Adolescents and Their Psychiatrist’s Suicide

A Study of Shared Grief and Mourning

John S. Graves, M.D.

Abstract. The work with two adolescent boys following the suicide of their previous psychia- trist is described. Clinical material is presented with a focus on grief and mourning and on how the author used his own mourning process as a significant ingredient in conceptualizing and undertaking the treatment, with special attention to countertransference issues.

Several years ago, a close friend and colleague of mine committed suicide. Shortly before his death I had agreed to take over respon- sibility for several of his hospitalized adolescent patients, because of his impending move. Dr. Smith’ died on the day he was to have introduced me. Thus, I was faced with the complex problem of handling my own grief and mourning at the very time my new patients experienced the same process. In the weeks and months that followed, I gradually came to identify and integrate my own responses to this event and to use the process that was unfolding in myself as a significant ingredient in my treatment of the boys. The purpose of this article is twofold: (1) to describe the phenomenol- ogy of grief and mourning in two of these adolescents; and (2) to discuss the countertransference issues involved.

The author is presently in private practice in Denver, and is Clinical Instructor in Psychiatry at the University of Colorado Medical Center, Denver.

I wish to thank the following people for their ongoing support during the formulation, working through, and writing of this article: Drs. Joan Fleming, John Conger, Eleanor Steele, John Biddinger, Gary May, Thomas Luparello, Homer Olsen, Judith Alexander Brice, Mr. Charles Brice, and Mrs. Ellen Graves.

Requests for reprints should be addressed to the author at Suite 720A, Writer‘s Tower, I660 South Albion Street, Denver, CO 80222.

0002-7 138/78/1703-052 1 $00.84 0 1978 American Academy of Child Psychiatry.

Material pertaining to Dr. Smith and his patients has been disguised for the purpose of maintaining privacy and confidentiality. I have been granted permission by both Dr. Smith’s family and the patients herein described to publish the material in this article.

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522 John S. Graves

LITERATURE REVIEW

Since Freud’s classic paper on mourning (1 9 17) there have been numerous articles concerning the normal, pathological, and treatment-facilitated forms of grief and mourning. However, there are few detailed studies concerning responses to a doctor’s death, particularly suicide. Ables (1974) described the first treatment ses- sion with a 10-year-old boy just informed of his therapist’s suicide. He described the child’s immediate reaction as a microcosm of all the elements of grief and mourning found in subsequent treatment sessions. Chiles (1974) interviewed five patients one year following their therapist’s suicide and observed a sense of omnipotent re- sponsibility for the death, questions about the continuation of therapy, and concerns about the fallibility of the dead therapist. Pasnau and Russell (1975) described the characteristics of five psychiatric residents who suicided, and made suggestions as to pre- vention.

Studies by Blackly et al. (1968) and others have demonstrated not only that physicians have one of the highest suicide rates among all professions, but also that psychiatrists lead all medical subspecialties. Shneidman (1975) concludes in a recent summary article: “Any suicide by a psychiatrist involves an unspeakable waste and an enormous tragedy-and a searing trauma for his patients” (p. 1777).

Wolfenstein ( 1966) demonstrated that surviving parents and children may use each other as object replacements following an important loss. Cain and Fast (1966) studied 45 children whose parents suicided and noted a striking degree of distorted com- munication coming from the parents and a pervasive sense of guilt in their children. Becker and Margolin (1 967) stressed the need for both parents and child therapists to become role models by honest exploration of death and encouraging expression of all affects, no matter how painful. Kliman and Feinberg (1969) stressed the im- portance of immediately cultivating a positive transference with parent-loss cases, and of interpreting all transference separation reactions. Furman (1 974) epitomized the problem faced by parents (and myself) as follows: “The very person who is afflicted is, from the child’s viewpoint, best suited to help him grasp and handle the tragic event” (p. 17).

Adolescents and Their Psychiatrist’s Suicide 523

CASE REPORTS

The Circumstances of the Loss

At the time of Dr. Smith’s death from a chronic medical condition complicated by a drug overdose, the two patients described below had been hospitalized for about one month. They had received intensive therapy with their doctor in a variety of individual, fam- ily, and group encounters. The announcement of the death was made on the same day in a community meeting by another psychiatrist, himself in a tearful state of shock and disbelief.

Dr. Smiths death was a deep personal loss for me. I organized and spoke at a memorial service attended by several physicians, hospital staff, and the two patients described below. At first I viewed my responsibility with his patients as an unwanted affliction, later as moral obligation, and finally, after I had resolved some of my own feelings, as an important clinical challenge.

Case 1 Ralph, age 17, was hospitalized for the first time following a psychotic decompensation. On admission, he was confused, sus- picious, socially withdrawn, and depressed. His autistic thinking involved intense religious preoccupations. At age 14, he had run away from home, and until admission, had lived in a series of foster homes. Records indicated frequent elopements and gradual onset of social isolation and paranoid behavior.

Prior to Dr. Smith’s death, Ralph continued to be withdrawn and suspicious; his rarely initiated communications with Dr. Smith were distant and obedient. He focused on his separations from parents and foster parents, and concerns that his new doctor might force him to stay in the hospital longer than necessary. Two days prior to Dr. Smith’s death, Ralph made an unsuccessful elopement attempt.

Ralph’s immediate reaction to Dr. Smiths death was to ask re- peatedly “why” and to state, “It doesn’t seem real.” During his introduction to me he hesitated to shake hands and turned his face away. I stressed my own shock and that an important part of beginning treatment would be identifying and sharing feelings about our mutual loss, and assured him of my easy availability. On the following day, he became increasingly paranoid, saying other patients were laughing at him, and that he couldn’t trust the staff who he felt were “bugging his room” and monitoring his prayers.

524 John S . Graves

During initial contacts, Ralph hesitated to enter my office (for- merly Dr. Smith’s) and looked around it with fear and suspicion. He said he had no appetite, that the hospital depressed him, that he felt like running but had no place to go. He also said he felt “like a broken record” and as if he were “running in place.”

At the end of the first week, he stated that Dr. Smith was “in Hell because he could not accept Christ as his Savior.” He denied that these comments represented his anger at Dr. Smith for betraying his trust by dying. Ventilation of his anger by using a punching bag proved too frightening for him. A change of medication from Stelazine to Mellaril was vigorously opposed since Stelazine repre- sented a part of Dr. Smith.

At the memorial service held in the hospital ten days following the death, a request was made for patients to come forth with anything they wished to say about Dr. Smith. Ralph hesitated at first, then slowly delivered the following message:

Dr. Smith is the only one I could ever trust. . . . I can’t put things into words . . . I’m sorry to see him go. . . . Seems like I could talk to him about anything. He’s been a good doctor to me. . . . It’s going to be hard to forget about him.

On his return to the ward several patients told him they wished they had been able to get up and speak as he had done. Ralph responded by withdrawing to a corner where he became engrossed in reading the Bible.

Despite Ralph’s extreme reluctance, I persisted with daily meet- ings and attempted to label for him the affects which he appeared to demonstrate, predominantly intense and pervasive anxiety about hostile impulses. One day, while walking together across a busy street, he suddenly put his arm out as if to protect me from injury. On my inquiry about this gesture, he blurted out his fear that I might be killed by the cars. I responded that it was hard enough for him to lose one doctor without having to deal with another frightening loss. Shortly after this incident, Ralph told another staff member that he was beginning to like and trust me, and had decided not to leave the hospital. . About three weeks after his doctor’s death, Ralph developed

chest pains, saying his “lungs hurt,” although workup was normal. Concurrently, he talked about his own fear of dying and asked how Dr. Smith had died. I told him that the single cause of death was unknown, but that his doctor had had chronic medical problems

Adolescents and Their Psychiatrist’s Suicide 525

and had been very depressed recently. Ralph thought death was by suffocation since his doctor coughed a lot, but stopped just short of mentioning suicide, saying with a horrified expression, “I can’t say it.” Although he denied that his own physical symptoms might be reactions to Dr. Smith’s death, they subsided following interpreta- tions to this effect.

After eight weeks, he had ceased talking about Dr. Smith en- tirely. Once, following a brief illness of mine, he became quite confused and depressed and, for a few days, called me “Dr. Smith.” I suggested that old feelings about Dr. Smith having abandoned him were stirred up. He accepted this and felt better.

Ralph’s frequent therapy sessions in the final eight weeks of hos- pitalization were characterized by avoidance of most past issues and preoccupation with residential placement as a panacea.

When informed three weeks prior to discharge about long-term residential placement, his reaction combined personal relief and intense feeling of staff rejection. 1 assured him that his placement represented a growth step, that I felt pleased with his progress, and that just as I had felt very rejected by Dr. Smith’s death Ralph’s leaving the hospital reminded him of this and of his many former painful separations. His usual response was silence.

During his final week in the hospital he became more regressed, paranoid, and complained of somatic ailments. He spoke spon- taneously to another patient about their experience of sharing Dr. Smith and then losing him. However, he was unable to talk about his feelings of termination with me, despite my attempts to em- pathize with his fears that I might “terminate” in the same way that Dr. Smith had. I flew with him to his long-term residential treat- ment center. Silent and withdrawn for most of the trip, he was never really able to say good-bye when we parted. I myself found our parting extremely difficult and painful, and it was only later that I realized that this involved a rather complex set of counter- transference issues.

Case 2

Hank is an 18-year-old male, hospitalized during an acute confu- sional state following a conflict with his parents. Both parents de- manded premature independence, and when Hank developed homosexual relationships, his parents frequently rejected him. During early childhood, Hank lived with a grandfather for two years.

526 John S . Graves

On admission, Hank was very anxious, laughed and giggled in- appropriately, and was fearful of losing control of hostile impulses against his parents. Most meetings with Dr. Smith had focused on angry feelings toward his parents and their rejection of his homosexual behavior. Hank had a good relationship with Dr. Smith, and indicated that he found him to be a sensitive and non- judgmental listener.

At the news of Dr. Smith’s death, Hank broke into uncontrol- lable laughing, giggling, and sobbing. He clenched his fists, hyper- ventilated, and required considerable staff support. During our initial meeting, I told him that this must be an awful occasion for him as it was for me, but that I would do everything I could do to insure continuity of treatment. Hank’s first request was that 1 ac- company him to the phone while he informed his family. I told him that I had called my own family and found this similarly help- ful.

During our initial sessions Hank sobbed and expressed fear of dying. I shared my own feelings and memories about my friend, including anger at Dr. Smith for leaving me. Following this, Hank became angry at the staff. On the night before the memorial ser- vice he made a dramatic suicide gesture by tightening a belt around his neck, and writing a note mentioning his doctor’s death. Despite denial of identification, he did say that he suspected his doctor had suicided. He agreed that he still had immense anger concerning his doctor’s death but would try to express it less self-destructively.

Although too upset to speak at the memorial service, Hank dedi- cated a drawing to his doctor, and said that his way of remember- ing Dr. Smith was to “commit himself to a life of social service.” He made a ceramic pot in which he nourished a cutting from one of Dr. Smith’s plants and wrote numerous poems about his life ex- periences, including his doctor’s death.

During the second month, he stopped discussing his feelings of grief, rapidly gained weight, and developed a close relationship with another former patient of Dr. Smith. Talking with a 16-year- old girl admitted for treatment of an acute grief reaction reacti- vated his own grief feelings about Dr. Smith: “I was the last patient he saw. He was a good doctor and listened well. I realize now that I had the belt around my neck because of him.” He developed with her his first meaningful heterosexual friendship.

Ten weeks after Dr. Smith’s death, Hank developed a serious viral illness, regressed, expressed intensely rivalrous feelings about

Adolescents and Their Psychiatrist’s Suicide 527

Ralph, and anger that Dr. Smith had abandoned him. During my trip with Ralph to his residential placement, Hank reexperienced the initial symptoms of confusion and anxiety. I interpreted these developments as my absence opening the wound concerning Dr. Smiths death. Hank agreed and his symptoms abated.

Hank’s final month in the hospital was characterized by a con- tinuation of viral illness, truancy from school, and periodic regres- sions and acting-out behavior. When confronted, he complained bitterly that Dr. Smith’s death had prolonged his treatment un- reasonably. I agreed, but stated that we would both have to accept this reality. He then expressed some gratitude for the work I was doing with him.

Hank’s reaction to terminating with me and leaving the hospital was appropriate, when, after five months, he moved to a nearby adolescent group home. He visited me on the six-month anniver- sary of Dr. Smith’s death, and on the one-year anniversary of his admission to the hospital. He reported with pride that he had lost 25 pounds, moved into an apartment, and was applying for work in a nearby hospital. His grandfather had died the previous summer, and Hank reported being able for the first time to share his grief feelings and other feelings with his parents. He said: “Being here taught me how to mourn.”

DISCUSSION

Chronologically only one year apart, Ralph and Hank were many years apart in their developmental capacities for grief and mourn- ing. Ralph was able to grieve for a brief period, but the longer and more arduous process of mourning was impossible for him. He was left with a high level of anxiety related to irrational fears that he had been the cause of his doctor’s death. This is consistent with Searles’s findings ( 1965) that schizophrenics have more difficulty dealing with any death due to reactivation of homicidal fantasies. Ralph’s use of religious metaphors appeared to relate to a psychotic identification with his father, who had often quoted Scripture to him.

One of the more conspicuous aspects of Ralph’s grief reaction was the presence of persistent somatic symptoms, a condition em- phasized by Lindemann (1 944). The safest channel for grieving, Ralph’s lung pain appeared to represent a complex mixture of

528 John S . Graves

partial identifications with his doctor; attempts at recovering him as a nurturing figure (Bowlby, 1961); a regression from secondary process thinking (Schur, 1955); and the further distortion of an already abnormal body image (Green, 1970). It would appear that Ralph grieved in part through his body ego and that this process may have represented a regression to a preverbal state of rage and helplessness where the fantasized loss of a nurturing figure posed an overwhelming threat to his survival.

In her paper on absent grief, Helene Deutsch (1937) proposed that “the ego of the child is not sufficiently developed to bear the strain of the work of mourning and . . . it therefore utilizes some mechanism of narcissistic self-protection to circumvent the process” (p. 13). Ralph lacked not only a sufficient ego, but also a sense of self-differentiation, integrity, and object constancy. Dr. Smith’s death reactivated multiple unresolved past separations where af- fects were overwhelming and had to be reversed or repressed.

Ralph’s cognitive development was also immature. He was forced to relive, with frightening intensity, rather than to remember, with growing detachment, both present and past losses. This important distinction is discussed by Fleming in several articles (1963, 1973, 1974) and appears to be an important prerequisite for the mourn- ing process. Ralph’s early adolescent history unfolded as an odyssey of painful separations, substitute parenting, and angry elopements. His repeated running away appeared to circumvent any possibility of the “trial mourning” of normal adolescence which Wolfenstein ( 1966) has described.

Finally, Ralph lacked the capacity for object relations which would have enabled him to form a good alliance with Dr. Smith. In his efforts at mourning he transformed a distant, passive, and am- bivalent relationship into a highly idealized one, and then pro- ceeded to relate to me as he had actually related to Dr. Smith.

Hank, on the other hand, was able to grieve and mourn Dr. Smith’s death in a way which was both phase-appropriate and growth-promoting. He was able to use treatment to rework rather than to relive his past. Of good prognostic value for this process were the following conditions: a good preloss relationship with Dr. Smith; an ongoing, albeit ambivalent relationship with his parents; adaptive use of me as a therapist; and a set of character defenses which enabled him to withstand the pain of grief and shoulder the work of mourning. Parallel with Hank’s mourning process, a steady and increasing heterosexual interest developed and he was able to

Adolescents and Their Psychiatrist’s Suicide 529

give up some of his passive homosexual longing for his father. A problem in the treatment of these two boys involved my own

countertransference reactions and behaviors. It was only with an emerging understanding of these reactions that I was able to carry on a reasonably successful treatment with these boys. Early authors, beginning with Freud (19 lo), tended to view countertransference as an undesirable ingredient in the treatment process, or as identi- cal to transference in a patient (Stern, 1924). Focus on counter- transference as an example of the identification, introjection, and projection which occur (Little, 195 1 ; Money-Kyrle, 1956; Racker, 1957), and mechanisms of “concordant” and “complementary” identification as described by Racker (1957) were found more re- cently to be useful in conceptualizing what I actually experienced in working with these boys. Concordant identification refers to the therapist’s identification with the particular affect o r attitude which a given patient is experiencing; while complementary identification refers to the therapist’s identification with the patient’s transfer- ence object, and with the attributed affects and attitudes.

As a therapist I identified with a number of key affects and attitudes which appeared in the boys, including their ambivalence about Dr. Smith as well as their pain, rage, helplessness, guilt, and avoidance of these feelings concerning his death. Initially, it was relatively easy to talk about our shared experiences with Dr. Smith, but then an attitude of mutual avoidance began to permeate the entire treatment situation. Only later did I realize that this mutual avoidance reflected my own inability fully to accept the suicidal component. In retrospect, Ralph’s frightening fantasies and Hank’s suicide gesture probably related to the fact that neither they nor I were able to discuss our feelings about his suicide more openly and frankly.

Many times during the treatment of these boys, I compared myself to a widower who has difficulties supporting grief and mourning in his children because of his own unresolved feelings concerning the loss. I found myself unconsciously using the same mechanisms of denial, distorted communication, and defenses against affects which have been described in the literature. At these times, I identified with the helpless, ineffectual parents who had raised my patients. I thus confirmed the observations of Kohrman et al. (1971) that child and adolescent therapists frequently face more countertransference “pressure” due to their accessibility as real objects, and their regressive identification with their patient’s

530 John S. Graves

parents. This pressure was no doubt increased by the inpatient set- ting, which gratifies a variety of regressive transference wishes.

A further consequence of this countertransference identification with my patient’s helpless parents was the omnipotent, narcissisti- cally motivated defense against it; namely, the operation of rescue fantasies. On a conscious level, this took the form of working over- time and personally escorting my patients to their long-term placements. Unconsciously, my helplessness stimulated the defen- sive need to be a better, more concerned, more helpful therapist than my predecessor, and, by extension, a better parent. I would not abandon them like their parents and previous psychiatrist; rather, I would treat them with a truly intense dedication that would make reparations for all previous wrongdoings. Thus, a process which began with the identification with parental helpless- ness was transformed into what I later came to recognize as the “dedication trap.” A similar elaboration of unconscious fantasies of rescue and competition in the child therapist has been noted by Coppolillo (1969).

Another form of countertransference identification which oper- ated concerned my identification with Dr. Smith. By referring these patients, Dr. Smith had, in effect, said: “Would you agree before I die to take care of these clinical responsibilities of mine which I cannot handle?” I had willingly accepted this task without, of course, realizing the future implications. The situation which I faced frequently caused me to wonder: Will I fail these boys as Dr. Smith had? If Dr. Smith’s work with these boys led to his suicide, what will become of me in my attempts to help them? Will my responsibility to treat them drive me to the edge of despair, or even to suicide?

In my work with these patients, countertransference projection took the form of my expecting them to talk about Dr. Smith’s death and somehow to express what I at times was unable to express. In effect, this amounted to the expectation that they would proceed with the mourning work which was so difficult for me to confront in myself on a day-to-day basis. Most often, when this would hap- pen, the boys would become more defensive, sensing my own pro- jection.

The purpose of discussing these countertransference issues has been to acquaint other clinicians of their importance in the treat- ment of similar cases. It is recommended that clinicians, in accept- ing such cases for treatment, be particularly sensitive to their own

Adolescents and Their Psychiatrist’s Suicide 53 1

reactions and that they seek consultation and supervision if indi- cated. A further recommendation would be that therapists, espe- cially if they knew their predecessor, carefully evaluate the number of such patients they feel comfortable in accepting.

REFERENCES

ABLES, B. S. (1974), The loss of a therapist through suicide. This Journal, 13:143-152. BECKER, D. & MARGOLIN, F. (1967), How surviving parents handled their young children’s

BLACKLY, P. H., DISHER, W., & RODUNER, G. (1968), Suicide by physicians. Bull. Suicidal.,

BLOS, P. (1964), O n Adolescence. New York: Free Press. BOWLBY, J. (1961), Processes of mourning. Int. J . Psycho-Anal., 42:317-340. CAIN, A. C. & FAST, I. (1966), Children’s disturbed reactions to parental suicide. Amer. J .

CHILES, J. A. (1974), Patient reactions to the suicide of a therapist. Amer. J . Psychother.,

COHEN, M. B. (1952), Countertransference and anxiety. Psychiatry, 15:23 1-243. COPPOLILLO, H. (1969), A technical consideration in child analysis and child therapy. This

DEUTSCH, H. (1937), Absence of grief. Psychoanal. Quart., 6: 12-22. ENGLISH, 0. S. & PEARSON, G. H. J. (1937), Common Neuroses of Children and Adults. New

FLEMING, J. (1972), Early object deprivation and transference phenomena. Psychoanal. Quart.,

(1974), The problem of diagnosis in parent loss cases. Contemp. Psychoanal., 10:439-

& ALTSCHUL, S. (1963), Activation of mourning and growth by psycho-analysis. Znt. /.

FREUD, S. (1910), The future prospects of psycho-analytic therapy. Collected Papers, 2:285-

(1917), Mourning and melancholia. Standard Edition, 14:243-258. London: Hogarth

adaptation to the crisis of loss. Amer. /. Orthopsychiat., 37:753-757.

4:l-18.

Psychiat . , 36: 873-880.

28~115-121.

Journal, 8:411435.

York: Norton.

4 1 :2349.

451.

Psycho-Anal., 44:41943 1.

296. London: Hogarth Press, 1946.

Press, 1957. FURMAN, E. (1974), A Child‘s Parent Dies. New York & London: Yale University Press. GREEN, A. (1970), The effects of object loss on the body image of schizophrenic gir1s.J. Child

KERNBERG, 0. F. (1975), Borderline Conditions and Pathological Narcissism. New York: Jason

KLIMAN, G. & FEINBERG, D. (1969), Facilitation of mourning during childhood. Amer. J .

KOHRMAN, R., FINEBERG, H. H., GELMAN, R. L., & WEISS, S. (1971), Techniques of child

LINDEMANN, E. (1944), Symptomatology and management of acute grief. Amer. J . Psychiat.,

LITTLE, M. (195 l), Counter-transference and the patient’s response to it. Znt. J . Psycho-Anal.,

MONEY-KYRLE, R. E. (1956), Normal counter-transference and some of its deviations. Int. J .

PASNAU, R. & RUSSELL, A. T. (1975), Psychiatric resident suicide. Amer. J . Psychiut.,

Psych&., 9:532-547.

Aronson.

Orthopsychiat., 39:247-248.

analysis. Int. J . Psycho-Anal., 52:487497.

1: 141-148.

32:3240.

Psycho-Anal., 3 7 : 360-366.

132:402406.

532 John S. Graves

RACKER, H. (1957), The meanings and uses of countertransference. Psychoanal. Quart.,

SCHUR, M. (1955), Comments on the metapsychology of somatization. The Psychoanalytic Study

SEARLES, H. F. (1965), Collected Papers on Schizophrenia and Related Subjects. New York: Inter-

SHAMBAUGH, B. (1961), A study of loss reactions in a seven-year-old. The Psychoanalytic Study

SHNEIDMAN, E . S. (1975), Suicide. In: Comprehensive Textbook of Psychiatry II, ed. A. M. Freed-

STERN, A. (1924), On the counter-transference in psychoanalysis. Psychoanal. Rev. , 11: 166-

WOLFENSTEIN, M. (1966), How is mourning possible? The Psychoanalytic Study of the Child,

26~303-357.

of the Child, 10:119-164.

national Universities Press.

of the Child, 16:510-522.

man, H. Kaplan, and B. J. Sadock. Baltimore: Williams & WiIkins, pp. 17741785.

174.

21x93-123.