Dealing with the Aftermath: A Qualitative

Analysis of Mental Health Social Workers’

Reactions after a Client Suicide
Laura Ting, Sara Sanders, Jodi M. Jacobson, and James R. Power

Social workers provide services to populations with mental health issues, including suicidal
ideations and are thus at risk of experiencing a client suicide at some point during their career.
Limited research using quantitative methods has explored the effect of client suicide on social
workers, but little is known about their reactions from a qualitative standpoint—a method of
study that is essential for fully understanding a social science phenomenon. This study
addresses the gap in the literature by providing findings from an in-depth qualitative study of
25 mental health social workers who shared their experiences and reactions in the aftermath
of a client suicide. Major themes were identified, including both professional and personal
reactions of denial, anger, grief, and acceptance. Avoidance and intrusion, as well as additional
themes of professional incompetence, responsibility, isolation, and justification were indicated
and discussed in the conceptual framework of grief and secondary traumatic stress. The
implications for practitioners, administrators, and educators are discussed.

KEY WORDS: client suicide; mental health; qualitative reactions; social worker; traumatic stress

A
s the 13th leading cause of death world-
wide, suicide is a global health concern
(Centers for Disease Control and Preven-
tion [CDC], 2004). In the United States, it is the
11th leading cause of death and continues to be a
major problem, especially among high-risk popu-
lations including adolescents, men, and older adults
(CDC). The effects of suicide are far reaching, af-
fecting not only families, but others with whom
the individual has come into contact, including
mental health professionals.
Mental health professionals who work with sui-
cidal clients often experience intense reactions in
the aftermath of a traumatic event, such as a client
suicide completion. Researchers indicate that men-
tal health professionals who experience a client
suicide display varying psychological reactions
(Chemtob, Hamada, Bauer, Torigoe, & Kinney,
1988; Chemtob, Bauer, Hamada, Pelowski, &
Muraoka, 1989; Farber, 1983; Jacobson,Ting, Sand-
ers, & Harrington, 2004; Jacobson, Ting, & Sand-
ers, 2004; Litman, 1965). Much of the literature on
the professional consequences of client suicide has
focused on the reactions of psychologists and psy-
chiatrists; research on social workers has been lim-
ited. Usng qualitative research methods, the present
study assessed the reactions experienced by a group
of mental health social workers following a client
suicide.
SOCIAL WORK WITH SUICIDAL
POPULATIONS
Despite the fact that social workers provide mental
health services to suicidal populations (Freedenthal
& Feldman, 2004; Ivanhoff & Riedel, 1995), few
studies have examined the effects of suicide on so-
cial workers. The literature in social work has fo-
cused on the prevalence of client suicidal behavior,
provided single case studies, and offered clinical
guidelines for educational and training needs
(Callahan, 1996; Feldman, 1987; Fox & Cooper,
1998; Freedenthal & Feldman). Brown’s 1987 study
explored the effect of client suicide on therapists in
training; 14 social workers participated and 14 per-
cent (n = 2) reported experiencing a client suicide
resulting in feelings of increased discomfort and

Ting
CCC Code: /
et0037-8046/06
al. A Qualitative Analysis
$3.00 ©2006 ofAssociation
National Mental Health Social
of Social Workers’
Workers Reactions after a Client Suicide 329
uncertainty regarding competence to work with
other clients. Linke, Wojciak, and Day (2002) ex-
amined reactions of 15 social workers on commu-
nity mental health teams; 40 percent (n = 6) re-
ported lasting reactions (such as avoidance of work
with higher suicide risk clients, increased irritabil-
ity, and anxiety) after a client suicide.
Using large national random samples of mental
health social workers (n = 697 and n = 515, respec-
tively) and standardized measures of traumatic stress
that allowed for comparisons with samples of psy-
chiatrists and psychologists, Jacobson and colleagues
(2004) and Jacobson,Ting, and Sanders (2004) ex-
plored reactions to client suicidal behaviors. Find-
ings indicated that approximately one-third of both
samples (n = 230 and n = 158 respectively) experi-
enced a client suicide completion: As many as 50
percent (n = 271) experienced either a client sui-
cide attempt or completion (Jacobson,Ting, & Sand-
ers).This rate is comparable to and within the range
of the 20 percent to 60 percent rate of client sui-
cide reported by psychologists and psychiatrists
(Chemtob et al., 1988; Chemtob et al., 1989; Pope
& Tabachnick, 1993), indicating social workers are
at as high of a risk of experiencing a client suicide
as other mental health professionals.
In addition to reporting avoidant behaviors and
intrusive thoughts, social workers had varying re-
actions to client suicidal behavior based on gender.
Women reported higher levels of intrusive thoughts
and secondary traumatic stress symptoms, and men
reported higher levels of avoidant behaviors
(Jacobson,Ting, et al., 2004; Jacobson,Ting, & Sand-
ers, 2004). Other professional reactions, reported
by psychiatrists, psychologists, nurses, and thera-
pists following a client suicide include guilt, self-
doubt, fear, and anger towards the client in addition
to personal feelings of hypervigilance, arousal, sad-
ness, grief, depression, and self-blame (Alston &
Robinson, 1992; Chemtob et al., 1988; Grad,
Zavasnik, & Groleger, 1997; Litman, 1965;
Menninger, 1991). These reactions could be con-
ceptualized within several theoretical frameworks.
McCann and Pearlman’s (1990) theory of
constructivist self-development would posit that
working with suicidal clients increases the risk of
secondary and vicarious trauma, resulting in cog-
nitive distortions for the therapist. Grief theory can
also be applied toward surviving traumatic experi-
ences of violent death (Shear, 2005) and adaptation
to loss (Prigerson et al., 1995).
330
METHOD
The current study, using a sequential explanatory
design within the framework of traumatic stress and
grief, built on available quantitative research find-
ings (Jacobson, Ting, & Sanders, 2004). This study
was guided by the principles of phenomenology, a
theoretical approach in qualitative research, the
purpose of which is to “describe the lived experi-
ence” of a group of individuals regarding a particu-
lar phenomenon (Creswell, 1998, p. 51), which in
this case is the client suicide completion. The re-
search question for the study was: What are reac-
tions experienced by mental health social workers
after a client suicide completion?
Participants
There were 25 participants, 21 women and four
men; 24 were white and one was black. Respon-
dents lived throughout the United States.The mean
age was 53.25 years (range from 37 to 69). Each
participant was a licensed clinical social worker, with
mean years in practice of 21 (range from nine to
34). Practice settings varied, including private prac-
tice, nonprofit organizations, community mental
health clinics, hospital-based agencies, state and
government agencies, insurance companies, and
employee assistance programs (EAPs). All but one
practiced predominantly with adult clients. Clients
served had diagnoses of severe and persistent men-
tal illness, major depression, addiction, personality
disorders, anxiety, posttraumatic stress disorder,
childhood abuse, sexual assault, eating disorders, and
adjustment disorders related to relationship prob-
lems. At the time of the interview, respondents re-
ported the length of time since the one client sui-
cide they identified as “most traumatic” ranged from
a few months ago to 25 years ago. Two-thirds of
clients who completed suicide were men in their
forties. Suicide methods included hanging, drug
overdose, jumping, asphyxiation, and firearms.
Typically, in a sequential explanatory design, the
strategy to identify participants for the qualitative
study is to locate outlying, extreme, or residual cases
from the quantitative study (Creswell, Plano-Clark,
Gutmann, & Hanson, 2003). The 25 participants
represent a subsample from an earlier anonymous
survey using a national random sample of 515 mental
health social workers (Jacobson, Ting, & Sanders,
2004). A total of 141 postcards indicating interest
in the current study were returned by social work-
ers who participated in the quantitative study, mailed
Social Work Volume 51, Number 4 October 2006
separately from their survey. Of the 141 postcards
initially returned, 48 had incorrect or illegible in-
formation; 21 did not return calls from the research-
ers; 17 declined to participate due to lack of time
or interest; and 30 had not returned the informed
consent form or were not available during inter-
view times by the time the study concluded. Al-
though this process ensured anonymity for the
quantitative study, it limited the ability for research-
ers to compare the current respondents with the
national sample participants who chose not to par-
ticipate in this follow-up study. It also limited the
researchers’ ability to identify whether the current
participants represent outliers with regard to reac-
tions to working with suicidal clients. However, all
25 participants self-identified as having experienced
a client suicide completion.The earlier study com-
prised respondents with no client suicide attempts,
or either attempts or completions. To determine
possible differences, aggregate comparisons were
made using available data; chi-square and indepen-
dent t tests were conducted and no statistical differ-
ences at the p < .05 level were found between the
current respondents and the initial sample. Com-
parisons were conducted on age, gender, highest
degree, race, number of years in practice, practice
setting, and client population served.Thus, although
the final sample of 25 social workers was a conve-
nience sample, it appeared to be similar demographi-
cally to the earlier sample, yet differed in that all
had experienced a client suicide completion.
Procedure
Qualitative data were collected from telephone
interviews. Interviews were scheduled after receiv-
ing the participant’s signed informed consent form.
All participants agreed to be audiotaped. Each
semistructured interview lasted between 50 and 90
minutes and was transcribed verbatim. Examples
of probes included “Can you tell me specifically
what your initial thoughts were?” and “What par-
ticularly about the suicide impacted you?” Notes
were taken during the interview and included with
the interviewer’s journal, as part of the audit trail
to maintain dependability and ensure trustworthi-
ness (Guba, 1981). In addition, several strategies as
noted by grounded theory (Strauss & Corbin,
1990) were used: The primary and a second re-
searcher met to debrief and provide support after
each interview and to minimize interviewer bias
and transference. Data were analyzed concurrently
Ting et al. / A Qualitative Analysis of Mental Health Social Workers’ Reactions after a Client Suicide
throughout the interviews, and the point of satu-
ration was determined when no new information
emerged (Padgett, 1998; Sherman & Reid, 1994),
thus no follow-up interviews were necessary, and
each participant was interviewed only once for the
study.
Qualitative Data Analysis
Two researchers used the constant comparative
method, as well as open coding independently to
analyze the data. Analytic triangulation (Denzin,
1978; Padgett, 1998) through the use of indepen-
dent coders was used to ensure intercoder consen-
sus on the themes. In addition to transcriptions,
triangulation of data also occurred through the use
of data sources, such as interview notes and journal
entries. Once the themes were determined, results
were given to a third researcher to review and vali-
date. A fourth researcher conducted a final review
of themes to confirm the findings. In addition, two
outside mental health social workers—clinicians
who were survivors of client suicides—were asked
to review the data and “member check” the final
list of themes to validate interpretations.To resolve
any discrepancies, data were reanalyzed and dis-
cussed before the themes were reclassified into the
final results.
RESULTS
Twelve major themes were identified using data
from the 25 mental health social workers.
Denial and Disbelief
A number of statements reflected feelings of sur-
prise, disbelief, and shock toward a client suicide
completion. Many reported being “unprepared,”
“didn’t see it coming,” “I had no warning about
this,” or “I had seen him that day, and he denied
being suicidal.” Especially in cases when there were
no earlier suicide attempts, social workers were
caught unaware: “There wasn’t any other time [at-
tempts].” Being “shocked” and “shook up when I
found out about it” were commonly reported re-
actions: “It took me several days to get over the
impact” of the suicide.
Statements reflected disbelief of what occurred,
as well as denial that suicides can happen. “My re-
action was...this was an accident...What turned out
[the suicide] was not what [she] meant; she did so
many bizarre things,” implying that the client really
hadn’t meant to complete suicide:
331
 I wanted to deny what happened.
* * *
I didn’t think he would do it.
* * * hard time with the fact that they survived all this
I had always kind of felt that suicide is so drastic
that most people won’t really do it.
Grief and Loss
Grief reactions were reported. “I could not control
my crying. I mean, I was grief-stricken.When I say
I came undone that’s when I really let myself open
up and sob and cry.” Clinicians reported feeling
“devastated” and “depressed.” “I wept,” or “I had a
very hard time and for the first weeks I didn’t sleep
well. I think I had some of the typical grief feel-
ings.” Many “felt sad,”“saddened,” or “very sad, and
disappointed.”
Some stated that they were “visibly shaken” and
had “not felt in control of my emotions,” or that
they “couldn’t calm down and be professional.”
Some even reported feeling physically ill,“the night
he died, I got deathly ill; I had to go to the emer-
gency room. I thought I was having a heart attack.”
Statements also reflected feeling “traumatized” or
having the suicide bring up feelings of personal
loss, specifically, memories and grief issues of other
deaths of friends or family. “[The client suicide]
brought up feelings of when my father died when
I was five...triggered this fear from when he died.”
Along with grief, feeling a sense of loss for the
client was reported,“It was such a waste;” the “whole
thing’s a tragedy. So many, many good points to
her;” and there were “so many good reasons for
living.”
Anger
Anger was a predominant theme reported with two
subthemes: anger toward the client, and anger to-
ward the agency or larger society.
Anger at the Client. Statements reflected angry
feelings regarding the client’s lack of trust in the
therapist and clinicians’ perceptions of being re-
jected by the client.
I was pissed [at the clients]; felt like why the
hell couldn’t they have called me? Why couldn’t
they have talked to me? Why couldn’t they have
reached out to me? Why couldn’t they have
reached out to [their] family? They have not
thought to turn to me?
332
In addition, there was anger at the client for giv-
ing up on life. One social worker specifically men-
tioned being angry at clients who survived sexual
trauma but completed suicide, “I just really have a
horrible stuff, and they want to kill themselves now.
I’m just really angry that they let the perpetrator by
extension win.”
There was also anger at the client for being self-
ish and inconsiderate, at the lack of care in how
their suicide would affect others’ lives, including
the social worker’s.
Having a suicide upsets your day... whenever
you have that kind of crisis it upsets your
day...the flow of your entire clinical day…you
end up having to drop or shuffle other things
around the need to make an appropriate call
and talk to the receiving people…so it ends up,
not just then, but a whole lot of the day. So
when it happens, it’s a pain in the butt. Because
everything else has to work around it.
There were statements suggestive of anger at cli-
ents’ selfish and manipulative act:
It was very clear to me that he killed himself to
punish her [his wife], leaving behind a son to
deal with it.
* * *
His death left fatherless four girls.
* * *
I felt for the child left behind…the worst part
of the whole thing, I mean, other than being
sad that this man killed himself...was feeling
bad for his family.
Clinicians reported they were left to deal with
the aftermath and indicated anger at having to pick
up the pieces and deal with those left behind.
I continued to provide services to his divorced
wife, his mother, and father. I provided services
for a year afterwards. And we processed with
books, and they brought in all of his writing
and all of his journals and all of that stuff he left
for posterity...I wanted it to be over. I really
wanted it to be over because it was like they
were talking about...they weren’t even talking
about the same man that I knew...it was like,
who is this?
Social Work Volume 51, Number 4 October 2006
 Anger at the Agency and Society. This theme re-
flected social workers’ feelings on how the system
and macro-level structures were insufficient to help
the clients. “…[these are] chronic suicidal clients,
but hospitals wouldn’t admit them without being
actively suicidal. Yet they could become active
anytime and commit suicide. But at the time I
send them to the ER, they get sent home and then
commit suicide a week later.” Many felt angry at
their agencies or supervisor, “who was more con-
cerned that the agency not be compromised.”The
“agency worried about legal issues,” “not recog-
nizing what is important, but only being concerned
with culpability.”
And we as a society were unable to protect her
and unable to protect her child. And the direc-
tor said [to me], “Oh, I pulled your file and
your notes were so clear. And you did every-
thing right, and I was so glad to see that our
agency wasn’t at all compromised by this.” I
was, like, who cares? Who cares? The woman is
dead and her child is dead. How can this be
okay by anybody’s measure?
Anger was directed toward the agency for not
taking responsibility and toward the “lack of insti-
tutional response…there were all the opportuni-
ties to intervene but we didn’t.”
The people here at the agency didn’t have any
sense [to] question who did wrong, or find
where the system broke down. We weren’t in
the path of trying to say, okay, let’s analyze this
and let’s fix the problem...if I was the agency
itself, I would think there would have been a
lot of personal soul searching, kind of institu-
tional response kind of thing, like, let’s investi-
gate the death and see what our role was in
that, and what steps might be in place so this
kind of thing never happens again.
Self-Blame and Guilt
Feelings of guilt and self-blame were reported. “I
felt the whole would’ve, could’ve, should’ve thing.”
Others reported, “should have seen it coming” or
that they “should have done something differently.”
Self-blaming statements included, “Why didn’t I
take the [suicide] note more seriously?” “I felt the
whole self-incrimination thing.”“Guilt was clearly
one [feeling] I had.” “I was experiencing remorse.”
There was also guilt regarding possible incompe-
Ting et al. / A Qualitative Analysis of Mental Health Social Workers’ Reactions after a Client Suicide
tence contributing to the suicide. “I felt guilty, that
I had not done enough.”
On one level I knew I couldn’t have prevented
it because he wasn’t suicidal at all and even if I
could have hospitalized him against his will, in
three days this man would have gone out and
done it. I really have a mixture of guilt...I re-
member thinking well, maybe I should have
told him to throw the pills away, but I also know
he wouldn’t have.
I guess I was feeling guilty, and I remember
thinking I couldn’t have hospitalized him on
the day that I saw him because there was no
way I would have had enough evidence to
hospitalize against his will...so part of me felt
like, okay, you’re not to blame.
Many questioned themselves and reflected a
mixture of self-blame and guilt.
What did I miss? How did I not see this? And
just feeling devastated by it…I was feeling that
the client had said something that I missed.
* * *
I struggle with the issue of how could I have
seen it differently, and what could I have done
differently? What were the clues that I didn’t
pick up on?
* * *
Could we have done something differently had
we acted another way? Hindsight is always 20/
20.
Professional Failure and Incompetence
Feeling incompetent and doubtful in one’s ability
as a clinician was reported along with a sense of
“professional failure.” Still, others questioned their
actions.
It makes me question being in the field when
that [a suicide] happens. It makes me feel like I
don’t know what the hell I’m doing and that I
have no business being a therapist.
* * *
I was questioning my competency.
* * *
[I was] a total failure of a therapist, how could
I not save him? I felt I failed the family.
* * *
What clues did I miss… how much of an im-
pact I am making, I questioned why I’m still in
the field.
333
 * * * emotional energy worrying if I screwed up on my
I’ve seen him for a couple of years; we had a
good relationship…I thought [we did]...but I
didn’t pick up on the fact that he was that tired
of living; I didn’t read that one right.
Many reported fear of being judged by colleagues
and clients’ families:“Did the family think I did the
right thing or think I’m stupid?” “I was just so
stunned, and worried what people thought…would
think ‘she did a terrible job or else her client
wouldn’t have killed herself.’”
I normally don’t get into what others think [of
me], but I found myself fearing people were
going to think I had done a poor job, that I was
somehow responsible. I found myself tempted
not to be honest about what really happened
which was surprising to me...that’s not my
norm.
Responsibility
Another theme reported was feeling personally
responsible and liable, regardless of work setting
(private practice or agency):“I felt really alone, not
part of a team,” indicating making the call for hos-
pitalization is an “issue of responsibility; it’s all on
you; you make the best call.”
I think the issue of responsibility is one that
always comes up. It came up when I used to do
suicidal evaluations in the emergency room. Do
we release this person or do we hospitalize them?
It’s your decision.You tell us. Oh, God. I think
that is a critical one, and I think it’s one that
they don’t discuss enough in school...I struggle
with the issue of how responsible I was...with
all of the suicidal people I’ve dealt with and all
the positions I was in, especially with the psy-
chiatric evaluation team where the police are
standing there saying, “So?” and you’re think-
ing, “Send them home? Or hospitalize them?”
It’s on you. [The decision’s] on you.
Clinicians reported concerns about being liable
for making decisions: “It’s your responsibility; this
could go the wrong way, and it’s a lot of pressure.
There’s a very helpless feeling too because there’s
only so much you can do.” “It feels like an incred-
ible responsibility. I know when I started with this
woman, she was suicidal on and off; I spent a lot of
334
decisions.” “There were risks and liability, and I bear
the weight.”
Isolation
Along with the feelings of being responsible, many
social workers felt alienated, isolated, unsupported,
and blamed after the suicide.The sense of isolation
was not unique to those in private practice, but
existed even in agencies: “I think I was pretty much
on my own.…There wasn’t anybody to really talk
to.…I just felt isolated; I wasn’t getting supervision.
I wish I had asked for it later….You know, I never
talked about it actually.” “I felt isolated from my
supervisor, surprised at how [she] didn’t know what
to say, didn’t debrief. I was on my own.”
I called my supervisor…and her response was
simply, “Why don’t you just go home?” and I
said,“I don’t want to go home. I’ll just sit there
at home by myself and think about it. I need
some help here.” She just didn’t know what to
say to me. I felt the most alone I have ever felt
in my career. I was very surprised by her reac-
tion actually. It was almost as though she just
didn’t really have the time to debrief with me,
so she wanted to get me off the phone and
wanted to send me home.
* * *
The worst part of the whole [thing], I mean
other than [my] being very sad that this man
killed himself and obviously feeling bad; I had
this clinical director, and during the staff meet-
ing when we were talking about what hap-
pened, he made a comment in front of the whole
entire staff, sort of blaming me, saying, “I
wouldn’t want to have his blood on my hands if
I were you.”And what really upset me as I looked
back on it was nobody in the whole room re-
acted to the fact that this was blatantly inappro-
priate and mean. He was intending to cause me
pain; I would have thought my supervisor, I
would have thought both of them would have
encouraged me to talk about it and help me
work through it. Nobody did, and that was it.
So I never really talked to anybody about it.
Lack of support intensified the isolation. Some
reported being actively discouraged from discuss-
ing the suicide due to fear of litigation, which in-
creased the clinician’s sense of isolation.
Social Work Volume 51, Number 4 October 2006
 There’s so much litigation that even sitting down
and talking about a case, you’re concerned that
whatever is said might be somehow
subpoenaed…some attorney will if they hear
about a discussion, they’ll subpoena everybody
that was there…things might have been found
negative or like we could have done this or we
could have done that…or didn’t do the right
thing.
Isolation also occurred because of the clinician’s
own fears of being blamed: “I was ashamed. I felt
talking about it would be admitting weakness, like
I dropped the ball, so I never talked to anybody
about it.” Others were unable to talk, needing to be
alone and imposing a period of self-isolation.
I remember...it must have bordered on a week-
end because I remember being at home isolat-
ing. At that time I had a workshop in my garage
and [I remember] being tearful and depressed
in reaction to the events. I don’t think I started
to discuss it with my clinical supervisor until
the next week.
Some social workers sought out sources of
suppor t that were objective, uninvolved, and
nonjudgmental.
Instead of calling my friends, I went back to
find this article I had read in the newspaper
[about an expert who started a suicide preven-
tion center]. I found out where he [was]...what
college he was associated [with] and went online.
Got the phone number for him. Called him
and left a message, thinking his secretary would
call me back and say, “he’s not available, here’s a
letter” or something...and then one day I got a
phone call and it was him. And he called, and
he said, “I understand you’re struggling”... Ac-
tually, I didn’t talk to him; he left a message. He
said,“I understand you’re struggling and I’ll talk
to you.” He left me his phone number, and that
was it. When I got that message I just started
crying.
Avoidant Behaviors
Avoidant behaviors toward other potential suicidal
clients as well as avoidant thoughts and reminders
of what happened were reported.
Ting et al. / A Qualitative Analysis of Mental Health Social Workers’ Reactions after a Client Suicide
I don’t think it changed my [actual] practice in
terms of turning down people that I thought
might be suicidal because I had no choice in
the matter, being in a mental health center. But
I can tell you for a fact it has added [stress] to
me whenever I have to accept somebody who
I think is going to be like that. I don’t want to
take them. I think it has made me a more fear-
ful person. Yeah, yeah, it’s like, here I am, sup-
posed to be the person helping them and my
client, if they get like that [suicidal], if they get
like that and I really think they are going to do
it, then they become a threat to me and my
mental health, which is obviously not good. I
mean, that’s a problem.
Many reported they would rather not see clients
who were suicidal and would “transfer clients to
others if suicidal,” or “I would try to turn down
[suicidal] cases if know I can’t be effective.” Both
individual and agency avoidance were reported.
We came up with this policy, if a person has
been actively suicidal within six months, we
send them elsewhere.We used that six months,
I think, to distance ourselves somewhat, to make
us less involved in the most at-risk clients. It has
impacted my practice. I try to create a little
more distance from being that first responder
to that level of crisis; we do have [in town]
another nonprofit that specializes in suicide. So,
there’s another resource that is a very excellent
quality resource available to people. So I didn’t
feel like we were the only option in town kind
of thing.
Personal avoidant decisions were reported, indi-
cating social workers left their jobs or were in the
midst of leaving:
I did not want this type of life dealing with
these clients; this is why I’m getting out of pri-
vate practice after working for so many years
with severely disturbed mental health clients. I
still want to stay within social work, but not as
a private therapist. I would rather work in a
nonprofit or something like that.
* * *
Well, it was out of that that I moved to another
state; it was out of that that I did a “geographic
cure.” There was about three or four years
335
 leading up to the decision....I felt like I was an
octopus, everybody had a piece of me, and these
were really tough clients.
Intrusion
Clinicians reported intrusive reactions, feelings of
anxiety and fear for the well-being of other clients,
and of another suicide occurring while in their
care. Some reported becoming “fearful of clients,”
that clients became a threat, spilling over and af-
fecting their personal and professional equilibrium
and mental health. “A lot of pressure, I was feeling
helpless because there’s only so much one can do; I
had a lot of anxiety, waiting for something to hap-
pen again.”
I was worrying about other clients; I get totally
preoccupied until I know they’re safe. So when
they’re in the hospital I can breathe and sleep at
night, and when they are discharged I’m so
worried that I’m all over them.
The effects of working with suicidal clients re-
portedly spilled over and intruded on personal lives,
indicating years of private practice have really hurt
their relationships with their spouses and children.
In fact, they saw a direct link of failed personal
relationships with the stress of working with men-
tal health clients. They could not separate profes-
sional responsibilities from their personal lives: “I
stay up late worrying about the personal lives of
my clients.”
I’m a mom, so when I’m stressed about a client
who’s suicidal I’m more short with my kids.
I’m more fearful for them and more distant from
my husband…. I feel more protective. And I
feel more fearful in the world with them. It
does affect me at home. I try not to make it
affect me, but I know I bring it home. They
[the kids] don’t have a clue and they have never
said, “Mom, you’re a total drip. What the hell’s
wrong?” but I feel like I’m kind of waiting to
find out if this client is okay when I’m with
them.
Memories continued to intrude upon social
workers; they could not forget and experience lin-
gering thoughts and reminders about their clients:
“What’s striking to me is I’ve never forgotten, and
I’ve seen hundreds of people. I certainly have al-
336
ways carried that experience. I remember the lady’s
last name…” Others were “tormented often be-
cause I can’t stop thinking about the client.” Unex-
pected triggers could also set off unexpected intru-
sive memories.
It really was quite bizarre...this was a year later.
I had brought a brand of shampoo at the store,
and I was taking a shower. And just the smell of
the shampoo made me feel nauseous, and I just
couldn’t figure out why and just felt so sick that
I rinsed it out. And when I finished the shower
I went, and I threw the shampoo in the trash
can outside. I couldn’t even stand having it in
the house. I thought, “I just can’t stand it; that
smell makes me sick.” And as I was driving to
work that day, it dawned on me that it was the
smell my client had. It’s like the olfactory or-
gans are the most primitive, so that it had come
through on some primal level before it had
clicked in my brain. Because the schizophrenic
woman had all kinds of cleansing rituals and
had the lotions that she put on herself and kept
her hair wrapped in a turban and had hers plaited
with all kinds of lotions and such. And what-
ever the perfume was that was in the shampoo
was the smell that I associated with her...It made
me realize how profoundly stirred I was by her
death, and that something as minimal as an odor
would create a sense of sickness.
Changes in Professional Behavior
Respondents reported on agency administrative
changes, as well as changes in individual interac-
tions with clients and colleagues, and sometimes in
their behaviors on a more global scale.
Changes in Practice. Reported changes in indi-
vidual practice behaviors included increased aware-
ness of possible suicidal ideation, not making as-
sumptions of what suicidal people are like, and
conducting more detailed screening and lethality
assessments.
I made some changes, thinking,“well, you know,
I would never have guessed that he would do
this.” So I started asking kids more questions
because we social workers often assume that if
they don’t say anything they’re okay...prior to
that I hadn’t been as specific in asking about
suicide with other kids, especially ones that
come into a group.
Social Work Volume 51, Number 4 October 2006
 * * * pieces of situations with people to convince
I have probably screened much more carefully,
probably almost to the point of annoying
people…I think that I really have never assumed
since [the suicide] that because someone looks
okay that they are okay.
Changes in the Professional Environment. Ad-
ministrative changes were reflected in increased
agency use of lethality assessments and screening.
As noted earlier, some agencies instituted policy
changes against treating actively suicidal clients. An
increase in postvention activities was also reported.
We have our Monday morning meeting where
we talk about who was hospitalized, who was
showing signs of lethality, decide on how we’re
going to deal with them as a team, discuss issues
of the case and then follow up with specific
supervisors in charge of the situation so noth-
ing falls through the cracks, so there’s some kind
of follow up and there’s some kind of contact.
So if they have an appointment and don’t make
it, we go looking for them and bring them in if
we find them or talk to them at home. We can
do home visits. That’s what we do.
Additional reports related to forming closer
working relationships. “More team work” and be-
ing “more open with colleagues” as well as having
“regular meetings and supervisions” were common
statements. “I think we need to have some way to
allow those who are involved to debrief; we’ve been
very fortunate that all of us were able to spend
some time together debriefing...to talk it through,
our feelings and reactions.”
On a more global level, there were reports of
actively advocating for changes, including educat-
ing others and the community about suicide, as
well as becoming more educated about self-care: “I
ran off an article and gave copies to everyone on
caregiver’s coping. As service providers, sometimes
we think we have to suck it up and be professional
and we can’t be.”
Right after something like this happens I get all
psyched up, and I’ll call a bunch of people that
I think somehow have influence. My state leg-
islators all know me on a personal basis. So I’ll
call and really get on the bandwagon for men-
tal health parity or whatever; sometimes I share
Ting et al. / A Qualitative Analysis of Mental Health Social Workers’ Reactions after a Client Suicide
them that we need to make some changes in
the system.
Justification
There was a theme of justifying one’s actions and
absolving oneself of blame.“Client self-determina-
tion” statements reflected how clients have to de-
cide to get better or not; “the client was strong
willed; he just didn’t listen,” or “committing sui-
cide was a choice he made.”
We didn’t find anything that we could have
done any better. He had been interviewed by
not just me but another licensed social worker
plus a crisis worker.We had offered him every-
thing we had as far as therapy, medication, hos-
pitalization if he wanted it. So it wasn’t like
there was a break or anything. It was just he
didn’t respond to it. He didn’t follow through
with any of it.
Some stated that they did their best; the rest was
up to the clients: “I make my best call given all the
information I have, and then I have to say, “it’s not
my responsibility because if they’re going to kill
themselves they’re going to kill themselves. I have
absolutely no control over that.”
You can make it as safe as you can, and then
people get to make the choice of do they want
to or do they not want to get well? He was
just so into creating a delusional reality, and
blaming everybody else. I consulted with his
[past] therapist and psychiatrist; I had done ev-
erything clinically possible. It’s like no matter
what, if they’re going to jump, they’re going to
jump.
Many reported no guilt or unresolved feelings
over their actions: “I wouldn’t change anything;
I’ve not done anything wrong so I didn’t make
any changes in practice.” “...[as a] therapist, I went
way beyond my duty, what anyone would ex-
pect.” “Didn’t have the sense of letting client
down; there were no professional ramifications and
I didn’t think I was a failure.” “Couldn’t have pre-
vented it; I couldn’t hospitalize him against his will;
I struggle with involuntary commitment, simply
because it jeopardizes the relationship I have with
them.”
337
 I had guilt, but I don’t think I had much guilt
because I had taken the appropriate steps. I had
done the [right] kinds of things, and I knew he
needed much more than I had to offer, and I
had done the [right] kinds of stuff. And that
made it so much easier, and I wasn’t blindsided
because he had a history of suicidal ideation.
Acceptance
A final theme was acceptance, reflecting feelings of
forgiveness and absolution.This was especially evi-
dent when there was support from others regard-
ing responsibility: “I realize the reality of not being
able to take care of all clients and protect them.This
[suicide] really just drove it home for me.” Others
reported accepting clients’ decisions.“I understood
why the client did it. I felt like it wasn’t a choice I
would have made, but I think it was a choice he
made.”
I had done everything clinically possible...but
you know, it was almost like he was at the end
of the rope. He could not tell another lie be-
cause everybody was in on him. He had no
place to go...but you know on the other hand,
I was relieved for him. Being out of his pain. It
was a situation where I went to his funeral. I
said goodbye to him.
* * * suicidal clients (Chemtob et al., 1988, 1989).
The agency was very supportive of me. Our
director is just a marvelous woman. All of us
were able to talk and debrief; it was very vali-
dating for me. It is easier to be harder on your-
self than others are on you, especially in a situ-
ation like this. And it was validating to hear the
psychiatrist and the team say they wouldn’t have
done anything different.
DISCUSSION AND IMPLICATIONS
The results from this qualitative study, although
not completely generalizable to the larger popula-
tion of mental health social workers, can be con-
sidered trustworthy as the primary goal of qualita-
tive analysis is to represent findings as closely as
possible to the experiences of respondents (Padgett,
1998). To ensure trustworthiness and minimize
threats to the credibility of the findings, the re-
searchers followed strategies to enhance the rigor
of the study, using methods such as triangulation,
peer debriefing, member checking, and an audit
trail (Guba, 1981).
338
Results indicate mental health social workers who
survived a client suicide experience a range of psy-
chological and emotional reactions. Although cer-
tain reactions appeared to affect the social worker
professionally, others were more generic, universal
human reactions after trauma. Conceptually, themes
of denial, disbelief, anger, grief, depression, loss, and
acceptance can be grouped within the framework
of generalized grief, as reactions after any death,
not limited to suicide (Kubler-Ross, 1970; Shear,
2005; Worden, 2002).
Unexpected loss, however, such as a client sui-
cide, is traumatic, with resulting avoidant behaviors
and intrusive thoughts or feelings. Research on
survivors of traumatic stress has identified such
posttraumatic reactions (Chemtob et al., 1988) and
secondary traumatic stress (McCann & Pearlman,
1990). Accompanying the avoidance were intru-
sive reactions and cognitive distortions (McCann
& Pearlman), which included feeling anxious, un-
safe, and fearful in this world and of the future, both
personally and professionally. Specific themes, such
as feelings of anger at the agency, self-blame, guilt,
professional incompetence, responsibility, isolation,
justification, and reported changes in behavior, were
enveloped professional reactions. These findings
were similar to professional reactions from studies
of psychologists and psychiatrists who work with
Social workers in this study, like other mental
health professionals, view the inability to prevent
client suicidal behavior or to protect the client as
evidence of incompetence (Chemtob et al., 1989;
Jobes & Maltsberger, 1995; Kleespies, Penk, &
Forsyth, 1993), and many feared blame, judgment,
or censure by others. Additional feelings of respon-
sibility for the decisions they made leading up to
the suicide were reported, with feelings of isola-
tion and liability afterward, especially in cases where
agency support was lacking. However, coming to
terms with the suicide entailed either both justifi-
cation of their actions and acceptance of the client’s
actions. Professionally, reviewing the client’s case,
conducting psychological autopsies, and group
debriefings helped them reach resolution and less-
ened the weight of personal responsibility, guilt, and
self-blame (Cavanagh, Carson, Sharpe, & Lowrie,
2003). In this study, being proactive through le-
thality and risk assessments was reportedly helpful.
In fact, such behaviors appeared to allow some so-
cial workers to regain a sense of competence and
Social Work Volume 51, Number 4 October 2006
control. Although social workers clearly did not
forget the details of their client’s suicide, having a
sense of collegial support, and professional com-
petence allowed many to remain in the field and
continue working effectively, with a few excep-
tions who indicated they prematurely left the field.
Within the framework of grief, such adaptations
are positive and necessary after a traumatic loss
(Shear, 2005).
Results from this study have implications for the
social work field. Practitioners have to become
knowledgeable of the effect of client suicide on
themselves and colleagues, given it is not a rare
occurrence. Multiple grief and support groups ex-
ist for friends, family members, and caregivers who
are suicide survivors; however, there is a lack of
support groups available for professionals who work
with suicidal clients. The recognition that profes-
sionals are survivors of suicide is an area that is be-
ing addressed by professional organizations such as
the American Psychological Association and the
American Association of Suicidology. A small, but
hopefully growing, clinician contact list is available
for “clinician survivors” (http://mypage.iusb.edu/
~jmcintos/contacts.htm). Additional links are avail-
able to other international and nongovernmental
organizations interested in suicidology and provide
educational materials and research findings specifi-
cally geared for clinician survivors. In the absence
of face-to-face support groups at this time, we sug-
gest the use of technology, not only to access infor-
mation on suicide but to improve our ability to
communicate regardless of geographical distance.
For example, technology would make the creation
of online support groups or discussion forums fea-
sible, and such forums may be less stigmatizing to
clinician survivors by providing more anonymity.
Administrators and educators need to increase
awareness of the effects of client suicides on social
workers, both personally and professionally, and be
prepared to deal with feelings of isolation, anger,
guilt, self-blame, grief, and loss through agency and
peer support, training, and skills development (Ellis
& Dickey, 1998; Freedenthal & Feldman, 2004;
Kleespies et al., 1993). Researchers who surveyed
psychology and psychiatry training programs re-
port that fewer than 40 percent of institutions pro-
vide information on post-suicide procedures, fewer
than 30 percent have policies in place, and fewer
than 8 percent offer post-suicide counseling (Ellis
& Dickey). No information on social work agen-
Ting et al. / A Qualitative Analysis of Mental Health Social Workers’ Reactions after a Client Suicide
cies’ preparedness to deal with client suicidal be-
havior was located. However, surveys of social work-
ers indicate only 21 percent to 46 percent received
formal training on suicide in their MSW programs
(Freedenthal & Feldman; Power, Jacobson, Sanders,
& Ting, 2006). Thus, the recommendation is that
social service agencies and educational institutions
work together to improve training for students and
clinicians related to suicide prevention, interven-
tion, and postvention. Content on suicidal behav-
ior needs to be infused into social work curricula,
at the baccalaureate and the masters’ level. The fo-
cus should not only be on assessment of client
suicidality, but also on reactions common to survi-
vors, including reactions common to clinician sur-
vivors. Continuing education courses and in-ser-
vice training need to be available for clinicians
already in the field. Agency administrators should
work with supervisors to develop a working policy
and procedural plan, providing instructions on how
to handle client suicidal behavior, how to debrief
with and provide psychological autopsies, and how
to best support and supervise staff and clinician
survivors. Agencies need to plan ahead and be ready
with either an internal team trained to provide sup-
port or external resources to summon. In the after-
math of a client suicide, postvention activities are
needed. One method would include a referral to
EAPs for a confidential assessment and additional
individualized support services. For agencies where
multiple staff members are affected by client sui-
cidal behavior, developing a crisis intervention team
to provide critical incident stress management ser-
vices (CISM) (Everly & Mitchell, 1999) may be
appropriate. CISM is a comprehensive, multicom-
ponent crisis intervention program that covers
preincident training and education through
postincident follow-up and evaluation services. One
of the primary services included in a CISM pro-
gram is critical incident stress debriefing (CISD), a struc-
tured group intervention with seven distinct stages
promoting coping and group social support fol-
lowing a critical incident, such as a client suicide. In
addition, after a client suicide, grief counseling may
be indicated. Morrow (2002) described a modified
version of a group CISD, which has been altered to
focus on grief and loss issues after a death.
Private practitioners also need to be prepared.
Along with malpractice insurance and ongoing
supervision, independent practitioners should have
a plan in place to deal with suicidal clients, as well
339
as a plan for self-care following client suicidal be-
havior. Being prepared means being knowledge-
able and trained about the effects of suicide on the
client’s family and friends, and on oneself as a pro-
fessional. In addition, having a dependable profes-
sional support system in place and being ready to
seek private consultation or supervision is essential
for successful recovery from a client suicide.
There are many future research recommenda-
tions. One is to explore the cumulative effects of
multiple suicides on clinicians, and to understand
the long-term effects. In addition, researchers need
to understand the relationship between exposure
to multiple traumatic experiences and professional
burnout and secondary traumatic stress or compas-
sion fatigue, which have implications for practice
and policy. Future research should also seek to un-
derstand coping strategies used by mental health
social workers in the aftermath of client suicidal
behavior. Finally, researchers should identify fac-
tors that would increase resilience and adaptive
behaviors among clinician survivors.
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Laura Ting, PhD, is assistant professor, School of Social

Work, University of Maryland, Baltimore County, Academic
IV 364B, 1000 Hilltop Circle, Baltimore, MD 21250;
e-mail: LTing@umbc.edu. Sara Sanders, PhD, is assistant
professor, School of Social Work, University of Iowa, Iowa
City. Jodi M. Jacobson, PhD, is assistant professor and
chair, Employee Assistance Specialization, University of
Maryland, Baltimore. James R. Power, MSW, is a doctoral
student, School of Social Work, University of Iowa, Iowa
City. A modified version of this article was presented at the
Annual Program Meeting of the Council on Social Work
Education, February 18, 2006, Chicago.
Original manuscript received January 24, 2005
Final revision received March 27, 2006
Accepted April 18, 2006

Ting et al. / A Qualitative Analysis of Mental Health Social Workers’ Reactions after a Client Suicide 341