Factors Contributing to Therapists’ Distress After the Suicide of a Patient

In three cases, the therapist’s severe distress resulted from the failure to hospitalize a patient who then died by suicide. In each of these, the patient had made the suicide intent clear in the final session; all three therapists recognized the suicide crisis, but none was able to take action and insist on hospital admission. One psychiatrist in practice for over 30 years did urge hospitalization; the patient said he would think about it, went home, and killed himself. In all three cases, the therapists’ inability to hospitalize reluctant patients had roots in the therapy itself, in which the patients had controlled what would or would not be discussed, whether and how much medication would be taken, and other matters.

Four therapists, all with 7 to 12 years of practice, were severely distressed about a treatment decision that they felt contributed to the suicide. In one case, a ward psychiatrist allowed the socially prominent uncle of a suicidal inpatient to persuade her to let the patient out on a pass to go to dinner with him. The patient absconded, went home, and shot himself.

Another therapist acknowledged early in treating a suicidal female patient that her power to hospitalize the patient was small in comparison to the patient’s power to kill herself without the therapist knowing. That exchange formed the basis of an alliance that was sustained through more than a year of therapy. When the patient revealed she was feeling suicidal but felt reluctant to discuss it, the therapist threatened to hospitalize her. This prompted the patient to feign improvement for several weeks, while she decided on and planned her suicide. Audiotapes the patient left detailed not only her deception but also her feelings about the therapist’s threat, which she regarded as a betrayal.

In each of the other two cases, the therapist had continued to press the patient to leave an institutional setting in which he was doing reasonably well, despite signs that the patient was not ready to live on his own. One therapist gave in to pressure from the mother of his 39-year-old bipolar patient to discharge him from a group home. As discharge plans were being made, the patient told his housemates he intended to drown himself and showed them ropes and cinder blocks assembled for this purpose. The therapist was summoned and confiscated the materials. He interpreted these preparations as resistance to change and continued to encourage the patient’s move to an independent apartment. Shortly thereafter, the patient weighted himself down and drowned exactly as he had intended.

In two cases, the therapist’s severe distress stemmed from his institution’s reaction to the suicide. Both cases involved therapists in training who felt blamed by hospital administrators for the patients’ suicides. One therapist, working in a municipal hospital outpatient clinic, had treated a 23-year-old woman with major depression, substance abuse, and suicidal ideation. He had been frustrated by the patient’s apparent lack of commitment to the treatment, reflected in her late arrival at her weekly sessions, unfavorable comparison of the therapist to the patient’s previous female therapist, and continued use of both alcohol and illicit drugs. At one point in the several-month therapy, while the therapist was on vacation, the patient was briefly hospitalized in a suicide crisis. About a month after discharge, she died in her apartment from a drug overdose while her roommates socialized in an adjoining room. At a postmortem conference, the hospital’s clinical director looked squarely at the therapist and said, “[The patient] appears to have died the way she was treated, with a lot of people around her but no one effectively helping her.”

In the last four cases, a potential lawsuit by relatives who blamed the therapist for the suicide was the cause of severe distress. One psychiatrist in his mid-30s lost a 56-year-old female patient to suicide. She had been referred to him by a psychopharmacologist whom the patient’s husband, a prominent local psychiatrist, had consulted. The patient had recently been hospitalized and treated with medication and ECT for severe depression. She remained deeply anguished after her release, with delusions of poverty and abandonment that appeared related to her experience as a young girl of being sent to live in an orphanage for a time when her father could not afford to support the family.

She continued to be markedly depressed and hopeless after 2 months of weekly outpatient therapy, finally revealing, at her husband’s urging, that 2 weeks earlier she had used one of his knives to “nick” herself on the neck. She minimized the incident, denying suicidal thoughts or wishes and refusing to increase her medication, but agreed to talk to her husband about attending a session with her. After discussing this during her next two sessions, she said she would ask her husband to come with her the following week. That evening, while her husband was out of the house at a meeting, she took a taxi to a spot near a river and drowned herself. The husband became enraged at the therapist and refused the therapist’s offer to meet with him and the couple’s adult children. In a note to the consultant who had referred the patient, the husband stated that he held him and the therapist responsible for his wife’s death and threatened to sue them both. Although a lawsuit did not materialize, this therapist, like the other three who were blamed by the patients’ relatives, lived for months fearing he would be made to pay for the suicide, both personally and professionally.

The severe distress of these 13 therapists was expressed in different ways. The psychiatrist with 30 years’ experience who had not hospitalized his suicidal patient had repeated dreams of failing examinations, which he said reflected feelings of inadequacy he had not had since medical school. Another therapist who had not acted to hospitalize an imminently suicidal patient had a flood in her office the day after attending her patient’s funeral. She had the fantasy that the stream of water running down the wall was the tears of the mourners, and she thought of the flood as her punishment for not preventing the suicide. A therapist named in a lawsuit brought by her patient’s wife became consumed by anger, not only toward the wife but also toward the patient for putting her in this position. She was aware that her anger sometimes became apparent in her interactions with other suicidal patients. For 2 years after his patient’s suicide, another therapist jumped up with anxiety when his telephone rang at night. He and another experienced psychiatrist for a time considered giving up their practices.

Although one emotion sometimes dominated a therapist’s response, the severely distressed therapists overall reported a significantly larger number of intense emotional reactions, with an average of 4.8 of the nine that were examined, compared to an average of 2.6 among those who did not experience severe distress (t=3.53, df=32, p=0.001). As seen in Table 1, intense levels of grief, guilt, inadequacy, anxiety, and depression were significantly more common among the severely distressed therapists than among the other therapists.

Anger was intense among 61.5% of the severely distressed therapists, including all four of those who were threatened with lawsuits. However, intense anger was also experienced by an almost equal proportion of the therapists who were not severely distressed (57.1%). As shown in Table 1, similar proportions of the two groups also experienced shock, betrayal, and shame.

Certain characteristics of the therapist, specifically gender, training status, and years in practice, appeared to affect vulnerability to severe distress. Female therapists were found to be almost twice as likely as male therapists to experience severe distress (Table 1). Severe distress was also found in over half of the therapists who were still in training at the time of the suicide, compared to one-third of other therapists. Nearly one-half of those with fewer than 15 years in practice were severely distressed, compared to just over one-tenth of those with more than 15 years. As summarized in Table 2, none of these relationships was found to be significant, probably because of the relatively small numbers in some cells. The difference in frequency of severe distress between the less and more experienced therapists approached significance.

Neither the therapist’s professional discipline nor work setting (private practice versus institutional setting) was related to severe distress to any degree. Neither did patient status at the time of the suicide (inpatient versus outpatient) nor patient’s length of time in treatment appear to contribute to severe distress among the therapists.

The participant therapists in this project were of necessity volunteers, and thus we cannot estimate how typical they are of the greater population of therapists who lose patients to suicide. Those whose cases are reported here had a wide range of professional experience, therapeutic orientations, and personal styles. It is possible, however, that therapists not volunteering their cases may be more troubled about the treatment they provided than those willing to have their cases reviewed. The requirements and procedures of this study may also have served to select a group of more highly involved and motivated therapists. On the other hand, it is also possible that participating therapists may be more than ordinarily disturbed about the suicide of their patients. Our earlier analysis of the reactions of the first 26 of our participating therapists (6) suggested that both possibilities were represented, and our work since that time confirms this observation.

Although in our work to date we have not found the frequency of severe distress to be different among therapists trained in different disciplines, as some earlier surveys (1, 2) have suggested, our participants thus far have included far more psychiatrists than psychologists and other therapists. We will remain alert to possible differences as the study progresses.

Although we did not systematically measure the duration of severe distress, in each of the severely distressed therapists the experience was described as lasting for at least a year following the suicide. We also observed among some therapists a significant lessening of distress about 2 years after the suicide. Other therapists were still severely distressed when we saw them, however, and because we did not follow them after the workshop, we do not know how long their severe distress lasted. Duration may be a dimension of severe distress worthy of separate investigation.

Most clinicians are not prepared for the intense emotional responses that accompany a patient’s suicide or for the reactions of the patient’s family and the institutions in which the therapists work. The finding that over one-third of therapists who experience a patient’s suicide suffer severe distress points to the need for further study of the long-term effects of patient suicide on professional practice.