To the best of our knowledge, this is the first published study to provide a quantitative comparison of clinician responses to acutely suicidal patients versus non-attempters and to patients who made high lethality versus low-lethality suicide attempts.
Such investigation is important, as problems in the management of countertransference (or emotional reactions in general) to patients may hamper treatment efficacy and even contribute to patient suicide in a small but significant proportion of cases [5, 36]. To date though, the literature has focused almost entirely on the development of qualitative treatments of the subject. A thorough literature search using the PsycINFO database resulted in our conclusion that there are no analogous studies in the literature. (Searches conducted using varied combinations of terms including “countertransference”, “suicide”, “therapist response”, “clinician response”, “predict”, “prevention”, “comparison”, and “quantitative” identified no peer-reviewed publications reporting on quantitative comparisons of clinician responses to suicidal versus non-suicidal patients or of patients with differing levels of suicidality). The only quantitative comparative work we have been able to find on the subject has been a small series of unpublished dissertations, which found no significant differences in negative therapist responses to suicidal versus “difficult” non-suicidal patients . While rich qualitative data are an essential starting point, this preliminary study aimed to pilot a much-needed quantitative and comparative approach using a validated instrument and easily replicable quantitative methodology.
This study found that clinicians treating imminently suicidal patients recalled, on average, moderately positive feelings towards these patients (though less so than for non-attempters), with higher hopes for treatment, while finding themselves more overwhelmed, distressed by, and, at low levels, avoidant of them. Further, we found that the specific paradoxical combination of hopefulness and distress/avoidance was a significant discriminator between suicidal patients and those who had unexpected non-suicide deaths, and cross-validated classification by discriminant analysis remained statistically significant both when a past history of suicide attempt was present and when it was not. This finding of ‘paradoxical response’ is consistent with the higher scores observed on the “overwhelmed-disorganized” subscale of the CQ in clinician recollections of their encounters with suicide attempters.
In our second comparison, we found no clear evidence of differences between clinicians’ responses in encounters with patients preceding either completed suicides or highly lethal suicide attempts and their responses in encounters preceding low lethality suicide attempts. Despite a trend towards a slightly more positive emotional responses overall, clinicians also recalled experiencing more sadness in encounters with patients preceding either successful or highly lethal suicide attempts than in encounters preceding low lethality suicide attempts. This difference in recalled sadness was found to be a modest discriminator between patients that went on to exhibit high and low lethality suicidal behavior. It is worth noting, however, that this difference appears attributable specifically to recalled responses to patients with a history of previous attempts; among these patients sadness in session was a significant discriminator of attempt lethality while among first-time attempters clinicians’ experience of sadness in the session prior to suicide attempt did not differentiate between lethality levels. This finding has not been supported or opposed in the literature, as the difference in emotional response to high and low lethality suicide attempters has not previously been explored. Further, interpretation is limited by significant risk of type-1 error given the small n’s and multiple comparisons involved.
Thus our findings, while grossly consistent with the qualitative literature findings of negative responses to suicidal patients [34, 36], differed in the important respect that the levels of recalled negative reactions to patients prior to their suicide attempts were, on average, fairly low, and even when significant, the magnitude of the differences in positive and negative responses elicited by suicidal versus non-suicidal patients was small. Maltsberger and Buie  were the first to describe in detail the negative countertransference (“countertransference hate”) that clinicians may experience in response to suicidal patients, and provided a theoretical framework which might account for our quantitative findings. First, as noted, we found that clinicians recalled fairly low levels of negative feelings towards their suicidal patients, though positive response was attenuated compared to non-attempters. This finding may be consistent with their predictions of repression of “countertransference hate”. On the other hand, our findings of distress and self-directed negative feelings combined with paradoxical hopefulness may be consistent with their predictions of turning of the countertransferential hate against the self and of reaction-formation against it, respectively. Indeed, our findings seem to suggest that the defense mechanisms described by Maltsberger and Buie may operate in concert.
Our findings point to the potential clinical utility of self-assessment of emotional response in the treatment of suicidal patients. This is a matter of some importance as both Modestin  and Marcinko et al.,  have used observational evidence to support the theory that emotional responses to suicidal patients that are not properly managed can have harmful consequences. The latter group concluded that negative emotional response probably contributes to or correlates with negative patient outcomes , while Modestin, further indicates how the failure to control these reactions (hostility, hate, and aggressiveness in particular) may in some cases help push patients to suicide .
We should note, however, that while both emotional responses and judgments of suicide risk reside in the clinician, they are not the same. Indeed clinical judgment has been found to be a poor predictor of critical patient behavior such as suicide  and violence . While clinical judgment is ultimately a conscious process, emotional responses may not become directly conscious [4, 24]. Thus systematic assessment of these responses, even in using self-report measures may reveal patterns generated by the clinician’s unconscious processes such as the “paradoxical hopefulness” identified using discriminant analysis. Quantitative self-report assessment may thus reveal data inherent in the clinician’s interpersonal experience with the patient that could potentially augment suicide-risk assessment.
The results of this preliminary study must be considered in light of several important limitations. Most prominently the study is subject to several kinds of recall bias.
First, many clinicians that have experienced a patient’s death by suicide report severe distress  and/or feelings of grief and self-doubt  stemming from treatment decisions that seem, in retrospect, to have been based on inaccurate assessments of the patient’s acute risk. Differences between such responses to patients’ suicide deaths, attempts of different severity, and unexpected non-suicide deaths have not been studied and are poorly understood . It is possible that the differences in recalled reaction to patients in the encounters preceding such events are attributable to their recollection being colored differently by those very events. Furthermore, individual items in the CQ might be differently subject to such effects thereby increasing or decreasing their apparent discriminatory power in our results.
Second, clinicians’ recollection of their responses to their patients in the encounters immediately preceding such events are almost certainly significantly combined with the rest of their preceding experience with those patients. Thus our findings cannot be interpreted as necessarily indicative of a “pre-suicidal” countertransference or emotional response.
Third, we are unable to control for the possible effects of clinicians’ reporting on their best-remembered patient of each type. Additionally, we were not able to control for the effects on recall of time elapsed since the events.
Fourth, as we were unable to obtain responses on each category of patient from most clinicians, it is possible that clinicians responding on suicidal patients we more likely to treat suicidal patients and thus represented a distinct group from those responding regarding non-suicidal patients only. Thus it is conceivable that differences in response are attributable to clinician differences rather than patient ones. However, the consistency between aggregate group findings and the within-clinician findings, for those clinicians who reported on patients belonging to different comparison groups, makes such an interpretation less likely.
Further, because the survey was distributed only within one institution, and was completed voluntarily, we cannot say that it accurately represents all clinicians who have experienced a patients’ completed suicide, attempt, or unexpected death.
Finally, limitations of sample size did not allow for reliable analysis of potential mediators and moderators of differences in therapist responses to patients of different types. Nonetheless it should be noted that no statistically significant differences in the rates of any diagnostic or demographic characteristics were observed between groups.
In sum, our findings must be viewed as preliminary results that justify further research. In order to more definitively verify our conclusions, the study will need to be repeated with a wider, larger sample. Additionally, prospective replication is necessary to confirm the findings.