Psychotherapy Bulletin

Psychotherapy Bulletin

Patient Suicides: Preparing Students for Difficult Challenges

Having a patient die from suicide is one of the events most feared by psychotherapists, yet a recent survey found that 6% of psychologists had at least one patient die from suicide while in treatment in the last year (Leitzel & Knapp, 2021). The ongoing possibility of a patient’s suicide prompted Simon (2011) to write “There are two types of psychiatrists—those who have had patients die from suicide and those who will” (p. 177).  

Of course, more competent psychotherapists are less likely to have patients die from suicide. Nonetheless, many psychotherapists who had patients die from suicide were delivering high-quality, evidence-based services. For example, cognitive behavior therapy is a highly researched and effective treatment for suicidal patients that outperforms treatment as usual in clinical trials. Even so, in one important study, 8 of the 76 participants receiving cognitive behavior therapy attempted suicide during the study (Rudd et al., 2015). Although this was far fewer than the number of suicide attempts in the treatment as usual condition, it shows that even patients receiving state-of-the-art services have a risk of attempting suicide.  

Patient suicides can occur under many circumstances. Sometimes, the psychotherapist had just met the patient; at other times, the psychotherapist had been treating the patient for a long time and had a considerable emotional investment in their relationship. Sometimes, the psychotherapist was the sole treatment provider; at other times, the psychotherapist was only one provider in a multidisciplinary treatment team. Sometimes, the psychotherapist knew that the patient had suicidal thoughts; at other times, the suicide came without warning. Sometimes, the psychotherapist and the family shared their grief; at other times, family members blamed the psychotherapist for the suicide (e.g., “If it wasn’t for you, my parent/spouse/child would still be alive today!”).  

 Although every psychotherapist’s reaction to their patient’s suicide is unique, some common themes emerge. Psychotherapist survivors of patient suicides often feel great emotional distress. Upon learning of the suicide of their patients, most mental health professionals felt shocked and stunned, and between 12% and 53% developed symptoms such as depression or anxiety that lasted for months or even years (Sandford et al., 2020). The impact may be especially hard on trainees still developing their professional identities (Gill, 2012). Psychotherapists are secondary victims of patient suicide but have unique factors that complicate their grief. Some may believe that their grief is less important than the grief experienced by others. Also, they may not have the same rituals available to other grieving persons, such as attending the deceased's funeral. They often feel deep regret or guilt that they could have done more to save their patient or missed some essential facets of care in some way linked to their patient’s death. Finally, the grief may be complicated by a fear of being accused of negligent conduct.   

The suffering may be reduced if the psychotherapists received social support following the suicide. Social support protects against professional burnout (Yang & Hayes, 2020) and is even more important following a professional crisis such as a patient suicide. One psychologist-in-training reflected on the support he received from his supervisor: “If I hadn’t received such positive support, I might have quit” (DeAngelis, 2001, p. 71).  

Other psychotherapists changed their practice patterns following a patient’s suicide. Some became more thorough or cautious when working with suicidal patients and sought more continuing education on suicide (Furqan et al., 2023). Nevertheless, the changes were not always positive. Reflecting on one’s practices may be helpful, but brooding or feeling shame is not. Others reported being less willing to treat suicidal patients or felt less effective with their suicidal patients. One professional wrote, “I felt though I was not as emotionally available as I normally am for patients and did not give hope with the same conviction as I normally would” (Croft et al., 2023, p. 249). Another psychiatrist stated, “I think I was more hesitant to discharge people who were suicidal for some time after that and, you know, that’s like 60% of my patients. . . I don’t think it was a positive” (Furqan et al., 2023, p. 193).  

In addition to the grief following the suicide of a patient, psychotherapists often fear that they will be sued or otherwise disciplined, even though the number of malpractice suits for outpatient suicides is rare (Knapp et al., 2013). Of course, a few psychotherapists may have acted with egregious disregard for the well-being of their patients, such as casually dismissing the concerns of patients who disclosed thoughts about suicide (e.g., “If you were serious, you would have killed yourself already”). Nonetheless, as noted previously, the death of a patient does not necessarily mean that a psychotherapist acted negligently. Many patients died from suicide while receiving evidence-based services from competent and compassionate professionals. Absent egregious behavior, we do not want to compound the death of a patient by an unwarranted assumption of guilt or an unjustified fear of an allegation of negligence.  

Four Steps to Prepare Students for a Patient Suicide 

Although a patient suicide is a possibility for all psychotherapists, training programs can reduce the likelihood of a patient suicide and also prepare their students for the possibility of a suicide by ensuring that their students can identify their professional obligations accurately and learn the competencies necessary to treat suicidal patients, including risk management strategies and self-care skills. 

Ensure Competence

Trainers can ensure that they teach the essential topics about suicide assessment and prevention (e.g., Cramer et al., 2013) and that their trainees have basic competencies in treating suicidal patients. (To facilitate learning about suicide prevention, I have developed a suicide glossary and test questions that I will share with any interested reader. Contact me at Samuelknapp52@yahoo.com). The research is clear that certain evidence-supported practices can save lives (e.g., Bryan, 2021; Nuij et al., 2021). Ensuring trainee competence would reduce the likelihood that the trainee would have a patient die from suicide. Also, if a patient were to die from suicide, the trainee would have the assurance that they delivered a high quality of service to their patients. That knowledge may reduce the likelihood of unwarranted guilt on top of the natural grief that all psychotherapists would feel in these circumstances.  

Focus on the Role of Psychotherapists

Trainers can teach their students about the proper role of a psychotherapist. No psychotherapist can prevent all suicides, and no psychotherapist can guarantee that their patients will live. They cannot monitor their outpatients 24 hours a day and have no or minimal control over external events in their patients’ lives. They cannot, for example, know if a factory will close down, resulting in a layoff for their patient, whether the patient’s spouse will leave them, or whether investments will suddenly decrease in value, resulting in a patient’s bankruptcy.  

Jobes (2023) stated “While we cannot guarantee a nonfatal outcome, we can nevertheless provide the best possible clinical care to every patient, including those with suicidal thoughts” (p. 60, italics in original). I initially had difficulty accepting this perspective because I misinterpreted it and assumed that I was relinquishing all responsibility for the patient’s well-being or exonerating myself for clinical errors. Nonetheless, upon reflection, I found the perspective of Jobes to be liberating. It expresses an appropriate level of humility. It recognizes the limitations of the psychotherapist’s ability to stop all suicides yet acknowledges the power of psychotherapists to help patients make positive changes. It allows psychotherapists to focus on their patient’s needs, empowering them, and respecting their decision-making without continually second-guessing everything they do.  

Jobes also emphasized direct honesty with patients and acknowledged that they have the final decision on whether they want to live or not. In an example of his informed consent process, Jobes wrote, “I would rather not debate with you whether you can kill yourself. Instead, I would propose that we consider a proven treatment that is designed to decrease your suffering and help save your life. The clinical treatment research shows that most people who are suicidal respond quickly to this treatment... So why not give it a try” (2023, p. 7).  

Teach Risk Management Strategies

Trainers can teach their students about ethically based risk management principles that focus on anticipating problems, such as listening carefully to patients when conducting a thorough evaluation and explaining treatment processes clearly to their patients. They can also teach students the importance of collaborating with their patients and detecting problems early in treatment by routinely asking patients about their perceptions of the treatment process and their progress toward reaching their goals (Knapp, in press). Finally, students can learn to seek consultation whenever the risk of a treatment failure arises and to document services carefully, especially in high-risk situations (Knapp et al., 2013).  

Promote Self-Care

Trainers should emphasize self-care. Although having high standards and engaging in self-reflection is good, excessive self-criticism, perfectionism, or the lack of self-compassion are associated with psychotherapist burnout (Yang & Hayes, 2020), and the death of a patient can activate these maladaptive schemas.   

Working with suicidal patients can be difficult because of the high stakes involved and because many patients lack social resources or have comorbidities that make treatment difficult. Even a nonfatal suicide attempt can be jarring for psychotherapists. Although some anxiety when working with suicidal patients is inevitable, students with adequate training and professional resources should feel confident that they can deliver high-quality services. Joiner (2005) identified the harmful attitudes of being dismissive (that denies or minimizes the threat of suicide) or alarmist (which overreacts to any suggestion of suicide). A third and helpful attitude is concerned alertness, which shows attention to the risk of suicide but responds with measured concern (Knapp, 2022).  

The proper way to handle fears and anxiety when working with patients, especially suicidal patients, is to admit and talk about those feelings. When painful emotions arise, it is best to process them by identifying, labeling, and sharing them. As Sternlieb (2013) has written, “You have to name it to tame it.” In addition, seeking out social support and connecting with others at this time is highly important; again, as Sternlieb has written: “You have to share it to bear it” (2013, p. 21).

Summary

The death of a patient by suicide is a painful possibility, even for experienced psychotherapists delivering high-quality services. Nonetheless, trainers can prepare their students by teaching them  

  • The competencies necessary to treat suicidal patients. 
  • To adopt an attitude of humility when treating suicidal patients, which means recognizing that they should focus on delivering high-quality services and cannot guarantee that their patients will live.  
  • To rely on ethically based risk management strategies that focus on the quality of patient care.  
  • To promote self-care by practicing self-compassion and recognizing and sharing their feelings in a protective social network.  
Cite This Article

Knapp, Samuel. (2023). Patient Suicides: Preparing students for difficult challenges. Psychotherapy Bulletin, 58(4), 17-21.

References

Bryan, C. J. (2021). Rethinking suicide. Oxford.  

Croft, A., Lascelles, K., Brand, F., Carbonnier, A., Gibbons, R., Wolfart, G., & Hawton, K. (2023). Effects of patient deaths by suicide on clinicians working in mental health: A survey. International Journal of Mental Health Nursing, 32(1), 245-276. http://doi.org.10.1111/inm.13080 

DeAngelis, T. (2001). Surviving a patient’s suicide. Monitor on Psychology, 32(9), 70-75. 

Furqan, Z., Cooper, R. B., Lustig, A., Simyor, M., Nakhost, A., Kurdyak, P., Rudoler, D., Naeem, F., Stergiopoulos, V., & Zaheer, J. (2023). “I was close to helping him but couldn’t quite get there”: Psychiatrists’ experiences of a patient’s death by suicide. The Canadian Journal of Psychiatry, 68(3), 187-199. http://doi.org/10.1177/07067437221125300 

Gill, I. J. (2012). An identity theory perspective on how trainee clinical psychologists experience the death of a patient by suicide. Training and Education in Professional Practice, 6(3), 151-159. http://doi.org/10.1037/a0029666 

Jobes, D. (2023). Managing suicide risk: A collaborative approach. (3rd ed.). Guilford.  

Joiner, T. (2005). Why people die by suicide. Harvard.  

Knapp, S. (2022). Helping psychotherapists adopt productive responses to suicidal patients. Psychotherapy Bulletin, 57(2), 6-11.  

Knapp, S. (in press). Listen, explain, collaborate, evaluate: Why promoting autonomy helps suicidal patients. Ethics and Behavior. http://doi.org/10.1080/10508422.2022.215338 

Nuij, C., van Ballegooijen, W., de Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., O’Connor, R. C., Smit, J. H., Kerkhof, A., & Riper, H. (2021). Safety planning-type interventions for suicide prevention: meta-analysis. British Journal of Psychiatry, 219(2), 419-426. http://doi.org/10.1192/bjp.2021.50 

Rudd, M. D., Bryan, C. J., Wertenberger, E. G., Peterson, A. L., Young-McCaughan, S., Mintz, J., Williams, S. R., Arne, K. A., Breitbach, J., Delano, K., Wilkinson, E., & Bruce, T. O. (2015). Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: Results of a randomized clinical trial with 2-year follow-up. American Journal of Psychiatry, 172(5), 441-449. http://dx.doi.org/10.1176/appi.apj.2014.14070843 

Sandford, D. M., Kirtley, O. J., Thwaites, R., & O’Connor, R. C. (2020). The impact on mental health practitioners on the death of a patient by suicide: A systematic review. Clinical Psychology and Psychotherapy, 28(2), 261-294. http://doi.org/10.1002/ccp.2515 

Simon, R. I. (2011). Preventing patient suicide. American Psychiatric Association.  

Sternlieb, J. (2013, September). A continuum of reflective practices: What, how and why—Part I. Pennsylvania Psychologist, 71(9), p. 21.  

Yang, Y., & Hayes, J. (2020). Causes and consequences of burnout among mental health professionals: A practice-oriented review of recent empirical literature. Psychotherapy, 57(3), 426-436. http://doi.org/10.1037/pst0000317 

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