Client Suicide and Clinician Response: Ensuring Policy Guidelines and Clinician Safety

In looking at issue of suicide within mental health field, we know that a person who suffers from mental illness, is more likely to be at risk for suicide.  According to the Mental Health America website of suicide victims suffer from major depression or bipolar (manic-depressive) disorder”.  One aspect that doesn’t often get looked into, is how does suicide of a client affect the clinician that they work with?  In working in mental health field, depending on setting and caseload, clinician’s often have fluctuating caseloads, and might lose a client to suicide, and then be required to have short turnaround in picking up a new client to replace them.  In dealing with a population that might show higher risk of suicide, the question becomes, are we ensuring that clinician’s are protected by policies, have confidence in being able to assess suicidal behavior?  An article does a study on 172 therapists, 125 who are from private practice, and 47 from institutions, and tries to assess their responses to suicide from clients.  The study finds that of these therapists, 85% from institutional setting and 17% from private practice had experienced at least one suicide in their professional careers.  From this article, it appeared there was more of a propensity for clinicians from institutional settings to be more at risk for having experienced a client suicide.  This would make sense in that institutional setting, clients would have more severe symptoms of mental illness, and in general, having to be institutionalized is a result of not being able to take care of one’s self, or possibly self harming behavior in the past.

The same study found that for psychiatrists who had “less than 5 years of professional experience” reported significantly more feelings of “guilty, shocked and insufficient” at their job, after 6 months of the study, opposed to colleagues with more experience. This makes argument for importance of developing policies, as well as offering trainings to ensure new staff feel confident in assessing clients for suicidal risk.  One of the main sources of distress, interestingly enough, was that of “fear of reaction of parent’s relatives” and that was found to be even higher than fear of a lawsuit in this study. This study also found that in dealing with client suicides, of the therapist responses, 80% reported being “supported by the institution” they worked for, 72.3% found some type of “conference” around grieving to be helpful, and 44% had reported wishing they had some type of “conference”. This data shows support for clinicians wanting to feel supported or protected by policy guidelines of institution, as well as some type of debriefing process to allow discussion of the client’s case.  Of all the therapists involved in the study, “one third or 34.5% suffered from severe distress”, which the study did not find significant differences in gender, but were slightly more prevalent among women, and also the study pointed out distinction that with mild distress, usually over 6 months, symptoms lessened, but with severe distress, symptoms were persistent over this time.  The study shows a  prevalence of “severe distress” within clinician’s, which argues for being able to notice this within staff, as well as developing policies that ensure staff protection and confidence in being able to assess client’s for suicidal risk.

Another article  was a study done within the United States Air Force and collected information from 74 of medical treatment facilities, to determine if trainings around suicide assessment, could impact clinician confidence, as well as impact policy or clinician ability to assess suicidal behavior.  One argument that the article starts with is the fact that most clinician ability to do suicide assessment effectively, is dependent upon organizational policies, as well as clinician motivation to access literature on, or continuing education into this area.  For instance, Bongar and Harmatz (as cited by Oordt et al. 2009) found that “only 40% of graduate programs in clinical psychology provided any formal training in clinical work with suicide patients”.  In other words, even clinicians with advanced degrees in psychology or other mental health degrees, would have minimal exposure with how to work with suicide patients, which puts their ability to be effective on what they learn working in the field, putting further emphasis on training their employer offers, what program policies are around this, etc. Depending on what state this occurs, continuing education might not be required, and so this  would put more emphasis on the clinician seeking out these trainings.  The article offers a link to the Air Force website, which offers “18 recommendations for effective clinical work with suicidal patients”.  Without continuing education, the article by Oordt et al. (2009) describes that clinical supervision would be primary source of setting guidelines for how to assess suicide risk.  This requires that with good policies, supervisors could also feel confident in providing feedback to clinicians, as well as in clinicians being trained and having knowledge of what to do in these situations, wouldn’t need as much supervision.

Going back to the article, the study used a 12 hour training session, with 4 hours spent on “suicide assessment”, 4 hours on “management and treatment of suicidal behavior” and 4 hours on “military specific practices, policies” around suicidal assessment.  The goal of the study was to follow up on participants from the training and see if this impacted them, up to 6 months after the trainings.  The study was made up primarily of 82 participants, 48% who were doctorate psychology clinicians, 27% doctoral social work majors, and 13% that were psychiatrists.  Initially, of these participants, 43% reported “little or no formal trainings in graduate programs” around suicidal assessment, and 42% reported “little or no postgraduate or continuing education”.  This information supports the findings that even with advanced degrees, clinicians don’t have much exposure to policies or guidelines around how to do suicide assessment?  At the 6 month follow up, 44% of all participants reported “increased confidence in managing suicidal patients”, 83% “changing suicide practices”, and 66%, “changing clinical policy”, as a result of attending the trainings. The article also offers a 9 step guide to what trainings should look like, around suicidal assessment.  This study was done specifically with the Air Force, but offers an example of support for giving clinician’s trainings around practice of suicide assessment, as well as making sure they have knowledge of what policies are and what is expected of them by organization, in doing suicide assessments.

From these articles, we can see prevalence of “distress” amongst clinicians in having to deal with a client who has committed suicide.  Oftentimes, as clinician’s, we feel sense of needing to be detached or be professional in dealing with our clients, and yet it is important to understand it is normal to experience some grief in losing a client to suicide, or other factors.  What is important is knowing organizational policies, or ways in which we are expected to assess suicidal risk, as well as knowing resources available to aid us.  As these articles point out, through trainings and continuing education, we can feel more confident, as well as develop better policies to deal with clients that display suicidal behaviors.  Here are some lists of resources for info on defining policies around suicide assessment, as well as helpful tips for clinician being able to deal with loss of a client to suicide.
Mental Health America (Suicide Info)
SAMHSA (Statistics on Suicide Likelihood)
Suicide.Org Non-Profit Organization (Warning Signs)
Mayo Clinic Website (General Coping Skills for Losing Someone to Suicide)

Citations

Oordt, M.S., D.A. Jobes, V.P. Fonseca, S.M. Schmidt (2009). “Training Mental Health Professionals to Assess and Manage Suicidal Behavior: Can Provider Confidence and Practice Behaviors Be Altered?” Suicide and Life-Threatening Behavior 39(1).

Wurst, F.M., S. Mueller, S. Petitjean, S. Euler, S. Thon, G. Wiesbeck, M. Wolfersdorf (2010).  “Patient Suicide: A Survey of Therapists’ Reactions”. Suicide and Life-Threatening Behavior 40(4).

submitted by Jim Linderman.  Jim is currently a M.A. student with University of Colorado-Denver Sociology Program.