Patient Suicide

[reluctantPhd01]

I was wondering to what degree Clinical PhD programs provide training for dealing with patient suicide

While I realize the ultimate goal is of course to avoid patient suicide, it also kind of goes with the territory of working in the mental health field, particularly for those of interested in working with more severely disturbed people.

I was just kind of wondering---Is this something anyone has actually had to deal with on internship or practicums? Do you find that it has been a part of your doctoral training? Do you feel prepared to deal with this or do you feel that it is a topic that is kind of shunned/ignored.

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[Ollie123]

I wouldn't say shunned/ignored but since it is (thankfully) a relatively rare event it certainly isn't the sort of thing we spend hours upon hours discussing and getting ready for. I think if it ever did happen our program would likely go all out to help the person get through it and deal with it.

I have not had a client commit suicide, but we actually had a research assistant who did so, which was pretty difficult to deal with. We were aware she had a variety of mental health problems she was struggling with - she made the decision to leave the lab because she "needed time to get her life together" and apparently took her life a few days later. Unfortunately, this was somewhat swept under the rug - I think in part because of the size of the lab and the fact that our faculty do not really know most of the undergraduates, so I ended up being the one who sat down with everyone individually and let them know. Definitely wasn't my favorite week. An email went out to senior staff from the faculty, but half of them didn't even realize it was a current RA.

Obviously this is a totally different scenario given it was a co-worker and not a patient, but given we were aware of the issues and everyone in the lab is in clinical psychology (except for a few experimental folks) there were still some oddities to the situation and many people still felt some sense of responsibility for "not doing enough" (not at all an atypical reaction). It was somewhat more tricky because even though she clearly wasn't doing well, we could make sure she was getting treatment but we were in somewhat of a bind with boundaries.

I think its good for anyone in the field to be prepared to cope with something like this, but I'm not sure it is ever something you can really be "ready" for. You just have to make sure you have supportive people in your environment, and hope that you don't need them.

 

[stigmata]

This comes with experience not schooling

 

[Shatani]

its not part of the general training, but i took a course specifically dealing with suicide and working with suicidal clients.

but no amount of book learning prepares you for it. have yourself a therapist on call!

 

[KillerDiller]

I agree with both of the above posts. There's no didactic training I know of that can reframe a patient's death into something that is easy to handle. I haven't had a patient commit suicide, but during my first placement we did have someone die of an overdose (he was being treated for substance abuse). It's just something you learn to deal with as it happens. You find support in your fellow staff members and learn to help the other patients work through their grief too.

 

[berlin81]

I myself have not had to deal with a patient suicide thus far, but I have (in my relatively short time in the field) had to deal with unexpected deaths and patients overdosing. In no way do I think that a patient suicide is similar to a patient death of drug overdose, but I know that I have had reactions where I question what I have done and if I (or my co-workers) ignored any signs of fatal behavior.

In regards to fatal drug overdose, that is something that I unfortunately fear of dealing with in my current workplace. Sadly, we do not have the resources to keep patients from leaving our facility physically. The only thing we can do is try to talk them down from leaving and to somewhat understand that going into the streets of a large urban area is dangerous. Moreover, we have patients that leave the facility regularly. Although some are simply just grabbing something to eat or buying cigarettes, some could (and have) left in order to get high or intoxicated. Obviously there is much debate on whether such patients should be placed in such liberal settings, but the fact is that drug overdosing or an unexpected death is greatly possible. It is not fun by any means, but somewhat preparing for X or Y thing to happen considering the environment does give acceptance to whatever horrible thing that could happen.

 

[katiekoala]

http://mypage.iu.edu/~jmcintos/therapists_mainpg.htm

This page might be generally useful in terms of support; it was sent out in our department not too long ago as something someone came across and thought was interesting (but not because of any suicide issue).

 

[Therapist4Chnge]

I doubt most programs address this specifically in a class, though it should be covered in supervision and/or in practica. I have never had one of my individual patients suicide, though I've covered patients that have suicided. During my intern year we had one, and the debriefing and follow-up supervision was a good learning experience. You will lose patients to many different things, so it is something worth exploring.

Having patients die for any reason can be tough. I've had more patients die in the last 6 months than I've had in my previous 6+ years, but that is one of the realities of working with medically compromised folks. I think it will bother most people on some level, though it is something that should be addressed because it will happen at some point of your career, and often at multiple points.

 

[roubs]

This was covered in a class in my program, and I think it does help you prepare. Preparation isn't a replacement for experience, but it's silly to say it doesn't count.

 

[NovemberRose15]

I'm not in grad school yet, so I can't speak for Clinical PhD coursework, but I received 40 hours of training in suicide and crisis intervention before volunteering for my county's suicide hotline. It was amazing training and it really shaped the way I counsel clients today (more client-centered/ supportive-expressive approach). I work as a case manager for people suffering from severe and persistent mental illnesses and my suicide intervention training has come in handy: knowing warning signs, how to de-escalate a person in crisis, finding resources/ support systems for people in crisis, making contracts for safety, etc. So if your school doesn't offer training/coursework in the subject, I recommend checking out your local suicide hotline.

 

[Therapist4Chnge]

No Suicide / No Harm Contracts are junk; it is amazing that so many hospitals still use them. They offer no legal protection, they provide a false sense of security, and they can be harmful to the provider/patient relationship.

 

[stigmata]

Yep

 

[cara susanna]

They don't offer legal protection? I thought that was the entire reason they're still used. Pretty much every place I've done clinical work in has used them.

 

[AcronymAllergy]

They don't offer legal protection? I thought that was the entire reason they're still used. Pretty much every place I've done clinical work in has used them.

From what I've heard, they generally don't provide much in the way of legal protection, no. I don't know that I'd fully equate them to junk (I feel that they could be therapeutically useful in some circumstances if properly constructed and used), but in general, most practitioners I've spoken with seem to mirror T4C's sentiment that they mostly just give a false sense of security.

Edit: I should mention that I personally will sometimes blur the distinction between a strictly-defined "no-suicide contract" and a more generally-defined safety plan.

 

[Neuropsych2be]

They don't offer legal protection? I thought that was the entire reason they're still used. Pretty much every place I've done clinical work in has used them.

I have done full time mobile crisis work and its true that a no harm contract will not provide any legal protection in most jurisdictions. A suicidal individual can and will say or do anything. It is the responsibility of the clinician involved to do a safety plan to ensure the client has teh resources to keep themselves safe. That typically involves getting family and other psychosocial resources involved. The responsibility is on the clinician to be pro-active and utilize active prevention steps. That provides you with some degree of legal coverage, not a piece of paper.

 

[AcronymAllergy]

The research on them does not support this. When 25-50% of people (depending on the study you look at) aren't "adhering" to a no-suicide contract they sign, I don't know how it can be argued that this is a valid and effective intervention. The research has found that when patients are asked why they signed such a contract, most say it's because the therapist is trying to cover themselves or they feel it conveys a sense of hopelessness that the therapist believes they're "crazy" and will commit suicide. The reason is does not hold up in court is that it has been shown to be an ineffective and inadequate intervention and there's a good case for negligence if a suit were filed.

As I mentioned above, I personally use the term "suicide contract" fairly broadly, and will include such things as safety and contingency plans which, to the best of my knowledge, have been shown to be effective in various patient populations. I definitely agree that a strict no-suicide contract, in and of itself, isn't effective.

 

[Buzzwordsoldier]

No Suicide / No Harm Contracts are junk; it is amazing that so many hospitals still use them. They offer no legal protection, they provide a false sense of security, and they can be harmful to the provider/patient relationship.

Thinking like an SDNer here for a moment, I'd have to say that though I agree with it whole heartedly, that last point seems empirically squishy... (ok, maybe squishy is itself too squishy )

As for the training, suicide has received brief mention in the subject of unplanned termination of therapy. As for working with the "severely disturbed," in many thousands of patient hours with folks labelled "severely dysfunctional," I've never had someone (and no ex-patients that I know of) commit suicide. Only a handful have attempted. I do consider myself fortunate and in no way claim that this should be the norm for treatment providers. But when you realize the deepest meanings of what T4C seems to have posited, above, you realize that commitment and accountability are the bedrock of successful treatment: if you have to establish them with a safety contract you're doing something wrong.

 

[psydtobe]

I have had a coworker deal with this and I think that as much training as you can get, the experience is different. We discussed it at a staff meeting and processed it with her, as well as provided support. I have dealt with a patient death, for medical reasons and it was definitely unpleasant for me.

 

[TenaciousGirl]

I have had a coworker deal with this and I think that as much training as you can get, the experience is different. We discussed it at a staff meeting and processed it with her, as well as provided support. I have dealt with a patient death, for medical reasons and it was definitely unpleasant for me.

I have not had a patient commit suicide but one of the students in my cohort committed suicide this year. I agree with psydtobe ... the experience is different from theoretically talking about it/preparing for it.

 

[nitemagi]

They don't offer legal protection? I thought that was the entire reason they're still used. Pretty much every place I've done clinical work in has used them.

Case law suggests it shouldn't be what you hang your hat on for lowering level of care or observation.
http://www.jaapl.org/cgi/content/abstract/37/3/363

We made a video recently for opening the discussion of the impact of suicide on clinicians. Focused on psychiatrists and intended for psychiatric residents, entitled:
Collateral Damage: Teaching Residents About The Impact of Patient Suicide

It's being presented at our APA this year. The consensus was that this is a conversation rarely had, and that can even be brushed over in many training programs.