For Therapists: Coping with the Suicide of a Person in Therapy

• September 28, 2017
• Contributed by Donald Meichenbaum, PhD

The first person I ever worked with in therapy, when I was a graduate student at the Veterans Administration Hospital in Danville, Illinois, died by suicide. While my supervisor and fellow clinical students tried to reassure me that his death was not my fault, that it was not due to clinical incompetence, I still felt deep down that his death was a reflection of my inexperience. This incident led me to wonder if clinical psychology was, in fact, the ideal occupation for me.

I did become a clinical psychologist, though, and in the 40 years since this initial death by suicide, three other individuals I have provided therapy services to (whether they were people I was directly working with or people a trainee under my supervision was working with) have died by suicide.

Unfortunately, this is not uncommon. Many mental health professionals work with people who are experiencing suicidal thoughts, and some of these individuals die by suicide.

Consider the following:

• Full-time therapists see, on average, as many as 5 people who are suicidal each month, especially those who frequently work with people who have a history of victimization and substance abuse.
• 1 in 2 psychiatrists and 1 in 7 therapists report losing a person in therapy to suicide.
• 1 in 3 clinical graduate students will work with an individual who attempts suicide at some point during their training, and 1 in 6 will experience the death by suicide of an individual.
• 1 in 6 individuals die by suicide while in active treatment with a health care provider.
• Working with people who are at high risk for suicide is considered the most stressful of all therapy practice endeavors. Therapists who lose a person to suicide may experience such a loss to the extent they would experience the death of a family member. The loss of a person in therapy by suicide can become a career-ending event.
• The distress therapists experience after losing a person in treatment to suicide can be further exacerbated by possible legal actions. Of those who die by suicide, 25% of family members choose to take legal action against the individual’s mental health care team (Bongar, 2002; Kleespies, 2017).

What Can Therapists Do After Losing Someone to Suicide?

It is important for therapists who work with individuals experiencing thoughts of suicide, are at high risk for suicide, and/or have attempted suicide to take certain steps to help themselves in order to continue their work.

Therapists who have a strong support network, who maintain a sense of hope and optimism, and who remember to practice self-care are more likely to be more able to overcome adverse events, such as the loss of a person in therapy to suicide.

One essential first step is documentation. Therapists who work with people at risk for suicide must document risk and protective factors, as well as accompanying interventions, in their progress notes.

The American Association of Suicidology offers a wealth of useful advice to mental health professionals who have lost a person in therapy to suicide. I have provide some additional suggestions to accompany their recommended procedural and psychosocial steps

Procedural steps to take immediately after losing someone to suicide: 

• Notify your supervisor and supportive colleagues, as well as the director of your service.
• Contact the hospital attorney.
• Consider contacting the family members of the person in therapy. Whether you choose to do so is likely to depend on the circumstances of the situation. You may wish to ask the family members if they would like you to attend the individual’s funeral.

 Psychosocial steps to meet your emotional needs:

• Seek support from your supervisor, colleagues, and significant others.
• Attend to your needs to mourn or grieve the loss of the person, whatever form that grieving process may take.
• Monitor any self-blame, hindsight, or biased thinking processes and utilize helpful methods of coping to deal with these and any stress they may cause.
• Use cognitive strategies to cope with the emotional aftermath of the person’s suicide, seeking help from a professional when necessary. For example, engaging in the mindful path of self-compassion can be a helpful way to cope (Gerber, 2009).

 Pursuing further education:

• Review your progress notes.
• Write a case summary of the ongoing risk assessment and the course of treatment interventions.
• Enumerate the lessons you learned from the death and share this, when able to do so, with interested and supportive others.
• Make a gift of this professional experience to others. By sharing the loss and what you have learned from it, you can help create awareness and help others learn.
•  You may find it helpful to include a supervisor, colleagues, or review groups in the process of pursuing further education on suicide and working with people who are suicidal.
• Finding ways to work with others to reduce suicide can often be a key component of this process.

Resilience is an essential component for those who work with people at risk for suicide. Therapists who have a strong support network, who maintain a sense of hope and optimism, and who remember to practice self-care are more likely to be more able to overcome adverse events, such as the loss of a person in therapy to suicide. Bolstering resilience can allow mental health professionals to become better able to cope with such a loss and experience posttraumatic growth following the death of a person in treatment.

References: 

1. Bongar, B. (2002). The suicidal patient: Clinical and legal standards of care. Washington, DC: American Psychological Association.
2. Gerber, C. K. (2009). The mindful path to self-compassion: Freeing yourself from destructive thoughts and emotions. New York, NY: Guilford Press.
3. Hernandez, P., Engstrom, D., & Gangseei, D. (2010). Exploring the impact of trauma on therapists: Vicarious resilience and related concepts in training. Journal of Systemic Therapies, 19, 67-83.
4. Kleespies, P. M. (2017). The Oxford handbook of behavioral emergencies and crises. New York: Oxford University Press.
5. Meichenbaum, D. (2005). 35 Years of working with suicidal patients: Lessons learned. Canadian Psychologist, 46, 64-72.
6. Meichenbaum, D. (2006). Trauma and suicide. In T. Ellis (Eds.), Cognition and suicide: Theory, research and practice. Washington, DC: American Psychological Association.
7. Meichenbaum, D. (2014). Roadmap to resilience. Williston, VT: Crown House Publishing.
8. Meichenbaum, D. (2017). Self-care for trauma psychotherapists and caregivers: Individual, social and organizational interventions. Retrieved from https://www.melissainstitute.org/documents/Meichenbaum_SelfCare_11thconf.pdf
9. Norcross, J. C., & Guy, J. D. (2007). Leaving it at the office: A guide to psychotherapists’ self-care. New York, NY: Guilford Press.
10. Pope, K. S., & Vasquez, M. J. (2005). How to survive and thrive as a therapist. Washington, DC: American Psychological Association.
11. Wicks, R. J. & Maynard, E. A. (Eds.) (2014). Clinician’s guide to self-renewal. New York, NY: Oxford University Press.

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