As humans, they may face grief, guilt, loss and anger not very different from that experienced by others left behind: simply, they react as humans who have lost another with whom they have had a close relationship.

But therapists also have to deal with the death in terms of their special role in that person's life and in the society of which the client formed a part. There is no right way to deal with such a loss. Nonetheless, in this article, we present a handful of what the limited consensus view seems to suggest are ways of easing the passage when dealing with the loss of a client to suicide.

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Your own emotional reactions

The research says an acute emotional reaction is likely to follow the suicide and last for a week to a month. This is the time during which support is most needed. Resnick delineates three stages in coming to terms with the suicide. During the first, psychological resuscitation, the survivor's emotional revival with support from a trusted colleague is important. The second, psychological rehabilitation is the processing of the loss and the third, psychological renewal, is about moving beyond the grief and establishing new contacts and relationships.

If your initial response is focused principally on anxiety about the professional ramifications, the self-doubt in your professional capacity and the idea that others are blaming you, you are in company with many other survivors of client suicide. You may also feel rage at the client for killing themselves or at the institution for which you work. Chemtob et al found that 57% of psychiatrists and 49% of psychologists who had a client commit suicide reported post-traumatic symptoms comparable to groups of individuals who had experienced the recent death of a parent.

Expect to deal with the suicide in what may feel like primitive ways. Therapists who have lost clients through suicide have been known to forget details of the case or distort features thereof. One psychiatrist admitted to newspaper reporters that he had prescribed the sleeping pills with which a patient committed suicide. It later transpired that the pills had been prescribed by other physicians. Blame, responsibility and inadequacy are most common. You may fear any number of adverse reactions from the family, your colleagues, other patients who hear about the suicide and from your profession as a whole.

It can be an isolated, lonely time. You may feel an urgency to avoid potentially suicidal clients in future at all costs. Some therapists experience identifications with the dead client in their dreams while some have been recorded to find their identification manifested in being accident-prone for some weeks after the death.

You can also expect, though, that you will have instincts to draw some professional and personal lessons from the death. Many have reported that a client's suicide has improved their professional judgment, made them more sensitive personally and as therapists and enlarged their psychological horizons.

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Factors which are likely to increase the emotional impact of the suicide on the therapist are:

- Pre-existing stress in the practitioner due to a high work load;

- The depth of the attachment between therapist and client more than the length of acquaintance;

- The therapist's ignorance about what the professional ramifications are of the death;

- The availability and use of supports by the therapist;

- Whether the psychologist was working alone or as part of a team with the client.

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In general

Keep track of what you have done, who you spoke to and any information given by colleagues, legal advisors and family members of the deceased.

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The funeral

Attending the funeral can be helpful in allowing you to join the grieving with the rest of the family. It may also tie some emotional ends up for you in respect of your own relationship with the client.

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The police

The police will probably open an investigation into the death. That doesn't mean they are gunning for you. Consult your legal counsel before making any statements. If it is comforting to do so, have legal counsel available at questioning, especially in the case of a more complicated suicide to which you may have been a witness or in which there are questions about your role.

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Your colleagues

If you follow none of the other pointers given here, at least seek the company of a trusted colleague. The number of therapists who have survived the suicide of a client is probably far higher than you think and many of those you think may not have had a patient commit suicide might just not have made it public knowledge.

Therapist survivors of suicide are unanimous that formal and informal consultation with colleagues is one of the most important and helpful actions to take as soon after the suicide as possible. Dubbed the psychological autopsy or postvention, it is something you must seek out as soon as possible. It is a way of bringing a close to the shock of the death and dissecting the feelings you may have, however inappropriate you think they might be.

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Your lawyer and your indemnity

Contact your lawyer before making any statements to the press, lawyers or aggrieved relatives. Let your insurer know timeously of the suicide. Many professional indemnity schemes provide legal advice in these sorts of situations to avoid a more messy situation in the event of a claim of negligence against you.

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Your notes

If you have been keeping comprehensive notes, there should be no problems with an inquiry. Notes should also be made after the death, avoiding drawing too many elaborate conclusions about the reasons for it.

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Sending accounts

This is one of the most difficult tasks after the suicide. You may be inclined, like many people who make use of therapeutic services of some description, to equate the outcome with the quality of the treatment. But this is not the case with professional services like therapy; you are billing for your knowledge and your time spent trying to help your client. At least some writers think the failure to send accounts may imply guilt. Others argue this reflects an unnecessary preoccupation with the legal implications of the suicide, so you are probably best off using your own discretion.

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The family

Contact the family as soon as possible after learning of the suicide. Preferably, do it in person in a quiet and private setting. Expressing how sorry you are does not constitute an admission of liability or a suggestion that your actions may have been negligent. It may also be a healthily cathartic action for you.

Allow the family members to react in a way that they choose, offering help in referral to other professionals if this feels appropriate. But be careful of becoming the family therapist if there was a complicated relationship between them and the deceased. Engaging in family therapy with the survivors may be construed as unethical behaviour if it is seen as an attempt to swing their opinions about your potential negligence.9 Make yourself reasonably available to them at least until the funeral has been conducted.

Also, be careful about disclosing information about the deceased or their treatment. The ethical constraints of confidentiality continue beyond death and a practitioner may be liable for harm caused by disclosures about deceased patients. Take, for example, a client who suffered abuse by another family member and requested that the therapist not let the family know that she was in therapy.

In hospital

You may be the person who has to tell the rest of the patients and other staff of the hospital. Approach it in much the same way as you would the family of the deceased. Other patients may be seeking reassurance that you, as the psychiatric staff, are able to help them. Research suggests patients in hospitals feel more vulnerable when a fellow patient commits suicide, possibly raising the risk of other suicidal behaviour in the following days.

Staff may be encouraged to attend the funeral to round out their understanding of the client. This may also assist them to process their musings about what they may have done to prompt the suicide.

Some recommend a psychological autopsy with the staff, presided over by a therapist unfamiliar with the client or the staff and aimed at allowing feelings to be aired and to address concerns about how patient care may be improved.

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The physical autopsy

Suicides will often be the subject of autopsies. Odd as it may sound, attending them may be of use to the practitioner both as a way of understanding the person's death more fully and, in the event that the cause of death is equivocal, psychiatrists or trained physicians may be able to assist the pathologist. But they can also be more upsetting, so use your own discretion.

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Further reading Freud, S. (1960) The Psychopathology of Everyday Life. London: Hogarth.

Kleespies, P. M. (1993) The stress of patient suicidal behaviour: Implications for interns and training programmes in psychology. Professional Psychology: Research and Practice, 24, 477 - 482.

Resnick, H. L. P. (1969) Psychological resynthesis: A clinical approach to the the survivors of a death by suicide. In E. S.

Schneidman and M. Ortega (Eds) Aspects of Depression (213 - 224) Boston: Little, Brown.

Horn, P. J. (1994) Therapist's psychological adaptation to client suicide. Psychotherapy, 31, 190 - 195.

Litman, R. (1965) When patients commit suicide. American Journal of Psychotherapy, 19, 570 - 576.

Chemtob, C. M., Hamada, R. S., Bauer, G. & Torigoe, R. Y. (1988) Patient suicide: Frequency and impact on psychologists. Professional Psychology: Research and Practice, 19, 416 - 420.

Kaye, N. S. and Soreff, M. (1991) The psychiatrist's role, responses and responsibilities when a patient commits suicide. American Journal of Psychiatry, 148, 739 - 743.

Ness, D. E. and Pfeffer, C. R. (1990) Sequelae of bereavement resulting from suicide. American Journal of Psychiatry, 147, 279 - 285.

Pearlman, T. (1992) Letter: American Journal of Psychiatry, 149, 282 - 3.

Schacht, T. E. (1992) Letter. American Journal of Psychiatry, 149, 282.

Fox, R. and Cooper, M. (1998) The effects of suicide on the private practitioner: A professional and personal perspective. Clinical Social Work Journal, 26, 143 - 157.

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On the internet

www.cyberpsych.org/aasmemb.htm. - American Association of Suicidology - A comprehensive resources on suicide, with an especially impressive listing of references on managing the suicide of a client.

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