In counseling, the therapeutic bond is essential. What happens when that bond is severed by a client’s suicide? “Many laypersons do not realize how closely counselors connect with their clients,” says Daniel Weigel, a professional counselor who lost a client to suicide just a few weeks after receiving his license. “Of course we set clear professional boundaries, but I had known this young lady for just over a year. Her loss was very painful for me, both personally and professionally.”

(Note: Details of counselors’ case stories have been altered to protect client privacy.)

The possibility of having a client die by suicide is a specter that hovers in the background for many counseling professionals. It is perhaps the crisis situation that clinicians most fear facing. Even so, client suicide is a subject often laden with shame, guilt, denial and many other difficult emotions — emotions that counselors excel at helping others handle but would much rather not face in themselves, say researchers and practitioners who have lost clients to suicide.

It would be unfair to say that counselors who have difficulty processing a client’s suicide are just practicing avoidance, however. Practitioners’ careers revolve around taking care of others. So when a client dies by suicide and practitioners are asked how they are holding up, their natural inclination may be to protest that the suicide isn’t about them but rather the client and the client’s family.

“Frankly, I was not sure I had the right to grieve her loss at the time because I was much more focused on taking care of others,” acknowledges Weigel, an American Counseling Association member who is now a professor of counseling and the practicum and internship coordinator at Southeastern Oklahoma State University. “I was, however, struggling with a great deal of sadness that had caught me off guard.”

Practitioners may also attempt to process a client’s suicide in solitude because they’re unsure of where to turn and fear possible judgment from colleagues. Unfortunately, say counselors who have experienced a client’s suicide, that fear of censure and avoidance on the part of colleagues and supervisors is not necessarily unfounded.

“I think there’s this quiet stigma for people who have had clients suicide,” says Ford Brooks, a practitioner and addictions specialist who lost a client to suicide about five years ago. “Others are saying, ‘I’m glad it’s not me’ or ‘There’s something you didn’t do.’ There is probably an underground group of counselors that this has happened to who just haven’t talked about it.”

This lack of peer support compounds what is already a personal and professional trauma, which is why those who have gone through a client’s suicide say that the counseling profession as a whole needs to develop a greater understanding of these incidents and their aftermath.

According to the Centers for Disease Control and Prevention (CDC), more than 41,000 people in the United States died by suicide in 2013, the most recent year for which statistics are available. That same year, almost 500,000 people in the United States were treated in emergency rooms for self-inflicted injuries. The CDC cautions that these numbers underestimate the overall threat of suicide to public health because many people who have suicidal thoughts or make suicide attempts never seek health or mental health services.

As noted by an April 2000 Journal of Mental Health Counseling study (“Client Suicide: Its Frequency and Impact on Counselors”), little research has been published about how frequently counselors lose clients to suicide or the personal and professional effects of those losses on counselors. The study’s authors, Charles R. McAdams III and Victoria A. Foster, reporting the results of a national survey in which 376 professional counselors participated, found that approximately 24 percent of counselors had lost clients to suicide. Among the counselors who had gone through that experience, approximately one-fifth were student counselors.

When asked about the effect of the client suicide on their lives, survey respondents reported feelings of anger and guilt and a lack of self-confidence. The respondents also reported having significant intrusive and avoidant thoughts about their clients’ suicides. The authors reported that student counselors experienced more severe and persistent reactions than did licensed practitioners.

McAdams and Foster also pointed out in their article that client suicide is a common crisis faced by mental health practitioners. Therefore, the authors asserted that training in coping with client suicide should be a routine part of counselor education programs.

Indeed, Weigel notes that nothing in his counselor education or supervision experience had prepared him for the possibility of losing a client to suicide. He believes that preemptive training would have helped him absorb and process the shock he subsequently experienced. At the same time, he — along with the other individuals interviewed for this article — says that nothing can truly prepare a counselor for the death of a client by suicide.

The client is ultimately in charge

E. Christine Moll, a licensed mental health counselor and private practitioner in Buffalo, New York, had been seeing her client, a man in his early 60s, twice a week for about five weeks when he died by suicide.

She notes that the client’s life had been in a significant state of upheaval. As he worked with Moll, the client realized that he had been experiencing recurring episodes of depression throughout his life. Some of his family members had a history of depression, but the client had never been diagnosed himself. The client had very recently retired and was still struggling to figure out that next stage of his life, says Moll, an ACA member who is a past president of the Association for Adult Development and Aging. In some ways, the client’s world was falling apart. His home was in a state of disrepair, and he had virtually no money to have it fixed. The client also felt inept because he didn’t view himself as handy, saying he couldn’t take care of even simple repairs that he saw other men doing, Moll says.

From the start, Moll was fully cognizant of the man’s significant level of distress. “As soon I met the man, I met with the psychiatrist [a clinician with whom Moll frequently consulted] and said, ‘I need supervision,’” she remembers. “Through it all, I was seeking guidance.”

Moll suggested that her client also see the psychiatrist and perhaps take medication if warranted, but the man refused, saying he was currently taking an herbal supplement. Moll researched herbal supplements to gain a better understanding of the self-help methods the man was using and his frame of mind.

She was also attentive to the possibility of suicide. The client had expressed some suicidal thoughts in their early sessions, but these thoughts were vague, and the man stated he had no present plans to kill himself. Still, each week Moll used a suicidal “barometer” to assess intent. When Moll saw the man the week that he died, he didn’t express any active thoughts of suicide, she says. In fact, he was making future plans. In the weeks prior, the client had decided to ask his sons — who were more adept at home improvement — to come in from out of town to help him make the necessary repairs, she recalls. The last time that Moll saw her client, he said he was looking forward to seeing his sons and to other plans that were five or six weeks in the future.

But then Moll received a call from the client’s wife saying that her husband and his car were missing. The man had exited their house, leaving his wallet and driver’s license behind on the table. A search was undertaken, and the client’s car was found in a state park where some tourists had seen an individual go over a barrier to the park’s waterfall. The tourists assumed the man had fallen, but evidence indicated he had jumped, Moll says.

When Moll went through the complete case with the consulting psychiatrist, he assured her that she had done everything by the book. For a time, she continued to meet with the psychiatrist for both formal sessions and informal talks. Moll also reached out to the client’s family in sympathy. As they went over the events preceding the man’s suicide together, Moll says it became clear that neither she nor the family held any missing information or insight that would have indicated the client might take his own life.

In the aftermath of the client’s suicide, Moll says that prayer was an important part of her healing process. She adds that her recovery was a gradual process that transpired in part through tackling everyday tasks and obligations. “It’s not that we forget but that life continues,” Moll says when asked how counselors persevere through a client’s suicide. “Our families need us. Our clients need us.”

As she recovered, Moll, who is also an associate professor and chair of the Department of Counseling and Human Services at Canisius College in Buffalo, came to the realization that many factors in clients’ lives were simply out of her hands.

“Even if we do everything by the textbook, we have no control over [whether] our clients make irreversible choices,” she says.

Eric Beeson, a licensed professional counselor (LPC) and lecturer at the University of North Carolina–Greensboro, has also grown to accept that a client dying by suicide is ultimately out of a counselor’s hands. Early in his career while working in a hospital behavioral unit, Beeson and his colleagues used all the clinical and legal tools at their disposal but couldn’t stop a patient intent on dying by suicide.

The patient was determined to leave the hospital’s behavioral unit despite the objections of the clinical team and the unit’s medical director. The patient’s son was concerned that his parent would attempt suicide if released and signed a petition to commit his parent for further care. However, the county’s mental health court determined there was no legal justification for holding the patient. The patient was released and died by suicide later that day.

“At that point, my colleagues and I were really angry and found ourselves blaming the court,” recounts Beeson, a member of ACA. However, the hardest part of the case was seeing how devastated the patient’s son was, Beeson says. The son had worked incredibly hard to get his parent the necessary help and wanted desperately for the parent to be well so they could be together.

The debriefing process Beeson and the rest of the clinical staff engaged in helped them move through their anger and grief, Beeson says. The unit’s medical director used the debriefing to help the staff understand that, despite what they might want, clients ultimately have the right to choose to die by suicide.

“It really does challenge our own God complex,” says Beeson, who now studies and lectures on suicide (see “Fresh thinking on old issues” in the May issue of Counseling Today to read about Beeson’s 2015 ACA Conference session on counselors’ attitudes toward suicide). He contends that it is not helpful for counselors to hold themselves responsible for their clients’ choices. All counselors can do is dedicate themselves to providing the best and most ethical care possible, he says.

Overwhelming pain

“I don’t blame myself, but for a long time I seriously wondered if I should,” says Julie Bates-Maves, a former addictions counselor who lost a client to suicide seven years ago. “Even now as I think about it, I’m racking my brain for unspoken clues, [but] I still come up with nothing.”

Bates-Maves’ client was in his early 30s and suffered from chronic pain after breaking his neck and back during a fall at his construction job. He had developed an addiction to his pain medication, and once that was no longer being prescribed to him, he turned to heroin and crack as a way to manage his pain. The man was in treatment for his addiction and was seeing Bates-Maves as part of his methadone maintenance treatment. She had been treating him for about nine months when he died by suicide.

“About seven months before [the suicide] happened, he had expressed suicidal ideation, and we worked through this over the course of a few months,” explains Bates-Maves, a member of ACA. “He had not expressed suicidal ideation in more than three months at the time of his death. On the contrary, he consistently used future talk and spoke about his hopes for his future children and impending marriage. He was also on the verge of settling his workers’ compensation claim — a payout that would have exceeded a million dollars. He had also stopped using heroin altogether and significantly reduced his crack use.”

The suicide happened when Bates-Maves was still a beginning counselor. She sometimes wonders if things would have turned out differently if she had possessed more experience at the time.

“With my current knowledge and additional experience, I’d like to think that I would have been more cautious as his depression lifted and he regained energy. I like to think that I would have caught on to something so that he’d still be here,” says Bates-Maves, who is now a counselor educator at the University of Wisconsin–Stout.

However, she wasn’t alone in not seeing any signs that the man was contemplating suicide. Bates-Maves’ supervisor and the client’s group counseling facilitator were just as shocked at what transpired. All three went over their clinical notes and discussed the case at length but still couldn’t find anything to suggest that they could have done anything that might have led to a different outcome.

Bates-Maves and the client’s group facilitator sought healing by attending the man’s funeral. “We sat in the back and didn’t speak to anyone,” Bates-Maves recalls. “We had never met his family in person, so no one knew who we were. For us, it was an important step in our grieving process to say goodbye. I vividly remember the happy pictures placed around the room and was thankful that [the client] had such a good support system at home. He deserved that.”

“After the funeral,” she continues, “I remember feeling more settled with the fact that he was gone and that no matter how many times I thought about what I maybe had missed, it wouldn’t bring him back. I had to move forward and keep his memory inside me as a constant reminder that more often than not, pain is not what it seems. People don’t have to appear sad to be hopeless, don’t have to appear depressed to be suicidal and don’t have to appear to be in pieces to take their life.”

Spiraling out of control

There was no question that Weigel’s client — a woman in her early 20s — was gravely troubled. She presented with signs of being in the prodromal phase of schizophrenia, which would later lead to a psychotic break. When the client came to the community mental health center where Weigel was working, she was struggling not only with a descent into psychosis but also a significant heroin abuse problem. The young woman had also started to experiment with other drugs, recalls Weigel, who is trained in the treatment of co-occurring disorders.

Weigel recognized that the client was spiraling into psychosis and sought assistance from the agency’s clinical director, psychologist and staff psychiatrist in hopes of preventing the woman’s first psychotic episode. However, several factors complicated the team’s efforts, he says. The woman actually had strong family support, but she lived alone and had isolated herself socially. Aside from her family, her interpersonal interactions were mainly limited to drug dealers.

Weigel and the treatment team launched an intensive effort to address the woman’s substance abuse problem while trying to stabilize her. The client went through detoxification twice, but neither time could Weigel secure the intensive level of care she needed to continue treating her heroin abuse after she was released from the hospital. Inevitably, this led to relapse.

In addition, the woman had started engaging in what Weigel describes as “graphic and bizarre” self-mutilating behaviors. But once again, getting the level of help the client needed proved nearly impossible.

“On one occasion, her family paid for her to receive inpatient care,” Weigel remembers. “She was uninsured, and inpatient, indigent mental health services were unavailable. Thus, her parents went into debt paying for inpatient mental health care for as long as they could before she was transitioned back to outpatient care. … I stayed in close communication with the hospital, where she showed optimistic improvement, but despite a carefully planned transition to outpatient counseling and psychiatric care, a [heroin] relapse quickly followed her discharge. Unfortunately, it also led to the discontinuation of medications that may very likely have prevented her first psychotic episode.”

The young woman began engaging in life-threatening self-injurious behaviors and was involuntarily hospitalized. “Again she showed improvement, and we [the treatment team] transitioned her care as precisely as possible upon release,” Weigel says, “but heroin quickly drew her in again.”

Not long after her release from the second hospital, the woman took her own life. Weigel, devastated by his client’s death, found few resources to help him cope in the event’s immediate aftermath.

“I was working in a very rural setting, as I have my entire career,” he explains. “Thus, options like support groups and personal counseling … were really not a viable option for me due to my geographic isolation. I tried to find books or journal articles addressing the effects of suicide on counselors and coping mechanisms, but at the time there was a real shortage of information for counselors coping with such a loss.”

Weigel decided to take some leave time to try and regain his focus. He also went over the client’s case with colleagues. “When a tragedy like this happened at the agency in which I worked, an interdisciplinary team critically examined what happened and what could be learned from it — a psychological autopsy of sorts,” Weigel explains. “My colleagues were very supportive. They realized I had done virtually all I could to help this young woman, which I now believe to be true. Unfortunately, my evaluation of myself at the time was much more critical. It took time for me to heal and regain my confidence.”

Today, Weigel uses those “lessons learned” to help prepare his counselor education students at Southeastern Oklahoma State. Each semester he reviews suicide prevention and intervention skills with the students. He also tells them about the young woman’s story, while maintaining her anonymity.

“I do it to help prepare them for what I consider one of the toughest aspects of our work as counselors but also to help them prepare for the likelihood that they will experience a client suicide during their careers or even during their internship experiences,” he explains.

“We also have a frank discussion regarding self-blame, burnout and the terrible but real possibility of being accused of malpractice in such a situation,” he continues. “This is always a possibility, and the fears it brings, in conjunction with the deep sadness that counselors experience, make for a highly volatile internal dialogue. Debriefing and talking with colleagues is critical.”

A counselor’s worst nightmare

Brooks, who is also a counselor educator at Shippensburg University in Pennsylvania, knows all about the real possibility of being accused of malpractice. When one of his clients died by suicide about five years ago, her family sued Brooks and the school that employed him. He had been practicing for more than 25 years when the crisis unfolded.

The client was a high school senior at a private school where Brooks was counseling part time as an independent contractor. The transition from adolescent to young adult can be an inherently unstable time for many individuals, and the prospect of transitioning out of high school can add to those feelings of instability, Brooks notes. In addition, this particular client had already experienced a significant amount of instability in her life since adolescence. Brooks and the client were just starting to talk through some of her troubles when their work came to an abrupt end — after about seven or eight sessions — because she was dismissed from the school campus (although she was given the opportunity to finish her courses independently and graduate). The student’s parents picked her up, Brooks says, and the next day, she took her own life by jumping off a bridge.

The young woman’s death was a total shock, Brooks says, but he barely had time to process it because her family almost immediately filed suit against the school, the director of the school and Brooks himself. The family claimed that the school and Brooks should have foreseen their daughter’s suicide and should have committed her for treatment involuntarily, he says.

“I don’t know what [the law] is in other states, but here [in Pennsylvania], unless someone says to you directly, ‘I’m going to kill myself,’ you can’t issue a temporary detention order for that person. You just can’t,” he says.

One of the things that pained Brooks about the lawsuit — aside, of course, from being partially blamed for his client’s death — was that during the legal process, the young woman’s privacy was completely violated. “Although the client was not at all interested in her family knowing anything about her therapy, because they took over the postmortem rights [to her record] … they were able to go through every single document that any therapist had ever created,” he says. “They got all the notes — including doctors notes — and could see everything she said, and that’s the exact opposite of what she wanted to have happen.”

In the aftermath of his client’s suicide, Brooks immediately sought counseling and treatment, including medication, and went to peers for support. But he also needed to address the pending legal case. He promptly retained a lawyer and contacted his liability insurance company to prepare for what would be a long and drawn out process. The case dragged on for roughly three and a half years. If he had been the sole defendant, Brooks says, he may have been able to reach a settlement with the family in less time, but because he was part of a larger group, he had to go along with whatever negotiations the other parties wanted to engage in.

As the legal case plodded along, Brooks notes sadly, the primary emotion he was processing was anxiety about its outcome. “It became more about the case than really grieving this person who had a pretty difficult life,” he recounts. “It wasn’t until it was all over that I could really process this feeling of having lost a client.” In the end, all of the involved parties agreed to a financial settlement.

In Brooks’ words, the suicide and subsequent lawsuit “enveloped” his professional life. Before his client’s death, Brooks was providing outside supervision, but he ceased doing that almost immediately. He also stopped practicing and hasn’t seen a client since.

“I like counseling, and I was doing this because I like helping other people,” he says, “but no good turn goes unpunished, so I am much more wary of putting myself out there [as a practitioner], sadly.”

In addition, the lawsuit has heightened his sensitivity to the possibility of vicarious liability in his role as a supervisor at the university and altered how he teaches, he notes.

“I am a real live nightmare that every counselor would want to avoid,” Brooks says. Brooks tries to help his students understand what it is like being sued as a counselor, while also presenting himself as an example of a helping professional who has gone through the legal grinder and survived.

Although the legal case often made Brooks angry, he says he tried not to give in to that feeling. “It didn’t really do me any good to be angry, so I was trying … to be really forgiving. My faith system is to pray for the family and their loss and what they’re going through and not get into ‘woe is me’ and ‘poor little old me,’” he says. “At times I slipped into it, but I tried not to, and that seemed to help.”

Brooks acknowledges that counselors are sometimes bad at taking care of themselves properly in the face of their job demands, but he also says that concepts such as “wellness” are inadequate for living through and bouncing back from a client’s suicide, at least in his personal experience. “There is no such thing as wellness [in these cases]. It’s survival and getting out of bed,” he says. “There was nothing well about it. I just did what I could.”

However, Brooks adds that throughout his ordeal, he did maintain certain activities, such as running, that had helped him cope with stress in the past.

Brooks also believes that some kind of nationwide network of clinicians who have gone through client suicide should be established. The network could serve as a supportive place to which these practitioners could turn to talk with others who have an understanding of what they are going through, he says.

Knowledge out of tragedy

Bates-Maves says she will never be completely at peace with losing her client to suicide, but the incident did help her arrive at some important realizations.

“What’s left with me is his memory and an even greater respect for suicidal thoughts and people courageous enough to express them out loud. They are never to be dismissed, forgotten or ignored,” she says emphatically. “It both scares and saddens me when I hear any practitioner or student say, ‘They [the client] are just doing it for attention.’ My response is always, ‘Yes, they are. And you know what? That matters. Attend to them, care for them, and don’t add to their pain by telling them their words are meaningless.’”

“Counselor educators need to do a better job of making that point, in my opinion,” she continues. “I’ve heard suicidal threats brushed off or ignored or blamed away far too often. It needs to stop, and clients need to be taken seriously. It will never hurt to be curious and to have a conversation to further explore intent and emotional state. But it could kill if we don’t take the time.”

Weigel urges his students — and all beginning counselors — to trust their instincts. “If counselors allow themselves to use their internal instincts as part of the suicide assessment process, I have found that they are much more likely to invite their clients to discuss this topic as early as possible and perhaps even save a life by asking the necessary questions the moment their instincts tell them to act,” he says. “This is the ‘art’ component of suicide assessment, which accompanies a formal assessment. It has been my experience that many highly skilled counselors struggle with allowing themselves to follow their gut instincts and [thus] risk missing windows of opportunities or getting lost in mnemonic devices or other interventions that come less naturally.”

“There is so much stigma around the actual possibility of death that I think even counselors brush off the seriousness of it at times,” adds Bates-Maves. “Fear is powerful, and yet we cannot be too scared to ask, check in and persist in those efforts.”

“Someone’s life could truly be at stake,” she continues, “and I’d rather have a scary conversation about death than wonder if I missed something or could have done something. … That’s a scary place too, and it is one that doesn’t really have an end point. I’ll always carry those thoughts with me to some degree.”

 

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Additional resources

The American Counseling Association offers the following resources that speak to the topic of suicide assessment and treatment and the legal issues surrounding client suicide. All resources are available on the ACA website at counseling.org.

Books

• The Counselor and the Law: A Guide to Legal and Ethical Practice, seventh edition, by Anne Marie “Nancy” Wheeler & Burt Bertram
• Harm to Others: The Assessment and Treatment of Dangerousness by Brian Van Brunt
• Clinical Supervision in the Helping Professions: A Practical Guide, second edition, by Gerald Corey, Robert Haynes, Patrice Moulton & Michelle Muratori

DVDs

• Suicide Assessment and Prevention, presented by John S. Westefeld

Webinars and podcasts

• Webinar series: “Confronting the Darkness: Nonsuicidal Self-Injury, Suicide Assessment and Counselor Self-Care After Client Suicide” (topics include “Nonsuicidal Self-Injury: Assessment and Risk Considerations,” “Distinguishing Between Depression and Suicidal Ideation,” “Suicide: Assessment Considerations,” “Suicide: Ethical, Legal and Risk Management Issues in Suicide,” “Nonsuicidal Self-Injury: A Treatment Overview” and “Self-Care for Counselors Working with NSSI and Completed Suicide”)
• Podcast: “Suicide Assessment: Sharpen Your Clinical Skills”
• Podcast: “The Counselor and the Law: A Guide to Legal and Ethical Practice”

Practice Brief

• “Suicide Prevention” by Paul F. Granello

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org