For mental health professionals, the loss of a client to suicide is surprisingly common, if not an unfortunate occupational hazard. Studies show that one in five psychologists and counselors (Bersoff, 1999; McIntosh, 2000, McAdams and Foster, 2000) and one in two psychiatrists (Ruskin, 2004; Chemtob, Hamada, Bauer, Kinney, & Torigoe, 1988) lose a patient to suicide in the course of their careers. Despite this, many mental health professionals continue to view suicide loss as an aberration. Consequently, there is often a lack of understanding and preparedness for such an event when it does occur.
Despite the many published guidelines, suggestions and postvention protocols available to help clinicians and mental health settings navigate the often-complicated sequelae to such a loss (see below for bibliography info), these resources have not been integrated into clinical training and tend to be poorly disseminated. Thus, clinicians are often left to cope with the consequences of this difficult loss on their own and under less than optimal conditions.
Grief After Suicide Loss
In many ways, the responses of clinicians after the suicide of a client are similar to the responses/reactions of survivors after the loss of a loved one to suicide, generally considered to be a “traumatic” loss. Reactions typically include initial shock, denial and numbness, intense sadness, anxiety, anger and intense distress. Survivors are also likely to experience PTSD symptoms such as intrusive thoughts, experiences of detachment, and dissociation. In addition, suicide loss is often accompanied by intense confusion and existential questioning, reflecting a blow to one’s core beliefs and assumptive world. Survivors also commonly experience guilt and shame, and this may be socially reinforced by the gene3ral stigma around suicide as well as the actual blaming and avoidance responses of others (Brown, 1987; Cvinar, 2005; Goffman, 1963).
Suicide loss affects clinicians on both personal and professional levels. In addition to the personal grief reaction entailed in losing a client, this loss is likely to impact clinicians’ professional identities, their relationships with colleagues, and their clinical work.
Assumptions around one’s clinical competence are often challenged, if not shattered, when a client takes their own life. A clinician’s sense of professional responsibility, the self-blame that may accompany this, the fear of and actual blame of colleagues and family members, as well as the real or imagined threat of litigation, may all greatly exacerbate this distress. Additional components of the grief reaction for clinicians may include “guilt, loss of self-esteem, self-doubts about one’s skills and clinical competence, fear of being blamed for the suicide and fear of relative’s reactions” (Farberow, 2005).
Hendin, Lipschitz, Maltsberger, Haas, and Wynecoop (2000) found that therapists described losing a client as “the most profoundly disturbing event of their professional careers”, noting that one-third of these therapists experienced severe distress that lasted at least one year beyond the initial loss. Many considered leaving the profession after this experience.
Many factors can affect the duration and intensity of a clinician’s response to this loss, such as treatment context, supervisory and colleague support, legal issues and personal history. Legal prohibitions around confidentiality, and the subsequent lack of access to grief rituals make the normative processing of grief difficult, if not impossible. In addition, many clinicians experience reactions from colleagues, staff and supervisors which are quite unsupportive. Quinnett (2008) reports that many clinicians reported a pattern of isolation and interpersonal discomfort with their colleagues, who implicitly or explicitly expressed judgment about their competence. Such reactions may lead to a well-founded ambivalence about disclosure, and consequent resistance to seeking out optimal supervision/consultation or even personal therapy that could help clinicians gain clarity or support. Many professionals have described feeling completely abandoned by their colleagues and by their own hopes and expectations for support, after the distressing experience of losing a client to suicide.
Effects on Clinical Work
In general, the suicide loss of a client commonly leads therapists to question their clinical abilities, and to experience a sharp loss of confidence in their work. The common responses to a suicide loss (including numbness, sadness, anxiety and generalized distress) are likely to result in at least some temporary disruption of a clinician’s optimal functioning. PTSD symptoms may impair clinical response and therapeutic judgment, and since such symptoms and states may be triggered by exposure to other potentially suicidal clients, they are more likely to impact clinical functioning when working with suicidal individuals. Hendin et al. (2000) noted that even the most experienced therapists expressed difficulty in trusting their own clinical judgment, or accurately assessing risk after a suicide loss, often tending towards hypervigilance in relation to potential suicidality or, conversely, the minimization or denial of suicide potential.
Positive Changes/Posttraumatic Growth
Traumatic experiences can paradoxically present a multitude of opportunities for new growth. Fuentes and Cruz (2009) found that post-traumatic growth was fostered by perceived social support, the willingness to discuss distressing issues with supportive others, and openness to change.
Despite their initial distress, many clinicians are able to identify retrospective benefits to their experience. These include becoming better educated about suicide and the likelihood of its occurrence, and an increased sensitivity towards suicidal clients and those bereaved by its loss. In addition, clinicians report more realistic appraisals and expectations in relation to their clinical competence, and more awareness around their own therapeutic limitations. They also become more aware of the issues involved in the aftermath of a client suicide, including perceived gaps in the clinical and institutional systems that could optimally offer support to both families and clinicians.
In addition to the changes related to knowledge and clinical skills, many clinicians also note deeper personal changes subsequent to their client’s suicide. Many clinicians feel that once they are more resolved with their own grief process, have expressed the desire to support others with similar experiences.
Clinician-Survivors Task Force
The Clinician-Survivors Task Force of the American Association of Suicidology provides consultation, education, support and resources to clinicians who have experienced the suicide loss of patients, family members, clinical colleagues or therapists. We recognize that all of these losses carry implications within personal, clinical and professional domains. The Task Force provides a listserve and a website, on which there are opportunities for clinicians to share experiences about suicide loss, a bibliography of relevant publications, and postvention protocols. In addition, the chairs of this task force conduct Clinician-Survivor support activities at annual AAS conferences, and in their respective geographic areas. Future goals for the task force include empowering current clinician survivors to advocate for the support of future clinician-survivors, to disseminate the information that is currently available on the sequelae of clinician suicide loss, and to increase the research that is conducted on this topic. To access the CSTF website, visit the AAS website (www.suicidology.org) and scroll down to the “I am” section of the home page or go to the “Survivor” page and click on the “Clinician-Survivor” link. To request to join the listserve, please contact Dr. Vanessa McGann at email@example.com.