‘You cannot wipe the tears off another’s face without getting your own hands wet.’ - Zulu proverb
As early as the late 1890s, Sigmund Freud reported his own suppression of feelings after his patient's suicide. For many years following, the suicide of a psychiatric patient was seen as the 'therapist’s failure'. Far too often, the distressing impact and personal challenges associated with this field area of practice are ignored or certainly not discussed. Perhaps this is another dimension of the stigma, which extends beyond that attributed to the suicidal person and survivors of suicide, to the mental-health worker, whose client is lost to suicide (or a suicide attempt). A particular ‘blame and shame’ stigma historically attributed to the therapist of the deceased client, originated from both the surviving family members, as well as from within the mental health profession itself (Weiner, 2005).
Although today suicide of a client is more acknowledged as a traumatic experience for the therapist, this phenomenon is still very much avoided, underestimated and tabooed in the literature. This is surprising given that studies have shown 25-75 per cent of individuals who suicide have had some contact with a health professional or mental health services in the year before death. Therapists are often not well prepared for the loss of a client to suicide despite the repeated identification in the literature of client suicide as an ‘occupational hazard’ for the psychologist. Coupled with the unspoken ‘silence’ of losing a client to suicide within the profession, is the proposition by Valente (1994) that lack of attention to the support needs of therapists may be a result of the view of therapists having “superior, even superhuman capacity for coping” (p.619). Some therapists may also perceive themselves as ‘omnipotent’ based on the (subjective, less informed) belief that they must save and rescue each suicidal client at all costs (James, 2005). Nevertheless, and in spite of the long-standing recognition that existential despair will lead some individuals to suicide despite therapists’ best efforts, therapist self-questioning and self-doubt is common following a client suicide or attempt. The impacts of such work can be stressful and even devastating for the therapist, yet formal education about suicide and coping with fatal and non-fatal suicidal behaviour is almost non-existent in psychology programs despite the identified need for such training. The aim of this article is to shed some light on the difficulties of this area of practice, as well to suggest ways for psychologists to deal with and respond to such challenges.
Psychologists’ experience of suicidal clients
Only one Australian paper exists on psychologist experiences of client suicide and/or treatment of suicidal behaviour (Trimble, Jackson & Harvey, 2000). This is surprising given survey findings of the high proportion of psychologists who have seen clients with suicidal ideation and behaviour. In this Australian study (N=437; response rate=29%), incidence of client suicide and a wider spectrum of suicidal behaviour was examined. The authors found 39 per cent of psychologists had had a client suicide, 76 per cent had a client attempt suicide, 86 per cent reported clients who made gestures and/or threats of suicide, and just over 90 per cent reported seeing clients with suicidal ideation. It is also remarkable that few papers have primarily focused on coping, self-care, supervision or other supportive strategies for therapists undertaking this work, much less, for psychologists. Self-care is such a critical ethical component of working effectively with suicidal people and necessary for continuation of such efforts following client attempt or suicide.
Renowned American studies by Chemtob and his colleagues (Chemtob et al., 1988a, 1988b) found that 51 per cent of psychiatrists and 22 per cent of psychologists experienced at least one client suicide. Further, they found factors which influenced risk of having a client suicide as follows: specialised training reduces risk of client suicide; female therapists experience less suicides than male counterparts; psychiatric hospital or ward workers and outpatient mental health agencies and, those working with more severely disturbed psychiatric clients (e.g. organic, affective, substance-abusing, schizophrenic clients) all experience increased suicides. Thus, psychologists are highly likely to encounter suicidal behaviour and client suicide in their work, and more so when working in inpatient and outpatient settings and with more impaired client populations.
Stress associated with working with suicidal clients
Effective treatment outcomes involve an element of ‘technical competence’ including specialist knowledge and skills in systematic risk assessment, formulation and commensurate management of suicidal clients – all elements that are rarely covered in most psychology programs. Lack of clinician perceived competency in these life-saving techniques only enhances fear of litigation, anxiety and self-doubt, and may increase clinician avoidance of this client population.
Subsequent to a client’s suicide attempt, therapists may experience increased personal self-doubt (e.g. a ruptured sense of power and control over the client’s behaviour), professional awareness (e.g. enhanced accountability, documentation and reporting vigilance), negative or ambivalent feelings towards the patient, and more defensive practice. If negative countertransference arises, therapist reactions can have devastating impacts on client care when left unprocessed. The reader is encouraged to view Leenaars, Maltsberger and Neimeyer’s (1994) comprehensive account of therapist reactions resulting from feelings of incompetence, anxiety and fear associated with such experiences. Other relevant readings are studies by Neimeyer and MacInnes (1981), Neimeyer and Bonnelle (1997), and Palmieri et al. (2008), which focus on the appropriateness of therapist responses to suicidal patients and the relational problems and difficulties of the therapeutic context.
The special task which differentiates working with suicidal people from traditional therapy is achieving the goal of keeping a person alive. Achieving this requires increased ability to maintain connectedness, rapport, giving of self, diligence and insightfulness on behalf of the therapist. The ability to attune to the client by non-judgementally accepting the client’s ‘suicidal wish’ demands a great deal of therapist energy. The maintenance and restoration of the therapeutic alliance following a client suicide attempt is reportedly one of the most stressful but important elements of working with suicidal clients (Rothes et al., 2014). Ramsey and Newman (2005) highlight important yet difficult clinical questions for the therapist which arise in the aftermath of a client suicide attempt: to resume client care (or not), and if so, how to do so (on what terms?), and how to regain the therapeutic alliance. Between session care including phone, email or other contact is almost always required, particularly in times of crisis, although in Australia such practice is neither standard nor ‘acceptable’ in most government mental health settings. Therapist endurance of this kind is a challenge rarely addressed in the literature or education of psychologists.
Impact of client suicide on treating clinicians
The literature concerning the impacts of working with suicidal clients is scant, despite surveys indicating that suicidal clients represent one of the most, if not the most stressful area of psychotherapy work. Therapists’ reactions include grief, guilt, depression, personal inadequacy, denial, isolation and anger. In the therapist's mind, suicide is often proof of one's incompetence or irresponsibility.
Affective and stress-related symptoms of therapists have been mostly investigated in the literature, and the most commonly experienced of these are shock and guilt (Seguin et al., 2014). Often the therapist experiences a ‘professional’ response of shame, self-blame and feelings of incompetency and responsibility; these appear to be more severe when associated with more severe recurrent suicidal behaviour (Kleespies et al., 1993). Also commonly reported are therapist expectations of blame from family, negative perceptions of colleagues and fear of litigation (Tillman, 2006). Women therapists have been shown to have higher distress and more shame and guilt experiences than men (Jacobson et al., 2004). Clinicians who did not receive sufficient support in the aftermath or who had a perceived close relationship to the client also had the highest stress responses (Castelli-Dransart et al., 2013).
Changes to clinicians' professional behaviour has included increased vigilance with record keeping and reliance on hospitalisation, increased peer consultation, referring clients onwards, or not seeing suicidal clients at all, as well as greater scrutiny (e.g. screening) of clients to be seen (McAdams & Foster, 2000).
Caring for the carer
Education
As mentioned earlier, there is a remarkable need for better educational preparedness of psychologists working with suicidal patients. Few initiatives to formalise pragmatic support responses for therapists in the aftermath of suicide and suicidal behaviour have been implemented. Currently, the most common mechanism for learning and support within this domain is supervision, however there is a major role for more formal education. Psychologists need to be provided with guidelines on coping with the aftermath of suicide and suicidal behaviour, together with specific information about suicidality. It is not enough to be advised about the ethical and legal responsibilities and implications of this work, rather, psychologists need to be supported in the ‘processing or working through’ their experiences with the suicidal client or the suicidal event.
Supervision
Of the available literature on therapist adaptation and coping following patient suicide or attempt, it seems that clinicians rely most commonly on informal sources of support to process the event by talking with peers and co-workers, as well as the more formal support gained from professional supervision (Kleepsies & Dettmer, 2000; Seguin et al., 2014). Supervision after client suicide often involves reviewing case notes and clinical audits with the objective of increasing technical knowledge and learnings from the event. Supervisors have a particular responsibility to support the therapist, not to assign responsibility or blame for the death, as well as to help the therapist to deal with any implications for working with other clients. Supervision of trainee psychologists during client treatment, as well as after client suicide, involves a critical collaboration with careful monitoring and support on behalf of the supervisor (who will bear the ultimate responsibility).
Additionally, attending the funeral, wake or other memorial/commemoration event, or making contact with the family has, interestingly, been mentioned as a source of coping for therapists following client suicide (Seguin et al, 2014).
Self-care strategies
Pragmatic support and self-care strategies for processing and decreasing the impacts of this work are described in the boxed information opposite, and have been gleaned from the literature and the authors’ personal suggestions. For further self-care guidance, Spiegelman and Werth (2004) have compiled an excellent list of suggestions targeted to each of trainees, supervisors and administrators on what to do before a client suicide or attempt, immediately following and, between three to six months post event. These practical guidelines are highly recommended for those working with suicidal clients. Valente (1994), Kleespies and Dettmer (2000), and James (2005) provide comprehensive discussions on recovery and adaptation following client suicide and attempt, specifying contextual differences in therapist preferences for support (e.g. hospital versus private practice) and providing other author reflections. The reader is also directed to the work of Kristen Webb (2011) who has applied a “practitioner-tested, research-informed” approach to selecting and reporting on appropriate self-care strategies for working with suicidal patients.
Conclusion
This article has attempted to convey the importance of both education and support, as well as therapist help-seeking and reflection for working with suicidal clients. However, the brevity of this article does not do justice to the complexity of this work, nor the depth of issues that may arise for the psychologist. Instead, this summary of relevant topics and the associated suggestions (for readings and self-care) are a starting point for initiating genuine desire in therapists to save lives! We believe that acknowledgment of the need for self-care in such work requires a certain level of therapist authenticity, tolerance and resilience, as encapsulated in the Zulu proverb that commenced this article: ‘You cannot wipe the tears off another’s face without getting your own hands wet.’
The first author can be contacted at [email protected]
| Self-care strategies for psychologists working with suicidal clients |
Pursue education on the occupational hazards of ‘this work’
Seek out professional development and training on suicide and coping post-suicide and suicide attempt.
- Avail yourself of an array of informational resources – firsthand accounts of therapists who have lost a client to suicide may be of particular use, e.g., Donna James (2005).
- Participate in peer-based group case conferences – e.g., focus on a ‘difficult or impossible client-at-risk’ scenario; de-identify real suicide attempt or post-suicide scenarios to process skill-based and process-related issues.
- Identify appropriate and specialist supervisor/s (see below).
Ensure formalised supervision arrangements
Set up a supervisory relationship with a knowledgeable and experienced practitioner. Working through important process and technical elements on a case-by-case basis may reduce ongoing anxiety, distress and self-doubt prior to any critical event. Trainee psychologists must be assigned appropriate clients commensurate with expertise and experience, and supervisors likewise (underlying the need for education in this domain).
Plan ahead and be prepared
Enquire about organisational policies and procedures that support and assist workers in the aftermath of suicide and suicidal behaviour – guidelines will differ and should be contextualised for different practice settings, e.g., private practice psychologists should develop structured plans or mechanisms for collegial consultation and support in the wake of such events.
Identify your needs for safety
Determine whether a group or individual setting with a supervisor or colleague best meets your feelings of safety for open discussion and processing of the event if required. On this issue, Valente (1994) eloquently points out: “The group can reduce confusion by reminding the therapist that what could have been done differently is not to be interpreted as what should have been done” (p.619).
Understand the limits of your powers
Process the realistic role you can play in ‘saving lives’ and preventing client suicide (see Ellis [2004] for an understanding of shared responsibility between therapist and client). A sample of Australian psychologists (Trimble et al., 2000) reported that decreasing sense of responsibility in the suicide was one of the most effective coping strategies. However, caution and critical self-reflection should be exercised to prevent denial of any potential ‘therapist errors’ associated with the suicide/suicide attempt. In working through such an event, James (1985) has some sage advice: “The conclusion that we have done the best we could needs to be a conclusion hard-won” (p.18).
Identify and define your own limits
It is strongly recommended that psychologists should not work with more than a few acutely suicidal clients at a given time, or at least should carefully monitor the number of back-to-back severely suicidal clients in any given day. Overall workload/caseload in the aftermath of suicide/attempt should be monitored and reduced if necessary to accommodate grief (supervisors should guide and support clinician responses to their work).
Engage in personal ‘care’ activities
- Ensure regular sleep patterns, exercise routine and healthy eating behaviours.
- Socialise and take holidays or short breaks planned ahead so that client hand-over is appropriate and less anxiety provoking for you.
- Diversify your caseload and workload.
- Maintain a spiritual or mindful sense of self.
- Most importantly, keep your sense of positive satisfaction for working in this domain alive (monitor signs of reducing satisfaction and address the same).
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