It is not uncommon for patients with histories of neglect and abuse to express profound doubts about whether their therapist “really” cares about them:

“Of course you act like you care; you’re trained to do that and that’s what you’re paid for.”

And there’s actually a grain of truth to this generalization. Indeed, therapists do care for patients in a different way than they care for their spouses or children. Only then is a healthy, effective therapeutic relationship able to develop.

On the other hand, those who doubt the reality of a therapist’s caring should know more about the impact of a patient’s suicide on the therapist. Indeed, the impact of such a jarring loss is often a revelation to the therapist as well.

Research on impact of a patient’s suicide

suicide of a psychotherapist's patientThe research on this topic is consistent and clear: When therapists who have lost a patient to suicide (somewhere between 20 and 50 percent) are studied as a group, most are found to have been profoundly affected. One study using an instrument called the Impact of Events Scale found that, on average, the sense of shock and loss was on a par with the death of a family member. Some therapists were found to have such profound self-doubts stemming from the experience that they contemplated leaving the field.

“What’s up with this?” you might be thinking, “Surgeons and nursing home workers lose patients all the time; they understand that it goes with the territory.”

The loss of a psychotherapy patient to suicide differs in some important ways. First, when death is self-inflicted, myriad thoughts about preventability inexorably arise: What did I miss? What might I have done differently to prevent this?

Second, in contrast to the surgeon, the primary tool of the psychotherapist is the person himself or herself. And, to the extent that the therapy has failed, it can be argued that it is the self of the therapist that has failed.

Suffering together

Finally, it is practically impossible for one human being to have deep knowledge of another person’s suffering without to some extent sharing that suffering and, by extension, suffering in response to that person’s death. It is simply how we are wired. Ever notice how uneasy you feel when you witness another person being seriously embarrassed? Or emotionally or physically injured? Imagine experiencing the death of someone who has shared with you his or her deepest insecurities, fears and traumatic memories, and someone in whom you have seen great promise and potential for future happiness. The extent of the tragedy of a self-inflicted death is never more apparent than in this context.

It is well-known that one of the leading reasons for malpractice lawsuits against mental health professionals is for wrongful death in cases of a family member’s suicide. What is less well-known is that, even more often, families understand the difficulties the clinician faced and the limitations of the power of psychotherapy in challenging cases. Some even appreciate that freedom, even when constrained by illness, can result in a choice to end life. Indeed, stories of family members, even in the throes of grief, reaching out to therapists to ask, “Are you OK?” are surprisingly common.

When a clinician loses a patient to suicide, the memory of the person, and the experiences shared, remain. Mourning the loss often entails a memorial service, as well as ongoing discussion with colleagues and private reflection. Like other losses, expressions of compassion and shared suffering are perhaps the surest route to coping and eventual recovery.

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I play jazz piano and have composed about 70 songs over the past 50 years – a small number in the 1960s and many in the 1990s. My playing isn’t that great, but lots of the songs are really good.

Given my enduring interest in jazz, it’s not surprising that I occasionally have thought that psychotherapy is like jazz: We must improvise. Yet, after a recent dialog with my son, Clifford – a jazz historian and critic – I started to take this analogy more seriously.

Similarities between psychotherapy and jazz

Jazz and psychotherapyA caveat: In making the analogy to jazz, I am referring (egocentrically) to what I think of as “classic” jazz – a style in the 1960s when I was a teenager and got hooked on jazz. Miles Davis’s Kind of Blue is a prototype. To the uninitiated, such jazz might seem freewheeling. On the contrary, it is highly structured in many respects: time signature, tempo, rhythm, harmonic organization and divisions into fixed numbers of measures.

Moreover, this “classic” jazz often resembles classical music (prototypically, “classical” classical, as in Haydn, Mozart and Beethoven). We are presented with themes and variations, with a difference: In jazz, the themes are written down, and the variations are improvised.

With the caveat comes the distinction between “classic” jazz and “free” jazz, which is loosely structured at most and (to my uneducated ears) can sound like cacophony. Of course, this distinction lies in a broad continuum from more to less structure. I like ample structure along with lots of freedom to improvise.

First effort with psychotherapy

My first effort to conduct psychotherapy (in 1968) was fateful. As a novice, I could undertake this endeavor legitimately, because I was to conduct a highly structured procedure: systematic desensitization for a person with a speaking phobia.

It’s simple. You ask the client to construct a graded series of increasingly frightening speaking scenarios (e.g., from making a point to a few friends to addressing a stadium full of critics). You teach relaxation, and the client imagines the scenarios (from least to most frightening) while maintaining a state of relaxation. Amazingly, it works. It was an “evidence-based” therapy.

But something troubling happened insidiously: The client wanted merely to talk to me about his life. I was stumped, stuck with the written score. I didn’t know how to improvise.

After decades of practicing psychotherapy, I’ve given up looking for the score, embracing improvisation and declaring myself a practitioner of “plain old therapy” – talk therapy.

Prompted by my dialog with Clifford, I looked up “improvise” in the Oxford English Dictionary:

“Compose (music or verse) or utter or do (anything) on the spur of the moment.”

This definition encompasses the whole continuum from classic to free jazz.

I’ve declared myself a plain old therapist because I don’t like too much structure. I find myriad “brands” of “evidence-based” therapies too constricting. From my critical vantage point, they are turning what should be improvised (i.e., intuitive and spontaneous) into a score – too technological, excessively governed by procedures, techniques and rules.

Learning to improvise

I acknowledge a caricature here, which I employ to make a point: Even the most structured of psychotherapies cannot be conducted without improvisation, as I discovered with my first client.

In psychotherapy as in jazz, I am a classicist, preferring improvisation within a structure. I like to have a focus for the therapy: one main theme – or at most a few themes – to explore in an improvisatory way. Often, I like to have a written formulation agreed with the client to provide some handholds for improvisation.

Sometimes, despite my best efforts, I wind up conducting a process more akin to free jazz, freewheeling without structure, everything “on the spur of the moment,” within and between sessions. Sometimes it can seem helpful to the client; I can do it, but I don’t like it.

Now for my tendentious point, based on my first experience as a therapist: Have we constructed all these therapy brands and procedures because we are not good at improvising or too timid to do it?

As I discovered in psychotherapy as in jazz, we can learn to improvise. We have many good teachers and models. As I learned at the outset, to some degree, we must learn to improvise. But many therapists, like me, will need a structure and a style. Kind of Blue works for me, and the title is apt for much of my work.

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Stigma is something many people with mental illness have long endured. Menninger’s Say No To Stigma blog was created to help dispel stigma. To further that cause, I hope you’ll take a few minutes to watch this video about Ms. Lizzie Velasquez.

She does not have a brain disease, rather another biological disorder that manifests itself visibly. Consequently, she has had to endure criticism and bullying on a scale few people could relate to. Her tips for coping and the way she thinks are inspirational.

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Music’s Influence on Teens: A Guide for Parents

by Elizabeth Newlin, MD May 27, 2015

Long before the emo generation, parents questioned the influence of music on impressionable youth. This topic caught my attention recently as an adolescent shared with me the importance of music in her recovery. She described how listening to “emo” music provided her with a sense of belonging to a larger community, something missing in her […]

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Is Binge Drinking in College the New Normal?

by Beth Eversole, LMSW, LCDC April 17, 2015

Have you heard a college student say this before? “I don’t drink every day so I’m not an alcoholic.” When most people picture someone with a drinking problem, they probably imagine someone who drinks every day and can’t function without alcohol. But even those who aren’t dependent on alcohol yet routinely drink to excess, i.e., […]

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Two Sides of Ambition – and a Middle Ground

by Jon G. Allen, PhD April 1, 2015

Ambition’s dark side regularly captures our attention. The relentless quest for status, fame and power is not only off putting but also damaging to the extent that the quest comes at a cost — getting to the top by climbing over the backs of others, potentially injuring them in the process. Narcissistic personality disorder Psychiatry, […]

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Haven’t We All Needed a Crisis Hotline at Some Point?

by Anonymous March 19, 2015

My name is not Anonymous, but it will suffice for this blog post because I must be, well, anonymous. Volunteering to help others in a crisis I’m one of hundreds of suicide/crisis hotline volunteers around the United States, and who we are is not important relative to our callers. Their crises are what we focus […]

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Navigating Mood and Food during National Nutrition Month

by Kim George, RD March 16, 2015

I am a nutrition geek. The science behind how our body and brain work is so amazing to me. The foods we eat help our brain work efficiently, and I love being able to teach others the link between food and mood. National Nutrition Month March is National Nutrition Month, and while my colleague, Tessa, […]

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Woman’s Obituary Highlights Child Abuse

by Michele Arnold January 25, 2015

I read the obituary of Marianne Theresa Johnson-Reddick with interest. She tortured people by her cruelty. This abusive mother did not get a free pass to the afterlife. Two of her eight children let the world know how they were all “abrasively exposed to her evil and violent life” in her obituary. “Mom” ran a […]

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Grocery Store-based Screening Better than Lucy’s Mental Health Advice

by Nancy Trowbridge January 22, 2015

On the shelf of my cubicle sits a Hallmark-brand Peanuts tree ornament with Charlie Brown seeking Lucy’s 5-cent psychiatric help. It reminds me of watching every holiday Peanuts TV special while growing up and the mental health setting where I work today. Hallmark moments create a warm feeling, don’t they? A kind of Hallmark moment […]

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