Exploring the therapist’s experience when a client dies by suicide

by Mary Spring

As we are reminded by Rilke (1989: Loc. 2850), “so we live here, forever taking leave”. Loss emanates from nearly every therapeutic session, nestling within the exploration of aging, physical decline, relationships, separation, divorce, children leaving home and bereavement. This intimate therapeutic encounter of two people is profoundly disturbed and abruptly ended when the client dies by suicide. What is the experience like for the therapist? What are the effects on the listening heart?

Research data on the impact of client suicide on the therapist has been mostly America-based. The motivation in pursuing this project is to reflect the voices of Irish-based therapists who have lost a client to suicide, to explore the emotional, cognitive and professional impacts and response strategies and, in an original piece of research, to consider any accompanying residue. Historically, silence has accompanied death by suicide, and the hope is that this paper will inform, stimulate and challenge conversation and perspectives among a broad therapeutic community of practitioners, supervisors, training facilitators and students.

Literature review: A brief history of suicide
The word suicide comes from the Latin sui, meaning ‘of oneself’ and caedere, ‘to kill’ and is defined by The Oxford Encyclopedic English Dictionary as “the intentional killing of oneself”. History has many references to the act of suicide (Leenaars, 2004, Williams, 2014). In ancient Greece, Plato and Aristotle both “espoused the view that suicide was against the State and, therefore, wrong” (Leenaars, 2004: Loc. 223). In pre-Christian Rome, “suicide was viewed either neutrally or, by some, positively” (Leenaars, 2004: Loc.236). Perspectives changed, however, as suicide was deemed by early Church thinkers such as St. Augustine to be a violation of the fifth commandment (Williams, 2014: 3). By the Middle Ages attitudes towards suicide were encapsulated in Thomas Aquinas’s view that suicide was against natural law as well as against God’s law and influenced by supernatural or devil forces that resided in the person (Williams, 2014: 4). In England, the person was identified as non compos mentis (not of sound mind) or as felon de se (felon of himself) and, if the latter, was tried posthumously, possessions being forfeited to the crown (Williams, 2014: 4). Denied a Christian burial, the desecrated naked corpse was often pierced through with a wooden stake and buried at a crossroads (Williams, 2014: 5). These practices, legal and ceremonial, continued in Tudor England (Williams, 2014: 6). However, the Enlightenment of the late 17th and early 18th centuries saw a growing secular viewpoint emerge with an emphasis on reason and individualism, with Hume, among others, considering suicide as a right (Leenaars, 2004: Loc. 266). The Christian churches continued, however, to refuse to pray for the dead by suicide and to deny burial in consecrated grounds (Williams, 2014: 19). In the 20th century, amid the backdrop of two world wars, Existentialism challenged the individual to consider freedom and a person’s right to end his or her life (Leenaars, 2004: 278). In contemporary times, suicide has been decriminalised in many countries. It was removed as a criminal classification in the United Kingdom in 1961 (Williams, 2014: 21). Ireland followed suit with the passing of the 1993 Criminal Law (Suicide) Act, section 2 providing that “suicide shall cease to be a crime”.

Epidemiology of suicide
According to the World Health Organization’s published report, Preventing Suicide: A Global Imperative (2014), an estimated 804,000 suicide deaths occurred worldwide in 2012. Irish statistics confirm the ubiquity of suicide and clearly demonstrate the real possibility of a therapist encountering client suicide. According to the Central Statistics Office, 437 deaths by suicide were registered in 2016, of which 350 were males and 87 were females. 425 deaths by suicide were registered in 2015 (335 males, 90 females) and 486 deaths by suicide were registered in 2014 (399 male, 87 female; www.cso.ie). In keeping with the WHO’s observation regarding the practice of occasional under-reporting, Ireland’s returned statistics might not fully represent exact numbers. It should also be noted that Ireland’s annual suicide statistics can be updated due to the addition of delayed coroner inquests, with revised figures for the year 2013, for example, increasing from 487 to 543 (www.cso.ie).

Literature review: The emotional impact on the therapist
Research evidence over the last 30 years clearly attests to the emotional impact on the therapist when a client dies by suicide. Chemtob et al. (1988a) and Chemtob et al. (1988b), in two of the earliest research findings, respectively reported psychiatrists and psychologists experiencing shock, guilt, anger, self-doubt, failure and loss in the aftermath of a client’s suicide. McAdams and Foster’s research (2000) supported these findings in their observation of therapists experiencing substantial distress, guilt, fear and anger. Further scholarship provided parallel evidence while also supporting a broader picture of the emotional impact on the therapist. Hendin et al. (2000) and Hendin et al. (2004) reflected the growing fear of blame and litigation. Collins (2003: 160) illustrated the experience of “emotional numbing”. Farberow (2005: 18) attested to the complexity of the impact on the “clinician-survivor”, given the unique professional relationship between the care-giving therapist and a now-deceased client. Ting et al. (2006) brought attention to the practitioner’s fear of being judged or blamed by colleagues and peers. Research continued to corroborate the findings that client suicide was a likely “occupational hazard” (Chemtob et al., 1988a: 227) and that such an occurrence had a substantial emotional impact on the therapist. Gutin et al. (2011) documented the experience of intense confusion along with shock, denial, numbness, sadness, anger, anxiety, shame, guilt, fear of judgement and of litigious blame, and echoed Ting at al’s findings five years earlier (2006) on the discomfort felt in talking with colleagues about the loss. Subsequent research by Ting et al. (2011) unequivocally rejected the comforting adage that time heals all (emotional) wounds. Clausen (2015: 10), emphasising the reality that the deceased’s therapist is a person in silent mourning, gave an evocative personal account of the groundlessness that it is part of the emotional impact where “shame isolates and evicts us from our relational home”. Finlayson and Simmonds (2018), consistent with findings documented nearly 30 years previously respectively by Chemtob et al, Hendin et al. and McAdams and Foster, concluded that the suicide of a client was associated with increased intensity of emotional reaction and found that the most intense feelings were sadness, shock and helplessness.

Literature review: The cognitive and professional impact on the therapist
McAdams and Foster (2000), attesting to the disrupted professional identity in some clinicians following the death by suicide of a client, documented therapists experiencing intrusive and avoidant thoughts, making more conservative client selection, keeping more conservative notes, increasing their hospital referrals, increasing their attention to legal matters and possessing a greater alertness to possible suicidal cues. Hendin et al. (2000) confirmed that some therapists decided to discontinue taking on clients who were at risk of suicide. Hendin et al. (2004) found that a number of practitioners considered leaving their practice. Expressing the view that such an experience is an opportunity for learning and regeneration, Collins (2003) suggested that work practices might positively change but research continued to demonstrate that change was rooted in heightened anxiety and fear, Gutin and McCann (2017), for example, documenting hypervigilance regarding clients, a greater professional self-doubt, an increased collegial and peer consultation regarding legal matters, the maintenance of more conservative records and the practice of other compensatory coping mechanisms such as overwork and over-involvement in the work.

Literature review: Response strategies to support the therapist
So how could a therapist, in negotiating the unsettling truth of the “unambiguous rejection of the therapeutic relationship” (Anderson, 2013: Loc. 2553), respond and find meaning in a client’s self-determined death? Extant research has illustrated various postvention supports. Hendin et al. (2000) confirmed the meaningful support found in supervisors and empathic colleagues who shared their experiences of client suicide, Tillman (2006: 169) later describing this support as a “special fraternity”. In such reflective spaces, the practitioner might acknowledge what Jeffreys (2011) defined as the therapist’s “cowbells”, and listen closely to what now stirs in the heart, pondering, for example, on death and suicide, exploring experiences of bereavement and attachment style in loss, both which might have fuelled the countertransference. Giving anecdotal evidence of allowing herself to process such a loss, Clausen (2015) reflected on leaving the time of the client’s weekly appointment vacant for a period and in those hours she ‘met’ both herself and the client in journaling, poetry and letter writing to the deceased. Additional support which mitigated the impact for some therapists was found in talking with family and friends about the suicide. Nineteen of the 26 therapists who partook in Hendin et al.’s research (2000) saw the deceased client’s relatives after the suicide, either on their own initiative or that of the relatives. Reeves and Nelson (2006), echoing the perspective of Ting et al. (2006), asserted that “suicide essentially remains an unpredictable phenomenon” and strongly advocated for policy-bound and practice-based support for the therapist following such an experience. Farberow (2005), reiterating the findings of Foster and McAdams (1999) and McAdams and Foster (2000), emphasised the need for training bodies to incorporate the study of suicidality in core training programmes. Gaffney et al. (2009) reflected this perspective, advocating for a culture of personal and professional learning.

Methodology
Research paradigm and method
The researcher’s social constructivist paradigm adheres to a core relativist epistemological principle which proposes that there is no one version of reality. This research would not present a right answer; instead, it would allow for complex and multi-faceted dimensions and sensitively respect and honour each participant’s unique experience of a client’s suicide. A qualitative approach, allowing “an exploration of the perspectives and life world of human beings and the meanings they give to their experiences” (Holloway & Wheeler, 2002: Loc. 550) and capturing the inherent “messiness of real life” (Braun & Clarke, 2013: 20), was subsequently adopted. Data was gathered through in-depth, open-ended, one-to-one, non-directive, semi-structured interviews. A thematic analysis (TA) approach for identifying and reporting patterns and themes in the gathered data was employed, such an inductive pathway allowing for the individual voice of each therapist to be truly heard and fulsomely represented.

Ethical considerations
This paper’s validity was to be determined by whether or not the work was transparent, credible and an honourable representation of each therapist’s individual experience of a client’s death by suicide. Underpinning the project was an adherence to General Data Protection Regulation (www.dataprotection.ie) and the core ethical principles embedded in the researcher’s accrediting body, IACP. Reflexivity “locates the researcher in a research project” and essentially is a “form of self-monitoring” (Holloway & Wheeler, 2002: Loc. 362) This research project necessitated then that subjectivity be tracked and every effort was made to ensure that the research analysis would be “plausible, coherent and grounded in the data” (Braun & Clarke, 2013: 20), the opposite of which implies losing perspective and “going native” (Flick, 2014: 469).

Profiling participants
Two female therapists and two male therapists, aged 57, 40, 60 and 65 respectively, all private practitioners, participated in this research. The four therapists had, up to the time of interview, practised for eight, six, seven and 30 years, respectively. Three stated their preferred theoretical framework as a humanistic-integrative model; one works primarily from a person-centred perspective. All four live in the west of Ireland. The duration of each therapeutic relationship with the deceased was nearly a year, over a year, one year, and two years. At the time of the interviews, it had been nearly three years, nearly a year, two years, and five years since the respective deaths, and this had been each therapist’s one experience of client suicide.

Analysis of data findings
Anderson (2013, Loc. 2561) posits that there is a “magical thinking” within the therapeutic professions with regard to client suicide. Located however in the experiences of four Irish psychotherapists, this research confirms the hypothesis found in the landmark research of Chemtob et al. (1988a: 227) more than 30 years ago that suicide is an “occupational hazard” and upholds Norcross and Guy Jr’s unequivocal statement that “substantial disruptions” (2007: 43) will be experienced by the professional. However, and as elucidated in this paper, there is no uniform experience. There are commonalities but the experience of a client’s suicide is unique to each clinician. It is an individual journey.

It is worth noting both the presence and the absence of certain affective responses in the findings. Commonly felt feelings included shock, upset, sadness and loss. Significantly, guilt, detailed as one of the commonly reported emotional responses, as identified in Gaffney et al. (2009) and Gutin et al. (2011), anger towards the client (Ting et al. 2006) and fear of litigation, as illustrated in Fox and Cooper (1998), Hendin et al. (2000) and Ting et al. (2006), did not feature in any of the four therapists’ responses. Failure, another emotion noted in Collins (2003), Farberow (2005), Ting (2006), among others, was only directly referred to by one therapist who recalled not experiencing a sense of failure and obliquely by another therapist in acknowledging his immediate scrutiny of case notes after the death of his client. However, this researcher cannot conclusively state nor even suggest that such feelings, though not stated in the interviews, were not felt by the therapists.

This research confirms that intrusive thoughts, typified in “could I have done something different?” surfaced. A hypervigilant attitude to the depressive and suicidal cues of their clients, as previously observed in Hendin et al. (2000), Ting et al. (2006) and Finlayson and Simmonds (2018), was experienced by three therapists and professional practice somewhat changed for them. In contrast to Hendin et al.’s findings (2000), there was no evidence that the four therapists discontinued taking high risk clients, and two therapists found themselves becoming fearless in their attitude towards the work with at-risk clients. One therapist stated, “maybe I have got riskier”, and cited the example, such as at the point of contracting, where she intentionally encourages new clients “if you are thinking of suicide, please talk with me about this…. I am here”. Another therapist noted that the experience made her “less afraid to cut through all the bullshit and able to say to the vulnerable client that I would be there as much as the client allows me to”.

This paper also points to the various coping strategies and supporting mechanisms which legitimised and helped process each therapist’s loss. Supervision, as highlighted by Hawgood (2015), was found to be helpful for the more recently trained professionals. “I processed the hell out of it”, uttered one therapist. Two therapists acknowledged that they “revisited death” in subsequent supervision sessions, one reconnecting with a late parent’s passing and another recognising that the pain he felt for his young client was also ‘tied’ to another suicide. One therapist, exploring the countertransference (as signposted in Gutin & McGann, 2017), acknowledged that “we had become kind of enmeshed and I had, quite insidiously, become almost his father or his mother figure, well, probably his father figure”. In a reflective process of making meaning of a “professional injury” (Tillman, 2006: 159), all four therapists learned to see the good collaborative work that had been completed. Supervision was not pursued by the longest-practising clinician. This may reflect an older and somewhat different model to contemporary training with the latter’s strong emphasis on process, supervision, reflection and self-care. The absence of relevant literature was noted but colleagues, partners and friends were identified as supports as was the personal faith of three of the therapists. As observed by Sequin et al. (2014), funeral attendance was a significant part of the grieving process for two therapists, one stating “I needed to honour her … to honour us”, one later placing two little angel figures at the graveside. Two therapists respectively met with the mother of the deceased client. “Safe memories were recalled.” In contrast, one therapist felt a strong impulse to ring the deceased’s father but did not act on the urge. The unexpected supported two therapists’ process. For one therapist, a dream, which she had in the early hours of the morning her client’s body was found, proved to be an immediate source of solace, the deceased speaking the following words to the therapist: “you can’t be all things to everyone”. A client’s handwritten letter to another therapist deeply moved him. In what he described as “an amazing mindset for someone who was going to kill himself”, the letter, two-fold in its intention, articulated the client’s gratitude to the therapist and “made it very clear that there had been no lack of duty of care on my part”.

This research found that residues of various hues remained with the therapists. Long reflective pauses, tears and the lowering of tone at different times in the four interviews attested to the felt truth that “something is always carried”. Clear memories, sometimes stirred by random moments such as when driving a route often walked by the deceased or when passing the client’s house where he took his own life, linger though time has passed for each therapist. Emotions are less strongly felt but sadness “remains deep”. “She will always have a special place in my heart … she will not be forgotten” are one therapist’s closing words. Do such indicate secondary trauma, each therapist respectively having acknowledged encountering depression and/or suicidal ideation earlier in their lives or are the clear recollections and intermittent silences perhaps, symptomatic of grief when one is touched deeply by unexpected loss and by the accompanying ache of absence? Or is there something in the relationship that remains incomplete and unfinished? A second residue was the deeply-felt anger felt by two therapists respectively, anger towards a medical-therapeutic professional disconnect where counsellors and psychotherapists are “at the bottom rung and need to be heard regarding the high-risk client” and anger at a perceived contemporary attitude “where suicide is ‘acceptable’ …. but it’s not ok. It’s never ok”. Another legacy identified was that of an emerging fearlessness to “go there” with other and future at-risk clients. “I can go there now”, said one therapist, “without fear because the thing I greatly feared had come upon me”. A fourth residue, and as previously documented by Hawgood (2015) and Gutin and McGann (2017), was that the four therapists were reminded to take care of themselves because of the nature of the work. As expressed by one respondent, we have a life outside our clients … I am reminded to live, to be curious, to be fascinated with the world”. Another imprint was that of deep and wise lessons being learned regarding the powerlessness of the helper-therapist, the shattering of a therapist’s illusion of omnipotence, what Tillman describes as a “narcissistic vulnerability” (2006: 159) and the suicidal choice ultimately being the client’s – one therapist stating “you are powerless essentially over the lives of people. If you don’t recognise that, you are trying to fix people and move them in a particular direction …”

Conclusion, limitations and recommendations
What the research concluded
Mirroring the researcher’s social constructivist paradigm which emphasises that there is no single version of reality, this evidence-based research project concluded that each participant’s experience was unique, notwithstanding some similarities. Secondly, emotional responses were found to be both similar and varied, sometimes influenced by the unexpected dimension of a dream or a letter. Certain emotions, i.e. guilt, anger towards the client and the fear of ligation were noted for their absence in the findings, and a sense of failure was only implicitly mentioned by one and disavowed by another. Thirdly, therapists subsequently thought differently, with professional practice and efficacy confirmed as being impacted on, some therapists, for example, becoming hypervigilant, some articulating a strong determination to challenge future at-risk clients. Fourthly, diverse postvention supports were acknowledged as important in validating and mitigating the loss and, fifthly, it was concluded that the client’s suicide left a deep residue, each therapist moving over time towards an “acquaintance with the invisible form” of the deceased (O’Donohue, 2007: 133).

The limitations of the research
This research, in the opinion of the researcher, is a valid and reliable piece of enquiry. Limitations, however, were evidenced in its planning and implementation and the findings of this paper ought to be considered and interpreted in the light of such acknowledged limitations. There is a need to gather further empirical evidence from a broader sampling of therapists. Another limitation emerged as part of the findings and this was that the time period that had elapsed since the deaths of the clients varied from nearly one year to five years; this researcher was left wondering whether or not a more limited time period would have contributed to a different conclusion. Such gaps and limitations signpost the need for future enquiry.

Recommendations
Though ubiquitous in society, suicide arguably is accompanied by silence in the Irish therapeutic community. This research contributes towards a necessary discourse. Listening professionals are invited to move from what perhaps is a fear-based anticipation towards a more personal and reflective professional readiness to engage with the occupational reality of a client choosing to end her or his life. If engagement with this reality is seen as an ethical imperative, there are implications for training, practice and policy making. There is, for example, an argument to be made in favour of suicidality and postvention considerations being core parts of professional training programmes. Accrediting bodies might consider formalising policy and introducing mechanisms by which an impacted therapist might be supported.

Conclusion
This research project became a journey of the heart as well as an academic endeavour, ultimately reminding the researcher that the work of psychotherapy is both tender and intimate. In this environment two hearts meet, the listening heart of the therapist and the listened-to heart of the client. Sometimes the unexpected happens on the Ithaca journey; sometimes clients die. Sometimes clients die by suicide. Learning to be gentle with ourselves as practitioners amidst this reality is both an art form and a necessary skill.

Mary Spring is an accredited psychotherapist with IACP. She has a private practice in Galway city and is a tutor/lecturer with ICPPD. She previously worked in second level education.

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