by Mollie Charter, MSW
I’ve been told there are two kinds of therapists: therapists who have had a client suicide and therapists who have not had a client suicide, yet. I was a student the first time I heard this saying, and I thought it was a gruesome statement that had no relevance to me. After all, I would never have a client suicide, I told myself, and furthermore, thinking about it was....I didn’t want to think about it at all.
Since then, I’ve wondered about my hesitance to contemplate such an important topic and why it seemed comparatively easier to think about other issues that often face our clients, like coping with trauma or struggling with physical and mental illness. I’ve also wondered about my denial in assuming I would never have to cope with client suicide. Social workers and social work students face some of the hardest realities, and suicide is a very real and possible one. According to the National Institute of Mental Health, suicide is the eleventh leading cause of death in the United States (2004).
I’ve come up with a few “maybes” to help explain my own reaction to the possibility of client suicide. Maybe it was too difficult for me to acknowledge that becoming a clinical social worker, a profession I loved from the start, had some serious drawbacks. Maybe it challenged my self concept as “helper” to accept that I could be helpless to prevent clients from taking their own lives. I’ve discovered a new “maybe” that seems to make sense: maybe I was not the only one comforted by refusing to think about client suicide. A collective quiet, both in the classroom and in agencies, makes it possible to maintain the safe stance of “it will never happen to me”—a stance that becomes dangerous, if it ever does.
Could It Happen to Me?
For those who would like to maintain the “it will never happen to me” stance, I am the bearer of bad news. In a 2004 study, roughly one third of mental health social workers reported having had a client who committed suicide (Jacobson, Ting, Sanders, & Harrington, 2004). Even if you are among the lucky two-thirds, there is a strong possibility that a colleague, friend, or former classmate will face losing a client to suicide. Further, social workers who do not work in mental health often interact with clients who exhibit psychosocial problems that are among the strongest predictors of suicide, such as substance abuse or unemployment (Feldman & Freedenthal, 2006). Suicide is an issue that will likely affect all of us at some point in our careers, and some of us sooner than later.
While no research is available pertaining to social work students, studies have documented that eleven percent of psychology interns and roughly six percent of mental health counselors in training have reported losing a client to suicide (Kleespies, Penk, & Forsyth, 1993; McAdams & Foster, 2000). Statistics can feel meaningless, so try thinking about it like this: if your class has ten people, one of you has a relatively strong chance of facing this issue before you don your graduation cap, before you’ve mastered listening empathically, and while you still feel like you’re swimming upstream in the challenges of school work and field placements. Unfortunately, you will probably feel drastically unprepared to face what is happening.
Being Unprepared is Not Uncommon
Take a moment to think back on your classes so far, or if you’ve graduated, on your social work studies in general. If you can recall having discussed client suicide in more than a passing way, consider yourself lucky. In a 2006 study of social workers who had graduated from master’s degree programs, most reported having received no formal education, such as courses or seminars, and little informal education, on suicide (Feldman & Freedenthal, 2006). Whereas field placements seemed to do somewhat better with suicide education, roughly 40 percent of the respondents received no training at all about suicide in their placements.
Yet, many social work students are placed in agencies with populations who are at high risk for suicidality. If we’re not talking about it in school, not reading about it in our piles of class reading, and not learning about it at our field placements, it’s easy to let the very idea slip into the background. It is easy to be unprepared, if no one is preparing you.
Students’ Responses to Client Suicide
Students who have lost a client to suicide respond strongly. In a 1993 study, it was found that psychology interns reported feeling shocked, ashamed, guilty, overcome with a sense of failure, and many other powerful emotions after experiencing a client suicide (Kleespies, et al., 1993). They were just as affected, if not more, by losing a client to suicide as their professional counterparts.
Students may face concerns that professionals do not. Students in field placements may fear being blamed and worry that the client’s suicide will impact their success at their placements or at school (Spiegelman & Werth, 2005). They may begin to question their career choice, become very anxious when working with suicidal clients, and doubt their clinical competence (Kleespies, 1993; Kleespies et al., 1993; Knox, 2006).
Additionally, Brown (1989) has suggested that unlike professional therapists, students may rely more on their personalities when working with clients, because they have not yet developed a full skill set. When they lose a client to suicide, they may experience the loss not only as a professional failure, but as a very personal failure, a failure as a human being. Further, Lafayette and Stern (2004) have reasoned that students have a limited number of client cases on which to base their success, and if one client suicides, it may be disproportionately damaging to their sense of ability.
It is possible that students can also grow positively from losing a client to suicide. They may become more careful in assessing and working with suicidal clients (Knox, 2006). They may realize the limitations of the therapeutic process and the extent to which clients truly do have personal freedom (Brown, 1989; Kleespies, 1993). They will have crossed the line from the category of therapists who have not had a client suicide yet, to therapists who have had a client suicide—with that journey may come a distinct inability to ignore the reality of suicide and, hopefully, a desire to encourage dialogue where it is currently scarce.
What If It Happens to Me?
Gaining support can be extremely helpful in processing a client suicide (Knox, 2006). If you are comfortable with your supervisor, talk to him or her as much as you need to about the client and the circumstances surrounding a client’s death (Kleespies, et al., 1993; Knox, 2006; Spiegelman & Werth, 2005). Talking with colleagues, peers, friends, or family may also be helpful, although some people have found that they feel blamed by those they have looked to for support (Kleespies, et al., 1993; Knox, 2006). Choose carefully the people with whom you share your feelings, and if you don’t receive the support you need from one person, try someone else.
Talk with your supervisor about steps you can take to process the suicide. Many students have found reviewing the client’s death and performing a “psychological autopsy” to be helpful (Kleespies, et al., 1993). Examining the circumstances around a client’s death can help paint a realistic picture of the client, which may counteract imagined scenarios that take the self-blaming form of “I should have....”
You may also want to discuss the possibility of contacting the client’s family and attending funeral services, as other students have found these steps helpful (Kleespies, et al., 1993). Of course, issues regarding confidentiality, and in some agencies, concerns about the possibility of malpractice suits, could have an impact on this decision (Bongar, 2002 as cited in Spiegelman & Werth, 2005).
Educational institutions will likely want to be made aware if a student faces client suicide. Informing your school could be helpful in a number of ways. If you need to change your caseload temporarily, or even long term, your school can help you facilitate changes with your agency. Or, if you find that your school work is being affected, the school can help you find solutions that will minimize long-term effects on your academic standing. Informing your school increases the supportive structures in your life, giving you more people to go to if you need to talk about the client.
Think about going to therapy yourself, even for just a few sessions. Gaining support and a time and space to process a client’s suicide could be very helpful in coping with the numerous emotions you may feel (Kleespies, et al., 2003). Many schools have access to free or almost free counseling.
Choosing to Talk About Client Suicide
Clearly, social work schools need to be better at educating students about suicide. Formal courses or workshops should be offered in which students receive training not only in preventing suicide, but coping if a suicide occurs. Students who are in agencies with populations at high risk for suicidality especially need exposure to this issue before having to face it in practice.
Communication between schools and field placements about client suicide could help ensure that students receive the support they need. Protocol requiring agencies to inform schools of student exposure to client suicide, rather than putting students in what could be an awkward position to report it themselves, could allow schools to touch base with students and provide resources. Further, agencies could have internal protocols that help to guide students and professional therapists about the actions taken if a client does commit suicide (Knox, 2006).
Students absolutely have the right to start asking for more of their schools and field placements. Ask your professors and administrators to spend more time talking about suicide. Ask your supervisor if he or she would be willing to share experiences with suicidal clients or about how the agency has coped with losing a client to suicide in the past. Open a dialogue and see where it goes.
Maintaining the “It Could Happen to Me” Stance
All of us who work with clients or train those who do—students, professors, therapists, administrators, and supervisors—have a duty to acknowledge that yes, it can happen. Awful, scary, alarming, and not at all what we want to think, but yet it does happen. Clients commit suicide. Students face client suicide. Once we accept that painful reality, we can start figuring out how to support one another and do what many social workers do best: listen and help each other through it.
References
Brown, H. N. (1989). Patient suicide and therapists in training. In D. Jacobs & H. N. Brown (Eds.), Suicide: Understanding and responding: Harvard Medical School perspectives (pp. 415-434). Madison, CT: International Universities Press, Inc.
Feldman, B. N., & Freedenthal, S. (2006). Social work education in suicide intervention and prevention: An unmet need? Suicide & Life-Threatening Behavior, 36, 467-480.
Jacobson, J. M., Ting, L., Sanders, S., & Harrington, D. (2004). Prevalence of and reactions to fatal and nonfatal client suicidal behavior: A national study of mental health social workers. OMEGA, 49, 237-248.
Kleespies, P. M. (1993). The stress of patient suicidal behavior: Implications for interns and training programs in psychology. Professional Psychology: Research and Practice, 24, 447-482.
Kleespies, P. M., Penk, W. E., & Forsyth, J. P. (1993). The stress of patient suicidal behavior during clinical training: Incidence, impact and recovery. Professional Psychology: Research and Practice, 24, 293-303.
Knox, S., Burkard, A. W., Jackson, J. A., Schaack, A. M., & Hess, S. A. (2006). Therapists-in-training who experience client suicide: Implications for supervision. Professional Psychology: Research and Practice, 37, 547-557.
Lafayette, J. M., & Stern, T. A. (2004).The impact of a patient’s suicide on psychiatric trainees: A case study and review of the literature. Harvard Review of Psychiatry, 12, 49-55.
McAdams, C. R., & Foster, V. A. (2000). Client suicide: Its frequency and impact on counselors. Journal of Mental Health Counseling, 22, 107-121.
National Institute of Mental Health. Suicide in the U.S.: Statistics and prevention. Retrieved January 22, 2009 from http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention.shtml
Spiegelman, J. S., & Werth, Jr., J. L. (2005). Don’t forget about me: Experiences of therapists-in-training after a client has attempted or died by suicide. In K. M. Weiner (Ed.), Therapeutic and legal issues for therapists who have survived a client suicide (pp. 35-57). Binghamton, NY: Hawthorn Press.
Mollie Charter, MSW, graduated from Boston University in the spring of 2008. Her field placements were with adults and adolescents with severe and acute mental illness, and involved training in group, family, and individual therapy. She has since moved to Denmark, which has afforded her the opportunity to travel much of Europe, and is keeping up with social work through volunteering for an organization for people with mental illness and for a multicultural women’s organization, in addition to writing. She plans to return to Connecticut in the fall of 2009, where she hopes to begin work toward her licensure.