I will never forget being told about his death…his death by suicide. He was the first patient I had known or helped treat who died by suicide. I was still a young clinician, fairly new out of internship. My supervisor was his primary provider, but many of us in the clinic had seen the patient and/or engaged with him over the weeks he was in treatment. I had personally seen him for an individual therapy session one week when covering for my supervisor. I will never forget that feeling, or should I say feelings. I could tell by looking at others in the clinic they felt something very similar. I felt a combination of sadness, bewilderment, and even some anxiety. Sadness, for the loss of this individual who was very engaging and thoughtful to all clinic staff. Bewilderment, in the fact that he was one of those patients who denied any past or present suicidal thoughts or behaviors and seemed to be doing well in treatment. And the anxiety…well, maybe that was related to knowing that there could be an investigation. Now I know that Medical Incident Investigations occur to help identify potential lessons learned, but it is also not uncommon for clinicians to feel judged and inspected in the process.
I share all of this and will then add, our clinic was fortunate. That may seem like an odd statement given the tragedy we endured, but we were fortunate in the sense that we felt supported throughout the entire after-action process. Once the clinic was informed of the patient’s suicide, my supervisor, the clinic chief, was asked by leadership to make sure the administrative requirements following a patient suicide would be met. We were a young group of providers under his leadership and we were close. I remember several of us checking in with him to see how he was doing. Although, he was in charge, he was also the patient’s primary provider and we wanted to know he was okay. In response, he did something many leaders may forget to do. He checked in with all of the staff. He acknowledged that many of us knew the patient and were potentially affected by his suicide. He acknowledged that many of us had checked him into appointments, greeted him in the waiting room, took calls from him, and genuinely liked him as a person. He normalized our feelings and offered for any of us to stop by his office to talk if needed. He continued to check in with us throughout the days and weeks following the event, as we did in return with him. The patient was an engaging Airman and his suicide shocked the clinic. However, I remember feeling the clinic pull together and feel comfort in the support we offered one another. It could have had a completely different outcome if we were not allowed the opportunity to process what we were thinking and feeling.
Clinicians are affected when a patient suicides. We may all be affected differently. Some of us may grieve the loss, some of us may question our competence, and some of us may fear seeing future suicidal or high-risk patients. There are also confounding variables that may arise following the suicide event that can complicate or extend the grief process, including legal/ethical issues, administrative requirements, and clinic procedures to name a few.
There are administrative requirements that need to occur following a patient suicide. The requirements may vary across agencies and look different for providers who are in private practice. For those who are part of a clinic, there is often pressure to address these administrative requirements without first checking in with clinicians and clinic staff. It is important for clinic leadership to inform clinicians of the routine administrative requirements following sentinel events prior to an event occurring. This way clinicians are aware of these expectations prior to the tragic event. That being said, it is vital to balance carrying out those tasks while providing support to the clinicians and the clinic staff.
I have seen clinics respond in both extremes. On one end of the spectrum, I have seen clinic leadership jump right into administrative tasks while ignoring the clinician (oftentimes leaving the clinician feeling guilt, shame, fear and anxiety about the event). On the other extreme, I have heard leaders and peer clinicians minimize the impact of a patient suicide, commenting that it is “inevitable” in our line of work. Both extremes can make it difficult for clinicians to process what they are experiencing. For clinicians in private practice, that loss may feel even lonelier. There are still administrative/legal issues to address, but they may lack any peer support. Having a peer to talk to is vital. Some clinicians may even benefit from having a support group to process the loss.
Recently, I have been asked by several peers about support for clinicians who have lost a patient to suicide. I have shared the limited resources I am aware of with them, stressing the factors that I think are most important – support, validation, and a listening ear. It can be difficult to find information and research on clinician survivors. As clinicians, many of us have either experienced a patient’s suicide or have supported a peer who has experienced a patient suicide. Either way, it is never an easy situation to deal with. There is a loss that comes with suicide, one that profoundly affects many people to include family, friends, co-workers, and even clinicians.
One of the best resources I have found is the American Association for Suicidology (AAS). AAS has established a Clinician Survivor Task Force that offers online information, support, and contacts. On their website: http://www.suicidology.org , there is a tab for “Suicide Survivors”, and on the dropdown menu you can select “Clinician Survivors”. If you select “Resources,” it will take you to the Clinician Survivor Task Force site that has a variety of helpful resources. There is a document with basic information about clinicians as survivors, a categorized bibliography, an annotated reference list, personal accounts of clinician survivors, and a list of clinicians who providers can contact about a patient suicide. There is also some very helpful postvention information, which includes postvention guidelines for professionals.
The American Foundation for Suicide Prevention (AFSP) also has several resources for coping with suicide. Although many of the resources are aimed towards friends and family members who have lost a loved one to suicide, I think much of what is written can also apply to clinicians. Under the “Coping with Suicide Loss” tab, select “Resources”. This will take you to a landing page with several resources to include: “Surviving a Suicide Loss: A Resource and Healing Guide,” “Books for Survivors,” and “A Manager’s Guide to Suicide Postvention in the Workplace”. There is a section of books/chapters specific to clinicians. In addition, although the Manager’s Guide is written to assist managers following the suicide of an employee, I think it also has good information for managers who supervise clinicians.
Another resource that I have found helpful is a Harvard Mental Health Letter that can be found at: http://www.health.harvard.edu/newsletters/Harvard_Mental_Health_Letter/2009/November/supporting-survivors-of-suicide-loss. This letter was written in 2009, but continues to have relevant information about supporting friends and family as well as clinicians following a suicide. The three key points outlined in the letter are: “Survivors of suicide loss include family, friends, coworkers, and mental health clinicians; survivors may grieve more intensely, and for longer periods, than people mourning other types of loss; and various psychotherapies and practical ways of expressing support can help survivors cope.”
The Harvard Mental Health Letter addresses much of what I have discussed above. The letter talks about how clinicians experience many of the same emotions as other people mourning a suicide loss and how clinics may lack systems to support clinicians following a patient suicide. In addition, it addresses how very few clinicians receive any training on this in graduate school or in internship training, unless discussed following a patient suicide.
In closing, I will say that I think one of the best things we can do as fellow clinicians is to simply reach out to our peers who have experienced a patient suicide. Letting them know they are not alone and have support can be immensely helpful. We all experience loss differently. It’s best to not assume how a clinician is doing/feeling, but allow them to share their own personal reaction. Giving them space to share their thoughts and feelings and normalizing their experience of the loss can be very beneficial. In our clinic, it even made us grow stronger.
Although there are some resources for clinician survivors as outlined above, it would be great to see more resources readily available to clinicians. Today I am reaching out to all of you to see how we can expand this list and create better supports for our friends and colleagues. What other resources are you aware of? Are there resources that you think would be helpful to add to this blog? I would love to hear YOUR thoughts.
Lisa French, Psy.D. is the Assistant Director of Military Training Programs at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.