A Psychiatrist’s Reaction to a Patient’s Suicide

The small literature addressing therapists’ reactions to patients’ suicide ­describes several typical reactions. Among the first are disbelief/denial followed by depersonalization, shame, guilt, and the finding of omens (5, 6). As an example of denial, one psychiatrist asked about the chance of recovery for a patient who was described to him as brain-dead after a self-inflicted gunshot wound. In the present case, Dr. G seemed not to have had a great deal of denial or disbelief. Instead, his predominant initial response was de­personalization, characterized by a feeling of numbness and unreality, while he maintained his usual behavior patterns.

Shame and guilt are common and predominant responses following a patient’s suicide. As described in other accounts, guilt has led psychiatrists to offer false confessions. At a review after a depressed patient committed suicide, one psychiatrist admitted to having prescribed an inadequately low dose of an antidepressant, which then led to a discussion that was critical of his care. In reality, he had prescribed a much higher and more adequate dose, but in response to his guilt at the outcome, he had falsely remembered his own treatment, making it seem more inadequate than it was (5). Dr. G’s fear of public humiliation and of potential litigation (a real threat) typifies therapists’ reactions to patients’ suicide. (No lawsuit was filed in Paul’s case.) Dr. G’s concern with “the way the chart looks” is also common, especially in academic medical centers, where the importance of adequate documentation is particularly emphasized.

Dr. G’s fantasy of moving to another city in response to his shame and fear of retribution by his community is also not unique. As described in a case report (7) unknown to Dr. G at the time, another psychiatrist, after a patient’s suicide, noted, “It reached the point in my fantasy where I was having to leave town, shunned like a leper for the terrible act I had committed.”

The searching for omens, exemplified by Dr. G’s looking for clues that might have alerted him to Paul’s incipient suicide, reflects the need to maintain one’s illusion of control in an unpredictable world in order to bind anxiety. The fact that practitioners and entire institutions alter treatment practices on the basis of a single suicide sometimes reflects the desperation to create new procedures that will allegedly protect against the unwanted event. Some changes in clinical practice as a consequence of a patient’s suicide are, of course, appropriate and reflect improvements in care. Other changes, however, more likely reflect magical thinking. Dr. G’s ritualistic inquiries about suicidal ideation in patients for whom this was clinically not necessary allowed him to feel that he was establishing more effective control of suicidal feelings and behavior in his practice, although these inquiries were not used in a clinically wise or particularly helpful manner. In institutional settings, changing hospital-wide policies and procedures on the basis of a single untoward event is common. To illustrate, a hospitalized patient killed himself after returning from a court hearing in which his petition to be released from an involuntary admission was denied. Thereafter, the ward leaders established a new policy requiring that after similar court hearings, patients would be obliged to stay in the dayroom for the rest of that day, ignoring the many hundreds of other such court hearings that did not lead to suicidal behavior.

Dr. G’s grief at Paul’s death is understandable. Less obvious, although well described in the literature, was his need to mourn the loss of grandiosity about his abilities to positively affect every one of his patients’ lives. This loss is generally considered to be maximally felt by young psychiatrists, either trainees or recent graduates, who have a patient who commits suicide.

Dr. G’s anxiety, middle-of-the-night awakenings, intrusive thoughts of the day of the suicide, startle response to phone calls, and the previously described depersonalization are all symptomatic elements of a posttraumatic stress syndrome. Other accounts of psychiatrists’ responses to patients’ suicide include their developing hallucinations, accident proneness, and suicidal ideation. In one study, within 6 months after a patient’s suicide, 57% of psychiatrists reported intrusive thoughts and avoidant behaviors at a level comparable to that of clinical populations (8). The two emotions most fraught with internal conflict for the psychiatrist after a patient’s suicide are anger and relief. Dr. G’s anger is fairly typical of responses described elsewhere. Often, the anger is projected at others—the family of the patient, a supervisor if the treating psychiatrist is a resident, nurses in an inpatient facility, and so on. (Projected anger as a method of protecting against grief is thought to be a frequent factor in families filing lawsuits after patients’ suicide.) Relief after suicide results from not having to continue to struggle with a patient’s suicidal ideation and threats. Such relief most commonly occurs after the death of chronically suicidal patients, who tend to exhaust even the most experienced clinicians. Since Paul was not chronically suicidal, Dr. G experienced no relief at all; however, relief definitely accompanied Dr. G’s responses to the suicide of a chronically suicidal patient many years later.

Among the most common concerns after a patient’s suicide is the response of colleagues. Dr. G’s responses are typical, vacillating between fears of being shunned and feeling special. Some authors have described the experience of having a patient commit suicide as a rite of passage; “to survive it is testimony to one’s hardiness, endurance, and being a ‘real physician’ ” (5). At the same time, the feelings of aloneness can be debilitating and provoke the seeking out of colleagues, as Dr. G did. Unfortunately, the reaction of his internist colleague is common (although not universal) among nonpsychiatric physicians. Since most physicians have some patients who die while under their care, they do not immediately perceive the different quality of a patient’s suicide for a psychiatrist.

In training programs and psychiatric hospitals, a “psychological autopsy” or suicide review is a standard procedure. In these conferences, the treating psychiatrist presents and discusses the case with other staff members with the goals of evaluating issues of the quality of care and of learning from the tragedy. The usefulness of such a conference for the treating psychiatrist is unclear. At least one study found that the psychological autopsy compounded rather than alleviated the treating psychiatrist’s doubt (9). Too often, psychological autopsies evolve into public shaming. Finding a middle ground between mindless support and excessive critical thinking is surprisingly difficult.

A number of variables will shape the impact of a patient’s suicide on the psychiatrist. Of these, the two main factors are the relationship between the patient and the psychiatrist and the individual psychiatrist’s psychological makeup, including personality features and the developmental stage of his or her career.

It is generally assumed that the more intense the relationship between patient and psychiatrist, the more difficult will be the psychological reaction to the patient’s suicide. Aside from the sheer duration of the therapeutic relationship, the nature and interpersonal intensity of the treatment—i.e., whether the modality was entirely psychopharmacological management, with less frequent and shorter visits, or some form of psychotherapy—seems especially relevant. However, rather deep relationships can develop in the course of psychopharmacological management over long periods of time, which might then predict more intense psychological reactions in the event of a suicide. Another important aspect of the patient-psychiatrist relationship is the extent to which the patient’s treatment is shared with other professionals. Both Dr. G’s experience and common sense suggest that situations in which the treating psychiatrist is the sole provider of care, such as individual solo practice, are associated with the greatest sense of responsibility, loss, and psychological distress in case of a patient’s suicide. A split treatment situation, in which the patient is in therapy with another mental health professional while the psychiatrist provides medical treatment, may buffer the sense of responsibility and guilt. This was especially clear to Dr. G when the patient for whom he was only part of the treatment team killed herself. The fact that another psychiatrist had seen the patient in psychotherapy a few times between her last appointment with Dr. G and her death significantly blunted his sense of guilt, although it did little to minimize the other psychological responses.

Psychological factors within the psychiatrist also play vital roles in predicting response to a patient’s suicide. These include an obsessional personality style, a tendency to internalize, and vulnerability to anxiety and depression. The fact that Dr. G had been out of residency for only 6 months at the time of Paul’s suicide was unquestionably a critical factor in accounting for his intense psychological reaction. The suicide of a patient is tragic and painful at any time; however, if the psychiatrist is older and has achieved some sense of competence, a mature professional identity, and some respect within his professional community, the ability to buffer the pain with internal strengths is likely to be greater.

Three of the most important methods for coping with a patient’s suicide are decreasing the sense of isolation, making efforts at reparative, constructive behavior, and using specific cognitive defenses. Decreasing isolation is best managed in the same manner that we typically suggest to our patients—talking to others one trusts and respects, be they lovers, friends, family, colleagues, or one’s own therapist. For each individual, different sets of people will be most helpful. In Dr. G’s case, talking with his girlfriend/wife-to-be (who was herself a clinical psychologist) and discussions with his two former teachers were the most helpful. The psychological autopsy, when done well, can also diffuse the isolating nature of the experience, assuming that it does not evolve into a critical blame-finding discussion. Sometimes, it is helpful to the psychiatrist (as well as to the patient’s family) to meet with the bereaved family, to grieve together in an atmosphere that is hopefully not dominated by blame and projection. In Paul’s case, the family declined Dr. G’s invitation to meet with them. In other cases, when Dr. G did meet with families of patients who committed suicide, the encounters were exceedingly helpful to him and, he observed, to the family members, who were often unaware of some of their dead relatives’ psychological struggles.

Repair is typically attempted by helping others prepare for or cope with similar experiences. Presenting a case of a patient’s suicide at grand rounds conferences, as Dr. G did, and writing a case report are typical examples. My writing of this Clinical Case Conference with myself as the thinly disguised Dr. G as my alter ego is another example. (Writing in the third person also helped me to distance myself slightly from the affect associated with the writing.) As has been pointed out elsewhere (5), the act of public repair may also reflect other motives, such as the need for public confession or a request for support.

Embracing certain facts and philosophical viewpoints can also help one to cope with a patient’s suicide. These include the fact that suicide is a predictable outcome of major psychiatric disorders, especially depression; that suicide is inevitable when an individual is not ambivalent about it; and that the field is currently unable to accurately predict suicidal risk for any individual (10). As a method of reducing the intensity of his guilt/pain, Dr. G often compared the potential outcome of suicide in a population of severely depressed individuals with the potential outcome of death from terminal cancer in patients treated in oncology practice. In both fields, the deaths reflect the natural history of the disorders and the imperfection of therapeutic modalities more than the failure of individual clinicians. Of course, these statements can also be used inappropriately for defensive purposes, to foster a sense of therapeutic nihilism, or to deny therapeutic responsibilities inherent in being a clinician.

A substantial proportion of psychiatrists will, at some point in their careers, experience the suicide of one or more of their patients. Overall, the field has been relatively silent about this phenomenon, as exemplified by the sparse literature on the topic and the paucity of formal attention given to it in residency training programs. Yet, except for protracted malpractice suits, patient suicides may be the most psychologically difficult experiences encountered in the life of a psychiatrist. Dr. G’s response to Paul’s suicide—­including a combination of post­traumatic stress disorder symptoms, shame, guilt, anger, isolation, and fears of both litigation and retribution from the psychiatric community—is typical of responses described elsewhere. Having a patient commit suicide early in one’s career may be particularly difficult, as it was for Dr. G, suggesting that training programs should prepare trainees for these tragic events. Strategies that decrease the isolation of the clinician and foster perspectives that reduce self-blame may blunt one’s overdeveloped sense of responsibility and limit one’s fantasies of having ultimate control over patients’ lives.

Received April 8, 1999; accepted June 30, 1999. From the Department of Psychiatry, University of California, Los Angeles. Address reprint requests to Dr. Gitlin, 300 UCLA Medical Plaza, Suite 2200, Los Angeles, CA 90095-6968