valuable supports were informal, and the trainees' consultants appeared particularly well placed to offer support and advice.

Clinical Implications

Many trainee psychiatrists experience the suicide of a patient. Such experiences have potential for adverse effects on doctors' professional practice and personal life. Greater availability of training in this area would allow trainees to be better prepared for such an event. Trainees' consultants have a pivotal role to play in providing appropriate advice and support after a patient suicide.

Clinicians' conflicting emotional responses to high suicide-risk patients-Association with short-term suicide behaviors: A prospective pilot study

BACKGROUND

Clinician's emotional responses to patients have been recognized as potentially relating to treatment outcome, however they have received little attention in the literature on suicide risk. We examine the relationship between a novel targeted measure of clinicians' emotional responses to high-risk psychiatric inpatients and their short-term post-discharge suicide behavior.

METHODS

First-year psychiatry residents' emotional responses to their patients were assessed anonymously with the novel self-report 'Therapist Response Questionnaire-Suicide Form' (TRQ-SF). Patient outcomes were assessed at 1-2months post-discharge, and post-discharge suicide outcomes were assessed with the Columbia Suicide Severity Rating Scale. Following exploratory factor analysis of the TRQ-SF, scores on the resultant factors were examined for relationships with clinical and demographic measures and post-discharge suicide behavior.

RESULTS

A two-factor model fit the data, with factors reflecting dimensions of affiliation/rejection and distress/non-distress. Two items that did not load robustly on either factor had face validity for hopefulness and hopelessness and were combined as a measure along a hopefulness/hopelessness dimension. The interaction Distress×Hopefulness, reflecting a conflicting emotional response pattern, significantly predicted post-discharge suicide outcomes even after covarying for depression, entrapment, and suicidal ideation severity.

CONCLUSION

Clinicians' conflicting emotional responses to high-risk patients predicted subsequent suicidal behavior, independent of traditional risk factors. Our findings demonstrate the potential clinical value of assessing such responses.

Survivors of Suicide: A Comprehensive Bibliography Update, 1986–1995

An update of a 1985–86 Omega bibliography of the literature on survivors of suicide is presented. Following brief introductory comments, including the identification of research and therapy needs and unresolved issues, the bibliography listings are organized by the following subtopics: general references on family members and friends as suicide survivors; children, adolescents, youth, and parents as survivors; school and educational settings; parental suicide; elderly suicide survivors; mental health professionals and clinicians in training as survivors; survivors of professionals' suicides; and research on attitudes toward survivors. Published works in professional journals, books, book chapters, and doctoral dissertations on the topic of survivor-victims are included.

Mental health workers’ views about their suicide prevention role

Aim

Mental Health workers bear responsibility for preventing suicide in their client group. Survey studies have indicated that staff can be seriously adversely affected when a client suicides. The aim of the current study is to describe and evaluate the effects on mental health (MH) workers of their ongoing role in managing suicidal behaviours and to identify the thoughts and feelings associated with this role.

Method

A survey was administered to 135 MH workers via an on-line self-report vehicle. The survey comprised standardised measures of anxiety and burnout as well as a questionnaire developed for this study concerning perceptions and attitudes to suicide and suicide prevention.

Results

Factor analysis of 12 retained items of the questionnaire identified three factors: 1) preventability beliefs (beliefs about suicide being always and/or permanently preventable); 2) associated distress (stress/anxiety about managing suicidal behaviour); and 3) the prevention role (covering views about personal roles and responsibilities in preventing suicidal behaviours). Analysis of these factors found that many MH workers experience an elevation of stress/anxiety in relation to their role in managing suicidal behaviours. This distress was associated with the emotional exhaustion component of burnout. Measures showed adverse responses were higher for outpatient than inpatient workers; for those who had received generic training in suicide prevention: and for those who had experienced a workplace related client suicide.

Conclusion

There is a need for the development of appropriate self-care strategies to alleviate stress in MH workers exposed to suicide.

Therapists' Experience of Loss: An Interpretative Phenomenological Analysis

This qualitative study aimed to explore therapists' experiences of loss. Semi-structured interviews were conducted with 6 therapists and the data were subjected to interpretative phenomenological analysis. Three master themes emerged from the analysis: (a) the grieving therapist, (b) hindrances in grieving, and (c) the impact of loss on therapeutic work. Therapists talked about their grief and elaborated on how they coped with their bereavement. Hindrances in their grief were reported, emerging both from others' stance and from their own. Participants found that their experience of loss was related to both challenges and advancements in their therapeutic work.

Professionals' reactions following a patient's suicide: review and future investigation

The objective of this study was to review the literature and make suggestions for further investigation into the topic of professionals' reactions following a patient's suicide. An extensive search of the literature has been undertaken using computer database search. Even if findings are heterogenous, most studies suggest limited stress-related or affective-related reactions for the majority of respondents. Whereas, findings with regards to the impact on professional practice are consistent in identifying important consequences in the way professionals conduct their clinical assessment and reach treatment decisions after a patient's suicide. Future research should investigate how this event changes the clinician's personal growth and capacity to establish a therapeutic alliance with other suicidal patients.

Distinctive emotional responses of clinicians to suicide-attempting patients--a comparative study

BACKGROUND

Clinician responses to patients have been recognized as an important factor in treatment outcome. Clinician responses to suicidal patients have received little attention in the literature however, and no quantitative studies have been published. Further, although patients with high versus low lethality suicidal behaviors have been speculated to represent two distinct populations, clinicians' emotional responses to them have not been examined.

METHODS

Clinicians' responses to their patients when last seeing them prior to patients' suicide attempt or death were assessed retrospectively with the Therapist Response/Countertransference Questionnaire, administered anonymously via an Internet survey service. Scores on individual items and subscale scores were compared between groups, and linear discriminant analysis was applied to determine the combination of items that best discriminated between groups.

RESULTS

Clinicians reported on patients who completed suicide, made high-lethality attempts, low-lethality attempts, or died unexpected non-suicidal deaths in a total of 82 cases. We found that clinicians treating imminently suicidal patients had less positive feelings towards these patients than for non-suicidal patients, but had higher hopes for their treatment, while finding themselves notably more overwhelmed, distressed by, and to some degree avoidant of them. Further, we found that the specific paradoxical combination of hopefulness and distress/avoidance was a significant discriminator between suicidal patients and those who died unexpected non-suicidal deaths with 90% sensitivity and 56% specificity. In addition, we identified one questionnaire item that discriminated significantly between high- and low-lethality suicide patients.

CONCLUSIONS

Clinicians' emotional responses to patients at risk versus not at risk for imminent suicide attempt may be distinct in ways consistent with responses theorized by Maltsberger and Buie in 1974. Prospective replication is needed to confirm these results, however. Our findings demonstrate the feasibility of using quantitative self-report methodologies for investigation of the relationship between clinicians' emotional responses to suicidal patients and suicide risk.

Psychologists' Experiences of Grief after Client Suicide: A Qualitative Study

Six clinical psychologists were interviewed regarding their experiences with client suicide. Interviewee's responses offered the following insights: (a) all their experiences met the criteria for prolonged grief; (b) the respective work settings significantly influenced the clinician's recovery process; and (c) male clinicians (in contrast to female respondents) reported no personal impact from the client's suicide. Finally and surprisingly, all participating psychologists did not question their clinical skills after the suicide, citing rather their understanding of the client's choice to suicide being outside of their control. Implications for clinical training, practice, and research are addressed.

The impact of inpatient suicide on psychiatric nurses and their need for support

BACKGROUND

The nurses working in psychiatric hospitals and wards are prone to encounter completed suicides. The research was conducted to examine post-suicide stress in nurses and the availability of suicide-related mental health care services and education.

METHODS

Experiences with inpatient suicide were investigated using an anonymous, self-reported questionnaire, which was, along with the Impact of Event Scale-Revised, administered to 531 psychiatric nurses.

RESULTS

The rate of nurses who had encountered patient suicide was 55.0%. The mean Impact of Event Scale-Revised (IES-R) score was 11.4. The proportion of respondents at a high risk (≥ 25 on the 88-point IES-R score) for post-traumatic stress disorder (PTSD) was 13.7%. However, only 15.8% of respondents indicated that they had access to post-suicide mental health care programmes. The survey also revealed a low rate of nurses who reported attending in-hospital seminars on suicide prevention or mental health care for nurses (26.4% and 12.8%, respectively).

CONCLUSIONS

These results indicated that nurses exposed to inpatient suicide suffer significant mental distress. However, the low availability of systematic post-suicide mental health care programmes for such nurses and the lack of suicide-related education initiatives and mental health care for nurses are problematic. The situation is likely related to the fact that there are no formal systems in place for identifying and evaluating the psychological effects of patient suicide in nurses and to the pressures stemming from the public perception of nurses as suppliers rather than recipients of health care.

When depression becomes terminal: the impact of patient suicide during residency

Patient suicide often results in profound personal and professional crises for the treating clinicians. Residency training in psychiatry represents a critical time for experiencing the death of patients by suicide. While residents often treat some of the most acutely ill, high-risk patients, during a uniquely vulnerable phase of professional development, many training programs do not have formalized procedures in place for aiding residents in the event of patient suicide. The working through of a suicide offers an opportunity for personal and professional growth. This paper examines this issue from the perspective of a resident-in-training who experienced the suicide of a long-term outpatient. Issues explored include personal and professional reactions to the patient's death as well as a discussion of the organizational response to the event.

Nurses' grief reactions to a patient's suicide

TOPIC

A patient's suicide may threaten the nurse's health and work performance until grief and mourning are transformed.

PURPOSE

To examine the literature, bereavement theories, and recommendations for supporting nurses' bereavement.

SOURCES

Bereavement literature on Medline, CINAHL, and PsychInfo from 1965-2001, and clinicians' and nurses' responses to a patient's death by suicide.

CONCLUSIONS

Nurses need a support system to help them cope with grief after a patient's suicide. Having knowledge of bereavement and using therapeutic support can help prevent burnout or stress and can encourage constructive coping strategies that transform grief. Grieving is facilitated when nurses recognize their own mortality and take time to process their grief.

Incidence of critical events in professional practice: a statewide survey of psychotherapy providers

The goal was to tabulate the incidences of clients' suicide, attack by a client, and sexual contact with clients in an Alaskan sample of masters and doctoral-level psychotherapy providers (excluding psychiatrists) and to assess which, if any, demographic or professional characteristics were associated with each critical event. Results from 151 respondents (response rate 43.5%) indicated that 42.7% of providers had experienced at least one client's suicide, 28% had been physically attacked by a client, 4% reported having had sexual contact with a then current client, and 6% reported sexual contact with a former client. Areas for research are outlined, specifically the importance of using methods other than surveys and exploring variables other than standard demographic data.

The stress of patient emergencies for the clinician: incidence, impact, and means of coping

This article presents evidence from the literature on the incidence and impact of behavioral emergencies on clinicians as well as suggestions for improved education and support for work in this area. Behavioral emergencies are conceptualized as including imminent life-threatening behaviors such as patient suicidal behavior, patient violence, and instances in which patients become the victims of interpersonal violence. Suggestions are offered for how clinicians can understand and cope with their own reactions during and after such patient emergencies. Additionally, data on deficits in the education and training of psychologists are presented along with suggestions for how programs and clinical sites can improve their training in emergency and crisis work.

Patient suicide in psychiatry residency programs : a national survey of training and postvention practices

Patient suicide, which has been shown to have great emotional impact upon trainees, is experienced by as many as one in three psychiatry residents. The authors report the results of a national survey of psychiatry residency training programs (N=166) that asked about 1) current training practices in the area of suicide and 2) required or recommended procedures in the event of suicide by a resident's patient. Results show that programs commonly offer training in the assessment and treatment of suicidal patients, but the question remains as to whether the training is adequate to meet the challenges of working with suicidal individuals. Results also reflect considerable variability in "postvention" practices among programs and training settings, especially in terms of what steps should be taken when a trainee's patient commits suicide. Implications of the survey for residency training programs are discussed.