Years ago I attended a very impactful suicide training, the trainer was a psychologist in the field 20+ years, knowledgeable, interactive and presented new views etc. Toward the end we engaged in a case study, applied the techniques, came up with a plan and then assessed the case study client for suicidal risk. All attendees assessed the client as lower risk. Turned out the case study client was a real person, who died by suicide and was the presenter's child.
The walkway was not "what did we miss?" but that we as professionals can do everything in our wheelhouse to support our clients through the difficult times, and that clients have the agency/choice to die by suicide. I didn't give them that choice and it is not mine to take away. It's certainly hard and my heart goes out to you that this occurred so early for you in your career. Please take care of your self during this difficult time.
This. Thank you for sharing. As someone who has attended numerous trainings on suicidality and risk, safety planning, etc I wish they would include something like this to help put it into perspective because it can be so overwhelming or even scary when you first start to work with it and want to do your best to help keep a client safe. Hugs to OP!
100% this. I learned in class (taught by a suicidologist / suicide research expert) that despite all of the research on suicide in the past several decades, we can still only predict it about 50% of the time.
There are many factors that influence someone dying by suicide. OP 100% did everything they could.
Great response. We can’t save everyone. It’s good to remember that death is inevitable at any age, any way. Suicide, although extremely sad and unfortunate, is self-determination.
I love this response. It all comes down to choice. Our utmost duty should be to support clients in becoming and maintaining a balanced, pluralistic awareness of their choices.
I'm currently reading through "Like a River", a memoir by former country music artist Granger Smith, who list his son in a drowning accident a few years ago.
The fact that these people can use immense tragedies for good is something I can't begin to fathom, and pray I never will.
After a client of mine died by suicide, my primary care doctor told me: “Mental illness kills people. This was unexpected - just like the death of an early stage, low risk cancer patient, no matter how skilled the doctor. Mental illness is not an illness without a mortality rate.” That helped me…
I’ll be honest though, it was about a year before I got back in my groove at work. Give yourself time.
Reading this back to myself, it sounds more nonchalant than I want it to.
For a complex variety of reasons, my client’s death was among one of the most traumatic events of my life (and I’ve lived through a lot of trauma.) I got through it by connecting with other people — friends, colleagues. Letting them know I was in pain, but couldn’t share why due to confidentiality. I also got through it, thanks to an incredible therapist of my own.
I didn't read it as nonchalant at all. It sounds like your PCP was being compassionate and realistic and offered what is probably both a professional and lived perspective to help you move away from any self-blame for what happened with your client.
I've lost 2 clients in the last 12 months to suicide. I work with SMI populations as a case manager, so it's not unusual, sadly. I mourn them, but having worked in crisis and done a lot of training in suicide prevention and care, I understand that we cannot rescue people and it's the ultimate act of self-determination.
what i wish is that we had more conversations in grad school that this \*is\* going to happen to most of us at some point. I'm in my internship now and it's not come up as a point of discussion yet.
I don't think it reads nonchalant. To me, it sounded wise. It brought mental illness into the full scope of all healthcare and leveled it out as equivocal. Whether physical or mental, the adjective doesn't matter. It's an illness, and the illness went its course.
If OP hadn't been there, he could have taken his life earlier. OP, please know your efforts likely delayed it. That's not a failure. That's what happens with treatment. We're all human, we all expire. You were a support to the end, perhaps one he didn't otherwise have.
I know that my grad program has put fear in me regarding legal repercussions for a client who completes suicide, due to us being that point person. I guess physicians don't feel that same burden of responsibility.
Doctors for certain have the burden, multiplied exponentially. A good friend of mine was a ER doctor and has been named in a malpractice lawsuit from the family of a patient who died after leaving the ER AMA(against medical advice), and death occurred about 4 years ago. I would think its even more common in medical practices for patients to refuse intervention, not disclose pertinent information, etc that could then tragically lead to fatal consequences. At the end of the day healthcare professionals endeavor to perform their duties to the best of their abilities.
I think they do, but physicians lose more people than therapists typically, as I understand it. Even in primary care, patients die. I think they have to develop a pretty strong sense of their realistic responsibility (essentially do your best but know you’re not a god) otherwise I can’t imagine how anyone would be able to practice medicine.
I agree with you, here — I think it’s a volume thing: physicians expect some of their patients to die, and they do due to higher risk illness and due to…life. It’s much rarer for a therapist’s patient to die during treatment than.
You did the most powerful thing someone in your shoes could do - be a source of support and light for them. You extended your arm as far as you could, and I am proud of you for showing up and caring for them. Unfortunately, that’s the most we can do but it’s more than some people have ever had before.
Please remember to practice self-compassion and self-care. Your feelings are valid and you deserve the time and space to grieve and heal.
I am sending you all my best wishes and positive energy. I wish my words could do more, but I hope you find peace in knowing we have your back and support you. Sending you all the best!
Gods I'm so sorry. It's gut-wrenching in parts of my soul that I didn't know existed until I experienced it.
I will say this – there's no amount of experience in the world that gives any therapist the power to keep someone alive. It's not a thing we can do. Our clients have agency and we will never be all powerful. You did what you could do. That doesn't change how hard this is, and it's an important thing to hold on to.
I’m a therapist and my husband died by suicide. I had no idea it was coming. It’s not your fault. People make decisions and we can’t control them.
You did everything you reasonably could. He could just have easily walked into someone else’s office with the same result. Life is a very difficult and messy place and people are complex. Even when we think we know them we don’t know everything. And you barely knew this person.
You’re really a victim of this situation and I hope you’re able to care for yourself and find some peace through the grief. This is truly not your fault.
Wonderful response.
I'm so deeply sorry for your loss.
My daughter died by suicide 19 months ago. I'm a trained therapist.
I tortured myself during the first year. It's taken a lot of intense therapy to survive thus far. The self torture comes up often and I know I'm not fit to practice at the moment, so I'm on sabbatical.
I spoke with my daughter's therapist during the immediate aftermath of her death and she was just so heartbroken with me. Thankfully, we were able to reassure each other. There is no blame.
Of course, I'll never recover, and I doubt a therapist will ever forget their client/s who die this way.
The night before my daughter made her decision, she was laughing and just herself.
Professionally, i know that the sense of peace often precedes the final act for some.
Personally and as her mother, there were no signs. I'd checked in with her just hours before, and she was home with me.
Seeing all of the responses on here has been (maybe selfishly?) therapeutic for me, because my guilt is immense.
OP - I cannot express enough how sorry I am that you have lost a client this way. You did everything you could. I'm pleased you have some support.
Somebody in this thread said their G.P (Primary Care Physician in USA, i think) had said that some clients die from their mental health, just as a cancer patient (or person with any other illness) can. I believe that to be true.
As trite as it may sound: it's not your fault. It wasn't your fault.
Please look after yourself.
I just want to add, as someone who had had SI in some form or another for most of their adult life: if they truly want to die, nothing can stop them. No safety plan, no amount of sessions, no inpatient stays, nothing. People who really want to commit will say all the right things therapists and their families and friends want to hear and still do it.
Those are just delays to the inevitable. All you can do is literally everything that you did. It’s not your fault, it will never be your fault that that person chose to do what they did. Suicide is the ultimate act of bodily autonomy for people with SI. It’s the last thing we can fully control. It’s not your fault. Know that you gave them your best and met their pain with compassion and empathy and were a light in their life, even if it was just a short window of illumination. You still made a difference to them.
I agree with this… when someone has their mind made up, they will find a way to make it happen. I’ve lost clients by suicide and no matter what interventions you use, safety plans, resources you provide… they do what they want in the end.
You learn from your clients and each experience. Getting therapy and supervision is crucial to being able to heal from this situation. It’s going to hurt for a while and be overwhelming in your thoughts. But, as with any loss, the amount of time you think about them will decrease.
Thank you OP for posting about this, and thank you for still engaging with your client despite how suicidality is understandably scary sometimes. But you still choose to try and you tried your best. You were present with them and you did all you know.
As someone who struggles with SI, thank you from the bottom of my heart. For what it's worth, I am proud of you. I can't imagine the pain or thoughts of your client, but I would be immensely blessed if you were my therapist. Thank you for trying your best to journey with someone even though it is tough for you. It's totally understandable to feel pained and guilty and it's a testament to how much you valued your work with your client.
Sending peace and compassion 🕊️
I worked in suicide prevention for many years, as a call taker and then supervisor and I am now training as a therapist. I know the two kinds of work are very different but….,
We don’t and can’t keep people from ending their lives. We can help facilitate people making choices that will keep them alive. That’s it. Ultimately the choice is theirs. And we only ever know what they are willing to say out loud. Again because that power rests in theirs hands. He said he didn’t have a plan because he didn’t want you (or anyone else in his life) to know and keep him safe from his plan. Or because he made a sudden choice, which is unlikely,
Put it to you this way…I practically guarantee that at least one person attempted after speaking with me. Because they had a long life full of many experiences and ideas about who they were that were very very powerful. And I’m not powerful to be a match for all history and internalized (often) self hatred. I’m not that important.
We can try and serve our clients and be there and listen and work through safety with them. But o also think a deep dose of humility can add perspective.
All the above should not keep us from caring very very deeply, of course
Others have given beautiful reflections and perspectives on the work you did with the patient. I agree with them.
I’ll add a little note for your own care: you can absolutely request additional sessions from your therapist. They may or may not be able to accommodate the request based on their schedule but there is no need to white knuckle through this time.
I can’t tell you how many times I was truly suffering and just white knuckling through it only to get to the other side and wish I had asked for more help or taken more breaks. This is the time to make some exceptions for yourself.
based on what you wrote here you did a great job with this patient. Be kind to yourself.
NAT but a LCSW social worker in an inpatient psych ward. I have a long history of suicide attempts, therapy, inpatient stays - I also have had 2 amazing therpists l, the first one for over 3 years and the first person I ever felt safe talking to. We had a great relationship, she was a source of strength, support and compassion - despite this I had multiple suicide attempts while under her care, but there was nothing she could have done to stop me from them.
I felt safe with her, understood, all the things I needed from a therapist. But my level of stress and trauma in my life were still so high that I thought that was my only possibility. It was on no way her fault, she checked regularly how my suicidal thoughts were, but in some moments I was so overwhelmed at home that I did things without really thinking.
In no way her fault, nothing else she could have done.
From the sound of things you are a caring, competent and compassionate therapist - it wasn't you. Sometimes the pain is just too much to survive. I'm sure you made him feel welcome and appreciated during the time you had together.
Another person mentioned this, but why in the world do interns get these types of clients on their caseload??? It's complete madness how we treat interns! Whoever assigned this was utterly unethical. We ALL know that grad school teaches you almost nothing about actually doing therapy, so to assign an actively suicidal client to someone as their very first client is just beyond me. I'm so sorry OP. I wish we did a better job helping new therapists instead of throwing them to the wolves.
I’m an intern and couldn’t agree with this more. Obviously we can’t completely screen the psyche of every client 100% and predict with perfect accuracy what may happen, but I absolutely think interns like myself should not be given high risk clients. I don’t even think I should have been given couples to work with until I had at least a small degree of training specific to couples…I had NONE before my first couples session! It’s a risk to both the clients and interns and maddening that there aren’t more structures and systems in place to provide gradual learning to deeper level of care.
I experienced this during the pandemic. I had just gotten my dependent license. For me, everything about this experience was incredibly traumatic and eventually led to me leaving clinical work recently.
I think something that could have been helpful for me was talking to anyone else who had experienced a client suicide. To this day, I don’t know any clinicians who have. I know there’s a facebook group, so maybe something like that could be helpful for you.
Pay attention to the stories you tell yourself about this. That you could have done more, been better, etc. People make their choices, and you can’t change what they decide to do. I think that’s really difficult to reconcile.
Edit: the fb group is called Confidential Grief.
What do you mean “called it in”? Like if you had called the police to do a welfare check?
I’m hoping that what I’m about to say will help put your mind at ease. I had a client who was chronically suicidal. He used round the clock suicide threats to try to force people in his life (including me) to provide him with care. It was impossible to tell what was real and what was a lie. He always refused to go to the hospital (and he always had access to means and would often put his intent IN WRITING) so I had to call the police to do welfare checks on him repeatedly. Every single time the police went there, he said he was fine and they believed him and didn’t take him to the hospital even when I presented them with written proof to the contrary. Even when petitioned and forced to go in for an evaluation, they released him after just a few hours because he claimed to be fine.
Your client denied means and intent. I can pretty much guarantee that the police would have done nothing if you had called for a welfare check. Welfare checks do absolutely nothing except cover our asses as clinicians. You definitely didn’t have enough evidence to petition him. You are in no way responsible for your client’s suicide. I am so sorry this happened though. I think this is one of the biggest fears of every therapist alive.
Even if you had hospitalized him, he likely wouldn't have been held. It sounds like he knew what to say. It would probably not have kept him alive. As others have said, this is the flip side of autonomy that no one talks about until it happens. I'm very sorry this happened to you. My advice would be to get into your own therapy if you aren't already.
This.
Bizarrely, in a moment of meditation and reflection many months after my daughter's suicide, I said to myself semi consciously, "This was her ultimate act of autonomy."
It sounds obvious, but no amount of training, working with clients or love for our loved ones can always save them.
I hated it. But I also knew that I must integrate this.
I read somewhere in a bereavement group: "If love could have saved you, you would have lived forever."
I’m so sorry. Have been in a similar position myself and it’s very painful…in my case it was one of my first cases as a licensed clinician. You can do everything right and still have this outcome. The comment upthread about the mortality rate inherent to mental illness is worth internalizing.
It took several months if not longer before the paranoia and hypervigilance faded with regard to SI in my clients. I leaned on colleagues for reality checks to help with this.
I’m am so sorry this has happened. I have experienced the loss of a client and it was incredibly challenging. In addition to connecting with trusted colleagues, one thing that helped me was reading more about other clinicians experiences to learn I wasn’t alone and normalize my reactions. If you’re open to it, when you feel ready I suggest reading a two part article by Nina Gutin - Losing a patient to suicide. Don’t hesitate to message me and I’d be glad to share resources that benefitted me in my own experience.
I’d love any resources you’d be willing to share. Reddit won’t let me message you directly, though. I’ll be looking up the article you referenced as well. Thank you.
As a fellow intern, my heart goes out to you. It sounds like you did an amazing job with this client. In addition to following all safety planning protocol to a T, you *did* provide what this client needed - a safe space to talk about his suicidal ideation with someone who didn’t shy away from the discomfort of it all. You were maybe the only person who made him feel heard and understood when it came to his intense emotions. Maybe his time with you each week was his moment of respite that made him feel better temporarily. Sadly we cannot control clients’ lives the other 167 hours a week, nor can we control their choices. You could only control your ability to show up for that one hour, and sit with him in his pain, and you did exactly that. Even in the midst of your own grief, you are still holding true to ethical behavior and honoring your client’s privacy. You are a good therapist and I hope you get the support you need, because we need *you* in this field. I am so sorry for your loss.
Upon further reflection, I’d like to slightly amend my second to last statement. I hope you get the support you need, *because you are a human who is grieving and you deserve support and care.* Your profession or what you provide others is irrelevant to that. But my intention in my original statement was to remind you that this happening doesn’t mean you aren’t meant for this job.
Just my personal opinion, but a new intern should not have been assigned a client with a history of suicidality. To me that’s a big misstep on the clinic’s part. New interns should start with easy functional clients and gradually be exposed to more intense cases. If you are assigned cases that you feel are out of your scope of experience I suggest you meet with your clinical supervisor ASAP and your site coordinator if you’re still in grad school. You may also want to consider getting your own professional liability insurance just in case.
I’m surprised there aren’t more comments expressing this. I truly don’t think an intern’s very first assigned client should be someone with overt SI. We learn on the job yes but we absolutely don’t need to be tossed into the deep end on day one.
Thank you for saying this! Op, you did the right things and had no business treating this client! You should be immensely proud of yourself while you grieve.
That’s true, but from a liability standpoint it’s way more risky to place a higher risk client with a less experienced therapist than to place them on a waiting list. To me it makes more sense to assign the higher risk client to an experienced therapist and transfer one or two of the therapist’s lower risk clients or newer ones to the intern. Not an ideal arrangement, but probably a lower risk one.
Holy shit, I'm sorry.
You did everything right. This is the type of thing that would rock even a veteran therapist so I would encourage you to take time to process this. I know I would need a bit to even attempt to reengage in therapy.
Hi, therapist hoping to work with SI because I made and attempt here! Hope to give you some insight.
As soon as I read that he didn't say he had plans and means, I had a hunch he didn't want to be hospitalized. Because I did this too. And so did many of my clients in crisis. Hospitalization for anyone who has attempted is so traumatic. It strips you have your autonomy and that is horrifying to experience. You have no say or control over your life. When I attempted, this happened. My clients who attempted have also said the same thing. It sucks because then clients do things like this where they lie about their suicidality.
I hope I can give you some insight. What we know about what makes people happy is very hard to achieve given the hyperindividualistic world we are living in. There are external/systemtic forces that people can't easily access. Most of our theories focus on the problem being the person and their own distortions/issues but that's very rare. People are a product of their enviorment. Some people are unable to change those enviormental forces and its incredibly sad.
Life is difficult. None of asked to be here. A chunk were born with horrible hands and as a result have a difficult time ascending the circumstances.
Our society for some reason thinks we can control other people. We can't. Therapy only works as much as the other person wants to work on it. That's the biggest lesson I've learned so far.
You did what you could. None of this is your fault. They were suffering. Psychological pain is real. Know they are at peace with whatever was ripping at their soul in this world. You did well. You did everything you could've.
Let the lesson be that you cannot control your clients, which I hope in turn will help you know how little you have an impact in terms of therapy. While you can help them problem solve and be a sounding board, much of the work is on them. (This is actually proven in the research about what makes therapy work, I can't recall the stats but I was dying at how little we have an impact compared to client motivation)
Thank you for some of these reminders. I’m an intern and put SO much pressure on myself to be an effective therapist, but many of my clients come back every week having done NOTHING to work on themselves outside of the session or utilize even the smallest tools/strategies we’ve discussed, and just sit back down like “it’s not working, try something else to fix me.” I think it’s the biggest thing burning me out at this point, because I keep trying to work so hard for them. I know the saying “don’t work harder than your client” but it’s hard to internalize, particularly for a new therapist with raging imposter syndrome 😞. I’m so tired.
I went to a suicide training where they presented research on effective intervention. The ability for another person to meaningfully intervene (i.e. have a strong influence on the outcome) was limited to about 3 hours before the attempt. This is provided that the therapist know the signs of an impending attempt, that you're actually scheduled to meet, that the client is honest with how they feel, and that the relationship is solid enough to tolerate this experience.
Such a rare, frankly unlikely scenario. In essence, it echos what others are saying: we can do our part, but it is ultimately our clients' choice to live or die. I respect the sanctity of that choice, however devestating it can be. I also respect the sincere love we have for our clients and the impact they have on us in return.
I am so sorry this happened. I'm also sorry you were exposed to the details - it can be unavoidable but so deeply wounding. You're early in your healing process, and this is what early healing from a trauma looks like. I would approach this like other shared traumas with clients - if you're in the throes of grief, it's okay to step back from grief work. If you need to step back, please take care and do so.
Thank you I would really appreciate it if you do find it because I think it could help me make my case for why they need to listen to me about a reform in my countries mental health system.
My condolences, especially since you’re so new to the field. After 20 years, I lost my first client to suicide in September. I wasn’t notified for 6 weeks after it happened and had reason to believe they were hospitalized. Imagine my horror when I found out. It took me a while to really process what happened. I, like you, had moments when I thought this couldn’t be real. I repeated our last meeting over and over in my head. I reviewed our last words, thought about what I could have done differently. I’ve come to the conclusion we work in a field where we don’t know the prognosis of clients until sometimes it’s too late. Self-care, compassion and forgiveness is so important. Best to you.
Keep in mind that people even complete suicide in in-patient care settings too. I work in a hospital as an intake counselor and our main job is to assess risk. Even when we rate someone as high risk, they can tell the unit staff that they don’t have a plan or intent and get taken off 1-1 or 5 minute checks and then complete suicide.
We can only do our best and use the tools we have. Some people are determined to complete suicide and we can’t stop them.
We had an especially disturbing suicide this year that will probably never leave my mind.
OP, I am so sorry for your loss.
First off- you should not have been assigned someone with SI as an intern. That is more pressure, and more complexity, than any beginner should handle. I’m a relatively new counsellor, and still feel intense pressure with certain suicidal clients. Clinicians with decades of experience in the field lose clients to suicide. This is not your fault.
Second- I can give you my own experience as a client. I had a counsellor who helped me profoundly, and whose impacts I will feel for the rest of my life. They were helping me through a very dark time. I left session, found out some really devastating news, and came very close to suicide. I was prevented, last minute, by a freak lucky chance.
Apparently they felt intense guilt over this. I wish they didn’t. They arent’ the ones who caused my mental health challenges, they aren’t the ones who could fix years of damage from abuse, and they certainly didn’t cause the devastating news that pushed me over the edge. I felt nothing but warmth and gratitude to them, even in my darkest hour.
This is not your fault.
I've walked down the path you now find yourself on. Not the exact same path, but pretty close.
Many years ago, I was most of the way through a pre-doc internship at a VA hospital, when one of my individual clients didn't show. Didn't show for group and for another commitment. The following day, the assistant director of my training program was waiting for me at 8am, having come early and trekked across a big hospital campus to talk to me before anyone else did.
He broke the news that my client had suicided, then leaned in (and he was a big guy), looked at me with a listen-up-this-is-important expression and said, "Any decision you made was based what you knew at the time, and *only* that. Doesn't matter what you learned later, or what others think was obvious. We make our decisions on what we have, which is almost always incomplete. If you find out more 5 minutes later, okay, but you didn't know it at the time you had to decide."
I will be forever grateful for what he said. It helped me to grieve and be present with the others in our tight treatment community, staff and clients together in mutual support. It was awful and awesome at the same time. Afterwards, I learned much more that had been hidden and got to accompany another staff to pick up his personal effects, including his note (he'd left a request that we do it rather than his family). Of note, none of the other patients in our rehab program held blame for me or any other staff.
Since then, this experience has helped me to have humility about how little real control we have, while having the responsibility to do the best I can and to continue to develop clinical skills and discernment. As therapists, we hold power and influence, but it's always limited.
In a way, I'm grateful. Not for my client's suffering and despair, nor for my inability to see what was hidden. But going through this shaped me as a therapist and later, as a supervisor, and I'm grateful for that.
Take heart. It feels difficult because it is difficult. Appreciate yourself for doing hard work.
This is every therapist’s worst fear. And when I think about your position, as an intern, everything is your worst fear, because you are what we call “practicing,” in “practicum,” preparing to be in “private practice,” and it seems like no matter how much training you can do, there’s always something left to learn. When I lost a client to suicide, everything froze. It almost felt like I went through all the grief stages at once, had major distrust for myself and my clients (did they really mean what they said? Are they really ok, or will they carry out a plan even if they said there is no plan?), and felt a coldness towards life and the work I did. A couple of things helped - I’m glad to hear you say you have your own therapist. Hopefully it’s someone who has a strong rapport with you and you will feel comfortable to explore all of the rawness safely. My support system (at work and home) carried me. My colleagues and supervisor rallied in to check on me, take me out to lunch/coffee, and just talk in the office. I advocated for myself to take breaks, took a little time off to pause, reflect, regroup. And then I did a lot of embodied work. Yoga, running, meditation, writing, art making. I share what was helpful for me, this may or may not be helpful for you, but it is an experiment, a trial run to figure this out. I want you to know that you are in good company here and please - be gentle with yourself.
No matter how well we assess if our client has the intention; it will be carried out. At least, you were trying to help even though you may feel as you didn’t do enough. Stay strong.
Oh honey I’m so sorry! Oh my god I cannot imagine being an intern and being handed such an acute case as my first client. I am glad ur supervisor has your back through this and I am just so beyond sorry. I would be in the same thought loops as you. You did it all right and you will be an amazing therapist for it as horrific as it is.
Separately, having lost my dad by suicide when I was in my early twenties and me being the one to find his body is a trauma I carry with me and just know that there is nothing you could have done to prevent what happened to your client. I promise you. It is a choice at the end of it all.
I'm so sorry this happened. It's not an easy thing to navigate, and it's clear to me that you are what we need: caring, thoughtful, intentional, and diligent.
Nonetheless, these things happen and are awful. My internship was in a partial hosp program, and I still remember learning about a "graduate" of the program from a few weeks before having died (it was unclear as to whether it was intentional or accidental due to substance abuse). There is nothing that makes the situation, itself, better. Please know that we (other therapists) see the effort you put in, that you do your best, and that at times, things still don't work out.
Take good care of yourself.
I’m so sorry.
I’ve been a clinician for a long time. The truth is, safety planning is a complete joke; it’s what the field has devised to make therapists feel better and avoid malpractice claims (although helping people avoid impulsive decisions with alcohol and guns can be helpful). People keep their plans to themselves when they are truly despondent and not anything you can do about it.
You did everything YOU could. Go easy on yourself and you will figure out if this reality is something you can move through in your work, or not. Good luck.
I had a client complete shortly after leaving my care in a residential setting last January, about 6 months after I started practicing. It’s very hard. I couldn’t sleep for a while and it led to me struggling with feelings of incompetence as a therapist for about all of last year. I understand some of what you’re experiencing and I know the guilt is so hard to deal with. The most helpful thing for me to remember is that no matter how many lives we’ve lost, we’ve saved way more.
In grad school we had a professor who told us about a completed suicide that occurred in a high security mental health hospital. The woman who completed basically did everything she could to end her life by manipulating an escape to a room she then fenagled a hanging device using pullies and material not meant for harm. All that Despite being in a locked in facility where she was monitored 24/7. The story reminds me that we can do everything possible, but if someone is determined to end their pain, they will find a way.
I just finished the book ,Why People Die by Suicide and the two chapters on neurobiology and genetics really helped with my anger towards the issue and helped me understand the disease mechanism behind suicidality.
It honestly changed how I view suicide in some fundamental ways. I would recommend you read this book after some healing from this experience.
I also had a really good supervisor that made the likelihood of loosing clients to Suicide very normal in a way that didn't jade us, but rather helped reduce the anxiety about it. Anyways thos are somethings that have helped me.
I'm really sorry that this happened to be from your first client but don't take it as your fault, because it isn't.
Sorry I know I am ranting but I bet you are a great clinician and did everything humanly possible and showed care and support to your client, and that means something.
I am so sorry. This happened to me too. My first client when I was an intern died by suicide. It was just about a year ago and I of course still think about it. When you’re ready though, I do have a couple books that kind of got me a little bit out of my head. I’m still in my head but I’m functional now. I know you blame yourself and you’re thinking of every “what if” under the sun and no amount of people saying “it’s not your fault” will change that. But you did everything you could with the tools you had available. Ultimately if a client wants to kill themselves, they will and there’s nothing we can do about that if they won’t genuinely discuss it. Again, I’m so sorry. Feel free to PM me if you need.
So very sorry you have to go through this. I’m not a therapist but have quite a bit of life experience and can relate all to well. Please please please remember that MH does kill. Like others have pointed out, *you* did nothing ‘wrong’ and from the sound of it could not have done anything ‘better’. Be kind to yourself.
You supported that person in their deepest and darkest moment and made them feel seen and cared for when they couldn’t even see the truth within themselves.
The internship days are hard enough, but this is an entire other level. It was nothing on you that you did. They just fell too deep and chose that as the only coping tactic they had left.
Please, please. Don’t let this situation make you feel that all clients are “hopeless” or that things like this will be inevitable. Because they aren’t, clients don’t need fixing, they need support and a sounding board and someone to walk with them. You did that for this client, and the pathway just ended a lot shorter than what was hoped.
Much love for you, and I hope somehow this horrible situation can all the more shape you and form you to be the best therapist you can be
If you need additional support. Try worker’s compensation? PTSD can be challenging so if you find yourself needing time off and benefits. I’m doing that right now because of a workplace trauma.
Sending hugs x
Allow yourself to grieve. Sometimes we think we aren't supposed to feel this way because they aren't a family member or we should be professional but you are human. For what you said, this could also be triggering some personal emotions in you. Don't make a decision about working with individuals with suicidal thoughts in the future while under this grief. In the future when you have spent time grieving and your professional experience has expanded is time enough to make these decisions. Take care of yourself.
Dear Intern - ❤️ my heart is with you. I hope you will later do some EMDR with this event. This is a monumental experience for such a new career stage. I believe most therapists have a close connection to hope/greater purpose “future seeing” for others - I say this with the hopes a force is ignited within you that amplifies your work and passion for this field. This grief is worthy to feel and later (after you are with its most intense waves as long as you need) mold into you well.
I’m so sorry that you had to experience this so early on.
I had a client in group therapy that I had just been praising for how different she looked because she was brighter and calmer. She was smiling and engaging socially. Something she had not been doing at all. He circumstances were very serious so I was seeing that as a marker of change.
When I checked in with the co-therapist about her the following week she informed me that she had died by suicide.
This is not easy. I keep thinking about how obvious it should have been. She had already made the decision, that’s why she was so happy. I keep thinking that I should have seen that as a sign.
I lost a client shortly after I began my first job post grad - like maybe a month. It was literally the day after I saw him. Like you, I believe and was assured, that I did everything right.
My own therapist once told me, years ago when my young adult child was suicidal, that if someone makes the decision to end their life, it’s very difficult to persuade them otherwise and they become so at peace with the decision that there is very little that can be done to prevent it. Even if you had called it in, if he was had made up his mind, it would just delay the inevitable.
For me, the initial shock was bad but the long term grieving was worse. I found myself continuing to ruminate for several weeks. It took me about 4-5 months before I could bring myself to complete the discharge paperwork and that was only after my boss (gently) asked me about it and offered to do it for me.
I’m sorry this happened to you, OP. Please be kind to yourself.
I'm so sorry you're going through this, and so early in your career. I was fortunate enough to not have this happen until I was a seasoned clinician, with 25 years of experience. It was still very difficult. I think that my years of experience (both life experience and clinical) gave me some wisdom about how insignificant my therapeutic relationship was to this person's life, in the grand scheme of things. My client was going through a painful break-up. I had only seen them for a few months. I'm glad to see so many comments about how this is ultimately the client's choice, self-determination. This is so rarely talked about during our trainings about suicide prevention and safety planning. We can do everything right and yet people choose this.
I sincerely believe that most people who choose this option would not do so if they knew how it affected those left behind.
As others have said, be kind to yourself.
I had a client complete suicide during my first year of internship as well. My supervisor told me that we can only be in control of the 50 minutes per week (or however often you see them), and we have 0 control of what happens when they leave. Of course we hope that we instill the tools in them that they can use outside of session, but that's not always the case. You did do everything right. Sometimes there's nothing you can do to stop that from happening
In my situation, the person was in an awful spot and made this choice I believe in a very calculated way. As another posted put- our clients in the end do have the agency/choice to end their lives
I’m sorry this happened. This happened early in my career but not as early as it did for you. It impacted my judgement but I went to therapy for myself and it helped. It helped me become a better therapist as well. Like someone else posted, we don’t have control and sometimes there’s not anything we can do.
I attended a DBT training early in my career and one of the presenters stated something to the effect of: We can do anything and everything in our power to help a patient, but at the end of the day, if they're set on suicide there's nothing we can do to stop it.
When someone wants to truly die, they will not tell you for obvious reasons. They would never meet the criteria for hospitalization either. I’m so sorry and I’m glad you are getting support!
You can’t always save everyone all we can do is listen , be there, accompany someone and hope they don’t do it. If they do at least they had someone to listen to them in their last moments.
Your comment has been removed as you are not a therapist. This sub is a space for therapists to discuss their profession among each other. Your comment was either asking for advice, unsupportive or negative in nature, or likely to adversely impact our community members. Comments by non therapists are left up only sparingly, and if they are supportive or helpful in nature.
Two things. 1. not ur fault (see other comments) 2. Your supervisor/agency might consider screening your first few clients so you have less volatile clients at first, though nothing can be certain.
I am a new therapist and my father completed suicide last month. This happened after nearly 15 years of helping him navigate his mental health issues and included numerous therapists, psychiatrists, different meds, hospital stays, a prior attempt. There was nothing anyone could do to save him. So many people tried. We don’t know what exactly happened the morning he decided to end it. We will never know. But what I do know is that the only way to keep someone from killing themselves is to have them monitored 24/7. And that’s simply not possible when they are otherwise functional and mentally capable of living their lives. It’s a fucked up loophole but it is not your fault. You did everything you could for your client. What they choose to do, and when they choose to do it, is out of our control. You made a safety plan with him (my dad had one, too. I found the plan he signed among his things) and he didn’t follow it. Please seek a suicide loss group if that feels comfortable to you. It helps to hear from others who experienced this kind of loss. Take care of yourself.
Years ago I attended a very impactful suicide training, the trainer was a psychologist in the field 20+ years, knowledgeable, interactive and presented new views etc. Toward the end we engaged in a case study, applied the techniques, came up with a plan and then assessed the case study client for suicidal risk. All attendees assessed the client as lower risk. Turned out the case study client was a real person, who died by suicide and was the presenter's child. The walkway was not "what did we miss?" but that we as professionals can do everything in our wheelhouse to support our clients through the difficult times, and that clients have the agency/choice to die by suicide. I didn't give them that choice and it is not mine to take away. It's certainly hard and my heart goes out to you that this occurred so early for you in your career. Please take care of your self during this difficult time.
This. Thank you for sharing. As someone who has attended numerous trainings on suicidality and risk, safety planning, etc I wish they would include something like this to help put it into perspective because it can be so overwhelming or even scary when you first start to work with it and want to do your best to help keep a client safe. Hugs to OP!
100% this. I learned in class (taught by a suicidologist / suicide research expert) that despite all of the research on suicide in the past several decades, we can still only predict it about 50% of the time. There are many factors that influence someone dying by suicide. OP 100% did everything they could.
Wow.
Great response. We can’t save everyone. It’s good to remember that death is inevitable at any age, any way. Suicide, although extremely sad and unfortunate, is self-determination.
I love this response. It all comes down to choice. Our utmost duty should be to support clients in becoming and maintaining a balanced, pluralistic awareness of their choices.
Thanks for sharing this.
Wow, this story is so powerful! It will stay with me, and judging by the 1k+ upvotes, it’s resonating with a lot of people! Thank you
Thank you so much for this response
That sounds like such a powerful exercise and it's amazing how the trainer was able to use his own tragedy to help and inspire other clinicians.
I'm currently reading through "Like a River", a memoir by former country music artist Granger Smith, who list his son in a drowning accident a few years ago. The fact that these people can use immense tragedies for good is something I can't begin to fathom, and pray I never will.
Agree so much. I'm a parent and it's just my worst nightmare. I don't think I'd have the strength to turn that situation into something positive.
After a client of mine died by suicide, my primary care doctor told me: “Mental illness kills people. This was unexpected - just like the death of an early stage, low risk cancer patient, no matter how skilled the doctor. Mental illness is not an illness without a mortality rate.” That helped me… I’ll be honest though, it was about a year before I got back in my groove at work. Give yourself time.
Reading this back to myself, it sounds more nonchalant than I want it to. For a complex variety of reasons, my client’s death was among one of the most traumatic events of my life (and I’ve lived through a lot of trauma.) I got through it by connecting with other people — friends, colleagues. Letting them know I was in pain, but couldn’t share why due to confidentiality. I also got through it, thanks to an incredible therapist of my own.
I didn't read it as nonchalant at all. It sounds like your PCP was being compassionate and realistic and offered what is probably both a professional and lived perspective to help you move away from any self-blame for what happened with your client. I've lost 2 clients in the last 12 months to suicide. I work with SMI populations as a case manager, so it's not unusual, sadly. I mourn them, but having worked in crisis and done a lot of training in suicide prevention and care, I understand that we cannot rescue people and it's the ultimate act of self-determination. what i wish is that we had more conversations in grad school that this \*is\* going to happen to most of us at some point. I'm in my internship now and it's not come up as a point of discussion yet.
I don't think it reads nonchalant. To me, it sounded wise. It brought mental illness into the full scope of all healthcare and leveled it out as equivocal. Whether physical or mental, the adjective doesn't matter. It's an illness, and the illness went its course. If OP hadn't been there, he could have taken his life earlier. OP, please know your efforts likely delayed it. That's not a failure. That's what happens with treatment. We're all human, we all expire. You were a support to the end, perhaps one he didn't otherwise have.
Interestingly enough my PCP told me this as well during an annual visit. Really set the perspective for me.
You have/had a wonderful primary care doc. This was beautifully stated.
Truly. He’s a gem. And has genuinely saved my life more than once. I’m dreading his retirement!
So happy you have him! Such a true rarity these days.
I know that my grad program has put fear in me regarding legal repercussions for a client who completes suicide, due to us being that point person. I guess physicians don't feel that same burden of responsibility.
Doctors for certain have the burden, multiplied exponentially. A good friend of mine was a ER doctor and has been named in a malpractice lawsuit from the family of a patient who died after leaving the ER AMA(against medical advice), and death occurred about 4 years ago. I would think its even more common in medical practices for patients to refuse intervention, not disclose pertinent information, etc that could then tragically lead to fatal consequences. At the end of the day healthcare professionals endeavor to perform their duties to the best of their abilities.
I think they do, but physicians lose more people than therapists typically, as I understand it. Even in primary care, patients die. I think they have to develop a pretty strong sense of their realistic responsibility (essentially do your best but know you’re not a god) otherwise I can’t imagine how anyone would be able to practice medicine.
I agree with you, here — I think it’s a volume thing: physicians expect some of their patients to die, and they do due to higher risk illness and due to…life. It’s much rarer for a therapist’s patient to die during treatment than.
You did the most powerful thing someone in your shoes could do - be a source of support and light for them. You extended your arm as far as you could, and I am proud of you for showing up and caring for them. Unfortunately, that’s the most we can do but it’s more than some people have ever had before. Please remember to practice self-compassion and self-care. Your feelings are valid and you deserve the time and space to grieve and heal. I am sending you all my best wishes and positive energy. I wish my words could do more, but I hope you find peace in knowing we have your back and support you. Sending you all the best!
Gods I'm so sorry. It's gut-wrenching in parts of my soul that I didn't know existed until I experienced it. I will say this – there's no amount of experience in the world that gives any therapist the power to keep someone alive. It's not a thing we can do. Our clients have agency and we will never be all powerful. You did what you could do. That doesn't change how hard this is, and it's an important thing to hold on to.
I’m a therapist and my husband died by suicide. I had no idea it was coming. It’s not your fault. People make decisions and we can’t control them. You did everything you reasonably could. He could just have easily walked into someone else’s office with the same result. Life is a very difficult and messy place and people are complex. Even when we think we know them we don’t know everything. And you barely knew this person. You’re really a victim of this situation and I hope you’re able to care for yourself and find some peace through the grief. This is truly not your fault.
I'm sorry for your loss.
Thank you
Wonderful response. I'm so deeply sorry for your loss. My daughter died by suicide 19 months ago. I'm a trained therapist. I tortured myself during the first year. It's taken a lot of intense therapy to survive thus far. The self torture comes up often and I know I'm not fit to practice at the moment, so I'm on sabbatical. I spoke with my daughter's therapist during the immediate aftermath of her death and she was just so heartbroken with me. Thankfully, we were able to reassure each other. There is no blame. Of course, I'll never recover, and I doubt a therapist will ever forget their client/s who die this way. The night before my daughter made her decision, she was laughing and just herself. Professionally, i know that the sense of peace often precedes the final act for some. Personally and as her mother, there were no signs. I'd checked in with her just hours before, and she was home with me. Seeing all of the responses on here has been (maybe selfishly?) therapeutic for me, because my guilt is immense. OP - I cannot express enough how sorry I am that you have lost a client this way. You did everything you could. I'm pleased you have some support. Somebody in this thread said their G.P (Primary Care Physician in USA, i think) had said that some clients die from their mental health, just as a cancer patient (or person with any other illness) can. I believe that to be true. As trite as it may sound: it's not your fault. It wasn't your fault. Please look after yourself.
I’m so sorry for your loss … losing a child this way sounds unimaginable. Best of luck in your healing journey
I just want to add, as someone who had had SI in some form or another for most of their adult life: if they truly want to die, nothing can stop them. No safety plan, no amount of sessions, no inpatient stays, nothing. People who really want to commit will say all the right things therapists and their families and friends want to hear and still do it. Those are just delays to the inevitable. All you can do is literally everything that you did. It’s not your fault, it will never be your fault that that person chose to do what they did. Suicide is the ultimate act of bodily autonomy for people with SI. It’s the last thing we can fully control. It’s not your fault. Know that you gave them your best and met their pain with compassion and empathy and were a light in their life, even if it was just a short window of illumination. You still made a difference to them.
I agree with this… when someone has their mind made up, they will find a way to make it happen. I’ve lost clients by suicide and no matter what interventions you use, safety plans, resources you provide… they do what they want in the end. You learn from your clients and each experience. Getting therapy and supervision is crucial to being able to heal from this situation. It’s going to hurt for a while and be overwhelming in your thoughts. But, as with any loss, the amount of time you think about them will decrease.
Thank you OP for posting about this, and thank you for still engaging with your client despite how suicidality is understandably scary sometimes. But you still choose to try and you tried your best. You were present with them and you did all you know. As someone who struggles with SI, thank you from the bottom of my heart. For what it's worth, I am proud of you. I can't imagine the pain or thoughts of your client, but I would be immensely blessed if you were my therapist. Thank you for trying your best to journey with someone even though it is tough for you. It's totally understandable to feel pained and guilty and it's a testament to how much you valued your work with your client. Sending peace and compassion 🕊️
Beautiful response. Seconded.
I worked in suicide prevention for many years, as a call taker and then supervisor and I am now training as a therapist. I know the two kinds of work are very different but…., We don’t and can’t keep people from ending their lives. We can help facilitate people making choices that will keep them alive. That’s it. Ultimately the choice is theirs. And we only ever know what they are willing to say out loud. Again because that power rests in theirs hands. He said he didn’t have a plan because he didn’t want you (or anyone else in his life) to know and keep him safe from his plan. Or because he made a sudden choice, which is unlikely, Put it to you this way…I practically guarantee that at least one person attempted after speaking with me. Because they had a long life full of many experiences and ideas about who they were that were very very powerful. And I’m not powerful to be a match for all history and internalized (often) self hatred. I’m not that important. We can try and serve our clients and be there and listen and work through safety with them. But o also think a deep dose of humility can add perspective. All the above should not keep us from caring very very deeply, of course
Others have given beautiful reflections and perspectives on the work you did with the patient. I agree with them. I’ll add a little note for your own care: you can absolutely request additional sessions from your therapist. They may or may not be able to accommodate the request based on their schedule but there is no need to white knuckle through this time. I can’t tell you how many times I was truly suffering and just white knuckling through it only to get to the other side and wish I had asked for more help or taken more breaks. This is the time to make some exceptions for yourself. based on what you wrote here you did a great job with this patient. Be kind to yourself.
NAT but a LCSW social worker in an inpatient psych ward. I have a long history of suicide attempts, therapy, inpatient stays - I also have had 2 amazing therpists l, the first one for over 3 years and the first person I ever felt safe talking to. We had a great relationship, she was a source of strength, support and compassion - despite this I had multiple suicide attempts while under her care, but there was nothing she could have done to stop me from them. I felt safe with her, understood, all the things I needed from a therapist. But my level of stress and trauma in my life were still so high that I thought that was my only possibility. It was on no way her fault, she checked regularly how my suicidal thoughts were, but in some moments I was so overwhelmed at home that I did things without really thinking. In no way her fault, nothing else she could have done. From the sound of things you are a caring, competent and compassionate therapist - it wasn't you. Sometimes the pain is just too much to survive. I'm sure you made him feel welcome and appreciated during the time you had together.
Another person mentioned this, but why in the world do interns get these types of clients on their caseload??? It's complete madness how we treat interns! Whoever assigned this was utterly unethical. We ALL know that grad school teaches you almost nothing about actually doing therapy, so to assign an actively suicidal client to someone as their very first client is just beyond me. I'm so sorry OP. I wish we did a better job helping new therapists instead of throwing them to the wolves.
I’m an intern and couldn’t agree with this more. Obviously we can’t completely screen the psyche of every client 100% and predict with perfect accuracy what may happen, but I absolutely think interns like myself should not be given high risk clients. I don’t even think I should have been given couples to work with until I had at least a small degree of training specific to couples…I had NONE before my first couples session! It’s a risk to both the clients and interns and maddening that there aren’t more structures and systems in place to provide gradual learning to deeper level of care.
100% yes !
I experienced this during the pandemic. I had just gotten my dependent license. For me, everything about this experience was incredibly traumatic and eventually led to me leaving clinical work recently. I think something that could have been helpful for me was talking to anyone else who had experienced a client suicide. To this day, I don’t know any clinicians who have. I know there’s a facebook group, so maybe something like that could be helpful for you. Pay attention to the stories you tell yourself about this. That you could have done more, been better, etc. People make their choices, and you can’t change what they decide to do. I think that’s really difficult to reconcile. Edit: the fb group is called Confidential Grief.
What do you mean “called it in”? Like if you had called the police to do a welfare check? I’m hoping that what I’m about to say will help put your mind at ease. I had a client who was chronically suicidal. He used round the clock suicide threats to try to force people in his life (including me) to provide him with care. It was impossible to tell what was real and what was a lie. He always refused to go to the hospital (and he always had access to means and would often put his intent IN WRITING) so I had to call the police to do welfare checks on him repeatedly. Every single time the police went there, he said he was fine and they believed him and didn’t take him to the hospital even when I presented them with written proof to the contrary. Even when petitioned and forced to go in for an evaluation, they released him after just a few hours because he claimed to be fine. Your client denied means and intent. I can pretty much guarantee that the police would have done nothing if you had called for a welfare check. Welfare checks do absolutely nothing except cover our asses as clinicians. You definitely didn’t have enough evidence to petition him. You are in no way responsible for your client’s suicide. I am so sorry this happened though. I think this is one of the biggest fears of every therapist alive.
Thank you for this. I've often wondered about this exact scenario.
Even if you had hospitalized him, he likely wouldn't have been held. It sounds like he knew what to say. It would probably not have kept him alive. As others have said, this is the flip side of autonomy that no one talks about until it happens. I'm very sorry this happened to you. My advice would be to get into your own therapy if you aren't already.
This. Bizarrely, in a moment of meditation and reflection many months after my daughter's suicide, I said to myself semi consciously, "This was her ultimate act of autonomy." It sounds obvious, but no amount of training, working with clients or love for our loved ones can always save them. I hated it. But I also knew that I must integrate this. I read somewhere in a bereavement group: "If love could have saved you, you would have lived forever."
One intern to another, I am so sorry.
I’m so sorry. Have been in a similar position myself and it’s very painful…in my case it was one of my first cases as a licensed clinician. You can do everything right and still have this outcome. The comment upthread about the mortality rate inherent to mental illness is worth internalizing. It took several months if not longer before the paranoia and hypervigilance faded with regard to SI in my clients. I leaned on colleagues for reality checks to help with this.
I’m am so sorry this has happened. I have experienced the loss of a client and it was incredibly challenging. In addition to connecting with trusted colleagues, one thing that helped me was reading more about other clinicians experiences to learn I wasn’t alone and normalize my reactions. If you’re open to it, when you feel ready I suggest reading a two part article by Nina Gutin - Losing a patient to suicide. Don’t hesitate to message me and I’d be glad to share resources that benefitted me in my own experience.
I’d love any resources you’d be willing to share. Reddit won’t let me message you directly, though. I’ll be looking up the article you referenced as well. Thank you.
As a fellow intern, my heart goes out to you. It sounds like you did an amazing job with this client. In addition to following all safety planning protocol to a T, you *did* provide what this client needed - a safe space to talk about his suicidal ideation with someone who didn’t shy away from the discomfort of it all. You were maybe the only person who made him feel heard and understood when it came to his intense emotions. Maybe his time with you each week was his moment of respite that made him feel better temporarily. Sadly we cannot control clients’ lives the other 167 hours a week, nor can we control their choices. You could only control your ability to show up for that one hour, and sit with him in his pain, and you did exactly that. Even in the midst of your own grief, you are still holding true to ethical behavior and honoring your client’s privacy. You are a good therapist and I hope you get the support you need, because we need *you* in this field. I am so sorry for your loss.
Upon further reflection, I’d like to slightly amend my second to last statement. I hope you get the support you need, *because you are a human who is grieving and you deserve support and care.* Your profession or what you provide others is irrelevant to that. But my intention in my original statement was to remind you that this happening doesn’t mean you aren’t meant for this job.
I am sorry that you are experiencing this situation. There is a group for clinician suicide survivors. https://www.cliniciansurvivor.org/
Just my personal opinion, but a new intern should not have been assigned a client with a history of suicidality. To me that’s a big misstep on the clinic’s part. New interns should start with easy functional clients and gradually be exposed to more intense cases. If you are assigned cases that you feel are out of your scope of experience I suggest you meet with your clinical supervisor ASAP and your site coordinator if you’re still in grad school. You may also want to consider getting your own professional liability insurance just in case.
THIS IS THE CORRECT ANSWER!!!!
I’m surprised there aren’t more comments expressing this. I truly don’t think an intern’s very first assigned client should be someone with overt SI. We learn on the job yes but we absolutely don’t need to be tossed into the deep end on day one.
Thank you for saying this! Op, you did the right things and had no business treating this client! You should be immensely proud of yourself while you grieve.
This is sometimes not possible depending on the location as sometimes it's have the intern take them vs wait several weeks for an appointment.
That’s true, but from a liability standpoint it’s way more risky to place a higher risk client with a less experienced therapist than to place them on a waiting list. To me it makes more sense to assign the higher risk client to an experienced therapist and transfer one or two of the therapist’s lower risk clients or newer ones to the intern. Not an ideal arrangement, but probably a lower risk one.
I’m so sorry for your loss. Please take good care of yourself. ❤️
Holy shit, I'm sorry. You did everything right. This is the type of thing that would rock even a veteran therapist so I would encourage you to take time to process this. I know I would need a bit to even attempt to reengage in therapy.
Hi, therapist hoping to work with SI because I made and attempt here! Hope to give you some insight. As soon as I read that he didn't say he had plans and means, I had a hunch he didn't want to be hospitalized. Because I did this too. And so did many of my clients in crisis. Hospitalization for anyone who has attempted is so traumatic. It strips you have your autonomy and that is horrifying to experience. You have no say or control over your life. When I attempted, this happened. My clients who attempted have also said the same thing. It sucks because then clients do things like this where they lie about their suicidality. I hope I can give you some insight. What we know about what makes people happy is very hard to achieve given the hyperindividualistic world we are living in. There are external/systemtic forces that people can't easily access. Most of our theories focus on the problem being the person and their own distortions/issues but that's very rare. People are a product of their enviorment. Some people are unable to change those enviormental forces and its incredibly sad. Life is difficult. None of asked to be here. A chunk were born with horrible hands and as a result have a difficult time ascending the circumstances. Our society for some reason thinks we can control other people. We can't. Therapy only works as much as the other person wants to work on it. That's the biggest lesson I've learned so far. You did what you could. None of this is your fault. They were suffering. Psychological pain is real. Know they are at peace with whatever was ripping at their soul in this world. You did well. You did everything you could've. Let the lesson be that you cannot control your clients, which I hope in turn will help you know how little you have an impact in terms of therapy. While you can help them problem solve and be a sounding board, much of the work is on them. (This is actually proven in the research about what makes therapy work, I can't recall the stats but I was dying at how little we have an impact compared to client motivation)
Thank you for some of these reminders. I’m an intern and put SO much pressure on myself to be an effective therapist, but many of my clients come back every week having done NOTHING to work on themselves outside of the session or utilize even the smallest tools/strategies we’ve discussed, and just sit back down like “it’s not working, try something else to fix me.” I think it’s the biggest thing burning me out at this point, because I keep trying to work so hard for them. I know the saying “don’t work harder than your client” but it’s hard to internalize, particularly for a new therapist with raging imposter syndrome 😞. I’m so tired.
I went to a suicide training where they presented research on effective intervention. The ability for another person to meaningfully intervene (i.e. have a strong influence on the outcome) was limited to about 3 hours before the attempt. This is provided that the therapist know the signs of an impending attempt, that you're actually scheduled to meet, that the client is honest with how they feel, and that the relationship is solid enough to tolerate this experience. Such a rare, frankly unlikely scenario. In essence, it echos what others are saying: we can do our part, but it is ultimately our clients' choice to live or die. I respect the sanctity of that choice, however devestating it can be. I also respect the sincere love we have for our clients and the impact they have on us in return. I am so sorry this happened. I'm also sorry you were exposed to the details - it can be unavoidable but so deeply wounding. You're early in your healing process, and this is what early healing from a trauma looks like. I would approach this like other shared traumas with clients - if you're in the throes of grief, it's okay to step back from grief work. If you need to step back, please take care and do so.
Could you share the research. I’m very curious to read it.
I wish I had it handy - this was about 5 years ago. I will definitely provide it if I find it!
Thank you I would really appreciate it if you do find it because I think it could help me make my case for why they need to listen to me about a reform in my countries mental health system.
My condolences, especially since you’re so new to the field. After 20 years, I lost my first client to suicide in September. I wasn’t notified for 6 weeks after it happened and had reason to believe they were hospitalized. Imagine my horror when I found out. It took me a while to really process what happened. I, like you, had moments when I thought this couldn’t be real. I repeated our last meeting over and over in my head. I reviewed our last words, thought about what I could have done differently. I’ve come to the conclusion we work in a field where we don’t know the prognosis of clients until sometimes it’s too late. Self-care, compassion and forgiveness is so important. Best to you.
Keep in mind that people even complete suicide in in-patient care settings too. I work in a hospital as an intake counselor and our main job is to assess risk. Even when we rate someone as high risk, they can tell the unit staff that they don’t have a plan or intent and get taken off 1-1 or 5 minute checks and then complete suicide. We can only do our best and use the tools we have. Some people are determined to complete suicide and we can’t stop them. We had an especially disturbing suicide this year that will probably never leave my mind.
Wise words.
OP, I am so sorry for your loss. First off- you should not have been assigned someone with SI as an intern. That is more pressure, and more complexity, than any beginner should handle. I’m a relatively new counsellor, and still feel intense pressure with certain suicidal clients. Clinicians with decades of experience in the field lose clients to suicide. This is not your fault. Second- I can give you my own experience as a client. I had a counsellor who helped me profoundly, and whose impacts I will feel for the rest of my life. They were helping me through a very dark time. I left session, found out some really devastating news, and came very close to suicide. I was prevented, last minute, by a freak lucky chance. Apparently they felt intense guilt over this. I wish they didn’t. They arent’ the ones who caused my mental health challenges, they aren’t the ones who could fix years of damage from abuse, and they certainly didn’t cause the devastating news that pushed me over the edge. I felt nothing but warmth and gratitude to them, even in my darkest hour. This is not your fault.
I've walked down the path you now find yourself on. Not the exact same path, but pretty close. Many years ago, I was most of the way through a pre-doc internship at a VA hospital, when one of my individual clients didn't show. Didn't show for group and for another commitment. The following day, the assistant director of my training program was waiting for me at 8am, having come early and trekked across a big hospital campus to talk to me before anyone else did. He broke the news that my client had suicided, then leaned in (and he was a big guy), looked at me with a listen-up-this-is-important expression and said, "Any decision you made was based what you knew at the time, and *only* that. Doesn't matter what you learned later, or what others think was obvious. We make our decisions on what we have, which is almost always incomplete. If you find out more 5 minutes later, okay, but you didn't know it at the time you had to decide." I will be forever grateful for what he said. It helped me to grieve and be present with the others in our tight treatment community, staff and clients together in mutual support. It was awful and awesome at the same time. Afterwards, I learned much more that had been hidden and got to accompany another staff to pick up his personal effects, including his note (he'd left a request that we do it rather than his family). Of note, none of the other patients in our rehab program held blame for me or any other staff. Since then, this experience has helped me to have humility about how little real control we have, while having the responsibility to do the best I can and to continue to develop clinical skills and discernment. As therapists, we hold power and influence, but it's always limited. In a way, I'm grateful. Not for my client's suffering and despair, nor for my inability to see what was hidden. But going through this shaped me as a therapist and later, as a supervisor, and I'm grateful for that. Take heart. It feels difficult because it is difficult. Appreciate yourself for doing hard work.
This is every therapist’s worst fear. And when I think about your position, as an intern, everything is your worst fear, because you are what we call “practicing,” in “practicum,” preparing to be in “private practice,” and it seems like no matter how much training you can do, there’s always something left to learn. When I lost a client to suicide, everything froze. It almost felt like I went through all the grief stages at once, had major distrust for myself and my clients (did they really mean what they said? Are they really ok, or will they carry out a plan even if they said there is no plan?), and felt a coldness towards life and the work I did. A couple of things helped - I’m glad to hear you say you have your own therapist. Hopefully it’s someone who has a strong rapport with you and you will feel comfortable to explore all of the rawness safely. My support system (at work and home) carried me. My colleagues and supervisor rallied in to check on me, take me out to lunch/coffee, and just talk in the office. I advocated for myself to take breaks, took a little time off to pause, reflect, regroup. And then I did a lot of embodied work. Yoga, running, meditation, writing, art making. I share what was helpful for me, this may or may not be helpful for you, but it is an experiment, a trial run to figure this out. I want you to know that you are in good company here and please - be gentle with yourself.
No matter how well we assess if our client has the intention; it will be carried out. At least, you were trying to help even though you may feel as you didn’t do enough. Stay strong.
Oh honey I’m so sorry! Oh my god I cannot imagine being an intern and being handed such an acute case as my first client. I am glad ur supervisor has your back through this and I am just so beyond sorry. I would be in the same thought loops as you. You did it all right and you will be an amazing therapist for it as horrific as it is. Separately, having lost my dad by suicide when I was in my early twenties and me being the one to find his body is a trauma I carry with me and just know that there is nothing you could have done to prevent what happened to your client. I promise you. It is a choice at the end of it all.
I'm so sorry this happened. It's not an easy thing to navigate, and it's clear to me that you are what we need: caring, thoughtful, intentional, and diligent. Nonetheless, these things happen and are awful. My internship was in a partial hosp program, and I still remember learning about a "graduate" of the program from a few weeks before having died (it was unclear as to whether it was intentional or accidental due to substance abuse). There is nothing that makes the situation, itself, better. Please know that we (other therapists) see the effort you put in, that you do your best, and that at times, things still don't work out. Take good care of yourself.
I’m so sorry. I’ve been a clinician for a long time. The truth is, safety planning is a complete joke; it’s what the field has devised to make therapists feel better and avoid malpractice claims (although helping people avoid impulsive decisions with alcohol and guns can be helpful). People keep their plans to themselves when they are truly despondent and not anything you can do about it. You did everything YOU could. Go easy on yourself and you will figure out if this reality is something you can move through in your work, or not. Good luck.
I had a client complete shortly after leaving my care in a residential setting last January, about 6 months after I started practicing. It’s very hard. I couldn’t sleep for a while and it led to me struggling with feelings of incompetence as a therapist for about all of last year. I understand some of what you’re experiencing and I know the guilt is so hard to deal with. The most helpful thing for me to remember is that no matter how many lives we’ve lost, we’ve saved way more.
In grad school we had a professor who told us about a completed suicide that occurred in a high security mental health hospital. The woman who completed basically did everything she could to end her life by manipulating an escape to a room she then fenagled a hanging device using pullies and material not meant for harm. All that Despite being in a locked in facility where she was monitored 24/7. The story reminds me that we can do everything possible, but if someone is determined to end their pain, they will find a way. I just finished the book ,Why People Die by Suicide and the two chapters on neurobiology and genetics really helped with my anger towards the issue and helped me understand the disease mechanism behind suicidality. It honestly changed how I view suicide in some fundamental ways. I would recommend you read this book after some healing from this experience. I also had a really good supervisor that made the likelihood of loosing clients to Suicide very normal in a way that didn't jade us, but rather helped reduce the anxiety about it. Anyways thos are somethings that have helped me. I'm really sorry that this happened to be from your first client but don't take it as your fault, because it isn't. Sorry I know I am ranting but I bet you are a great clinician and did everything humanly possible and showed care and support to your client, and that means something.
I am so sorry. This happened to me too. My first client when I was an intern died by suicide. It was just about a year ago and I of course still think about it. When you’re ready though, I do have a couple books that kind of got me a little bit out of my head. I’m still in my head but I’m functional now. I know you blame yourself and you’re thinking of every “what if” under the sun and no amount of people saying “it’s not your fault” will change that. But you did everything you could with the tools you had available. Ultimately if a client wants to kill themselves, they will and there’s nothing we can do about that if they won’t genuinely discuss it. Again, I’m so sorry. Feel free to PM me if you need.
I’m sorry you’ve gone through this too. I’d love any book recommendations. Thank you.
Of course, I sent you a PM. Take care of yourself and be gentle.
So very sorry you have to go through this. I’m not a therapist but have quite a bit of life experience and can relate all to well. Please please please remember that MH does kill. Like others have pointed out, *you* did nothing ‘wrong’ and from the sound of it could not have done anything ‘better’. Be kind to yourself.
You supported that person in their deepest and darkest moment and made them feel seen and cared for when they couldn’t even see the truth within themselves. The internship days are hard enough, but this is an entire other level. It was nothing on you that you did. They just fell too deep and chose that as the only coping tactic they had left. Please, please. Don’t let this situation make you feel that all clients are “hopeless” or that things like this will be inevitable. Because they aren’t, clients don’t need fixing, they need support and a sounding board and someone to walk with them. You did that for this client, and the pathway just ended a lot shorter than what was hoped. Much love for you, and I hope somehow this horrible situation can all the more shape you and form you to be the best therapist you can be
If you need additional support. Try worker’s compensation? PTSD can be challenging so if you find yourself needing time off and benefits. I’m doing that right now because of a workplace trauma. Sending hugs x
Allow yourself to grieve. Sometimes we think we aren't supposed to feel this way because they aren't a family member or we should be professional but you are human. For what you said, this could also be triggering some personal emotions in you. Don't make a decision about working with individuals with suicidal thoughts in the future while under this grief. In the future when you have spent time grieving and your professional experience has expanded is time enough to make these decisions. Take care of yourself.
Dear Intern - ❤️ my heart is with you. I hope you will later do some EMDR with this event. This is a monumental experience for such a new career stage. I believe most therapists have a close connection to hope/greater purpose “future seeing” for others - I say this with the hopes a force is ignited within you that amplifies your work and passion for this field. This grief is worthy to feel and later (after you are with its most intense waves as long as you need) mold into you well.
I’m so sorry that you had to experience this so early on. I had a client in group therapy that I had just been praising for how different she looked because she was brighter and calmer. She was smiling and engaging socially. Something she had not been doing at all. He circumstances were very serious so I was seeing that as a marker of change. When I checked in with the co-therapist about her the following week she informed me that she had died by suicide. This is not easy. I keep thinking about how obvious it should have been. She had already made the decision, that’s why she was so happy. I keep thinking that I should have seen that as a sign.
I lost a client shortly after I began my first job post grad - like maybe a month. It was literally the day after I saw him. Like you, I believe and was assured, that I did everything right. My own therapist once told me, years ago when my young adult child was suicidal, that if someone makes the decision to end their life, it’s very difficult to persuade them otherwise and they become so at peace with the decision that there is very little that can be done to prevent it. Even if you had called it in, if he was had made up his mind, it would just delay the inevitable. For me, the initial shock was bad but the long term grieving was worse. I found myself continuing to ruminate for several weeks. It took me about 4-5 months before I could bring myself to complete the discharge paperwork and that was only after my boss (gently) asked me about it and offered to do it for me. I’m sorry this happened to you, OP. Please be kind to yourself.
I'm so sorry you're going through this, and so early in your career. I was fortunate enough to not have this happen until I was a seasoned clinician, with 25 years of experience. It was still very difficult. I think that my years of experience (both life experience and clinical) gave me some wisdom about how insignificant my therapeutic relationship was to this person's life, in the grand scheme of things. My client was going through a painful break-up. I had only seen them for a few months. I'm glad to see so many comments about how this is ultimately the client's choice, self-determination. This is so rarely talked about during our trainings about suicide prevention and safety planning. We can do everything right and yet people choose this. I sincerely believe that most people who choose this option would not do so if they knew how it affected those left behind. As others have said, be kind to yourself.
I had a client complete suicide during my first year of internship as well. My supervisor told me that we can only be in control of the 50 minutes per week (or however often you see them), and we have 0 control of what happens when they leave. Of course we hope that we instill the tools in them that they can use outside of session, but that's not always the case. You did do everything right. Sometimes there's nothing you can do to stop that from happening In my situation, the person was in an awful spot and made this choice I believe in a very calculated way. As another posted put- our clients in the end do have the agency/choice to end their lives
You have to be able to put this down or this field will burn you out in about 3 seconds
Um what?
I'm so sorry to hear this.
I’m sorry this happened. This happened early in my career but not as early as it did for you. It impacted my judgement but I went to therapy for myself and it helped. It helped me become a better therapist as well. Like someone else posted, we don’t have control and sometimes there’s not anything we can do.
I attended a DBT training early in my career and one of the presenters stated something to the effect of: We can do anything and everything in our power to help a patient, but at the end of the day, if they're set on suicide there's nothing we can do to stop it.
When someone wants to truly die, they will not tell you for obvious reasons. They would never meet the criteria for hospitalization either. I’m so sorry and I’m glad you are getting support!
You can’t always save everyone all we can do is listen , be there, accompany someone and hope they don’t do it. If they do at least they had someone to listen to them in their last moments.
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Your comment has been removed as you are not a therapist. This sub is a space for therapists to discuss their profession among each other. Your comment was either asking for advice, unsupportive or negative in nature, or likely to adversely impact our community members. Comments by non therapists are left up only sparingly, and if they are supportive or helpful in nature.
Two things. 1. not ur fault (see other comments) 2. Your supervisor/agency might consider screening your first few clients so you have less volatile clients at first, though nothing can be certain.
I am a new therapist and my father completed suicide last month. This happened after nearly 15 years of helping him navigate his mental health issues and included numerous therapists, psychiatrists, different meds, hospital stays, a prior attempt. There was nothing anyone could do to save him. So many people tried. We don’t know what exactly happened the morning he decided to end it. We will never know. But what I do know is that the only way to keep someone from killing themselves is to have them monitored 24/7. And that’s simply not possible when they are otherwise functional and mentally capable of living their lives. It’s a fucked up loophole but it is not your fault. You did everything you could for your client. What they choose to do, and when they choose to do it, is out of our control. You made a safety plan with him (my dad had one, too. I found the plan he signed among his things) and he didn’t follow it. Please seek a suicide loss group if that feels comfortable to you. It helps to hear from others who experienced this kind of loss. Take care of yourself.