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Sandford, D.M., Kirtley, O.J., Thwaites, R., & O’Connor, R.C. (2021). The impact on mental health practitioners of the death of a patient by suicide: A systematic review. Clinical Psychology and Psychotherapy, 28, 261-294.

In the UK, it is estimated that up to 27% of those who commit suicide have been in contact with a mental health professional in the past year. Even though suicide is a rare event, a mental health practitioner is likely to experience at least one instance of a patient suicide during their career. A psychotherapist who experiences a patient suicide could experience symptoms of burnout, PTSD, grief, and a sense of being overwhelmed. Sandford and colleagues conducted a systematic review of the existing research on the impact of a patient’s suicide, experiences of support by the practitioner, and factors that may minimize the negative impacts of patient suicide. They reviewed 54 quantitative and qualitative studies in order to synthesize the research. Professionals included psychiatrists, psychologists, psychotherapists, counsellors, and other mental health professionals. The most common responses of professionals to a patient suicide were guilt, blame, shock, anger, sadness, and grief. Over 20% of practitioners met criteria for PTSD in some studies. Many practitioners across all studies reported some negative impact on their personal life, with 24% identifying severe emotional impact (lower mood, poor sleep). Following a patient suicide, practitioners reported an increased focus on risk assessment, greater caution in their practices, and increased self-doubt about their own judgement. The average practitioner reported an impact that lasted about 4 weeks. A closer therapeutic relationship with the patient, patients who were younger, and the fear of blame and litigation were each associated with a higher level of distress in therapists. However, the impact was not related to therapist gender, age, or experience. Most practitioners felt inadequately prepared for dealing with a patient suicide. But protective factors included support from colleagues, friends and family, and supportive supervision.

Practice Implications

Even if suicide is a rare event in the population, an important minority of patients who commit suicide were in contact with a mental health professional in the preceding year. And so, one might expect to have a patient who commits suicide during one’s career that will have a negative impact on one’s own well-being and professional practice. Increased awareness of the incidence of suicide, informal social supports, and empathic supervision may mitigate the negative impacts. So will tailored training experiences on managing one’s own reactions to patients, as well as a professional work environment that is non-blaming and supportive.

Cristea, I.A., Gentili, C., Cotet, C.D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.4287.

Borderline personality disorder (BPD) is a debilitating disorder characterized by: severe instability of emotions, relationships, and behaviors. More than 75% of those with BPD have engaged in deliberate self-harm, and suicide rates are between 8% and 10%. BPD is the most common of the personality disorders with a high level of functional impairment. Several psychotherapies have been developed to treat BPD. Most notably, dialectical behavior therapy (DBT), cognitive behavioral therapy (CBT), and psychodynamic treatments like mentalization-based and transference-focused psychotherapy. This meta-analysis by Cristea and colleagues examined the efficacy of psychotherapy for BPD. Studies included in the meta-analysis (33 trials of 2256 clients) were randomized controlled trials in which a psychotherapy was compared to a control condition for adults with BPD. For all borderline-relevant outcomes (combined borderline symptoms, self-harm, parasuicidal and suicidal behaviors) yielded a significant but small effect of the psychotherapies over control conditions at post treatment (g = 0.35; 95%CI: 0.20, 0.50). At follow up, there was again a significant effect of the psychotherapies over control conditions with a moderate effect (g = 0.45; 95% CI: 0.15, 0.75). When the different treatment types were looked at separately, DBT (g = 0.34; 95% CI: 0.15, 0.53) and psychodynamic approaches (g = 0.41; 95% CI: 0.12, 0.69) were more effective than control interventions, while CBT (g = 0.24; 95% CI: −0.01, 0.49) was not. The authors also reported a significant amount of publication bias, suggesting that published results may be positively biased in favor of the psychotherapies.

Practice Implications

The results indicate a small effect of psychotherapies at post-treatment and a moderate effect at follow-up for the treatment of BPD. DBT and psychodynamic treatment were significantly more effective than control conditions, whereas CBT was not. However, all effects were likely inflated by publication bias, indicating a tendency to publish only positive findings. Nevertheless, various independent psychotherapies demonstrated efficacy for symptoms of self harm, suicide, and general psychopathology in BPD.

Pomerville, A., Burrage, R.L., & Gone, J.P. (2016). Empirical findings from psychotherapy research with indigenous populations: A systematic review. Journal of Consulting and Clinical Psychology, 84, 1023-1038.

Indigenous people around the world have a higher incidence of mental illness compared to other ethnic or racial groups. These higher rates may be related to the historical effects of colonization and to current discrimination. Despite this, there is very little empirical research on psychotherapy provided to Indigenous peoples. Psychotherapy, as commonly practiced, has Eurocentric values by emphasizing individuality, independence, rationality, assertiveness, and by sometimes taking an ahistorical present-centered focus. These values may conflict with some Indigenous cultures that emphasize community, interdependence, mysticism, modesty, and the historical context of current functioning. Hence, psychotherapy as typically defined may require adaptations when used with Indigenous groups. In their review, Pomerville and colleagues examine what is currently known about psychotherapy with Indigenous populations. The populations studied in the existing research includes Indigenous peoples of the US, Australia, Canada, Pacific Islands, and New Zealand. There were no psychotherapy studies prior to 1986, and only 23 studies since then. Most studies emphasized some form of cultural adaptation of the treatment. The majority of studies focused on substance abuse, with only a few on anxiety and depression. Only two studies were controlled outcomes studies (i.e., randomized controlled trials considered by many to provide the best evidence from a single study). Research on individual therapy for Indigenous adolescents is completely lacking. The authors concluded that the efficacy of novel or adapted treatments or the generalizability of existing empirically supported treatments to Indigenous people are currently unknown.

Practice Implications

The virtual absence of controlled outcome trials of psychotherapies for Indigenous populations is serious gap in the practice of mental health interventions. This state of the research is particularly problematic given the high rates of mental illness and alarming rates of suicide among adolescents in Indigenous populations. Some studies found discontent among Indigenous communities with the current application of empirically supported treatments, and others argue that Indigenous healing be given the same legitimacy despite no controlled outcome research. On the other hand some authors favour training cultural competence among clinicians who practice standard empirically supported treatments. Pomerville and colleagues suggest that in the absence of evidence, tailoring psychotherapy to address the needs of Indigenous clients by taking into account specific practices of their communities may improve retention and outcomes.

Sledge, W., Plukin, E.M., Bauer, S., Brodsky, B.,... Yoemans, F. (2014). Psychotherapy for suicidal patients with borderline personality disorder: An expert consensus review of common factors across five therapies. Borderline Personality Disorder and Emotion Dysregulation, 1:16. doi:10.1186/2051-6673-1-16.

Treating patients with suicidal ideation and borderline personality disorder (BPD) can cause significant anxiety, concern, anger, and guilt in clinicians. Strong emotional reactions can lead to risky therapeutic interventions, poor clinical decisions, and professional burn out. The outcome of therapy can have serious consequences for such patients. Recently, a panel of 13 experts reviewed the efficacy of the most common treatments for suicidal ideation in BPD. As part of the review, they identified the common factors that may be useful for all clinicians who work with these clients. The five therapies they reviewed included the following. Dialectical behavior therapy, which emphasizes the role of emotional dysregulation and impulsivity in suicide. Treatment includes distress tolerance, emotional regulation, interpersonal effectiveness, and mindfulness. Schema therapy decreases suicide risk by challenging negative thoughts with cognitive and behavioral techniques while using the therapeutic relationship to improve the patient’s capacity to attach to others. Mentalization based therapy works toward improving the patient’s capacity to keep in mind the patient’s own mind and the mind of the other. This encourages new perspectives on relationships and emotion regulation. Transference focused psychotherapy views suicidal behavior in BPD as related to distorted images of the self and others. The treatment emphasizes gaining greater awareness of self in relation to others, and integrating a more realistic experience of the self. Good psychiatric management is an integrative approach that uses both psychodynamic and behavioral concepts. The approach sees BPD as a problem with interpersonal hypersensitivity, but the management tends to be more pragmatic than theoretically based. The expert panel defined six common factors among these treatments. (1) Negotiation of a frame for treatment – in which roles and responsibilities of therapist and patient are defined before the start of treatment, including an explicit crisis plan. (2) Recognition of the patient’s responsibilities within therapy. (3) The therapist having a clear conceptual framework for understanding the disorder that then guides the interventions. (4) Use of the therapeutic relationship to engage the patient and to address suicide actively and explicitly. (5) Prioritizing suicide as a topic whenever it comes up in the therapy. (6) Providing support for the therapist through supervision, consultation, and peer support.

Practice Implications

Suicidal ideation in patients with BPD can have serious consequences for the patient and can be highly stressful for the clinician. This expert panel identified six common features of most major treatment approaches to suicidal ideation in BPD. Even if clinicians are not explicitly trained in any one of the approaches, ensuring that these six factors are present in their work will improve the likelihood that their patients will experience a good outcome.

Fowler, J.C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49, 81-89.

The journal Psychotherapy regularly publishes Practice Reviews, which are clinician-friendly practical articles that are based on the best current evidence. Recently, James Fowler published a Practice Review on suicide risk assessment. The assessment, management, and treatment of suicidal patients are some of the most stressful events in clinical practice. However, there is very little that is clear in the evidence base to help clinicians to make accurate assessments about suicide risk. Assessing suicide risk factors tends to result in making an inordinate number of false-positive predictions (i.e., deciding that a patient will attempt suicide when in fact the patient will not attempt suicide). Making false positive suicide predictions might be seen by some as desirable because doing so represents a conservative course of action. However, a clinician acting as if a patient will suicide when he or she will not can lead to unintended negative consequences for the therapeutic alliance and for the patient’s future trust in health professionals. Fowler suggests an assessment approach in which efforts are made to enhance therapeutic alliance by negotiating a collaborative approach to assessing risk and understanding why thoughts of suicide are so compelling. The list of protective factors (e.g., supportive social contacts, religious beliefs, therapeutic contacts) and risk factors (e.g., past suicide attempts) based on the most current evidence are presented in the article in easy to read tables. Fowler also presents a list of clinician resources for suicide assessment and facts with handy web site addresses. For example, Fowler suggests the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) that incorporates the risk and protective factors with the best evidence base.

Practice Implications

Most methods of predicting suicide risk result in false positives (i.e., predicting suicide when suicide will not occur). Though conservative, a false positive prediction of suicide risk can have a negative impact on therapeutic alliance and patients’ future trust in health care providers. Evidence-based assessments of risk and protective factors may help. A free SAFE-T pocket guide is available to download at the Substance Abuse and Mental Health Services Administration (SAMHSA) web site: http://store.samhsa.gov/product/SMA09-4432.

Author email: cfowler@menninger.edu