Dead reckoning: When therapists lose a client to suicide

CrossCurrents

The client seemed very agreeable, thought Dr. Ian Dawe, as he left the room to make admitting arrangements. Dawe, at the time a psychiatry resident completing his final year of specialized training at a Toronto emergency department, saw no indication of what was about to happen. Left alone, the client, who had come to emergency of his own accord, fled the hospital. The police were called, and Dawe, concerned but unable to do anything, went home at the end of his shift. When he returned the next day, a supervisor told him the news over the phone: The client had gone home, left the gas on and was fatally burned in the subsequent explosion.

“It was horrific,” says Dawe, now director of Psychiatric Emergency Services at St. Michael’s Hospital in Toronto and an assistant professor at the University of Toronto’s Department of Psychiatry. “I was gripping a table to hold myself up while I answered [routine inquiry] questions. I thought this was the worst possible thing that could happen.”Although the incident was never ruled an accident or suicide, Dawe always suspected the latter.

The next several days were hazy: After the shock, horror and sadness came guilt and self-recrimination on both professional and personal levels. “I wondered, could I have done something differently? Could I have seen it coming? Could I have predicted it?” Dawe also recalls thinking this was a major professional failure at the beginning of his career.

Many mental health professionals who experience a client suicide confuse the reasonable limitations of their professional skills with fears of failure (and even negligence), leaving them to cope with the aftermath in isolation. Yet client suicide is a fact for many mental health clinicians, from psychiatrists to social workers to nurses. The particulars of the relationship between the therapist and client, for example, whether it was a brief encounter or a long-term relationship, will affect the degree and manner in which the loss is experienced; but whatever the particulars, client suicide may be the most difficult bereavement crisis a clinician will encounter.

Half of all psychiatrists in the United States and Canada will experience a client suicide attempt or completion over the course of their career, according to statistics that researchers say are underestimated. And, during residency – a time when the youngest and brightest are most vulnerable – the rate for client suicide is between 14 and 33 per cent. A study of University of Toronto psychiatrist graduates in a 2004 issue of Academic Psychiatry found that 60 per cent of those who experienced a client suicide did so by the end of their first postgraduate year.

The numbers aren’t that different for other mental health professionals. A study in Omega: Journal of Death and Dying shows that up to 52 per cent of social workers reported experiencing either an incident of fatal or non-fatal client suicidal behaviour. And several studies show there is at least a 22 per cent chance that psychologists in clinical practice will experience a client suicide in the course of their careers.

The University of Toronto study, co-authored by Dr. Ron Ruskin, an assistant professor of psychiatry at the university and a psychiatrist at Toronto’s Mt. Sinai Hospital, also found that emotions resulting from a client suicide, including guilt, anger, loss of confidence and feeling a loss of peer respect, can persist throughout one’s career.

Given this “universal reality,” as one researcher puts it, of facing client suicide or suicide risk, a growing body of research is focusing on what can be done to help mental health professionals cope. The challenge, according to most researchers, is the lack of support in place for helping mental health clinicians through what is truly a professional reality and certainly a career altering time.

Unlike other medical professions, mental health clinicians can’t compartmentalize the mind, says Dr. Russell Ramsay, an assistant professor of psychology at the University of Pennsylvania School of Medicine Center for Cognitive Therapy. “It’s easy to compartmentalize the heart: A cardiologist isn’t going to blame himself if a patient dies of a heart attack at 63. But when we are trying to change human behaviour, we see ourselves as more accountable for the mental decisions of our patients. It can be very difficult not to personalize the experience.”

This fine line of accountability is in part to blame for the largely self-imposed stigma of client suicide, self-perpetuated by uneducated colleagues. To change this attitude, many experts call for better training to deal with emotions that result, such as guilt, anxiety and helplessness, and feeling professionally devalued. Social workers and nurses, in particular, are calling for more education around suicide and how to cope, since many schools offer no such preparation.

In addition to formal training and guidance, informal support can go a long way. Dawe, still reeling several days later from his client’s suicide, received a dinner invitation from a respected colleague. Half expecting a dressing down for the incident, Dawe reluctantly accepted. It turned out the colleague too had experienced a client suicide. That evening of frank conversation had a powerful effect on Dawe. “He talked to me about it in a non-judgmental way.He listened to me and allowed me to vent and to mourn,” recalls Dawe.

Indeed, one of the best ways to dilute negative attitudes following a client suicide is to establish channels for support and communication among peers. “If clinicians perceive a client suicide as a ‘dirty little secret,’ they will be left to cope with the stress on their own,” says Ramsay. Hearing about someone else’s client loss can be personally and professionally affirming, he explains. Not only does it help to remove the sense of isolation; it can also normalize the experience.

Dawe attributes his career path choice – emergency psychology with a focus on treating suicidal behaviour – to the simple, kind outreach he received. Without similar types of support, the field risks losing talented mental health clinicians who may deliberately avoid suicidal clients or worse, leave the profession. Ruskin’s research found that the emotional impact in an important minority of postgraduate students reached extreme levels. Almost all researchers (in many cases motivated by personal experience) call for better training in schools about this “occupational hazard” and for formal and informal support networks in hospitals and among professional peer networks.

How well certain clinicians cope with a client suicide or suicide attempt depends on various factors, in addition to receiving adequate support, according to Sara Sanders, an assistant professor at the University of Ottawa School of Social Work, and co-researcher of a 2005 Omega study about the reactions of mental health social workers to client suicide. Lifestyle factors like exercise and meditation can provide stress relief, says Sanders.And clinicians need to be aware of how their own attitudes toward death and suicide can complicate their perspective. Among clinicians who have difficulty with these realities, feelings of anger and resentment could be amplified. In cases where talking about the experience informally does not alleviate a clinician’s trauma, Ramsay says counselling should be encouraged.

Another stressor during this time is fear of a malpractice claim. However, Ruskin’s study showed that although nine per cent of participants were worried about being sued, only two per cent actually encountered legal complications.

In addition to inadequate education and support networks, experts contend there is inadequate information for re-establishing a therapeutic relationship with a client who has attempted suicide. In a 2005 issue of Suicide and Life-Threatening Behavior, Ramsay discusses the challenges of maintaining a therapeutic alliance with clients who have attempted suicide during the course of the therapeutic relationship. Ramsay recommends including an honest assessment of whether to continue treatment, how to rebuild trust with the client and how to modify the treatment plan to suit the client.

With the right coping tools, the “occupational hazard” that is client suicide can be a positive learning experience for clinicians. “I ended up arriving at a recognition of the limitations of my own power,” says Dawe. “I recognized that I can’t stop somebody from killing themselves. I may want to, but I can’t be with them 24 hours a day to take the pills out their hands. What I can do is help them choose to live differently, and to help treat their illness.”

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