A patient's suicide is an occupational hazard for psychiatrists, one that
leaves a torrent of personal and professional aftershocks, said Eric M.
Other medical specialists face the death of their patients, but the
self-inflicted death of a psychiatric patient may differ in its effect on the
treating physician because of the different nature of the doctor-patient
relationship, said Plakun, director of admissions and professional relations
at the Austen Riggs Center in Stockbridge, Mass. He spoke last month at the
48th winter meeting of the American Academy of Psychoanalysis and Dynamic
Psychiatry in Washington, D.C. "It makes us wonder why we didn't go into
Suicide accounts for more than 30,000 deaths a year in the United States.
Its incidence may well be underreported, given the stigma and possible
insurance problems associated with it. Psychiatric disorders like alcoholism,
schizophrenia, borderline personality disorders, and major depressive episodes
are risk factors for suicide. Moreover, many people who commit suicide are
often already being treated by a psychiatrist or mental health
Perhaps half of all psychiatrists can expect a patient to commit suicide
during their careers. And 1 in 6 psychology interns and 1 in 3 psychiatry
residents have experienced a patient's suicide during training, said Plakun.
Higher rates in training probably occur because junior residents are often
assigned to vulnerable populations in emergency or inpatient settings.
"There are three kinds of psychiatrists: those who have had a patient
commit suicide, those who will have one commit suicide, and those with
both," said forensic psychiatrist Robert I. Simon, M.D., a clinical
professor of psychiatry at Georgetown University Medical School and chair of
the psychiatry department at Suburban Hospital in Bethesda, Md. "If you
practice long enough, someone will commit suicide. It's
Eric Plakun, M.D.: "Too often therapists deal with [a patient's
suicide] in isolation" instead of discussing it with colleagues.
Research reveals that the event is neither simple nor shortlived.
For instance, one-quarter of 239 responding graduates of a University of
Toronto residency program said that experiencing a patient's suicide had a"
profound and enduring effect on them throughout their careers as
physicians." Plakun likens the experience to hovering on the edge of a
"If a psychiatric patient suicides, a murder is committed, and the
murderer is our patient with whom we have had an empathic relationship,"
Jane Tillman, Ph.D., a staff psychologist and manager of performance
improvement at Austen Riggs interviewed 12 therapists about the impact of
patient suicide on their lives and careers. From this research, several common
themes have emerged, reported Plakun. Shock, numbing, anger, and grief assert
themselves first, often followed by a sense of unreality, disconnection, or
withdrawal. Some doctors have a hard time overcoming the feeling that"
it could never happen to them." They may experience a sense of
survivor's guilt in that the "murderer" has chosen to kill himself
or herself rather than the therapist. They may feel overwhelmed by shame and
humiliation at "failing" a patient.
Some psychiatrists may even endure a crisis of faith about their training
and therapeutic work. They may switch to a purely psychopharmacological
approach to minimize the personal connection with patients. Others decide not
to work with overtly suicidal patients. Fear of litigation is a natural
consequence as well. Relationships with colleagues may suffer if therapists
feel stigmatized as incompetent or worse by their peers.
However, if psychiatrists are only a flip of the coin away from having a
patient commit suicide, perhaps the profession should build preparation for
dealing with it into the residency curriculum, argued Plakun.
Simon, author of Suicide Risk, published in 2004 by American
Psychiatric Publishing Inc., advised new residents: "Be sure you learn
how to do a competent, systematic, suicide-risk assessment."
Besides assessing and treating suicidal patients, training should include
lectures and role playing to improve young clinicians' understanding of the
aftermath of suicidal events, added Plakun.
Once a suicide occurs, Plakun advised clinicians to seek consultation and
support and to avoid isolation. "Recognize that you won't be able to
think clearly about it for a while," he said. "Too often
therapists deal with this in isolation rather than risk difficulties with
colleagues. It's hard to talk about it with them."
A formal discussion of the patient's death will be covered by a JCAHO
sentinel event review if an institution is involved. More than the usual
morbidity and mortality conference is needed, however. Plakun also recommended
that clinicians find a "secure, peer-reviewed, protected space" to
consider the event as a traumatic experience affecting both the therapist and
the entire staff.
Legal requirements vary from state to state, but Plakun and Simon advised
consulting with insurance carriers or attorneys regarding subsequent
Finally, the clinician should prepare for contact with the patient's
family, said Plakun. He advised meeting them in person after giving some
thought on how to manage issues of confidentiality.
"Lawyers tell you not to make any statements, but a professional must
understand what makes the family feel good or bad," said Simon."
The balance between maintaining patient confidentiality and responding
openly and empathically to surviving family members' questions and feelings
can be a daunting task for the clinician."
"The prime motive for meeting with the family is to meet their needs,
not your own," added Plakun. "Offer them a blame-free,
nonjudgmental, nondefensive time to recognize their grief, guilt, anger, and
Nevertheless, psychiatrists must take the steps needed to maintain their
professional and personal equilibrium while understanding that the
aftereffects may linger.
"Clinicians who lose patients to suicide are not ordinarily
considered suicide survivors; however, they usually carry a lifelong emotional
burden" said Simon.
Information on contacting family after a patient's suicide is
included in APA's practice guideline on suicidal behavior. The guideline is