WHAT WE KNOW WHAT WE CAN DO Nina J. Gutin, Ph.D. - - PowerPoint PPT Presentation
THE IMPACT OF SUICIDE ON MENTAL HEALTH CLINICIANS And PROFESSIONAL CAREGIVERS: WHAT WE KNOW WHAT WE CAN DO Nina J. Gutin, Ph.D. ngutin@earthlink.net Vanessa L. McGann Ph.D. VLMcGann@aol.com Co-chairs: Nina J. Gutin Ph.D.
THE IMPACT OF SUICIDE ON MENTAL HEALTH
WHAT WE KNOW WHAT WE CAN DO Nina J. Gutin, Ph.D. ngutin@earthlink.net Vanessa L. McGann Ph.D.
Nina J. Gutin Ph.D. ngutin@earthlink.net Vanessa L. McGann Ph.D. VLMcGann@aol.com
The AAS Clinician Survivor Task Force provides
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Occupat ational H Haza zard:
professionals at time of death
51% P
Psychi ychiatrist sts, 2 22% p psych chologists (Chemtob, 1988)
15,000 clinician survivors a year (Weiner, 2005) 17.8%-35.6% psychologists (Goodman, 1997) 39% psychotherapists (Menninger, 1991) 23% counselors (McAdams & Foster, 2000) 1 in 9 psychologists in training have client die by suicide, 1 in 4 have client attempt (Kleespies, 2013)
*Caveats: Clients may not disclose, Clinicians can make best
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In many ways, clinicians’ response to suicide of a client is similar to the responses and reactions of
Traumatic loss: initial shock/numbness Hopelessness Depression Despair, suicidal ideation (normative, but assess!) Guilt, regardless of whether justified Shame Anger Existential questions (assumptions shattered) PTSD symptoms: intrusive thoughts, dissociative
responses, avoidance of triggers Any of these are likely to to be exacerbated by by stigma around suicide, directed towards attempters, completers and loss survivors.
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Impacts clinicians both personally and professionally Also true for clinician’s family suicide loss! (significant
trust (re self & cts.) challenged
professional career” (Hendin et al. 2000)
for more than one year
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Context of treatment (active or subsequent tx, tx
environment: clinic, hospital, private practice)
Presence/involvement/quality of mentors/supervisors Extent of training around suicide, experience with
suicidal clients (trainees)
theoretical orientation Clinician’s assumptions, self-imposed expectations
for tx
Relationship with client Personal issues: previous trauma, loss,
anxiety/depression, clinical omnipotence (Gorkin, 1985), gender (Grad, Zavasnik & Groleger, 1997 )
Potential legal issues Countertransferential issues
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length of time in/since treatment
intensity and closeness of the relationship
character of the therapeutic alliance
Dx, Severity (treatment resistant)
shock of the suicide vs. quasi-expected
age of patient
isolation vs. family network, public suicide suicide note
Ex
Extent t nt to whi hich ch i inti timacy cy a and d depth o th of f the herap apeuti tic c relationship m may ay b be e ackno knowl wledged ged ofte ften c n compromised by c confi nfiden enti tiality ty/l /legal egal issue ues ( (disen enfr fran anch chised ed g grief) f)
Exte
tent o
access to to gr grief ef ritu tuals th that f faci acilitate he healing (funer eral/ l/memor
ial l atten tendance ce, shar aring m ng memories es, validation n of grie rief) a als lso
compromised ed
Scarcity o
ailable places to to p process l loss wi s with others who a
re f familiar r wit ith it its sequelae
Ma
May y lea ead to to per ersonal a and p professional i isolation
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Assumptions of mismanagement of case (Jobes &
Implicitly/explicitly expressed concerns re:
Institutional reviews insensitive and unsupportive
Isolation, interpersonal discomfort from colleagues
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Profe
tigma gma may play an important role in how staff/colleagues respond to grieving clinicians
Stigma re: suicide and suicide loss, also directed towards survivors
(Goffman/Doka-disenfranchised grief)
Normative grief reactions pathologized/minimized: “Only a patient” Stigma around pe
perc rceived v d vuln lnerabil ilit ity-in MH colleagues
US/THEM dichotomy: Projection of colleague’s fear of/aversion to
vulnerability onto suffering clinician, making them the pariah
Judgment and blame around clinical competence (autopsies=tribunals) Avoidance due to anxiety aroused in colleagues
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Intensified guilt, shame, self-blame, depression, grief Fear of what others think, will say-non-disclosure as self-
protection
Ambivalence/resistance to seeking out
consultation/supervision
Self doubt, decreased clinical confidence, competence Isolation Change of profession
Complicates, derails or extends grief process Confidentiality-implications for grief process Dealing with Surviving Family (mixed messages)-
Anger from family/Anger at family Possibility of lawsuit, professional censure Anxiety, anger, blame of patient, self, supervisor Actual lawsuit (all-consuming anxiety, derails grief
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Combination of effects on clinical work, professional role and colleagues’ reactions may lead clinicians to question their implicit assumptions around clinical work, the efficacy of treatment, the support of colleagues, and whether they can trust their own clinical judgment and
Role confusion/compartmentalization between “roles” of clinician and survivor are likely to be reinforced by structure/content of professional venues, lack of clinical training around survivor issues and continued denial of the ubiquity of suicide loss with the mental health field (i.e., it encourages splitting)
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Traumatic experiences may present opportunities for profound
personal, and in this case, professional transformation
Post-traumatic growth fostered by willingness to discuss distress
and openness to change (Fuentes & Cruz, 2009)
Despite initial distress, most report long-term benefits:
Clinical
limitations Personal
granted
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Learn about how to treat suicidal individuals Care Take good notes Involve the family (if possible) Consult often and record consultations
Confidentiality issues/Holder of privilege
Use psycho-education to help them make sense of loss Cultural sensitivity- ask about what would be helpful Help locate SAS groups, (trained) tx for grief support
Do not isolate, take personal time as needed Talk to trusted colleagues, ideally w/similar
Seek support: family and friends (protect
Seek therapy, consultation (knowledgeable) Consider spiritual guidance if so inclined Journal Watch your use of alcohol and other drugs/self-
Be aware of institutional policies/state laws re:
Act as advocate for trainees/interns, support
Support/educate supervisees re: normal sequelae
Provide resources (cliniciansurvivors.org) Help attend to family outreach issues
Avoid /curtail rumors
Provide consultation, supervision (awareness of issues)
Acknowledge/normalize potential impact on clinical functions
Allow for changes in schedule, caseload, responsibilities Provide info re/ normative Clinician- Survivor reaction and resources (cliniciansurvivors.org)
Identify Mistakes to gain knowledge Identify Gaps in System/Training
Include all affected Staff (Needs Assessment)
Do not describe method unless necessary
Complicated, potentially traumatic grief
Many complications ensue from contextual
Factors often amenable to positive change via:
Increasing research/literature on topic needed Dissemination of existing information needed
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Chemtob, C. M., Hamada, R. S., Bauer, G., Kinney, B., & Torigoe, R. Y. (1988). Patients' suicides: Frequency and impact on psychiatrists. American Journal of Psychiatry, 145, 224-228.
Farberow,N. L. (2005, February). The mental health professional as suicide survivor. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 2(1), pp. 13-20.
Fuentes, M. & Cruz, D. (2009) Posttraumatic growth: Positive psychological changes after
Goffman, E. (1963) Stigma: Notes on the Management of Spoiled Identity, Englewood Cliffs, NJ: Prentice Hall.
Gorkin, M. (1985). On the suicide of one’s patient. Bulletin of the Menninger Clinic, 49, 1-9.
Grad, O. T., Zavasnik, A., & Groleger, U. (1997). Suicide of a patient: Gender differences in bereavement reactions of therapists. Suicide and Life-Threatening Behavior, 27, 379- 386.
Hendin, H., Lipschitz, A., Maltsberger, J. T., Haas, A. P., & Wynecoop, S. (2000). Therapists' reactions to patients' suicides. American Journal of Psychiatry, 157, 2022- 2027.
Jobes, D. A., & Maltsberger, J. T. (1995). The hazards of treating suicidal patients In Sussman, M. B. (Ed.). (1995). A perilous calling: The hazards of psychotherapy practice (pp. 200-214). New York, NY: Wiley & Sons.
Jones, F. A. (1987). Therapists as survivors of client suicide. In Suicide and Its Aftermath, In Dunne, E.J., McIntosh, J.L., & Dunne-Maxim, Eds. New York: Norton & Co.
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Kleespies, P. M., Smith, M. R., & Becker, B. R. (1990). Psychology interns as patient suicide survivors: Incidence, impact, and recovery. Professional Psychology: Research and Practice, 21, 257-263.
Plakun, E. M. & Tillman, J. G. (2005). Responding to clinicians after loss of a patient to suicide. Directions in Psychiatry, 25(4), 301-310.
Administrative Directory. QPR Institute, Inc., Spokane, WA
Schultz, D. (2005). Suggestions for Supervisors When a Therapist Experiences a Client's Suicide (pp. 59-69) in Weiner, K. M. (Ed.). (2005). Therapeutic and legal issues for therapists who have survived a client suicide: Breaking the silence. New York, NY: Haworth Press. 108 pp. ISBN 0-7890-2377-6.
Weiner, K. M. (Ed.). (2005). Special full issue of the journal Women & Therapy, Volume 28(1), 2005, with the same pagination published also as: Therapeutic and legal issues for therapists who have survived a client suicide: Breaking the silence. New York, NY: Haworth Press.
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