728 Suicide and Life-Threatening Behavior 38(6) December 2008

 2008 The American Association of Suicidology

Impact of Death by Suicide of Patients

on Thai Psychiatrists
Prakarn Thomyangkoon, MD, and Antoon Leenaars, PhD

The objective of this study was to identify the impact of a patient’s suicide
on psychiatrists in Thailand. A confidential coded postal questionnaire survey was
sent to 320 eligible psychiatrists; with a response rate of 52.18%). The results
showed that 94 (56.28%) of responding psychiatrists had a patient die by suicide,
consistent with high rates found in similar large-scale studies in the United States
and United Kingdom. Less than half (41.5%) of patients had been diagnosed with
schizophrenia, 33% had a depressive disorder, and the others had a wide array of
diagnoses. More than 50% of psychiatrists reported personally experiencing sad-
ness, depression, hopelessness, and guilt; 74.5% reported professional reactions,
most frequently a review of their practice (93.4% reported being more aggressive
in assessment of suicidality). Respondents were diverse in their postvention; 90%
of Thai psychiatrists reported that working through with colleagues was most
helpful. Family and friends helped. A majority (72.4%) of psychiatrists prayed or
did “merit” for the dead patient; 86.8% found it helpful. This finding suggests
that cultural sensitivity may be needed to understand the impact of suicide on
psychiatrists but also to its response.

Suicide in Thailand is low compared to
nearby Asian countries (Thomyangkoon, Lee-
naars & Wasserman, 2005); the current (2002)
rate of suicide (per 100,000) is 7.8. The ratio
of male to female is 3.16:1; the highest rate
was in young males, aged 25–29. Although
the risk is highly associated to mental disor-
ders, HIV/AIDS has been identified as an in-
Dr. Prakarn Thomyangkoon is with the
Rajavithi Hospital in Bangkok, Thailand; and Dr.
Antoon Leenaars is a psychologist in private
practice in Windsor Canada.
This research was supported by Rajavithi
Hospital. The authors would like to thank Danuta
Wasserman, Supa Malakul Na Ayudhya, Vanpan
Boonyaprokob, Anon Barinayakanon, Somluk
Kanchanapongkul, Paritat Watiktinkorn, Somp-
son Tassniyom, Lindsey Leenaars, and Susanne
Wenckstern.
Address correspondence to Prakarn Thom-
yangkoon, MD, Department of Psychiatry, Rajav-
ithi Hospital, Rajavithi Road, Rajathvee, Bangkok
10400, Thailand; E-mail: KARN249@yahoo.com
creasing risk factor. The comparatively low
rate of suicide is highly associated to Thai’s
Theravada Buddhism (Cooper, 2007; Klausner,
2000, 2002; Mulder, 2001). Thailand’s rate of
suicide is lower than other Buddhist coun-
tries, such as Japan and the Republic of Ko-
rea, that hold to Mahayana Buddhism. There
is a great difference in the beliefs, views of
life, and religion. Monks in Mahayana Budd-
hism are vegetarian and self-sufficient (e.g.,
they cook for themselves); this is not so in
Theravada ways of life. Thai monks are de-
pendent on the community; they do not
cook. They are dependent on the villagers to
give them food. They cannot ask; the villag-
ers will give food to the monks with respect.
The monks, in return, do “a good practice
and the villagers follow the good action.”
Mulder (2001) noted:
In a similar sense, a village community
may nurture auspiciousness and feel it-
self protected by the strength of merit
Thomyangkoon and Leenaars
that is generated and accumulated in
the village temple. The discipline of the
monks, their chanting and preaching,
the merit—making ceremonies and the
power vested in the Buddha image: all
serve to increase the ambience of secu-
rity, continuity, and auspiciousness in a
life situation surrounded by potentially
harmful agents. (p. 30)
It is generally believed that this social
integration/regulation results in lower sui-
cide rates (Durkheim, 1897/1951; Thom-
yangkoon et al., 2005). Despite the lower
rates, there has been little study to date on
suicide in Thailand and, nothing to our
knowledge, on the sequelae of bereavement
resulting from suicide, despite its adversity
(Ness & Pfeffer, 1990).
Suicide has been reported to be a fre-
quent crisis and most stressful situation for
health providers around the world (Bongar &
Greaney, 1994; Leenaars et al., 2002). It re-
sults in substantial and professional effects on
providers. The risk is high for all mental
health providers, but especially so for psychi-
atrists (Bongar & Greaney, 1994). It has been
called an occupational hazard, although there
has been sparse literature on the topic (Git-
lin, 1999). Despite this lack, it is for almost
all psychiatrists an unforgettable event (Hen-
din, Lipschitz, Maltsberger, Haas, & Wyne-
coop, 2000; Hendin, Haas, Maltsberger,
Szanto, & Rabinowitz, 2004; Kayton &
Freed, 1967; Litman, 1965; Soreff, 1975).
Gitlin (1999) offers a personal case study,
giving insights into therapists’ reactions to
patients’ suicide, some to the point of psy-
chopathology, such as depression and post-
traumatic-stress disorder (PTSD).
The early research on this topic was
largely anecdotal, case study, or personal
memoirs. Low mood, poor sleep, and irrita-
bility, for example, had been identified. De-
spite the shortcomings, such as small sample
sizes, these early studies were valuable, espe-
cially because of the overall sparcity of stud-
ies (Chemtob, Hamada, Bauer, Kinney, &
Torigoe, 1988); yet there are problems in re-
liability, validity, and generalizability.
Although many of the early studies
729
rates of patient suicide were not exclusively
focused on psychiatrists, a few early ones re-
ported estimates of the frequency of 20–22%
in this group (Kahne, 1968; Litman, 1965);
yet there were also reports that the frequen-
cies may be as high as 50% (Binder, 1978;
Brown, 1987; Henn, 1978). More recent
studies have used large and national repre-
sentative samples of psychiatrists, assessed
the sequelae in greater detail, and used struc-
tured instruments to measure the impact.
Following the work of Chemtob and col-
leagues (1988) and Alexander, Klein, Gray,
Dewar, and Eagles (2000); we decided to un-
dertake such a study focused on psychiatrists
in Thailand.
To date, the effect of suicide by pa-
tients on psychiatrists has been studied in
Canada, New Zealand, the United Kingdom,
and the United States (Alexander et al., 2000;
Chemtob et al., 1988; Gralnick, 1993; Kaye
& Soreft, 1991; Litman, 1965; Little, 1992;
Menninger, 1991; O’Reilly, Truant, & Don-
aldson, 1990). There have been no studies in
Asia; ours marks the first. We conducted a
systematic inquiry into the sequelae of pa-
tients’ suicide in a large group of Thai psy-
chiatrists.
Psychiatric practice in Thailand, like
other health services, is limited, but also ex-
panding. At the time of this study, there were
320 members of The Royal College of Psy-
chiatrists of Thailand. The rate of psychia-
trists to the population of Thailand is 1:
150,000. More than 80% of Thai psychia-
trists work in the government sector such as
general hospitals, mental hospitals, and uni-
versities (but few in the latter). More than
55% work in Bangkok and suburban areas
(population = 10 million). Services are lim-
ited; for example, Srithanya Hospital is the
largest mental hospital and it has only 18
psychiatrists. The number of psychiatric out-
patients is 107,000 per year. Sixty percent of
inpatients and outpatients are schizophrenics.
Thus, each psychiatrist is responsible for
many patients. The situation in rural areas is
even more dire. For outpatients, the duration
of treatment is from 1 day to 180 months;
the average is 17.5 months. The frequency of
730
visits ranged from 1 to 120 times; the average
is 16 times. In the past, only psychiatrists
rather than psychiatric nurses or social work-
ers treated most of the outpatients. Only in
the last 5 years or less, outpatient treatment
has become a team approach, but still not so
in rural areas. Yet it would be accurate to
state that, like much of Asia, mental health
care is developing.
METHOD
Participants
We sent a confidential six-page ques-
tionnaire and a cover letter explaining the
nature of the survey, with a letter from the
President of The Royal College of Psychia-
trists of Thailand, to all members of The
Royal College of Psychiatrists of Thailand
(320 psychiatrists). The questionnaire was
based on a clinician suicide survivor survey
(accessed October 10, 2000, and April 10,
2001) from the website of the American As-
sociation of Suicidology and its Clinician
Survivor Task Force. It offers the only pub-
licly available questionnaire that has been
used in the study of the impact of the suicide
of patients on the health professional (McIn-
tosh, Talcotl, & Jones, 1999). With permis-
sion to use this questionnaire from the au-
thors, and some question modifications, the
questionnaire was translated into the Thai
language and checked for the accuracy of
translation by three Thai psychiatrists. The
questionnaire was composed of five sections.
The first section collected personal in-
formation: age, sex, specialty, number of
years in psychiatry, and experience of suicide
by patients. If they had an experience of sui-
cide, they would go on to the next section;
otherwise, they stopped. The second section
asked about the first suicide patient’s infor-
mation: sex, age, diagnosis, previous suicide
attempt, and method of suicide. The third
section collected therapeutic data, length of
therapy, status of patient, and frequency of
therapy. The fourth section collected clini-
cians’ experiences about suicide, such as
Impact of Suicide on Psychiatrists
personal emotional reactions, professional
emotional reactions, individual actions and
responses, helpful interactions and activities,
and other issues. The last section was an
open questionnaire about the depth of im-
pact of the suicide. The questionnaire and
study were approved by the Rajavithi ethic
committee and confidentiality was assured.
One month after the mailing, a thank
you letter was sent to all survey recipients
and a second request was made for question-
naires, if they did not send it back. We waited
for the questionnaire for another month to
finally determine the sample.
RESULTS
Of the original 320 questionnaires
mailed, 167 were returned, a response rate
of 52.18%. Ninety-six (59.28%) respondents
were men (mean age = 45.29, SD = 8.96) and
68 (40.72%) were women (mean age = 49.07,
SD = 16.20). The age of respondents was be-
tween 25 and 83 years old. Ninety-four psy-
chiatrists (56.28%) reported having had pa-
tients under their care die by suicide; 65
(69.15%) of those psychiatrists were men and
29 (30.85%) were women. The age of psychi-
atrists who had patients die by suicide was
between 25 and 79 years old (mean age =
45.37, SD = 11.027). Thirty-seven psychia-
trists (39.36%) had one patient die by sui-
cide; 50 (53.19%) experienced this event
between 2 to 8 times, and 7 (7.45%) experi-
enced this event between 10 to 50 times.
Sixty-four (68.1%) patients were men;
30 (31.9%) were women. The age of the pa-
tients was between 18 and 70 years old (mean
age = 34.41, SD = 12.89). Thirty-four (37.2%)
patients had a history of attempted suicide,
48 (51.1%) patients had no history of at-
tempted suicide, and the others had unknown
suicide history.
The standard of diagnosis/reporting of
mental disorders is the ICD-10 (although
psychiatric education requires familiarity
with the DSM classification scheme). The di-
agnosed disorders of the patients in this study
are shown in Figure 1. Schizophrenia (41.5%)
Thomyangkoon and Leenaars
Figure 1. The disorder of suicide patients.
was the most frequent diagnosis, followed by
major depressive disorder (33%) and bipolar
I disorder (7.4%).
The method of suicide varied, re-
flecting common Thai methods. Thirty-one
(33.0%) patients died by hanging, 18 (19.1%)
died by jumping, and 11 (11.7%) died by
drug overdose. The other patients used fire-
arms (8.5%), insecticide (8.5%), drowning
(6.4%), and less frequent means.
Effects on Personal Lives
and Professional Practice
The impact of the patient’s suicide on
personal emotional areas is reported in Table
1. (Q: The most difficult of these personal emo-
tional reactions for me was . . .). Thai psychi-
atrists gave predominantly the lowest possi-
ble rating on a scale of 1 (least) to 9 (most) to
the personal reactions of being suicidal them-
selves, disbelief that the death was a suicide,
accident-proneness, anger (toward the de-
731
ceased, family, supervisor), relief, and loss of
patterns of conduct. The highest mean rank-
ings and more than half above midpoint were
observed for sadness/depression/hopelessness
and guilt. Thirty-three (35.1%) Thai psychi-
atrists rated the highest ranking for not ap-
plicable in the item of being suicidal them-
selves.
The impact of the patient’s suicide on
professional emotional areas is shown in Ta-
ble 2. (Q: The most difficult of these profes-
sional reactions was . . .). In this section, Thai
psychiatrists gave predominantly the lowest
rating possible (least = 1) to doubt concerning
professional competence, feared damage to
reputation/publicity, and fears of lawsuit.
Forty-one (47.3%) psychiatrists rated fear of
blame by the family in the 3 to 5 range.
Effects on Personal Lives
and Professional Practice
The impact of the suicide on individ-
ual actions and responses is shown in Table 3.
732 Impact of Suicide on Psychiatrists

TABLE 1
Psychiatrist Ratings of Personal Emotional Reactions
1 2 3 4 5 Total 9

1 Disbelieved the death was a

suicide 66 (75) 10 (11.4) 6 (6.8) 4 (4.5) 2 (2.3) 88 6 (6.4)
2 Anger (toward deceased,
family, supervisor) 49 (57.6) 18 (21.2) 13 (15.3) 4 (4.7) 1 (1.2) 85 9 (9.6)
3 Sadness/depression/
hopelessness 14 (15.7) 20 (22.5) 34 (38.2) 14 (15.7) 7 (7.9) 89 5 (5.3)
4 Relief 44 (55.7) 18 (22.8) 15 (19.0) 2 (2.5) 0 79 15 (15.9)
5 Guilt 15 (17.4) 21 (24.4) 27 (31.4) 16 (18.6) 7 (8.1) 86 8 (8.5)
6 Shame 22 (27.5) 30 (37.5) 20 (25) 8 (10) 0 80 14 (14.9)
7 Loss of patterns of conduct 39 (52.7) 27 (36.5) 5 (6.8) 3 (4.1) 0 74 20 (21.2)
8 Accident-proneness 45 (66.2) 19 (27.9) 2 (2.9) 2 (2.9) 0 68 26 (27.6)
9 Suicidal yourself 59 (96.7) 2 (3.3) 0 0 0 61 33 (35.1)
10 Other emotional reactions
(specify)_____ 0 0 3 (23.1) 5 (38.5) 5 (38.5) 13 81 (86.2)

1 = least; 2 = less; 3 = medium; 4 = moderate; 5 = strong; 9 = not applicable

(Q: The most difficult of the above actions/
responses for me was . . .). The highest rank-
ing of individual actions and responses was
that Thai psychiatrists persistently reviewed
their actions and actions that they may have
missed. On the other hand, Thai psychia-
trists did not isolate themselves from family/
friends, did not isolate themselves from col-
leagues, did not consider changing their pro-
fession, had not become more conservative
with others, did not turn down referrals of
other suicidal patients, nor did they avoid the
patient’s family. Thirty (31.9%) Thai psychi-
atrists rated the highest rankings for not ap-
plicable on the item of considered changing
their profession.
Impact of Suicide on Helpful Intentions
and Activities and Other Observations
The ratings on helpful interactions
and activities is shown in Table 4. (Q:
Which of the above actions was most helpful
to you?). More than 90% of Thai psychia-
trists ranked talking to colleagues, talking to
family, presenting a formal review, and talk-

TABLE 2
Psychiatrist Ratings of Professional Emotional Reactions

1 2 3 4 5 Total 9

1 Feared blame by the family 22 (26.5) 20 (24.1) 28 (33.7) 10 (12) 3 (3.6) 83 11 (11.7)
2 Feared lawsuit 33 (42.3) 29 (37.2) 10 (12.8) 6 (7.7) 0 78 16 (17.0)
3 Feared censure by colleagues 27 (34.6) 28 (35.9) 14 (17.9) 8 (10.3) 1 (1.3) 78 16 (17.0)
4 Feared damage to reputation/
publicity 36 (45.6) 23 (29.1) 14 (17.7) 5 (6.3) 1 (1.3) 79 15 (15.9)
5 Doubts regarding
professional competence 38 (48.7) 21 (26.9) 16 (20.5) 1 (1.3) 2 (2.6) 78 16 (17.0)
6 Other emotional reactions
(specify)_____ 9 (37.5) 4 (16.7) 5 (20.8) 0 6 (25.0) 24 70 (74.5)

1 = least; 2 = less; 3 = medium; 4 = moderate; 5 = strong; 9 = not applicable

Thomyangkoon and Leenaars 733

TABLE 3
Psychiatrist Ratings of Individual Actions and Responses
1 2 3 4 5 Total 9

1 I persistently reviewed by
actions 2 (2.2) 0 31 (33.7) 30 (32.6) 29 (31.5) 92 2 (2.1)
2 I persistently reviewed by
missed actions 4 (4.3) 1 (1.1) 28 (30.1) 32 (34.4) 28 (30.1) 93 1 (1.0)
3 I became more conservative
with others 43 (66.2) 19 (29.2) 2 (3.1) 1 (1.5) 0 65 29 (30.8)
4 I avoided the client’s family 36 (50.0) 21 (29.2) 13 (18.1) 2 (2.8) 0 72 22 (23.4)
5 I turned down referrals of
others 44 (62.9) 18 (25.7) 7 (10.0) 0 1 (1.4) 70 24 (25.5)
6 I isolated myself from
family/friends suicidal
clients 60 (90.9) 5 (7.6) 1 (1.5) 0 0 66 28 (29.8)
7 I isolated myself from
colleagues 56 (86.2) 7 (10.8) 2 (3.1) 0 0 65 29 (30.8)
8 I considered changing my
profession 51 (79.7) 9 (14.1) 3 (4.7) 1 (1.6) 0 64 30 (31.9)

1 = least; 2 = less; 3 = medium; 4 = moderate; 5 = strong; 9 = not applicable

ing to the supervisor as helpful. The highest DISCUSSION

ranking of most helpful was talking to col-
leagues.
Answers to the other issues are shown
in Table 5. Eighty-five (93.4%) of the 91 psy-
chiatrists who responded to this noted that
they are more aggressive in searching for sui-
cidality among patients since the death; 81
(91.1%) rated that they grew as a result of
the experience; and 79 (86.9%) accepted that
their ability to prevent suicide is limited. We
also found that 74 (78.7%) psychiatrists had
learned about the experience of being a clini-
cian survivor prior to the death, although
only 53 (56.4%) had learned during resi-
dency training.
There were 77 psychiatrists who an-
swered an open question about the impact of
the suicide. We can classify the answers into
the following categories: 24 psychiatrists de-
scribed elements of sadness, 18 reviewed
their missed actions, 15 used the experience
to help other cases, 11 felt guilty, 10 thought
that things were beyond their control, 10 felt
shock, 10 blamed themselves, 2 felt no im-
pact, and only 1 feared a lawsuit.
We conducted a survey of the effect of
death by suicide of patients in a large sample
of Thai psychiatrists, one of only three such
large surveys globally. It was the first in Asia.
The response rate of 52.18% was reasonably
high, higher than an American study, which
was 46% (Chemtob et al., 1988), but lower
than the response rate of a study in Scotland,
which was 78% (Alexander et al., 2000). Al-
though some may read this as a low response
rate, previous studies would suggest that this
is not so. Not only cultural factors, but also
studies of other tragedies such as homicide
(Eastman, 1996), with even lower would sug-
gest that our rate was acceptable. Further,
like Alexander and colleagues, we were struck
by the psychiatrists’ openness, confirming
that suicide by patients is important to all
psychiatrists.
Our study replicated the findings of
Alexander and colleagues in the United
Kingdom (2000) and Chemtob and his team
in the United States (1988) that a patient’s
suicide is not rare. Although earlier estimates
734 Impact of Suicide on Psychiatrists

TABLE 4
Psychiatrist Ratings of Helpful Interventions and Activities
1 2 3 4 5 Total 9

1 Talking to family/friends was

helpful 2 (2.7) 3 (4.0) 26 (34.7) 19 (25.3) 25 (33.3) 75 19 (20.2)
2 Talking to colleagues was
helpful 1 (1.2) 30 (34.9) 22 (25.6) 33 (38.4) 86 8 (8.5)
3 Talking to other clinician/
survivors helpful 2 (3.1) 7 (10.9) 29 (45.3) 15 (23.4) 11 (17.2) 64 30 (31.9)
4 Attending the funeral was
helpful 8 (15.4) 18 (34.6) 18 (34.6) 3 (5.8) 5 (9.6) 52 42 (44.7)
5 Talking to my supervisor was
helpful 1 (1.5) 5 (7.7) 28 (43.1) 7 (10.8) 24 (36.9) 65 29 (30.8)
6 Utilizing my personal therapy
was helpful 12(30.8) 18 (46.2) 8 (20.5) 1 (2.6) 0 39 55 (58.5)
7 Talking with lawyer was
helpful 21 (53.8) 16 (41.0) 0 1 (2.6) 1 (2.6) 39 55 (58.5)
8 Presenting to a formal review
was helpful 2 (3.1) 3 (4.7) 28 (43.8) 14 (21.9) 17 (26.6) 64 30 (31.9)
9 Presenting in a case conference
was helpful 1 (1.8) 6 (10.7) 20 (35.7) 15 (26.8) 14 (25.0) 56 38 (40.4)
10 Attending professional meeting
was helpful 1 (1.8) 6 (10.7) 21 (37.5) 14 (25.0) 14 (25.0) 56 38 (40.4)
11 Reading materials about the
clinician/survivor experience
was helpful 3 (5.0) 5 (8.3) 31 (51.7) 15 (25.0) 5 (8.3) 60 34 (36.2)
12 Pray/do merit for suicide
patient 2 (2.9) 7 (10.3) 26 (38.2) 22 (32.4) 11 (16.2) 68 26 (27.6)
13 Other helpful activities/
relationships (specify)_____ 2 (28.6) 1 (14.3) 4 (2.4) 7 87 (92.51)

1 = least; 2 = less; 3 = medium; 4 = moderate; 5 = strong; 9 = not applicable

suggested 20%, the current systematic large- had had patients who died by suicide. This
scale studies suggest that over 50% of psychi- compared with 67% in the U.K. study and
atrists can anticipate this event in their career. 51% in the US study. Consistent with the
In our Thai survey, 56.28% of respondents previous studies; we found that many psychi-

TABLE 5
Other Issues

1 2 3 4 5 Total 9

1 I recognized/realized that my
ability to prevent suicide is limited 3 (3.3) 9 (9.9) 35 (38.5) 26 (28.6) 18 (19.8) 91 3 (3.2)
2 I grew as a result of the experience 4 (4.4) 4 (4.4) 36 (40.0) 29 (32.2) 17 (18.9) 90 4 (4.2)
3 I am more aggressive in searching
for suicidality among clients since
the death 1 (1.1) 5 (5.5) 31 (34.1) 26 (28.6) 28 (30.8) 91 3 (3.2)

1 = least; 2 = less; 3 = medium; 4 = moderate; 5 = strong; 9 = not applicable

Thomyangkoon and Leenaars
atrists face this crisis several times in their
career. Unfortunately, we know little about
the factors that influence the higher risk of
having patients die by suicide. We suspect
that in Thailand, the reason why a few psy-
chiatrists experienced 10 to 50 patients die by
suicide is the nature of the practice itself; it
is limited and highly associated with patients
diagnosed with schizophrenia, who have a
high risk. The determination of the factors
that result in risk calls for further study, how-
ever.
Patient Characteristics
Seventy-five percent of the suicide
cases in our study were outpatients; the rest
were inpatients. Alexander et al. (2000) re-
ported that half of their suicide cases were
outpatients, 45% were inpatients, 4% were
day patients; and 2 died in prison. Chemtob
and colleagues do not offer such data; thus,
further study is warranted, not only about
risk, but also why such differences occur.
Unfortunately, and as Chemtob et al.
(1988) note, they did not obtain data on diag-
noses, nor did Alexander and his group. We
studied this factor and found that different
patients offer different risks. The weights of
risks in this study are consistent with general
risks. It is estimated that about 5% of people
with schizophrenia die by suicide (Palmer,
Pankratz, & Bostwick, 2005), the risk is
higher with inpatients (Hawton & van Heer-
ingen, 2000), and about 2% of people with
depression die by suicide (Bostwick, 2000).
Speculatively, we believe that not only in
Thailand, but in much of Asia, the rate of
patients with schizophrenia who die by sui-
cide is high, compared to Western studies.
This is associated to the fact that 60% of all
inpatients and outpatients in care are diag-
nosed with schizophrenia. Services are lim-
ited; there are problems with follow-up,
complications with medications, and patients
from rural areas who return to their village
with no after care. There is a great deal of
stigma associated with mental illness, and
thus we are not surprised that 40% of pa-
tients who die by suicide are schizophrenic;
735
it reflects the reality of care in Thailand. For
this reason, we also suspect that the rate of
suicide in for those suffering from depression
is higher in Thailand and much of Asia. Rep-
lication of these findings is needed to confirm
our theory.
Hanging was the most common method
of suicide by the patients; this corresponds to
the main method in Thailand (Thomyang-
koon et al., 2005). It is probable that the
main method will differ from country to
country (Leenaars et al., 2000).
Impact After Suicide
Litman (1965) and subsequent reports
(Goldstein & Buongiorno, 1984; Kolodney,
Binder, Bronskin, & Friend, 1979), including
the two large-scale studies in the U.S. and
the U.K., report shock, guilt, grief, and anger
by psychiatrists after a patient’s suicide.
Chemtob et al. (1988) found that the psychi-
atrists who experienced a suicide noted the
same reactions, but also that they reported
posttraumatic reactions, some even reported
intrusive thoughts of suicide. Gitlin (1999)
reported his response to a patient’s suicide to
include anger, shame, guilt, isolation, and
fears of both litigation and retribution from
the psychiatric community. We found a simi-
lar array of reactions, except Thai psychia-
trists did not report anger frequently. This is
likely a reflection of Thai cultural mores of
not expressing or showing anger (Klausner,
2002). Thai psychiatrists also did not show
being suicidal themselves, accident-prone,
loss of patterns of conduct, or personal relief.
Thai psychiatrists, unlike some Western psy-
chiatrists, did not withdraw from seeing sui-
cidal patients or consider changing profes-
sions. In the UK, Alexander et al. (2000)
report that 15% of psychiatrists considered
taking an early retirement after the incident.
Clearly the event can be stocktaking one.
In regard to professional status, both
Chemtob et al. and Alexander et al. reported
that psychiatrists feared changes to reputa-
tions/publicity and fears of lawsuit, but this
was very infrequent for Thai psychiatrists.
Yet, like other countries in the western
736
world, about half feared blame from the fam-
ily. It is of note that the doctors that feared
blame were also more likely to feel guilt.
Surviving After Suicide
The highest ranked reaction in our
study was the persistent review of actions and
possibly missed actions. Chemtob and Alex-
ander report a similar reaction; it appears
that the death by suicide is a common stimu-
lus for review of actions. Thus the postven-
tion offers an opportunity for prevention
(Leenaars & Wenckstern, 1998).
Postvention refers to those things
done after a tragic event, such as a suicide of
a patient (Shneidman, 1973). Ness and Pfef-
fer (1990), in a review of bereavement after
suicide, pointed out: “With striking unanim-
ity therapists have said that formal and infor-
mal consultation with colleagues is one of the
most important and helpful activities to take
in coping with a patient’s suicide” (p. 281).
Litman (1965), Hendin et al. (2000), and
many others have reported that working
through the experience with colleagues is an
adaptive coping strategy. Alexander et al. and
Chemtob et al. reported the same in the
large-scale studies. Thai psychiatrists felt the
same; 90% found speaking with colleagues as
most helpful. Thus, it can be stated unequiv-
ocally, that support from colleagues is para-
mount to survive the suicide of a patient. In
fact, early education of this fact should be
part of all medical training.
Outside of the professional realm,
families and friends proved helpful. The Thai
psychiatrists did not isolate themselves from
family, did not withdraw, and rather, like pro-
fessionals, family and friends were experi-
enced as helpful.
On the other hand, formal inquiries
and institutional responses have been found
to be not helpful. Alexander and colleagues
reported that psychiatrists found such re-
sponses unhelpful, often noting a climate of
blame. Chemtob et al. noted the same. Hen-
din and his group (2000), after intensive in-
terviews of clinicians who experienced a pa-
tient’s suicide, concluded the same: they may
Impact of Suicide on Psychiatrists
not be helpful. Thai psychiatrists were more
optimistic, however. We believe from the re-
view of the literature and our study, that the
key issues in whether helpful or not are ones
of blame, false assurance, and the like.
Based on the research to date (Lee-
naars & Wenckstern, 1998), it has been
shown that consultation and review after a
patient’s suicide should be supportive, posi-
tive, and constructive (e.g., What do you
want? What do you need to review about
your practice? What can we all learn? What
can we do next?). This contrasts with a more
assaultive, overly blaming approach or expe-
rience (e.g., Did you do X? Why didn’t you
consider Y?) that can easily become the tenor
of the consultative process under such pro-
fessionally and personally stressful, anxiety-
impacting conditions. The psychiatrists in
the large-scale studies on three continents
(U.K., U.S., and Thailand), in fact, have
called for a cooperative approach.
A supportive approach is helpful,
whether talking to a colleague or having a
formal review. Gitlin (1999), in his insightful
personal account surviving a patient suicide,
says the same. It is probably not so much
what is done than how it is done, a basic in
standards of care.
Cultural Sensitivity
On a few cultural notes, first, most of
the psychiatrists in Thailand reported, unlike
those in the U.S. and U.K., that talking to a
lawyer was not helpful. Since suicide of a pa-
tient is rarely seen as a legal mater in Thai-
land (Bongar & Greaney, 1994). Also cultur-
ally different, Thai people are strikingly
spiritual; they believe that praying/doing
“merit” will help the dead person to go to the
place of peace (Klausner, 2002). Sixty-eight
(72.4%) psychiatrists prayed/did merit for
their lost patients; 86.8% of them found this
most helpful. Neither Alexander nor Chem-
tob noted prayer as a postvention strategy. In
Buddhism, the predominant belief, Thai peo-
ple believe that to pray/do merit for the de-
ceased, even by suicide, will help them go to
heaven.
Thomyangkoon and Leenaars
Thailand is perceived as the “Land of
smile, let it go.” Thai people believe that
people who do the good will have the good
done unto them (the reverse is true too).
One’s actions will pass on to the next life;
therefore, one will receive the good in the
next. As an example of the bad, if one com-
mits suicide, it is believed to lead to condem-
nation to kill for 500 lifetimes. Prayer in this
context has a therapeutic value; it provides
comfort. “If an individual is seriously ill,
friends and relatives will help him to direct
the mind to Buddha and Buddha’s teachings.
This provides the dying with psychological
comfort by preparing his mind for a good re-
birth” (Cooper, 2007, p. 233). This is true for
the person that commits suicide and true for
the survivor of a suicide.
Belief in reincarnation is essential to
the Thai view of life and religion,
which maintains that an individual’s
material existence is determined by a
spiritual balance of all of his or her
good and bad actions (karma) and that
the course of existence, in this life and
the next, can be changed by making
“tham boon” (religious merit). Because
of the importance of these ‘rites of pas-
sage’ from one life to another, they are
usually as elaborate as a dead person’s
relatives and friends can afford. (Cooper,
2007, p. 233)
Thai psychiatrists believe that praying
and participating in religious merit, such as
chanting, preaching, and ceremonies, can
help patients after death. This action is one
of the traditional healing methods for Thai
psychiatrists. Like many regions of the world,
traditional approaches are integrated into
modern health approaches to wellness in
Thailand ( Jenkins, McCulloch, Friedli &
Parker, 2002).
Thai psychiatrists were also more
likely to attend the patient’s funeral; 55.3%
(52) attended the funeral, whereas Alexander
et al. (2000) reported that only 15% (24) of
psychiatrists in Scotland attended the funeral
(Chemtob et al. offered no information). It is
of note that Hendin et al. (2000) reported
737
that therapists found attending the funeral
helpful. Not only personally and profession-
ally, but also legally (Bongar & Greaney,
1994; Leenaars et al., 2002; Markowitz, 1990).
Psychiatric Training
The suicide of a patient can impact
one’s practice, often considerably. Eighty-five
(93.4%) Thai psychiatrists reported that they
are more aggressive in their scrutiny for sui-
cidality. Eighty-one (91.1%) Thai psychia-
trists rated that they grew as a result of the
experience. Seventy-nine (86%) accepted that
their ability to prevent suicide is limited. Pro-
fessionally, postvention can become a stock-
taking event, even providing an opportunity
for improving one’s skill.
Historically, psychiatric training in sui-
cidology was poor (Brown, 1987). Chemtob
et al. (1988) found that practicing psychia-
trists do not have formal training in policies
and procedures for dealing with the impact
of a patient’s suicide. Gitlin (1999) stated
from his own experience that training pro-
grams should prepare psychiatrists to be fa-
miliar with tragic events. This is true for
Thailand and probably for everyone.
Conclusions
Based on the three large-scale studies
discussed here, we can state that further re-
search is needed; we do not know enough
about this hazard of being a psychiatrist.
There are limitations with the current
nomothetic studies. For example, different
instruments have been used. The question-
naire used here at least allows researchers
around the world to have access to the same
measure; yet, much greater study of the in-
strument is needed. Further, these standard-
ized studies need to be augmented by in-
depth idiographic studies, such as that of
Hendin and his group (2000). In fact, Hen-
din et al. offer beginning insight into the di-
rection needed not only in the research, but
also the praxis (Hendin, Haas, Maltsberger,
Koestner, & Szanto, 2006). There are few
such studies in psychiatry that can have an
738
impact on us, personally and professionally.
Indeed, we are currently planning a follow-
up study; we are planning to interview indi-
vidual psychiatrists using the scheme of Hen-
din and his group.
To conclude, from the two previous
large-scale studies on the impact of suicide
on psychiatrists we knew the following: psy-
chiatrists experience a high level of personal
and professional stress, and suicide by pa-
tients has been shown to cause significant im-
pairment, even posttraumatic distress. Our
study adds the following: suicide by patients
has a personal and profession impact for psy-
chiatrists, probably worldwide (certainly it is
true in Thailand.); postvention should be
multifaceted and may include culturally unique
aspects such as prayer and doing merit; sup-
port from family and colleagues is particu-
larly helpful; and cultural sensitivity may be
needed in postvention.
On the importance of cultural sensitiv-
ity, it is critical to understand that suicide is
a multidimensional event (Leenaars, 2004;
Shneidman, 1985; World Health Organiza-
tion [WHO], 2002). It is an interplay of indi-
vidual, relationship, community, and social
factors. This interplay is sometimes called
the ecological model (Bronfenbrenner, 1979;
Dahlberg & Krug, 2002; Leenaars, 2007;
Leong & Leach, 2007) (see Figure 2). The
model simply suggests that there are differ-
Figure 2. Ecological model for understanding suicide.
Impact of Suicide on Psychiatrists
ent levels that influence suicide and thus, by
implication, its impact and survivorship (Leach,
2006; Leenaars, 2007; Leenaars, Maris, &
Takahashi, 1997; WHO, 2002). Our study
addresses factors beyond the individual; it
studies the impact of suicide in one culture,
Thailand. Although it may have implications
for the larger region of Asia, there are vast
differences (Leong & Leach, 2007; WHO,
2002). From an ecological view, we believe
our study shows that one must, indeed, have
cultural sensitivity—and this is probably true
for cultural and ethnic groups in the U.S. and
elsewhere (Leong & Leach, 2007).
The very practice of psychiatry is dif-
ferent; it is limited in Thailand. This may, in
fact, be the main reason why so many pa-
tients with schizophrenia die by suicide in
Thailand; most of psychiatrists’ patients have
such a diagnosis. Of course, such limits in
service are worldwide ( Jenkins et al., 2002).
Yet because the previous research in the
United States and United Kingdom did not
study this factor, we cannot compare patient
characteristics. Suicide may well be different
in different cultures. Although the impact of
suicide may be similar in many ways around
the world; in Thailand, and by implication,
much of southeast Asia, there are differences.
Thai psychiatrists do not express anger or
withdraw services for suicidal patients. Un-
like U.S. and U.K. therapists, few fear legal
Thomyangkoon and Leenaars
consequences; yet, in all regions it is a stock-
taking event in one’s practice. Postvention is
different; Thai psychiatrists are very likely to
attend the funeral, to pray, and to do merit
for the patient. This is highly associated to
the integration/regulation of its Buddhism.
Theravada Buddhism is not only a way of life
and religion, but also a way of psychiatric
practice. Traditional ways are part of the ap-
proach. Friends and colleagues are helpful
but so also are the monks. Thai psychiatrists
are more optimistic than American and Brit-
ish psychiatrists; it is the way of the “Land of
the smile, let it go.” Worldwide, psychiatrists’
call for a cooperative approach to postven-
tion may be answered in culturally different
ways. The Thai psychiatrist prays, but also
he/she is likely to do so daily. It is perceived
REFERENCES
Alexander, D., Klein, S., Gray, N.,
Dewar, I., & Eagles, J. (2000). Suicide by pa-
tients: Questionnaire study of its effect of consul-
tant psychiatrists. British Medical Journal, 320,
1571–1574.
Binder, R. (1978). Dealing with patients’
suicides (letter). American Journal of Psychiatry,
135, 1113.
Bongar, B., & Greaney, S. (1994). Essen-
tial clinical & legal issues when working with sui-
cidal patients. In A. Leenaars, J. Maltsberger, &
R. Neimeyer (Eds.), Treatment of suicidal people (pp.
179–194). Washington, DC: Taylor & Francis.
Bostwick, J. (2000). Affective disorders
and suicide risk: A re-examination. American Jour-
nal of Psychiatry, 157, 1925–1932.
Bronfenbrenner, U. (1979). The ecology of
human development: Experts by nature and design.
Cambridge: Harvard University Press.
Brown, H. (1987). The impact of suicide
on therapists in training. Comprehensive Psychiatry,
28, 101–112.
Chemtob, C., Hamada, R., Bauer G.,
Kinney, B., & Torigoe, R. (1988). Patients’ sui-
cides: Frequency and impact on psychiatrists.
American Journal of Psychiatry, 145, 224–228.
Cooper, R. (2007). Culture shock: Thailand.
Singapore: Marshall Cavendish.
Dahlberg, L., & Krug, E. (2002). Vio-
lence—A global public health approach. In World
Health Organization, World report on violence and
health (pp. 3–21). Geneva: WHO.
Durkheim, E. (1951). Suicide ( J. Spaulding
739
as helping with their own and their patient’s
wellness.
There are, of course, great cultural dif-
ferences between Thailand and other mainly
Western cultures; the only region previously
studied. Klausner (2000) stated, “One of the
most prevalent patterns of social behavior in
Thai village society is that of harmonious hu-
man relationships with one’s fellow villagers
and a concomitant avoidance of overt acts
that express anger, displeasure, criticism and
the like. The ‘cool heart’ is the ideal; the ‘hot
heart’ is to be avoided” (p. 70). We believe
that this is central in understanding the dif-
ferences between previous results and ours.
One must be culture-centered to understand
suicide and the impact of suicide on psychia-
trists and people in general (Leenaars, 2007).
& G. Thompson, Trans.). Glencoe, IL: The Free
Press. (Original work published, 1897)
Eastman, N. (1996). Inquiry into homi-
cides by psychiatric patients: Systematic audit
should replace mandatory inquiries. British Medi-
cal Journal, 313, 1069–1071.
Gitlin, M. (1999). A psychiatrist’s reaction
to a patient’s suicide. American Journal of Psychia-
try, 156, 1630–1634.
Goldstein, L., & Buongiorno, P. (1984).
Psychotherapists as suicide survivors. American
Journal of Psychotherapy, 38, 392–398.
Gralnick, A. (1993). Suicide in the psychi-
atric hospital. Child Psychiatry & Human Develop-
ment, 24, 3–12.
Hawton, K., & van Heeringen, K. (Eds.).
(2000). The international handbook of suicide and at-
tempted suicide. Chichester, UK: Wiley.
Hendin, H., Haas, A., Maltsberger, J.,
Koestner, B., & Szanto, K. (2006). Problems in
psychotherapy with suicidal patients. American
Journal of Psychiatry, 163, 67–72.
Hendin, H., Haas, A., Maltsberger J.,
Szanto, K., & Rabinowicz, H. (2004). Factors
contributing to therapists distress after the suicide
of a patient. American Journal of Psychiatry, 161,
1442–1446.
Hendin, H., Lipschitz, A., Maltsberger,
J., Haas, A., & Wynecoop, S. (2000). Therapists’
reaction to patients’ suicides. American Journal of
Psychiatry, 157, 2022 – 2027.
Henn, R. (1978). Patient suicide as part of
psychiatric residency. American Journal of Psychia-
try, 135, 745–746.
740
Jenkins, R., McCulloch, A., Friedli, L.,
& Parker, C. (2002). Developing a national mental
health policy. East Sussex, UK: Psychology Press.
Kahne, M. (1968). Suicide among patients
in mental hospitals. Psychiatry, 31, 32–42.
Kaye, N., & Soreft, S. (1991). The psy-
chiatrist’s role, responses, and responsibilities when
a patient commits suicide. American Journal of Psy-
chiatry, 148, 739–743.
Kayton, L., & Freed, H. (1967). Effects
of suicide in a psychiatric hospital. Archives of Gen-
eral Psychiatry, 17, 187–194.
Klausner, W. (2000). Reflections on Thai
culture (5th ed.). Bangkok: The Siam Society un-
der Royal Patronage.
Klausner, W. (2002). Thai culture in tran-
sition (rev. ed.). Bangkok: The Siam Society under
Royal Patronage.
Kolodney, S., Binder, R., Bronstein, A.,
& Friend, R. (1979). The working through of pa-
tients suicides by four therapists. Suicide and Life-
Threatening Behavior, 9, 33–46.
Leach, M. (2006). Cultural diversity and
suicide: Ethnic, religious, gender and sexual orientation
perspectives. New York: The Haworth Press.
Leenaars, A. (2004). Psychotherapy with sui-
cidal people. Chichester, UK: Wiley.
Leenaars, A. (2007). Suicide: A cross-
cultural theory. In F. Leong & M. Leach (Eds.),
Suicide among racial and ethnic minority groups (pp.
13–37). New York: Routledge.
Leenaars, A., Cantor, C., Connolly, J.,
EchoHaw, M., Gailiene, D., He, Z., et al.
(2000). Controlling the environment to prevent
suicide: International perspectives. Canadian Jour-
nal of Psychiatry, 45, 639–644.
Leenaars, A., Cantor, C., Connolly, J.,
EchoHawk, M., Gailiene, D. He, Z., et al.
(2002). Ethical and legal issues in suicidology: In-
ternational perspectives. Archives of Suicide Re-
search, 6, 185–197.
Leenaars, A., Maris, R., & Takahashi, Y.
(Eds.). (1997). Suicide: Individual, cultural, interna-
tional perspectives. New York: Guilford.
Leenaars, A., & Wenckstern, S. (1998).
Principles of postvention. Death Studies, 22, 357–
391.
Leong, F., & Leach, M. (Eds.). (2007).
Impact of Suicide on Psychiatrists
Suicide among racial and ethnic minority groups. New
York: Routledge.
Litman, R. (1965). When patients commit
suicide. American Journal of Psychotherapy, 19,
570–584.
Little, J. (1992). Staff response to in-
patient and out-patient suicide: What happened
and what happened and what do we do? Australian
& New Zealand Journal of Psychiatry, 26, 162–167.
Markowitz, J. (1990). Attending the fu-
neral of a patient who commits suicide (letter).
American Journal of Psychiatry, 147, 122–123.
McIntosh, J., Talcotl, L., & Jones, F.
(1999, April). Therapists as survivors of client suicide.
Paper presented at the American Association of
Suicidology Conference, Houston, TX.
Menninger, W. (1991). Patient suicide
and its impact on the psychotherapist. Bulletin of
Menninger Clinic, 55, 216–227.
Mulder, N. (2001). Inside Thai society. Bang-
kok: O.S. Printing House.
Ness, D., & Pfeffer, C. (1990). Sequelae
of bereavement resulting from suicide. American
Journal of Psychiatry, 147, 279–285.
O’Reilly, R., Truant, G., & Donaldson,
L. (1990). Psychiatrists’ experience of suicide in
their patients. Psychiatry Journal of University of
Ottawa, 15, 173–174.
Palmer, B., Pankratz, V. & Bostwick, J.
(2005). The lifetime risk of suicide in schizophre-
nia: A reexamination. Archives of General Psychia-
try, 62, 247–253.
Shneidman, E. (1973). Suicide. In Encyclo-
pedia Britannica (vol. 21, pp. 383–385). Chicago:
William Benton.
Shneidman, E. (1985). Definition of suicide.
New York: Wiley.
Soreff, S. (1975). The impact of staff sui-
cide on a psychiatric inpatient unit. The Journal of
Nervous and Mental Disease, 161, 130–133.
Thomyangkoon, P., Leenaars, A. A., &
Wasserman, D. (2005). Suicide in Thailand, 1977–
2002. Archives of Suicide Research, 9, 361–368.
World Health Organization. (2002).
World report on violence and health. Geneva: Author.
Manuscript Received: May 15, 2007
Revision Accepted: March 2, 2008