The Sacrifice, The Labyrinth and
the Minotaur
Silvia Baba Neal
silviababaneal-psychotherapy.co.uk/mindspace
Facts provided by the American
Association of Suicidology
Many beginning clinicians are unaware that suicide is an occupational
hazard
Approximately 1 in 5 psychotherapists (and as many as 1 in 2
psychiatrists and psychiatric trainees), lose a patient to suicide during the
course of their career (McAdams and Foster, 2000, McIntosh, 2003, Ruskin
et al., 2004)
Novice clinicians have been found to experience higher rates of
suicide among their clients than more seasoned clinicians.
Experiencing the loss of a client by suicide can be psychologically
traumatic for the provider, and may even become a career-ending event.
Unfortunately, few training institutions or graduate programs prepare
students for this possible traumatic loss (Reeves, 2010)
Ariadne
The clinician as survivour
Significant emotional impact (Kleepsies, and Dettmer,
2000)
Therapists have described client suicide as “the most
profoundly disturbing event of their professional
careers” (Hendin, et al. 2000)
Fear of being blamed by supervisors, managers or
trainers, and the client’s family (Farberow, 2005)
May cause the therapist to seriously doubt their skills
and competence therapist to consider abandoning a
career in psychotherapy (Farberow, 2005)
Therapist begins to use rules rigidly and defensively to
prevent another suicide
Therapists in training
• Some authors have suggested that therapists in
training may experience reactions even stronger
than do their qualified colleagues
(Brown, 1987; Kleespies et al., 1990, 1993)
• Trainees may be less able to separate “personal
failure from the limitations of the therapeutic
process”
(Foster & McAdams, 1999, p. 24)
Five stages of grief model
(On Death and Dying, Kübler-Ross, 1969)
“The stages were never meant to help tuck messy emotions into
neat packages. They are responses to loss that many people have,
but there is not a typical response to loss as there is no typical
loss. Our grief is as individual as our lives.”
(Kübler-Ross and Kessler, 2006)
www.suicidology.org/suicide-clinician-survivors
Clinician 1
“Through shock little vibrations trickle through my body, a
sinking feeling comes into my heart, then my stomach. I can
not move. My mouth goes dry. Thoughts start tumbling
through the air-landing on my body -- how, when, what does
this mean, what will happen, will I be blamed, what is going
on, how will I get through the day, don't scream must act
professional, get concrete, O.K. I have a client waiting, stop
the tears, act AS IF.”
http://mypage.iu.edu/~jmcintos/therapists_mainpg.htm
Clinician 2
“His death made absolutely no sense to me. After all, I had
carefully assessed his suicidality during our last session and
there was nothing there to alarm me. Yet, he was dead, and
with his death, a part of me died as well.
After the total shock and disbelief began to diminish, I
started to sob, sobbing uncontrollably at times. I
experienced extreme anxiety, gross sleep disturbances, and
profound sadness. I was spiraling downward quickly, and I
was emotionally paralyzed.“
Clinician 3
“Day 46: The feeling of loss has been very strong lately. I lost
Mary. I lost being a member of the elite who has never lost a
client to suicide. Already, I lost many hours of my time -planning, fretting, and talking. I lost sleep. I lost confidence. I
may have lost part of my joy in being a therapist.”
7 months later: I still think of Mary. The waves of loss are
farther between and much less overwhelming but the
undercurrent is still there. Her suicide has touched me on many
levels. During these past months, one professional implied that
clinicians are not affected by a client's suicide and brushed me
aside. I felt very invalidated and angry. Another colleague
insisted that anti-suicide contracts really work. I felt defensive. I
had taken this step and others, but it was not enough to save
Mary's life.”
Clinician 4
“I must say at the start that this is a very difficult case to
discuss. In 25 years I have not publicly talked about it. This
is a case where it is important to tell you all about my
credentials as an analyst, as a senior university faculty
member, etc. Notice that I included the word "Senior ."
Can you believe that? After 25 years I still need to armor
myself?”
Trauma
Trauma is “a sudden and violent emotion capable of
provoking a permanent alteration of psychic activity” (Devoto
and Oli, 1990 p. 2002 in Mazzetti, 2008, p.285)
Prolonged stress following unprocessed trauma significantly
impacts the neurological structures in the limbic system
related to implicit memory and emotional life (thalamus,
amygdala, hippocampus, and prefrontal cortex) (McEwen et
al., 2009)
the learning involved in trauma is resilient or “fixated”
(Cozolino, 2010)
Traumatic ego-states (Berne, 1961/2005)
Berne (1961)– a traumatic stimulus modifies an ego state in an
abrupt way. A traumatic ego-state is like “a warped coin, which
would skew the pile” (1961/2005, p. 52)
Penfield’s experiments (Penfield and Perot, 1963 in Milner,
1977)
• Summary maps indicating all points
from which electric stimulation of the
exposed cortex has elicited complex
auditory experiences in patients undergoing
a surgical operation for epilepsy
Trauma, stress response and the brain
Psycho-social stress and the brain, (McEwen et al.,
2009)
Amygdala and hippocampus neurons exposed to
chronic stress (Davidson and McEwen, 2012)
One dendrite synapses (www.harvard.edu)
Memory systems
(Allen, 2011)
Impasses:
developmental
perspective
P2
(Mellor, 1980)
A2
Type 1
P1
C2
A1
P0
A0
C0
Type 2
Type 3
Type 3 impasse
When Mellor described his model of impasse, he suggested
that third degree impasses can also develop later, whenever
someone is:
“(…) so traumatized or otherwise overloaded at the
time they develop impasses that their current levels of
functioning give way to earlier levels. This type of
response results in the development of higher levels of
impasse at ages when their development would no
longer be possible if a strict developmental ordering
would apply.” (Mellor, 1980, p. 218)
Factors that may contribute to development
of Type 3 impasse
Your own Script System: core beliefs about yourself, others
and the world (Erskine, 2010) and personality style
Your Parent Ego state (P2): Rigid views about suicide
influenced by religion, philosophy, public policy. Antidote:
Tim Bond, 2000, Anddrew Reeves 2010
The context: “prevention-prediction culture” associated
with the medical model views every completed suicide “a
failure at instiutional or individual level” Antidote: Reeves,
2010 and Szatz, 2011, Mental Capacity Act, 2005, Suicide Act, 1961
Prescriptive, unchallenged, TA practices formally and
informally handed down to the therapist i. e. “no-suicide”
contracts Antidote: Erskine, 2009, Little, 2009, Hargaden and
Stuart, 2000/2001 debate
Psychological modifiers of stress-response
(Sapolsky, 2004)
Outlets for frustration
A sense of predictability and control
Social support
A perception of life improving
Self- Care
•
Activate support systems.
Let it out: express feelings of anger, rage, despair, grief in a safe
and appropriate context (therapy, supervision, peer
supervision).
•
•
•
Take control: manage workload, be proactive in seeking
information and support, deal with the tasks of writing
reports, informing the relevant people etc.
Silver lining: How can you use this experience to teach and
support others? How can you improve your practice and the
general pool of knowledge?
Ethical considerations around:
Collaborating with police investigation
Case review- psychological autopsy (Marshall, 1980)
Coroner’s report
Notifying insurance company
Letting the relevant people know (course director, placement
facilitator)
Calls of condolence (There is a GP/psychiatrist/social worker
out there going through the same experience!)
Receiving calls from family members or friends of the deceased
Attending the Coroner’s Inquest
Possibly attending the funeral, depending on circumstance
(Bond and Mitchels, 2008) Bond, 2010, Gabriel and Casemore,
2009)
Supervisers’ helpful/unhelpful responses
The response of the immediate supervisor to the (supervisee’s) client’s suicide is
a critical factor in influencing how the event personally or professionally affects
trainee development (Foster & McAdams, 1999)
Talking with a colleague who knew the patient or who had had a similar
experience with a patient was beneficial in reducing isolation and providing
support (Hendin et al., 2000)
Providing emotional support and an intellectual context for understanding
and growing from the experience of a client suicide (Brown, 1987)
Supervisors helpful if they assured trainees that the way in which the trainee
reacted to the suicide was clinically appropriate and if the supervisor shared
responsibility for the outcome of the case (Kleespies et al. 1990, 1993)
Unhelpful those supervisors who prematurely requested that trainees talk
about their cases or immediately barraged them with stories of their own
patients who suicided when the trainees were not ready (Kolodny et al., 1979)
Need sufficient time to prepare themselves for the painful but necessary task of
a “psychological autopsy” (Marshall, 1980)
Recommendations for supervision (Knox et
al., 2006)
Allow supervisees to control when, where, how, and with whom they
process the suicide
Allow supervisees to access extra supervision, consultation, therapy
Continue to provide a supportive time and place for supervisees to
work through the client suicide even after the immediate responses
seem to have abated
Acknowledge/normalize that the effects of a client suicide, both
short term (e.g., more thorough assessment for suicide) and long
term (e.g., awareness of therapeutic responsibilities of suicidal
clients, lingering feelings), may be painfully learned growth
Bibliography
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American Association of Suicidology [founded in 1997 to support clinician survivours]
Clinician survivours testomonies:
http://mypage.iu.edu/~jmcintos/therapists_mainpg.htm
Comprehensive bibliography on suicide impact:
http://mypage.iu.edu/~jmcintos/Surv.Ther.bib.htm
Berne, E. (1961/2005) Transactional Analysis in Psychotherapy, London: Souvenir Press
Bond, T. (2010) Standards and Ethics for Counselling in Action (third edition), London: Sage
(Kindle edition)
Bond, T. and Mitchels, B. (2008) Confidentiality and Record Keeping in Counselling and
Psychotherapy, London: Sage
Brown, H. N. (1987) The impact of suicide on therapists in training, in Comprehensive
Psychiatry, 28(2): 101-112
Davidson, R. J. and McEwen, B. (2012) Social influences on neuroplasticity: stress and
interventions to promote wellbeing, in Nature Neuroscience, 15: 689-695, Available online:
http://www.nature.com/neuro/journal/v15/n5/full/nn.3093.html (Accessed 13 Nov.
2013)
Erskine, R. (2009) The culture of transactional analysis: theory, methods and evolving
patterns, in TAJ, Vol. 39, no. 1
Erskine, R. (2010) The Script system in Life Scripts [Richard Erskine, ed]
Farberow, N. L. (2005, February). The mental health professional as suicide survivor.
Clinical Neuropsychiatry: Journal of Treatment Evaluation, 2(1), pp. 13-20
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Foster, V. A., & McAdams, C. R. (1999). The impact of client suicide in counselor training: Implications
for counselor education and supervision. Counselor Education and Supervision, 39, 22–29
Gabriel, L. and Casemore R. (2009) Relational Ethics in Practice: Narratives from Counselling and
Psychotherapy, East Sussex: Routledge
Glaser (2007) The effects of maltreatment on the developing brain, in The Link, 16(2): 1 and 4
Hargaden, H.(2000) Escape hatches: Sacred rite or useful tool?, in TA UK, 58: 33-34
Hendin, Lipschitz, Maltsberger, Haas, and Wynecoop (2000) Therapists’ reactions to patients’ suicides, in
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Kleespies, P. M., Smith, M. R., & Becker, B. R. (1990). Psychology interns as patient suicide survivors:
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Kolodny, S., Binder, R. L., Bronstein, A. A., & Friend, R. L. (1979). The working through of patients’
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