When someone dies by a person’s own hand, the loss deeply affects each of those closest to him or her. What may often be missed, however, is how that loss also affects the therapist trained to keep this suicide from happening. In the popular mind, it may seem inappropriate to be concerned with the professional on the sidelines after a successful suicide attempt, but for the human being behind that degree, a death can have many repercussions both professionally and personally.
After a colleague experienced the shock and trauma of a patient dying by suicide, Jane Tillman, Ph.D., ABPP, the Evelyn Stefansson Nef Director at the Erikson Institute for Education and Research at the Austen Riggs Center, a long-term psychiatric hospital and treatment center in Stockbridge, Mass., decided to explore the topic of how a therapist copes with this type of loss.
Also an assistant clinical professor at the Yale Child Study Center and a clinical instructor in psychology in the department of psychiatry at the Harvard Medical School, Tillman spoke with New England Psychologist’s Catherine Robertson Souter about her work and the shockingly high number of psychotherapists and psychiatrists who will experience a death among their clientele over the course of their careers.
Q: How did you get involved in this work?
A: I became interested in the effects of patients who die by suicide on clinicians in the late 1990s when I had a colleague whose patient died by suicide but who could not find anything in the literature. This time was before search engines and the like so it is not exactly true that there wasn’t anything in the literature, but I became interested in doing a research project on the topic.
I conducted a study over several years with funding from the International Psychoanalytic Association which was published in 2006 in the International Journal of Psychoanalysis. I recruited 12 psychotherapists who had a patient die by suicide and did in-depth interviews and a qualitative study trying to understand what experiences are common. We identified eight common themes associated with the experience of having a patient die by suicide.
Q: What are those themes?
A: In the first, our participants described a traumatic response, the initial reaction to finding out a patient had died by suicide. In the second theme, our participants described affective responses, crying or sadness or anger or grief, intense feelings related to the experience.
The third theme was what we call treatment specific relationships, where participants would tell us about their relationship with the patient’s family and how they continued to worry and feel guilty about the patient’s family.
The fourth, the most fraught and difficult category, was our participants describing relationships with colleagues and how they often felt they would be looked down on by colleagues or known as the therapist who had a patient die by suicide. Participants talked about how helpful it was to have supervisors or peers who had also had the experience that they could talk to.
In the fifth theme, the big thing was risk management concerns, fear that insurance rates would skyrocket or their hospital or clinic would be put out of business by a lawsuit over the death of a patient.
For the sixth theme, they described a kind of worry that they had been grandiose as psychotherapists for treating patients who were at such high risk. They spoke about shame, guilt and blame.
In the seventh, there was a crisis about professional identity. About a third were early career professionals and some wondered if they had chosen the right specialty.
Finally, the eighth theme was the effect on their work with other patients, feeling hyperaware of the fact that a patient can die by suicide and being taken by surprise. They knew that many of their patients were at risk for suicide but many of them still felt blindsided because they didn’t think they were at heightened risk at the moment the death occurred.
Q: Did they find that colleagues treated them differently?
A: We do know from research that there is a stigma attached to suicide and to suicide survivors. I think that there is also a way that stigma can be elaborated for some people who feel quite persecuted by being scrutinized or having work reviewed.
Q: What was the long-term outcome for the clinicians?
A: I interviewed one participant several months after a patient had died by suicide and one who was 12 years out. The person who was 12 years out was doing okay in many ways but in the interview, he was surprised at how it came back as a fresh and painful experience. He was aware that he was always carrying around something about this.
Q: What have you worked on since this study was done in 2006?
A: Along with a colleague, Eric Plakun, M.D., I teach a workshop for the American Psychiatric Association most years. We have worked to get residency training programs to acknowledge that suicide is an occupational hazard for psychiatrists and for psychotherapists. There needs to be better education about what to expect if you have a patient die by suicide. Around 50 percent of psychiatrists, and a little lower for psychologists, will have a patient die by suicide in the course of their career. Yet, there is such silence.
Q: I don’t know if most people realize how high that number is.
A: It is not uncommon and the suicide rate is rising in this country. Yet, we act as a field as if this will not happen to us. There is very little training about what to expect, how to take care of yourself, how to navigate legal questions, how to meet with a family afterwards or how to learn from the case.
Q: You have turned your research focus away from how the death of a patient by suicide affects the therapist or psychiatrist, correct? Tell us about your current research.
A: I am looking at patients who have made a nearly lethal suicide attempt to try to understand something about their state of mind in the hours prior to the attempt. I am studying that group who is alive by accident to see what they can tell us about more proximal warning signs in that time before a suicide attempt.
A study came out recently in the American Journal of Psychiatry saying that the chances of dying on a first attempt are higher than we thought but also, of that group who survived on a first attempt, their chances of subsequently dying by suicide within a year are quite high. So, once someone has made a suicide attempt there is a chance for aggressive intervention that should be pursued.
Q: What message would you give to psychologists? What is the takeaway lesson here?
A: Getting some preventative education, knowing current best practices in assessing and working with suicidal patients. Thinking in advance of what to do if one has a patient make a near-lethal suicide attempt or die by suicide. In one’s mind, have a kind of rehearsal about how to manage it.
Reaching out for support and self-care following the death of a patient by suicide is really important. Sometimes I think, out of determination or stoicism or guilt, people try to act like it should not affect them and for some that is true. But some are deeply affected – and if you are one of those, choose to get some help.