Summary of "Don’t Forget About Me: The Experiences of Therapists-in-Training After a Client has Attempted or Died by Suicide", by Jason S. Spiegelman and James L. Werth, Jr.
This chapter can be found in Breaking the Silence: Therapeutic and legal issues for therapists who have survived a client suicide, Edited by Kayla M. Weiner and available through Haworth Press. This important reference was published in 2005, and was co-published as a special edition of Women and Therapy, Volume 28, issue number 1.
Summary by Jason S. Spiegelman April 15, 2010
When Dr. Werth and I were first approached about writing a chapter in what was then a loosely-formed idea for a new publication in the area of postvention for clinicians and clinician-trainees, we were both excited and honored. The thought that we’d have an opportunity to blend our own personal experiences with such issues with what was then the most current research in the field was one that was too good to pass up, even despite our inordinately busy schedules. Through the magic of the internet, we were able to work collaboratively from 3 states away, sending drafts and sections of the chapter back and forth, each time polishing, segueing, and finally constructing a piece that we were very proud to submit. It’s co-publication as both a journal article and a book chapter was even more of a thrill, as we felt that both our own work and those of our colleagues writing different chapters would have maximum opportunity to reach as wide an audience as possible.
Our chapter begins with our own first-person accounts of our own experiences in this area; I speak about having lost a client when I was a Master’s student in the late 1990s, and Jim writes about a similar incident, where a client attempted (but did not complete) suicide when he was a trainee. Despite the fact that one story ended in death and the other did not, there are stark similarities between our experiences. Our initial reactions include shock, horror, fear, and a sense of being massively and rapidly overwhelmed by the revelation of what had occurred. Of our various memories, the most tangible was the sense of guilt; we both wondered if we had somehow done something wrong, missed something, or in some way had contributed to the events that had taken place.
Personally, I have long been haunted by a second dose of guilt for wondering about myself in that moment. I asked questions like “am I going to be fired,” “will I lose my internship,” and “will I be thrown out of my program?” Though I will not speak for Jim, his own account of his reaction to the events mirrors my own. The existing literature shows this to be a consistent them; in fact, how could someone in such a circumstance NOT spend just a moment wondering about him/herself and what these events would mean in their own personal and professional life? In the decade-plus since my own event occurred, I have come to recognized and accept that my fears were not the indication of a shameful level of arrogance and self-centeredness, but rather a rational response to a traumatic event, and quite likely the invocation of an unconscious defense mechanism immaturely trying to help me reestablish some sense of normalcy and control.
The second part of our chapter speaks about the literature into the incidence of client suicide in training years, the training that is provided for such events, and the ‘state of the field’ when the chapter was written. Though the chapter is now several years old and not as current as we’d like, there are some themes that are still salient:
Suicide in training centers (and among the clients of trainees) is real and common (though we’d not go as far as to say “real common.”) (*okay, just a little joke there. Are you paying attention?*)
These events can have a dramatic impact on a clinician-trainee’s personal and professional life
The training in this area is sadly lacking (which has been noted in the research for as long as the research has been published in this area) and both supervisors and trainees are left to learn by fire. This is true of both clinical and didactic training institutions
These events affect clinicians without bias – gender did not affect the extent to which a clinician or clinician-trainee is impacted by the suicide or attempted suicide of a client. Years of practice, however, did seem to have a slight level of insulating effect, though not enough to suggest that seasoned clinicians are impervious to the impact of a client suicide
When clinicians need support, they are often scapegoated and left to their own devices in the wake of such events. This phenomena is magnified when we are looking at trainees, and the impact can be that much greater.
There are several interventions that are recommended across the literature
There are also complicating legal and ethical issues that can potentiate the negative response of a clinician/trainee, and these must not be ignored even though it might feel unseemly to consider such issues after such a devastating personal loss
Our chapter concludes with a set of recommendations for clinicians, supervisors, and clinical training sites/programs. Rather than try to summarize them, I am simply going to copy those pages below so that they can be viewed in their entirety:
Suggestions for Training and for Supervisors
Based on the material reviewed above and our own experiences, we provide several suggestions for what trainees, supervisors, and training sites/programs can do following a suicide attempt or death by a student’s client. The recommendations provided below should be viewed with three considerations in mind. First, it should be noted that all of the suggestions– to trainees, supervisors, and programs – are made with the assumption that client confidentiality will always be given requisite consideration. For example, if inquiries or contacts are to be made, they must be done so with the client’s privacy respected to the greatest extent possible. Second, the proposals which encourage open communication between a trainee and her or his supervisor(s) should all be considered while bearing in mind Bongar’s (2002) cautions regarding the privilege, or lack thereof, of such conversations. Finally, where possible, these lists are organized with a temporal sequence kept in mind, so that trainees, supervisors, and program administrators can utilize them before an attempted or completed suicide occurs, immediately after, and between three and six months following such an event.
Trainees
1. As soon as possible, meet with your immediate supervisor or if this person is unavailable, another supervisor at the site/in your department; try not talk to others about what happened until you can confer with a supervisor.
2. Bring the client file and any audio-/videotapes to a meeting with your supervisor.
3. If your supervisor allows, tell her or him your emotional reaction to the news.
4. Discuss what you should do following the meeting, especially in terms of talking with others; follow these directions.
5. If your supervisor directs you to, consult legal counsel and a malpractice insurance carrier, with your supervisor present.
6. Strongly consider obtaining personal counseling related to the experience, and if you decide against beginning your own counseling, seek out support mechanisms specifically geared toward this sort of event, in order to reduce any sense of isolation you may feel (e.g., books or publications written for survivors, organizations of suicide survivors).
7. Discuss with your supervisor how to inform other staff members and students at the site, and your peer group, as well as your significant others, about the incident. Consider how to obtain support from them.
8. Complete case notes about the news and the supervision session, being careful not to make any self-incriminating or apologetic statements. Be clear about what has been reported versus what you know as fact. Do not change or delete entries and do not add pre-dated entries. Such additions to a file could be viewed suspiciously should a clinical review be initiated.
9. Try to obtain facts about the incident from a neutral party but do not make any statements that may sound like an assumption of responsibility.
10. If your supervisor allows, contact the significant others of the client but be careful about saying anything that may contribute to anger or guilt among the loved ones or that might lead them to assume negligence on your part.
11. If significant others want to, and your supervisor allows, meet with the family; discuss with your supervisor whether she or he should be present.
12. Consider making a counseling referral for the significant others.
13. Consider whether you want to ask the appropriate person about whether to attend the funeral, wake, or other ritual if death has occurred.
14. Consider whether you would be willing to participate in a psychological autopsy in the future (e.g., 3-6 months later).
Supervisors
1. Follow the training program’s/clinic’s established policies and procedures related to supervision and students interacting with clients (see below).
2. Rearrange your schedule to allow plenty of time to meet with the supervisee.
3. Allow the supervisee to talk about her or his emotions, thoughts, and fears, without attempting to determine responsibility or judge the adequacy of the supervisee’s care.
4. If it seems appropriate, remind the trainee that she or he is not alone in this experience and self-disclose if relevant (note: we say “remind” because we are assuming that training programs and supervisors will have informed supervisees that they are likely to see a client who is suicidal and may have a client attempt or die by suicide, see below).
5. Review the client’s file and appropriate portions of relevant audio-/videotapes.
6. Discuss what the supervisee should do and what you will do following the meeting, especially regarding the student talking with others.
7. Discuss with the supervisee whether to cancel any scheduled clients, how to engage in self–care, and consider whether to encourage the student to seek counseling related to the incident. Discuss the grieving process and offer support as the student moves through it.
8. Discuss with the supervisee how to inform other staff members and students at the site, and the student’s peer group, as well as her or his significant others, about the incident. Consider how the trainee can obtain support from them.
9. Discuss what sort of record keeping needs to take place.
10. Document the supervision session and recommendations; continue keeping contemporaneous supervision notes as other meetings, interventions, consultations occur related to the incident.
11. Consult your own superiors, legal counsel, and malpractice insurance carrier.
12. If necessary, involve the student in the meetings outlined in #11.
13. Try to obtain facts about the incident from a neutral party but do not make any statements that may sound like an assumption of responsibility on your part or the trainee’s.
14. Consider whether the student should try to contact the significant others of the client. If so, remind her or him to be careful about maintaining the client’s confidentiality and about saying anything that may contribute to anger or guilt among the loved ones or that might lead them to assume negligence on the trainee’s or your part.
15. Consider whether it would be acceptable to allow the trainee to meet with the client’s significant others, if that is what they want; consider whether you want to be present.
16. Suggest the trainee consider making a counseling referral for the significant others.
17. Discuss with the student whether she or he wants to ask the appropriate person about whether to attend the funeral, wake, or other ritual if death has occurred.
18. Discuss with the student whether she or he would be willing to participate in a psychological autopsy in the future (e.g., 3-6 months later).
19. Act as an advocate for the supervisee in situations where it appears as if others may be penalizing or attempting to assign blame to the student, or pressuring the student to “get over” the grief she or he may be feeling.
20. Monitor the supervisee’s emotional state; work with clients (especially those who present with depression, suicidality, or somehow resemble the client who attempted or completed suicide); and interactions with peers, faculty, and staff.
21. Monitor your own involvement such that the supervisory relationship with the trainee does not change into a counseling relationship. If you become aware that you are acting as your trainee’s counselor, albeit unintentionally, reconsider referring the student for her or his own personal counseling.
Training Programs/Sites
Before an attempt or death occurs.
1. Most importantly, administrators must remember that suicide can and does happen in the mental health industry and must keep in mind that despite the best and most professional efforts of even well-trained and experienced therapists and trainees, sometimes a client will attempt or die by suicide.
2. Attempt to foster a supportive, nonjudgmental, and non-blaming atmosphere that allows students to experience and share their concerns and feelings.
3. Ensure that supervisors are well trained in suicide-related issues. Develop written guidelines about the confidential nature of supervisory records and conversations, especially in situations where there has been a suicide attempt or death.
4. Develop a training program for students about suicide assessment and intervention. As part of the training incorporate data on the incidence of suicide attempts and completions experienced by trainees and professionals and the types of sequelae that may follow an attempt or death. Ensure that students are educated about how much control or responsibility they have with clients (especially in outpatient settings) and that there are natural and acceptable limits on what the student can offer (e.g., the student is allowed to go on vacation even if a client is depressed; training must end at some point). Make sure trainees and supervisors are aware of the post-incident protocol (see below).
5. Establish guidelines for meeting with supervisors; obtaining additional consultation; and documenting sessions, supervision, and consultations.
6. Develop an “impossible case” or “person at risk” conference where students can learn about difficult clients and outcomes. Institute non-judgmental “psychological autopsy” conferences as appropriate. Institute written guidelines about the confidential nature of these sessions, consult with an attorney about how to ensure the information remains privileged in the event of a suit or ethics charge.
7. Contract with a consultant and develop an on-going support group for students who have experienced a suicide attempt or death.
8. Attempt to assign clients to supervisees based upon skill and experience of the student.
9. Ensure that the site has clients sign paperwork acknowledging that they are seeing a student.
10. Ensure that intake paperwork includes a section asking the client about prior mental health treatment and history of taking psychotropic medications. If the client has a history of either or both, make sure it is standard practice for students to attempt to obtain prior mental health/medical records. Be sure this is documented in the file.
After an attempt or death occurs.
1. All faculty/staff should demonstrate empathy, unconditional support, and respect.
2. Have the student and supervisor meet (see above).
3. After the supervisor and trainee meet, the supervisor should meet with her or his superiors to discuss the incident, inform legal counsel, and malpractice insurance carrier. If necessary, include the student in such meetings.
4. As additional information becomes available, revisit plans and needs.
5. Encourage the student to use the confidential impossible case conference or psychological autopsy to allow the student, her or his peers, and faculty/staff to learn from the situation.
6. Do not allow other students, faculty, or staff to penalize, attempt to assign blame, or pressure the student to “get over” the grief she or he may be feeling.
7. Do not attempt to minimize the impact of the incident on the student, peers, supervisor, faculty/staff; determine how the event can be used to help the program and student.
8. Allow the supervisee to grieve.
We believe that following these guidelines will help training programs/sites and supervisors provide appropriate and sufficient support to trainees who experience a client’s suicide attempt or death. Although each student’s experience and reaction will be different, the literature seems consistent enough to support the outline we have provided. We also hope that our suggestions will help trainees themselves be more aware and prepared if they experience such an event and will help them get the support they need in such a difficult time. We encourage continued exploration into these issues and hope that more discussions will take place in the literature about what trainees experience and how programs have helped them in the wake of a suicide attempt or death.
Finally, this is only one of several extremely important and valuable chapters in this resource. I would strongly suggest that it be on the shelf of any supervisor or administrator of a training institution. I cannot stress enough the idea that prevention is often the most crucial element in postvention, and having a set of standard operating procedures that are invoked in response to a suicide event in a clinical setting is the most effective way to protect and care for the clinician (or trainee), supervisor, and institution.