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Letter to the Editor   |    
Dr. Hendin and Colleagues Reply
HERBERT HENDIN, M.D.; JOHN T. MALTSBERGER, M.D.; ANN P. HAAS, Ph.D.
Am J Psychiatry 2004;161:2330-2331. doi:10.1176/appi.ajp.161.12.2330
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To the Editor: We welcome the comments about our case conference and join Dr. Plutzer’s acknowledgment of the treating psychiatrist, whose willingness to share his experience made this presentation possible. Each writer comments that the wife’s extramarital affair precipitated the patient’s depression, a conclusion that we made in our published report. Clearly, opening up and exploring the patient’s intense unexpressed feelings about the affair was an essential but neglected therapeutic task. The treating psychiatrist had come to the same conclusion.

Dr. Gudeman identifies a number of possible lines of inquiry for therapeutic exploration. To these, we might add the question: What had the patient been like before his wife’s affair? This would have been useful to explore from the wife’s as well as the patient’s perspective. Drs. Lieberman and Wolin suggest that family therapy was needed. Such treatment would have been premature, in our view, and not indicated before the patient could acknowledge how he felt about his wife’s unfaithfulness, which this particular patient was more likely to be able to do without the presence of his wife.

Although we concur with the general thrust of the comments on our report, we wish to make a point about the tone in which some of the comments were conveyed. From the beginning of our Suicide Data Bank project, we were keenly aware that the literature about therapists’ experiences with patients who had died by suicide while under their care is meager, at best. Through our in-depth study of 36 such patients to date, we have come to understand how ill-considered remarks by supervisors and colleagues invite sealing over the singularly painful experience of losing a patient to suicide.

Some colleagues hasten to reassure the therapist that the suicide was inevitable, that nothing could have been done to prevent the patient’s death. However well-intended, such assurances serve to stop further discussion, preventing the therapist from voicing and coming to terms with feelings about treatment decisions and about the suicide. On the opposite side of the spectrum is the more harmful tendency to blame the therapist. Although we trust that this was not his intention, several of the comments made by Dr. Plutzer are illustrative of this reaction, which our studies show has been the source of considerable additional pain for many therapists who have experienced a patient’s suicide.

Rather than judgment, colleagues who are willing to openly discuss treatment cases that have ended so tragically deserve our support in examining their responses to the patient and exploring strategies and interventions that might have made a difference. Scrutinizing cases of completed suicide can tell us much about what did not work in the patient’s treatment. In every case of suicide we have examined, problematic interventions or noninterventions can be identified. It is quite a different matter, however, to conclude that the suicide could have been prevented had the therapist done something different. Such certainty is simply not warranted.

Our experiences working with therapists who have lost a patient to suicide has convinced us of the critical need for forums that invite talking through experiences and learning from mistakes without fear of blame and recrimination. We are gratified that our project has provided one such forum and are deeply grateful for the enormous amount that these therapists have taught us about suicidal patients and their treatment.

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