A young woman James L. Werth Jr., PhD, was seeing in therapy during his practicum at Auburn University was learning to cope with her difficult emotions in better ways than binging and purging. He had every reason to believe she'd keep moving in a positive direction during what would have been her ninth therapy session.
Instead, the woman never showed up for their meeting. The following week, she arrived at her scheduled time and told him she had been hospitalized for attempting to take her life.
"I was just floored," says Werth, now an assistant professor in the department of psychology at the University of Akron. "All of these questions came rushing into my head--What did I do wrong? How could I miss this?"
The evening of her suicide attempt, the woman had broken up with her boyfriend. Werth hadn't yet had a chance to help her develop coping mechanisms for a situation as devastating as a breakup, and consequently, "she had figured out another way to cope," he says.
Fortunately for Werth, his on-site supervisor's specialty was eating disorders and after re-reviewing tapes from the counseling sessions, she assured him that his work with the woman was appropriately helpful and empathic. He also had the chance to air his feelings in a two-hour debriefing with his departmental supervisor and fellow students.
"If I hadn't received such positive support, I might have quit," he says. "It showed me how important it is to have had that support."
Many clinicians are not so lucky. Despite the fact that at least one in five mental health professionals loses a patient to suicide, many who have experienced such a loss say they received little or no support from colleagues, supervisors or administrators.
Some fear being shunned by colleagues, sued by the client's family or ostracized by the profession. In effect, they face an impossible emotional task: trying to cope with intense grief, anger and pain and at the same time suppressing those feelings for fear of professional disapproval.
Fortunately, there are beginning to be more resources to help clinicians faced with such trauma. The American Association of Suicidology (AAS)--a national organization that promotes research on suicide and provides education and training for professionals, survivors and the public--has created a task force to address the concerns of what it's dubbed "clinician-survivors." The group has developed an assortment of activities to promote its cause, including lobbying for suicide assessment and debriefing training in more graduate programs, and for standard postsuicide protocols in hospitals, clinics and other health-care facilities.
The political climate bodes well for its efforts. Last year, Surgeon General David Satcher, MD, released the first-ever "National Strategy for Suicide Prevention," which expands on his earlier "Call to Action to Prevent Suicide," a 1999 document that declared suicide a public health problem. The first installment of the strategy outlines 11 goals and 68 objectives to be used in both public and private arenas for suicide prevention.
Slowly, the difficult subject of client suicide is moving from the back burner, though more work is ahead, says AAS Executive Director Lanny Berman, PhD.
"The field needs to become more enlightened about how to help therapists learn from the tragedy of a patient's suicide," says Berman. "Too often, postmortem reviews either do not occur or are cursory. To learn something from a patient's death requires that both therapist and supervisor be willing to ask and answer tough questions with humility and nondefensiveness."
A sin and a crime
One reason the field's attitude toward patient suicide lingers in the closet is that suicide itself remains shrouded in mystery and shame.
"The taboo aspect of suicide has diminished, but it isn't absent," says Norman Farberow, PhD, co-founder of the Los Angeles Suicide Prevention Center. "There's still a tendency to condemn and disparage the person who dies by killing himself or herself."
It's also difficult for clinician-survivors to admit and face their feelings, even though it's likely that they did a good job and had nothing to do with the suicide, research suggests. Nonetheless, a recent unpublished survey of 91 therapists, conducted for the AAS clinician-survivor task force, found that therapists commonly cited sadness, depression, hopelessness, guilt and anger as reactions to a patient's suicide.
"I just felt so alone on both a personal and professional level as I dealt with the loss of my client," recalls Judy Meade, a licensed marriage and family therapist in Vienna, Va., who lost a client to suicide a decade ago. She lost 12 pounds in 12 days, tortured herself with repeated thoughts about the event and questioned whether she should remain in the profession. "It was only later that I learned that my feelings of grief, anxiety and guilt were similar to other clinicians' experiences," says Meade, who today serves on the AAS clinician-survivor task force.
In the ensuing years, Meade's efforts to find colleagues willing to talk about their experiences have been difficult at best. The irony, of course, is that helping people discuss and work through their feelings is the mental health profession's stock in trade, says Frank Campbell, a social worker who heads the Baton Rouge Crisis Intervention Center in Baton Rouge, La.
"We've got to get to the point where we can face ourselves in the mirror and look at the faces of others without the fear they will judge us," Campbell says. "I decided to practice what I preach--and it's a relief."
Fear and risks
In addition to being unable to face their own feelings about a patient suicide, the mental health hierarchy may "whitewash" these deaths, underplaying their importance for legal reasons or to protect practitioners' and the profession's reputations, those involved say.
The supervisor's conflicting role--on one side, supporting trainees, and on the other, being responsible for trainees' actions--demonstrates how this dynamic can unfold. Jason S. Spiegelman, a psychology doctoral candidate at the University of Akron and a predoctoral intern at Johns Hopkins, recalls the rush of bureaucratic events that left him feeling unsupported, lost and angry after a client completed suicide during Spiegelman's training at a clinical master's program in California.
By happenstance, both Spiegel-man's immediate supervisor and secondary supervisor were out of town when the incident occurred. "In the aftermath, there was a very rapid push by the administration to have questions answered and accountability assigned," Spiegelman says. "They asked me very directed questions about the suicide and suggested that I needed to explain what caused it. I felt like I was being blamed."
When he asked if he could discuss the suicide with his supervisor before continuing to talk with administrators, they told him, "No, we need to have these answers now." It wasn't until a supervisor at a different institution addressed the issue with him a year later that he was able to acknowledge the shock of the episode, Spiegelman says. He has since become a member of the AAS board and is considering writing his doctoral dissertation on factors that may drive people to suicide.
Studies confirm the importance of supporting interns during such crises. In a survey of 292 clinicians at 11 intern sites throughout Massachusetts, Boston Department of Veterans Affairs psychologist Phil Kleespies, PhD, and colleagues found that supervisory support was more helpful than support from peers, family or significant others in helping interns cope with difficult clinical events. "Especially with young clinicians, it's critical to have a responsive supervisor," Kleespies says. "In phone surveys, we heard about some unfortunate instances where trainees were told to 'keep quiet about this, because the image of the clinic will suffer.'"
Other trainees were warned to keep things to themselves because of the potential of legal discoverability--that if a trainee discussed the case with his supervisor, the material could be used in court. "This effectively cuts the trainee off from a major source of support," Kleespies says.
The survey was published in the March 1993 issue of Professional Psychology: Research and Practice (Vol. 24, No. 3).
The road ahead
There's much being done, and much that remains to be done, to address the way mental health professionals respond to this painful reality. One major area in need of improvement is graduate training in suicide assessment and debriefing.
A survey of the nation's psychology internships and psychiatry residency programs by Thomas E. Ellis, PsyD, and Thomas O. Dickey, MD, of the West Virginia University School of Medicine, finds that while most programs offer some instruction in treating suicidal patients, large gaps remain. For example, only 38 percent of psychology programs offer specific instructions on what trainees should do in the event of a suicide. Likewise, only 30 percent of such programs specify postsuicide procedures in a policy and procedures manual.
Furthermore, specialized workshops--one of the most comprehensive ways to deliver such information--are offered in fewer than half of psychology internship programs and only 28 percent of psychiatry residency programs, according to the study, reported in Professional Psychology: Research and Practice (Vol. 29, No. 5). Also, only 8 percent of psychology programs and 5 percent of psychiatry programs provide trainees with counseling after a suicide, the study finds.
There is help available, meanwhile, at the AAS Web site--www.suicidology.org--which provides resources that can enable clinicians to forge links with other clinician-survivors. The site includes detailed stories of clinicians' experiences and urges clinicians to contact members of the task force if they're interested. It also provides basic information on the topic, paper references and links to other Web sites.
To date, APA hasn't addressed the issue of patient suicide in any formal way. However, AAS plans to begin a dialogue in the near future with all of the mental health professional organizations, including APA, regarding setting training standards, says Berman.
All of these efforts may eventually help put the act of client suicide into a more realistic perspective, those affected say.
"As therapists, we must understand that a person's decision to take his or her own life is that person's own decision," says Farberow. "Our ultimate responsibility is to do everything we can to help the person."
Adds Spiegelman, "Suicide is an occupational hazard of being in the mental health industry. When it happens, you have to remember that you may have done everything right--but it can still happen."
The American Association of Suicidology can be reached at www.suicidology.org; (202) 237-2280.
Tori DeAngelis is a writer in Syracuse, N.Y.