Encountering Patient Suicide: The Need for Guidelines

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Encountering Patient Suicide: The Need for Guidelines

Richard Balon, M.D.

Twenty years ago, Brown (1) pointed out that the sub- As I stated, formal training in suicidology (proposed by

ject of the impact of suicide on therapists-in-training received too little attention. The article by Fang et al. (2) reminds us that things have not changed much since Brown’s review article. As Fang et al. note, there have been a few studies devoted to this topic, but no formal training for residents has been established. Interestingly, even the Comprehensive Textbook of Suicidology (3) devoted only about half of one page of its 650 pages to this topic. Even in that short half page the authors (4) mention the pro- found psychological consequences of experiencing a pa- tient’s suicide, such as intrusive thoughts relating to patient suicide, avoidance of situations that might remind one of the suicide, self-blame, guilt, loss of confidence in one’s professional competence, and fear of losing standing with professional colleagues. We can only speculate about the reasons for this unfortunate lack of attention to this im- portant topic.

I have experienced patient suicide as a resident and as a supervisor of residents whose patients committed sui- cide. Formal training would probably help a little, but I have to say that nothing could fully prepare me as a resi- dent, and the residents I supervised later, for the emotional impact of suicide. As Joel Paris notes, “our greatest fear is losing a patient to suicide” (5). This is not what we are trained for, this is not what we went to medical school for. “Suicide is an emotional issue” (5). We find it emotionally more tolerable to see our patients dying of cancer than of suicide. Cancer is this “mysterious illness” and we had nothing to do with it being inflicted on our patients. We just save people from it. Death of our cancer patients is tough, but tolerable, though barely at times. One feels that he or she lost a battle with a tough enemy. But death by suicide of someone young, physically healthy, to whom we talked just a day or so ago and who hanged or shot himself on our watch? Intolerable. One feels like a total failure. How come I didn’t know, didn’t see it coming, couldn’t stop it . . . ?

Lomax [6] and called for by me [7]) would probably have helped me, and others, a little. We would learn that suicide is impossible to predict and probably unavoidable when you treat certain patients. However, I feel that I, and oth- ers, would probably benefit more from formal or informal support by our supervisors. As a resident coping with pa- tient suicide, I was not totally left alone. We did the psy- chological autopsy and I was “cleared by my senior col- leagues of any wrong doing.” Yet, nobody really talked to me about how I felt, what I thought about my role in the patient’s suicide, my feelings of incompetence, and what I should do following a patient suicide.

During my years as a supervisor, remembering my res- idency experience, I always tried to talk at length to resi- dents whose patients committed suicide. I have seen resi- dents crying, feeling that they totally failed their patient, and feeling that they are not suited for psychiatry. I con- sider one of my greatest supervisory achievements the “case” of a very clinically talented resident whom I helped convince not to quit the residency training because of feel- ings of failing a patient who committed suicide.

One additional blow nothing could prepare me for (and one of the residents I supervised) was the impact of a law- suit that came 2 years later. As Paris (5) writes, “litigation is a nightmare for all therapists who work with people who consider suicide.” Suddenly, the nightmare of the patient’s suicide was back, and this time nobody wanted to talk to me about it at all. One of the supervisors recommended that I talk about it with nobody as “anybody could be then deposed and you could be caught in a web of statements.” The feeling of incompetence and inadequacy only deep- ened. The malpractice insurance company’s lawyer helped, but not much.

Many (8) suggest that contacting families of the patient after suicide and meeting to comfort them helps to de- crease the chance of a lawsuit. However, as Paris (5) writes, “The climate following a complete suicide works against

336 http://ap.psychiatryonline.org Academic Psychiatry, 31:5, September-October 2007RICHARD BALON, M.D.

developing these guidelines. Let us hope the article by Fang et al. and the accompanying commentaries will serve as a stimulus for the collaborative development of these activities, and that we do not have to wait another 20 years for another stimulating yet almost forgotten article.

References

cool reason. The family may be guilty about the outcome, leading them to seek out someone else to blame. At the same time, most therapists tend to feel guilty about a sui- cide. The issue is how to handle that emotion.” That ex- actly has been my experience as a resident and as a super- visor. I did not know how to handle the emotions.

Most of us probably will not be able to avoid a patient suicide during our career. In my opinion, we can learn about suicide in a formal course, but we cannot be fully, if at all, prepared for the emotional toll of patient suicide. However, I believe that we can substantially help our train- ees and colleagues by investing more in a post-patient sui- cide intervention with our trainees. A lot has been pro- posed regarding school-based suicide postvention (4), but what about organized (mandated?) postvention in psychi- atry training programs? The American Association of Di- rectors of Psychiatry Residency Training (AADPRT) should, together with the American Association of Suicid- ology (AAS), develop two guidelines, one for a brief course in suicidology (including the legal issues) suggested by Lomax (6) years ago, and one for postvention by su- pervisors. Perhaps even workshops during the AADPRT meetings would be helpful. The AAS has a lot of experi- ence, enthusiasm, and maybe even resources to help in

1. Brown HN: The impact of suicide on therapist in training. Compr Psychiatry 1987; 28:101–112

2. Fang F, Kemp J, Jawandha A, et al: Encountering patient sui- cide: a resident’s experience. Academic Psychiatry 2007; 340– 344

3. Maris RW, Berman AL, Silverman MM: Comprehensive text- book of suicidology. New York, NY, Guilford, 2000

4. Jobes DA, Luoma JB, Hustead LAT, et al: In the wake of suicide: survivorship and postvention, in Comprehensive Text- book of Suicidology. Edited by Maris RW, Berman AL, Sil- verman MM. New York, NY, The Guilford, 2000, pp 536–561

5. Paris J: Half in Love With Death: Managing the Chronically Suicidal Patient. Mahwah, NJ, Lawrence Erlbaum Associates, 2007

6. Lomax JW: A proposed curriculum on suicide care for psy- chiatry residency. Suicide Life Threat Behav 1986; 16:56–64

7. Balon R: Impact of suicide on therapists in training (letter). Compr Psychiatry 1987; 28:362

8. Gutheil TG: Suicide, suicide litigation, and bordeline person- ality disorder. J Personal Disord; 2004; 18:248–256