Recovering from the suicide of a client with schizophrenia: recommendations for case managers

Many case managers in mental health settings occasionally experience a client's suicide, and this can be an emotionally devastating event. The symptoms of schizophrenia, including the difficulties those client face in forming trusting relationships with others, brings special challenges to the case manager's recovery because of the efforts put into developing that relationship. The purposes of this article are to describe a range of possible reactions of case managers following the suicide of a client with schizophrenia and how those persons can be helped to make a positive recovery from such an event. A summary of suicide risk factors for case managers to assess when working with clients who have schizophrenia is included.Keywords: case management; schizophrenia; suicide; community mental healthA client's suicide is almost always considered by human service practitioners to be a tragic act. Many case managers occasionally experience a client's suicide and the event can be emotionally devastating. They may wonder if they have been negligent in some way or made a mistake that contributed to the client's despair that life was not worth living, and as a result, they may experience a severe blow to their sense of competence. The characteristics of clients with schizophrenia, especially their difficulty forming trusting relationships with others, brings special challenges to the case manager's emotional recovery in the event of a suicide. Case managers often spend much time with these clients in their natural environments and may have a relationship that is more informal than other professionals who provide more structured interventions. The depth and scope of those relationships can create an attachment that leaves the case manager vulnerable to persistent negative emotions in the event of a suicide. The purposes of this article are to describe a range of possible reactions of case managers following the suicide of a client with schizophrenia and how these professionals can be helped to make a positive recovery from such an event. The first part of the article focuses on the uniquely intense relationship that can develop between a case manager and client, and the second part considers how, given this attachment, a case manager can be helped to cope with a client suicide.CONNECTING WITH CLIENTS WHO HAVE SCHIZOPHRENIADeveloping solid working relationships with clients who have schizophrenia is challenging because the symptoms of that disorder give rise to a sense of interpersonal detachment in those persons. The case manager who is able to become a part of the client's trusted inner world can potentially assist greatly with the client's growth process. Hewitt and Coffey (2005) conducted a meta-analysis of studies on the significance of the therapeutic relationship with clients who have schizophrenia and concluded that clients who experience an empathic, positive, and facilitative relationship with their providers have better outcomes.The process of connection is complicated because of the effects of the client's thought disorder. The cognitive and perceptual distortions in schizophrenia include disruptions in the client's information processing capacity, which produce impairments in stimulus filtering. A subsequent overload of externally and internally generated stimuli leads to the person's misinterpretations of the words and actions of others (Cadenhead & Braff, 2009). These perceptual distortions feature a loosening of an integrated visual context so that the individual perceives partial elements of a scene without grasping its overall meaning (Uhlhaas & Mishara, 2007). Delusions develop as the person attempts to construct a new context for the unexplained perceptual fragments. Likewise, auditory hallucinations are the result of mental processes that are experienced as detached from their internal source.The resulting changes to the sense of self create an existential crisis for the client (Crane & McDonough, 2014). …