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Helping Residents Cope with a Patient Suicide

Having a patient die by suicide is one of the most difficult events to deal with during a psychiatrist’s career, but is especially hard during residency. It is common for residents to blame themselves and to experience a myriad of emotions in response.

This information is intended to provide you with support, to help you learn from the experience of patient suicide, and to grow as a psychiatrist and as a person. It was initially developed by Columbia University psychiatry residents who had patients who died by suicide, and was revised by several faculty members who have also had experience with patient suicide and wanted to help residents through the process.

Common Reactions

Initial Reactions

  • Shock
  • Disbelief
  • Denial
  • Depersonalization

Second-phase Reactions

  • Grief
  • Shame
  • Guilt
  • Fear of blame
  • Anger
  • Relief
  • Finding of omens and subsequent behavioral changes
  • Conflicting feelings of specialness

[Adapted from Table 24-1 from Chapter 24: Psychiatrist Reactions to Patient Suicide by Dr. Michael Gitlin in Simon, RI and Hales, RE. Textbook of Suicide Assessment and Management. 2006. American Psychiatric Publishing, Inc. Washington, DC.]

How to Cope

Below is a list of suggestions that have been helpful to prior residents after a patient’s death by suicide.

  • Take a day off of work at some point after the event to reflect and process your emotions
  • Allow yourself to experience your full range of emotions and reactions as valid
  • Be mindful of self-care and your own wellness
  • Talk to people about the experience and your reactions.
    • Co-residents (process group)
    • Chief residents
    • Training directors
    • Attending supervisors involved in case
    • Attending supervisors NOT involved in case
    • Prior attending supervisors NOT involved in case
    • Therapist
    • Family and friends (in an unidentified manner)
  • Read literature on suicide risk assessment
  • Read literature on dealing with the death of a patient (see article by Gitlin)
  • Consider giving a case conference on the topic
  • Consider participating in the annual APA workshop on dealing with patient suicide during residency
  • Consider writing a paper about your experience

Also, for other ideas, please refer to Table 24-3 (pg. 487) in Chapter 24: Psychiatrist Reactions to Patient Suicide by Dr. Michael Gitlin in Simon, RI and Hales, RE. Textbook of Suicide Assessment and Management. American Psychiatric Publishing, Inc. Washington, DC. 2006

Questions for Supervisors

General Questions:

  • Should I talk about this experience with my colleagues?
  • How much should I reveal to them?
  • Should I worry that my revelations to them may change their perception of me, or even affect our working relationship going forward?
  • How should I begin to process my patient’s death?
  • How is this going to affect my treatment with other patients? How do I know when that is appropriate?
  • Is it best to try not to think about it and pretend it didn't happen? Or should I engage in an activity that would help me to learn from the experience? Or would that be too painful?
  • Is it unrealistic to think that this will affect my career?

Questions about interacting with the patient’s family

  • Should I contact my patient’s family?
  • If so, what method should I use (phone, letters, even visit)?
  • What should I say to the family (should I be supportive, explanatory)?
  • How much information can I provide to family members?
  • Should I attend the funeral?
  • What should I do if they accuse or blame me?
  • How much should I reveal to them about my thoughts on what went wrong?
  • What do I do if the family member needs urgent crisis management after I break the news?
  • How does what I say, and how I say it, have an impact on my chances of being sued?

Useful ReferencesImpact of Suicide on Practitioners

  • Biermann B: When depression becomes terminal: the impact of patient suicide during residency. J Am Acad Psychoanal Dyn Psychiatry 31:443-457, 2003.
  • *Brown HN: Patient suicide during residency training, I: incidence, implications, and program response. J Psychiatr Educ 11:201-216, 1987b.
  • *Gitlin, MJ. A Psychiatrist's Reaction to a Patient's Suicide. American Journal of Psychiatry 156(10):1630-1634, 1999.
  • *Havens, LL. The Anatomy of Suicide. New England Journal of Medicine 272:401-406, 1965.
  • Hendin H, Haas AP, Maltsberger JT, et al: Factors contributing to therapists' distress after the suicide of a patient. Am J Psychiatry 161:1442-1446, 2004.
  • Hendin H, Ligpschitz A, Maltsberger JT, et al: Therapists' reactions to patients' suicides. Am J Psychiatry 157:2022-2027, 2000.
  • Kaye NS, Soreff SM. The psychiatrist's role, responses and responsibilities when a patient commits suicide. Am Journal of Psychiatry 148(6): 739-743, 1991.
  • Litman RE: When patients commit suicide. Am J Psychother. 19:570-576, 1965.
  • Lomax JW: A proposed curriculum on suicide care for psychiatry residency. Suicide and Life-Threatening Behavior. 16(1): 56-64, 1986
  • Misch, DA. When a Psychiatry Resident's Patient Commits Suicide: Transference Trials and Tribulations. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 31(3):459-475, 2003.
  • Perr, HM. Suicide and the doctor-patient relationship. American Journal of Psychoanalysis 18:177-188, 1968.
  • Reeves, G. Terminal Mental Health: Resident Experience of Patient Suicide. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 31(3):429-441, 2003.
  • Sacks MH, Kibel HD, Cohen AM, et al: Resident response to patient suicide. J Psychiatr Educ 11:217-226, 1987.
  • *Simon, RI and Hales, RE. Textbook of Suicide Assessment and Management. American Psychiatric Publishing, Inc. Washington, DC., 2006.

Suicide Risk Assessment

  • *American Psychiatric Association: Practice guidelines for the assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry 160(suppl):1-60, 2003.
  • Bongar B, Maris RW, Bertram AL, et al: Outpatient standards of care and the suicidal patient. Suicide Life Threat Behav 22:453-478, 1992.
  • Busch KA, Clark DC, Fawcett J, et al: Clinical features of inpatient suicide. Psychiatr Ann 23:256-262, 1993.
  • Harris CE, Barraclough B: Suicide as an outcome for mental disorders. Br J Psychiatry 170:205-228, 1997.
  • Jacobs DG, Brewer M, Klein-Benheim M: Suicide assessment: an overview and recommended protocol, in Guide to Suicide Assessment and Intervention. Edited by Jacobs DJ. San Francisco, CA, Jossey-Bass, 1999, pp3-39.
  • Mann, JJ, Arango V: The neurobiology of suicidal behavior in Guide to Suicide Assessment and Intervention. Edited by Jacobs DJ. San Francisco, CA, Jossey-Bass, 1999, pp98-114.
  • Mann, J.J. A current perspective of suicide and attempted suicide. Ann. Int. Med. 136:302-311, 2002.
  • Oquendo MA, Halberstam, Mann JJ: Risk factors for suicidal behavior: the utility and limitations of research instruments, in Standardized Evaluation in Clinical Practice (Review of Psychiatry Series, Vol 22, No 2; Oldham JO and Riba MB, Series Editors). Edited by First MB. Washington, DC, American Psychiatric Publishing, 2003, pp 103-130.
  • Shaffer DA, Pfeffer CR, Bernet W, et al: Practice parameters for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry 36(10), 1997.
  • *Simon, RI and Hales, RE. Textbook of Suicide Assessment and Management. 2006. American Psychiatric Publishing, Inc. Washington, DC.

* Denotes highly recommended resources

APA's Practice Guidelines on Assessing and Treating Suicidal Behaviors

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