Editor’s note: The opinions expressed by the authors do not necessarily reflect the opinions of the AAMC or its members.
Several years ago, in a psychiatric hospital where I worked, a colleague’s patient suddenly took her own life. The patient seemed to be doing well in therapy, and my colleague was utterly devastated by the loss. She wondered over and over if she had missed warning signs or failed to hear something her patient had been trying to tell her. In the immediate aftermath, my colleague withdrew from coworkers, spent hours going over her notes, and experienced many painful feelings, including anger at her patient and her patient's family. Later she told me about the sense of disbelief and defeat she felt from losing a patient after having worked so hard with her. Even several years afterward, she said, feelings of sadness about the suicide emerged at unexpected moments.
And the death did not affect just my colleague. Throughout our small hospital, many staff members and trainees were struck by terrible sadness. Confusion and blame also spread among us as we pondered a deluge of questions that often can emerge following a patient suicide.
Since that time in the mid-1990s, the suicide rate in the United States has risen by over 30%, and suicide is now ranked as the tenth leading cause of death. More than 47,000 people ended their own lives in 2017, and an estimated 129 people die by suicide each day in this country.
Those disturbing statistics mean that a growing number of physicians and other providers will lose a patient to suicide. For example, studies show that between 20% and 60% of psychiatrists experience a patient suicide at some point. And many providers will be unprepared for the emotional and professional devastation that can follow.
What’s more, the experience can be especially tough for trainees and those early in their careers, as they are just developing a sense of expertise and can be particularly susceptible to self-doubt and professional embarrassment.
[T]he death of a patient by suicide can produce enduring personal and professional distress — and may even cause a provider to leave their chosen field.
If we are going to promote employee and trainee well-being, we need organizational policies and procedures that recognize the possibility of patient suicide and that support staff when it happens. If we fail to do so, we are ignoring the painful reality that the death of a patient by suicide can produce enduring personal and professional distress — and may even cause a provider to leave their chosen field.
I have spent more than two decades studying the reactions of clinicians who have experienced a patient suicide and have spoken with dozens of providers who shared their personal stories of loss and healing. Most notably, I conducted an in-depth research project interviewing psychotherapists around the country about losing a patient to suicide and the impact that experience had on them immediately afterwards and even many years later.
Although each person’s reactions differed, my research revealed certain recurring themes. Those I interviewed described experiencing sadness, fear, anger, and episodes of crying. In fact, several of my interviewees unexpectedly cried as they shared their stories with me. More than half described having disturbing dreams, including ones with vivid death scenes. Often, they were plagued by doubts over their professional abilities — in some cases for weeks, months, or years — and even the effectiveness of their entire field. Their experiences also sometimes spilled over into their work with other patients as they worried about the unbearable possibility of losing someone else.
[Providers’] experiences also sometimes spilled over into their work with other patients as they worried about the unbearable possibility of losing someone else.
And then there were worries about practical matters, like fear of a lawsuit, worry about what a patient’s family might say, decisions about whether to attend a memorial service, and concerns over how their career might suffer.
One interviewee’s story offers a glimpse into what can be a profoundly upsetting experience. The provider, who I will call Dr. A, had been treating a patient for two months when the man took an overdose of psychopharmacological medications and walked off into the woods, where he was found dead two days later. When she heard the news, she told me “I was absolutely stunned and completely and immediately traumatized. I was absolutely shocked.”
Dr. A talked about how horribly sad she felt long after the suicide. She shared that she had imagined what it must have been like for her patient to die alone, cold, and in the woods. She went on to say that even three years later, “When I notice beautiful things in the world, or my own progress in my life or my training, I think about how none of that is possible for him and there is just tremendous grief.” She also experienced significant professional self-doubt. “I really thought that if you were good enough, you can help almost everybody,” she told me.
Dr. A described connecting with some of her colleagues as an important aspect of processing her painful experience. “It was very important for all of us involved in his treatment to share the last contacts we had with him and what he had said, what we had said, and where we were left … searching for anything that could help us make sense of it.” Working closely with her own therapist, Dr. A added, also helped her accept that it was not necessarily within her power to save all her patients.
She shared that she had imagined what it must have been like for her patient to die alone, cold, and in the woods.
At one time, training programs rarely provided information to help providers like Dr. A prepare for such a loss. Over the years, some programs have made suicide loss education a standard part of their curriculum, but much more work still needs to be done. Based on my experience in the field, I would estimate that less than half of psychiatric residency programs provide this kind of training.
Each year, I teach a workshop at the American Psychiatric Association with my colleague Eric Plakun, MD, about how individuals, colleagues, and organizations can prepare for and respond to the death of a patient by suicide. Although our recommendations are designed for psychiatrists, psychologists, and social workers, much of what we suggest can be used by anyone hoping to prepare staff members for such a possibility or to help staff deal with suicide once it occurs.
We advise taking a two-pronged approach, teaching about the possibility of losing a patient to suicide and related effects as a standard part of curricula — and then providing education and support following a patient suicide.
Below are some of our key suggestions:
- Educate staff on what to expect. Knowing what feelings may arise can be hugely helpful, so we suggest educating staff about the possible range of reactions they may experience, including a sometimes-unexpected response of feeling almost nothing about the death. This knowledge also can prevent alienation between coworkers struggling to comprehend each other’s experiences. For example, staff who are not suffering a great deal may become impatient with those who experience intense or lengthy grief, particularly if they believe the staff member wasn’t very close to the patient.
- Offer to meet with the family. Practitioners often ask whether they should meet with the deceased patient’s family. We recommend asking whether the family would like to meet, but certainly not pressuring them to do so. The purpose of such a meeting is to listen to the family’s concerns, answer questions without violating patient confidentiality, and offer sincere condolences. It is not an opportunity for the practitioner to focus on his or her personal loss. Also, the provider should know that although the meeting could be quite healing, it also can be painful if a family unleashes anger and blame — or even seems insufficiently affected by the suicide.
- Have both short- and long-term plans following a patient suicide. Accrediting agencies require sentinel event reviews and root cause analyses to explore an unanticipated death, but those are meant to improve performance. We recommend meetings with staff to specifically address the many emotions they may experience. What's more, sessions hosted for specific groups such as residents may allow them to speak more openly about their experiences. Sometimes a “psychological autopsy” that reconstructs circumstances related to the death is useful, but those involved should remember to avoid a quest to ascribe blame that can corrode morale and well-being. Conversely, it’s important to be sensitive when attempting to reassure staff that everything possible had been done for the patient, since such assurances can be uncomfortable for clinicians who still have feelings of guilt.
- Make sure that organizational leaders set a supportive tone following a patient suicide. Practitioners who lose a patient to suicide are often concerned about professional stigma, and a climate of support can lessen those feelings. Sometimes, providers who lose a patient to suicide are reluctant to take time for self-care, as they hope to convey the impression that they are functioning fine. At such times, institutional support for self-care may decrease those feelings. It would be a shame if providers suffering a significant loss feel they can’t afford to take time for rest, exercise, meditation, and other personal supports.
- Continue checking in even months later to see how bereaved staff are coping. Follow-up meetings with staff who are most affected, additional support through psychotherapy referrals, or other measures to support staff well-being may be necessary for weeks and even months after a patient suicide.
[A] “psychological autopsy” that reconstructs events and circumstances related to the death can be useful, but those involved must be careful to avoid a quest to ascribe blame that can corrode morale.
The suicide of a patient can be a terribly traumatizing and humiliating experience for a practitioner. Providing support and decreasing the stigma around patient suicide and the feelings that go with that loss are essential if we are going to support the well-being and professional growth of the many providers who may face such a loss.
Jane G. Tillman, PhD, is director of the Erikson Institute for Education and Research at the Austen Riggs Center and a clinical assistant professor in the Child Study Center at Yale Medical School.