While we strive to provide our clients with a good enough therapeutic experience, the therapy does not always proceed smoothly and we find ourselves faced with difficult clinical situations. Responding to the aftermath of a completed suicide, supporting clients who become ill, perhaps mortally, and terminating inappropriate therapy are situations that require considerable thought and skill on the part of the therapist and can threaten her reputation if not handled well.
My experience of suicide came rather early in my career, when someone I was training killed himself. He did it in a quiet self-contained way on an anniversary, which produced minimal repercussion for me personally. I wasn't able to feel that anything I could have done would have made any difference. I did wonder why he had started training and whether I had let him down by talking so little about suicide.
Later I was involved with a serious attempt, which was much more disturbing. One way of understanding suicide is that a person attempts suicide in order to kill the unbearable psychic pain inside him. He cannot see any other way of dealing with it. The only way to kill the pain is to kill himself. Of course feelings, which require such a violent act, are not so easily disposed of. The unbearable feelings frequently transfer to those who are left behind, through a process of projective identification. Rob Hale (1991) has written helpfully and comprehensively about suicidal acts.
Therapists are used to being on the on the receiving end of projections but these extreme feelings can be particularly difficult to metabolise. Careful attention to what the therapist is left feeling will reveal which unmanageable feelings have been evacuated into the therapist. In my case, while I might have expected to feel rage or despair at the attempted suicide, what I identified was feeling helpless in the face of what had happened. Eventually I realised that an abusive dynamic had come into play. The client had made sure I could not help him. My hands were metaphorically tied behind my back and then, in phantasy, I was forced to watch him act out his self-destructiveness. I was left feeling helpless in the face of his self-destructiveness. Since this was precisely how he felt, he had eloquently allowed me to understand his feelings. The question was whether he had destroyed my capacity to think. Once I understood the dynamic, the feelings I had internalised lifted and I had the bizarre physical sensation, of a weight off my shoulders. I was then able to talk with the client about it. In the event of a completed suicide we are deprived of the opportunity to return the digested feelings but it is just as essential to ensure they do not become lodged in the therapist.
If we practice for any length of time the chances are that we will have to deal with a serious attempted suicide or a completed suicide. It is difficult to be prepared for the emotional turmoil that ensues but it helps if it can be seen as something that goes with the territory rather than a personal failure.
Unexpected breaks are probably a prime time for suicidal behaviour. Where the pain of abandonment is unbearable a suicide attempt may follow to blot out the abandonment. A therapist who becomes ill or pregnant and requires time away from the client cannot be there for them and the client may act out the annihilation. Linda Anderson (1994) describes how, when she was pregnant, a borderline client killed himself during the break. He found it difficult to look at his fantasies about the intruding baby, in anything other than a concrete way and became stuck between the wish for a child and a self-destructive envy. While personal circumstances precipitated the act, it seems likely that his feelings about the break and the baby highlighted his already persecuted isolation.
Our reactions to suicide are not always what we would expect and it can be reassuring to know that others have had similar responses. ‘A special scar: The experiences of people bereaved by suicide' (Wertheimer, 2001) is a useful book, which helpfully describes the reactions of those who have been bereaved by suicide. In the book people who have been bereaved by suicide describe their experience of attending the inquest, the particular difficulties of the funeral, how they faced suicide as a family, the impact on them and how they sought and used support in the wider world. Any therapist who is bereaved in a similar way by a completed suicide will recognise much of what is described.
When a client dies the Coroner's Court has the task of deciding the cause of death. They need information and may well approach a therapist to ask for it. What they are interested in is the last person to see the client in different settings. However whether you could have managed a crisis in therapy differently is not their concern. They are interested in what happened. Therapists I have interviewed describe how helpful the coroner's officer , who is usually a policeman, was in understanding the therapist's anxieties and their loss. He conveyed to the therapist that it was something that happened and that the coroner was looking to understand what had happened, not to find a scapegoat.
Answering questions at a Coroner's Court may well be part of the process. It is helpful if someone who is used to the process, as many consultant psychiatrists are - can do it. It is unusual to be called to give evidence, but if you are, there is advice available on evidence giving which can enable you to do so more confidently. Generally the advice when attending any court is to address your comments to the judge. You can stand facing the judge and when asked questions turn to the counsel asking the questions before turning back to the judge. Preparation is important. You need to be confident of your facts and know what it is that you want the court to hear. If you have a point of view or an argument that you want to get across it needs to be clear in your own mind. The answer to any question needs to use facts to illustrate the picture you are concerned the court should grasp. Deciding beforehand what you want the court to take away from your evidence will clarify your thinking and enable the court to get the best from you.
The coroner's brief is to ascertain the identity of the deceased and how when and where they died. The full inquest may not be held for several months and waiting can inhibit the grieving process and prolong the anxiety for a therapist. It is a very public scrutiny of personal tragedy and both the public and the press may attend. The coroner decides how much of the written evidence will be read out in court. It is a formal procedure and witnesses can be cross-examined. Families, who go to the inquest for answers, or to feel heard, can be disappointed by the limited scope of the inquest. The reporting in the local paper can also be hurtful where small details are wrongly reported or blown up out of proportion. Bereaved families respond in a variety of ways. Some simply want to know what happened and find some reconciliation; others may be looking for someone to blame. Guarding one's professional reputation can occasionally become a priority.
As a supervisor or manager we owe a duty of care to colleagues in this situation. This may mean ‘carrying the can' for what has happened. The last thing someone needs, at a time like this, is a senior colleague who will step sideways out of the firing line. A therapist, who was feeling a failure on learning of a completed suicide, described how helpful it was to have a supervisor who could keep it in proportion and find time to talk about other issues as well. The supervisor is holding the therapist and trying to learn from the situation.
Suicide, which involves evacuating the feelings, is an attack on thinking and can initially undermine the therapist. Therapists rely on linking their thinking and feelings, to manage the unmanageable. Suicide is an aggressive concrete intrusion, which it is difficult to come to terms with. A supervisor can help the therapist to distinguish her own feelings, from those that the client has evacuated into her. I find it helpful to use Winnicott's ideas in ‘Hate in the counter transference' (Winnicott, 1975) to hate the client's boundarylessness. Both the supervisor and the therapist are trying to digest what has happened. They need to identify the split off elements that are thrown up and can so easily be swallowed whole by the therapist.
A clear objective assessment of whether each step was taken at the time in good faith and professionally, helpfully encourages therapists to learn from the experience about the professional procedures followed. Carefully reviewing each step of the therapy will reveal areas where things could have been done differently but will often reveal just how well the client was taken care of. Linda Anderson (1994) in her article wonders whether, with hindsight, she could have provided more external support. Providing support that clients will actually use is difficult. Anyone other than the therapist can be experienced as a poor substitute, rather like losing mother and being fobbed off with the babysitter. Also in providing extra support one can feed into the client's sense of shame and inadequacy.
When a suicide is unexpected, a therapist can be left trying to understand what happened, looking for clues. Trying to fit missing pieces together can evoke a sort of madness and distress in the therapist and help is needed to think about what happened. If there are aspects of merging, and fears of survival, that overlap in the therapist's unconscious, it can be difficult for the therapist to separate and understand who the therapist is and who the client is. Searching for missing clues is part of a normal grieving process but the therapist may also be experiencing unconscious resonance, such as trying to communicate with an internalised absent, depressed or dead mother. Thinking about the analytic meaning of feelings evoked by suicide can diffuse the dread of difficult feelings and help in working through them.
In the case of a group client, the therapist may have to tell other clients the news of the suicide. One therapist was left wondering about whether to tell her client group even though the client had left the group, and had not been in it for 9 months. The therapist's pondering about whether to tell the group can be explained by understanding suicide as something in the social environment that is so deeply disturbing that it can impinge on the counter transference feelings of the therapist. If a client has attempted suicide at a time that coincided with the therapist's absence, the therapist may become more concerned than usual, about being seen as uncommunicative with her clients. Of course the reverberations last for a long time, but it does relieve the therapist of any omnipotent fantasies. It instils in the therapist a real sense of respect for unconscious processes and just how unmanageable, feelings can be.
Winnicott wrote “There will be suicides, management committees must learn to reconcile themselves to suicide, to truancy, and the occasional maniacal outburst with something in it very like murder, broken windows and destruction of things. Psychiatrists who are blackmailed by these disasters are unable to do what is best for the rest of the community in their care.” (Winnicott, 1979: 245)
Anderson, L. (1994) The experience of being a pregnant group therapist. Group Analysis , 27, 75-85.
Hale R (1991) Suicidal Acts. In Holmes J (Ed) Textbook of Psychotherapy in Psychoanalytic Practice . Edinburgh: Churchill Livingstone.
Wertheimer, A. (2001) A Special Scar: The experiences of people bereaved by suicide. Hove: Brunner-Routledge.
Winnicott, D. (1975) Hate in the counter transference In Collected papers: Through paediatrics to psychoanalysis (Ed, Winnicott, D.). London Karnac Books. (Originally published in 1958 by Basic Books, New York; paper first published in 1947).
Winnicott, D. (1979) In The Maturational Processes and the Facilitating Environment, pp242-8 (Ed, Winnicott, D.) London, The Hogarth Press/ Institute of Psycho-Analysis.
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