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Eric M. Plakun, MD interviewed by Norman Sussman, MD
 

Primary Psychiatry. 2007;14(4):35-37

 

This interview took place on December 4, 2006, and was conducted by Norman Sussman, MD.

 

This interview is also available as an audio PsychCastTM at http://psychcast.mblcommunications.com.

Disclosure: Dr. Plakun reports no affiliation with or financial interest in any organization that may pose a conflict of interest.

 

Dr. Plakun is director of admissions and professional relations, a treatment team leader, psychotherapy supervisor, a member of the management group of the Erik H. Erikson Institute for Education and Research, and co-principal investigator of a prospective study of treatment outcome that utilizes objective measures of psychodynamic constructs at the Austen Riggs Center in Stockbridge, Massachusetts. He is also a distinguished fellow of the American Psychiatric Association and chair of its Committee on Psychotherapy by Psychiatrists.

 

How did your interest in the impact of suicide on physicians evolve?

Clinicians and other mental health professionals encounter the issue of suicide in many forms. Many patients at the Austen Riggs Center, which is a national referral center for treatment-refractory patients, are suicidal. Approximately 10 years ago, a difficult-to-treat patient at the center who had treatment-refractory mood disorder and borderline personality disorder committed suicide. There was a significant reaction to the patient suicide among clinicians, which cascaded through the center. My colleagues and I decided to examine the reasons behind this suicide and look for methods that would improve care in the future. One colleague, Jane Tillman, PhD, began a study interviewing therapists whose patients had committed suicide in the course of treatment. We realized that important clinical issues dealing with the treatment and evaluation of suicidal patients as well as with the significant impact of suicide on clinicians should be addressed, and that additional contributions to the literature on these subjects were needed.

Can suicide be prevented, or do clinicians have little effect on chronically suicidal patients?

There are patients who are chronically and relentlessly suicidal. However, upon closer inspection clinicians may find that this is not a homogeneous category. Some of these patients are struggling with ambivalence about suicide. These patients may have the wish to die as well as the recognition that they want to live.

An interesting issue, which is often difficult for patients to express in outpatient treatments, is the role of aggression, hatred, negative feelings, and the importance of dealing with such issues in individual psychotherapy of suicidal patients. This is one issue we have learned is important.

Are there differences in suicide rates among patients being treated by primary care physicians (PCPs), psychologists, psychiatrists, or other professionals?

The likelihood that a clinician will experience suicide of a patient depends in part on the number of patients the clinician treats. A PCP in a family practice environment who treats a large number of patients with depressive illness may deal with a significant number of suicides. Studies suggest that for psychiatrists there is an approximately 50% risk of experiencing the death of a patient by suicide.1

It is believed that one in three psychiatry residents will have the experience of a patient suicide and potentially one in six psychology residents in the course of training. The impact of patient suicide may be higher for clinicians with less experience. The American Psychiatric Association (APA) Assembly recently passed an action paper recognizing patient suicide and its impact on the clinician as an occupational hazard for psychiatrists. In addition, the Assembly action paper suggested training not only in the treatment and evaluation of suicidal patients but also in how best to anticipate and handle this identifiable and definable occupational hazard. The action paper also asked that resources be made available to APA members to help them handle patient suicide.

Are there geographical, age, and/or gender differences in suicide rates?

Suicide is one of the higher frequency causes of death among adolescents and young adults. Men are more likely to successfully complete suicide while women are more likely to be unsuccessful attempters, but there are significant suicide rates for both genders. Research has also shown cultural differences in suicide. For example, women in China have a particularly high suicide rate.

Are there any myths surrounding suicide?

The idea that a patient could agree not to commit suicide and that such an agreement alone acts as a form of protection is a myth. While such a conversation is important, it is the process rather than the agreement alone that is central, and the agreement is not a substitute for conducting a thorough evaluation and making a clinical judgment. Another myth is the confusion of population-based epidemiological risk factors with actual predictors of individual patient suicide. There is benefit in understanding that male patients, those with a physical illness, or patients with agitation or panic disorder comorbid with other difficulties have increased suicide risk. However, that information does not really help predict the risk of suicide in the individual patient that is being treated. There is often an over-reliance on epidemiological factors gathered across populations and their application to an individual patient.

What are the types of emotional reactions experienced by PCPs or mental health professionals after a suicide?

Patient suicide is a traumatic loss that appears to have a significant impact on PCPs and other mental health professionals. Recent studies found that those who work in the mental health field often have similar and predictable reactions.2,3 There is often an initial traumatic response with descriptions comparable to the impact found after a sudden loss, including crying, sadness, and grief. A sense of dissociation is also present, however, it typically does not reach the level of pathology. Clinicians often have a sense of disconnection from emotion and report feelings of shame, humiliation, guilt, isolation, and the grandiose thought that they had the power to keep a suicidal patient alive, although isolation is a key emotion. A crisis of faith about work in the mental health field, feeling stigmatized as if colleagues question their ability, and a fear of losing referrals by speaking about a patient suicide are also common among professionals after a suicide.

In addition, clinicians typically begin to question working with suicidal patients in the future or the possibility of changing how they work with depressed or suicidal patients. Suicide can affect how clinicians work with other patients as well as prompt a fear of litigation. While these findings are not true for every professional, the range of experiences is shared among many clinicians after a patient suicide.

My colleagues and I have conducted workshops across the country for much of the past decade on this subject. When speaking to groups of clinicians about suicide, my colleagues and I notice that the meeting room becomes still and many clinicians want to share stories about the impact of patient suicide, which can be quite significant. Studies suggest that the impact of patient suicide for some clinicians can be comparable to the impact of the loss of a parent, however, this finding is not true for every clinician.4

Patient suicide has such a great impact on psychiatrists and other professionals for two reasons. First, mental health professionals intentionally form an empathic attachment to patients. Working with a patient is not solely focused on a disease. Instead, the clinician-patient relationship tends to be more intimate and involves a deeper connection. This may create a significant sense of loss when that attachment is disrupted. Second, suicide involves a deadly act, and the patient is not only the victim but also the perpetrator. That situation creates an intensely ambivalent reaction to the patient’s death. I believe that significantly accounts for the impact of patient suicide on mental health clinicians.

Does response to completed patient suicide differ based on the clinicians’ role?

Response not only differs in terms of the clinicians’ role but also in terms of the clinicians’ character. A hospital administrator may be concerned with bad publicity due to a lawsuit after a patient suicide. A supervisor or a training director may be concerned about impact on trainees and how a suicide reflects upon the training program. A trainee may be concerned that suicide reflects their inexperience.

At the center, my colleagues and I suggest that response to a suicide should be reviewed in the context of the clinicians’ role. For example, a training director may want to anticipate this issue and ensure that residents learn about treating and assessing suicidal patients and ensure that they also have the opportunity to learn about patient suicide and methods to cope with its effects.

How should colleagues respond if a clinician’s patient has committed suicide?

Remember that after a patient has committed suicide, the clinician may be struggling with isolation. Although they may need some privacy to deal with what has happened, it is useful for colleagues to reach out to the clinician in his or her isolation.

It is also sensible to convene or participate in a nonjudgmental review of the suicide using role-related groups, if possible. While a sentinel event review required by the Joint Commission on Accreditation of Healthcare Organizations and a mortality and morbidity conference should be conducted, there should also be an arena for clinicians to speak about this traumatic experience focused on the impact on the clinician and the system.

It is also beneficial for residents to discuss this experience with one another outside of discussions involving senior staff members, which can make these discussions difficult for residents. Hendin and colleagues2 found that sometimes psychological autopsies are experienced as placing blame on or prematurely reassuring the clinician. Blame may arise if a staff member concludes that “Any practitioner would have known to increase an antidepressant dose or hospitalize the patient to prevent suicide.” The other extreme of premature reassurance may be a clinician being told that suicide is “Just going to happen.”

The task of a review is to find a medium between those two extremes and to speak about the suicide as an event that has a significant impact for clinicians. Offering relief from isolation is critical for this type of situation.

After a patient suicide, should the treating clinician attend the funeral of the patient or contact family members?

Some mental health professionals do attend the funeral of a patient who committed suicide while others do not. That is a question of context, often dependent on the clinician’s relationship with the patient and their family. Some clinicians find the experience of attending the funeral very important. However, clinicians can sometimes feel as if they are viewed as an intruder at the funeral by family and acquaintances of the patient.

The clinician should also meet with the patient’s family, but there are considerations the clinician should remember. First, plan in advance how to manage the issue of patient confidentiality. For younger or adolescent patients, parents have a right to gain access to patient materials. If the situation is different, for example a divorced spouse who commits suicide leaving behind anger and negativity, that information may not belong in the discussion with the surviving former spouse. Advice from legal counsel or a professional risk manager may be necessary in such a situation.

In a meeting with the family of a patient who committed suicide, clinicians should offer a blame-free, nonjudgmental, nondefensive space to recognize and contain the family’s grief, guilt, anger, and blame that may be directed at the clinician from family members. Nevertheless, the primary task is to meet the needs of the family. Clinicians should know that there are ways to offer condolence and state sorrow about patient suicide without acknowledging fault or involving self-criticism. It is a loss for everyone concerned and that can be communicated without defensiveness.

As expected, there are also medical/legal issues surrounding patient suicide. Oversimplified legal advice can be described as “It is better to say nothing” after a patient suicide. There is also reason to think that showing that the patient’s suicide has left an impact and being available to the family may decrease the risk of litigation against the clinician as well. PP

References

1. Chemtob CM, Bauer GB, Hamada RS, Pelowski SR, Muraoka MY. Patient suicide: occupational hazard for psychologists and psychiatrists. Prof Psychol Res Pr. 1989;20(5):294-300.

2. Hendin H, Haas AP, Maltsberger JT, Szanto K, Rabinowicz H. Factors contributing to therapists’ distress after the suicide of a patient. Am J Psychiatry. 2004;161(8):1442-1446.

3. Tillman JG. When a patient commits suicide: an empirical study of psychoanalytic clinicians. Int J Psychoanal. 2006;87(pt. 1):159-177.

4. Chemtob CM, Hamada RS, Bauer GB, Kinney B, Torigoe RY. Patients’ suicides: frequency and impact on psychiatrists. Am J Psychiatry. 1988;145(2):224-228.