As discussed in earlier columns describing an approach to therapeutic risk management of the suicidal patient, risk management is a reality of psychiatric practice.1 The work of providing care for patients at risk for suicide can be clinically and emotionally demanding, in part due to the complex and dynamic factors that underlie suicidal thoughts and behaviors. The reality that we lose some of our patients to suicide can be disheartening and overwhelming. Even in “best case” scenarios where providers and patients are working collaboratively to assess and monitor risk, engage in safety planning, and incorporate interventions to mitigate risk, some of these patients will die by suicide. And these losses can occur despite collective efforts, commitment, and collaboration across patients, providers, families, friends, and systems of care. What is critical to recognize is that therapeutic risk management does not end when a patient dies by suicide. In this article, we extend the philosophy of the therapeutic risk management model to consider ways in which we can take good care of the extended community of affected individuals, including ourselves, both before and after a suicide loss.1–6
THE IMPACT OF SUICIDE LOSS
Estimates suggest that at least half of all individuals will know someone who has died by suicide in their lifetime, equating to >5.3 million suicide loss survivors in the United States alone.7,8 Although these estimates include providers, the recognition of providers as suicide loss survivors is often overlooked or deemphasized. Yet, over the course of their careers, anywhere from one quarter to one half of mental health providers will experience a patient suicide.9–11 When providers lose a patient to suicide, they can be affected by the loss both personally and professionally.9,12–14 A body of empirical evidence indicates that these losses can affect providers’ professional identities, relationships with colleagues, and clinical work.10 Losses have been tied to burnout, compassion fatigue, self-doubt, a challenge to therapeutic assumptions, and fear.
Given the stigma often associated with patient loss and the demands providers face, preparing for the possibility of future loss and/or seeking support after a loss is challenging.11 However, these represent crucial steps that are essential to resilience, both in and out of the office. Although suicide prevention is a commonly used and understood term, the term suicide postvention is less well known. Suicide postvention builds upon prevention efforts by providing immediate and ongoing support to those impacted by a suicide loss. This support is essential to mitigating negative outcomes, such as depression and suicide risk, in a cohort of individuals who are now at increased risk due to exposure to suicide.15–18 This logic also extends to postvention for providers; seeking and receiving support after a patient suicide is critical to promoting personal and professional growth and healing after suicide.
BEFORE A LOSS: POSTVENTION PREPARATION
Although postgraduate mental health training programs (eg, psychiatry residencies, clinical psychology doctoral programs) have begun to offer enhanced suicide prevention curriculums and training programs, preparation specifically on suicide postvention continues to lag behind. For example, in a recent survey of psychiatry chief residents, only 25% of respondents indicated that postvention was covered in their training, with 70% noting that attention to this topic was needed by their program.19 These rates are especially problematic given that psychiatry trainees are the most likely to receive postvention education, despite the common experience of losing a patient to suicide across trainees of a variety of disciplines.20 This underscores the substantial need to enhance curriculums across mental health graduate programs (eg, clinical, counseling, social work). Because trainees commonly experience a patient suicide, educators and supervisors must prioritize these discussions to proactively support short-term and long-term professional development.20 It is recommended that supervisors working with trainees intentionally ensure that the experience of patient suicide is discussed during a supervisory relationship (regardless of whether a suicide loss touches the supervisor/trainee). If all supervisors embraced this call to action, we could experience incredible suicide postvention growth.
Regardless of years of experience or previous training, many providers report feeling underprepared about what to do after a suicide loss.21 Thus, awareness, education, and support for this especially challenging topic must occur “on the job” to not only reach providers who have not received education in this area, but also to promote an ongoing dialog about patient suicide across the professional career. It is recommended that providers proactively consider strategies that can help with managing a suicide loss by developing a personalized Suicide Postvention Preparation Plan. Creating a preparation plan can help decrease the anxiety associated with having to quickly determine next steps following a suicide, allowing the focus to center on taking care of oneself personally and professionally. See Table 1 for general recommendations, including potential sections and self-care strategies to consider incorporating when developing a Suicide Postvention Preparation Plan.22
Although it can be aversive to deal with the reality that one might lose a patient to suicide, embracing appropriate attitudes upfront can be instrumental to professional growth. As featured in the Suicide Postvention Preparation Plan (Table 1), developing philosophical and cognitive approaches when working with individuals at risk for suicide is essential to psychiatric practice.9,23 Two examples include: (1) recognizing that when working with patients who experience severe mental illness, providers must embrace the reality that some of their patients will die due to the distress and impairment of their disorder—mental health providers cannot prevent the worst outcome for every case any more than an oncologist or cardiologist can; and, (2) understanding that suicide is a complex behavior—despite advances in the science of suicide risk, individual providers remain unable to accurately predict death by suicide at the patient level; inevitably, some patients will die by suicide despite varying levels of known, and unknown, risk.24 It is recommended that providers engage in reflective practices about these complexities individually, but also in open dialogs with colleagues. Further, supervisors should openly lead discussions on these topics, prioritizing these complexities in tandem with those related to suicide prevention.
As with many areas of professional practice, and especially given the dearth of training often received in postvention, it is recommended that providers seek ongoing education and training in postvention. This learning can assist with postvention preparation and the ability to support patients, trainees, and colleagues who are touched by suicide loss. Providers are encouraged to review published guidelines, such as Responding to Grief, Trauma, and Distress After a Suicide: US National Guidelines published in 2015 and available on the Suicide Prevention Resource Center website (www.sprc.org) and postvention trainings, such as those available on the PsychArmor Institute website (https://psycharmor.org/courses/postvention-healing-after-suicide) and the Tragedy Assistance Program for Survivors (TAPS) (www.taps.org). Providers may also find benefit in a Suicide Postvention Podcast series developed by the Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) and the American Association of Suicidology (AAS), which includes 10 episodes dedicated to a variety of suicide postvention topics including lived experience, legal and ethical considerations, and practice-specific guidance. These episodes are freely available via the Rocky Mountain MIRECC Short Takes on Suicide Prevention podcasts accessible via iTunes, iHeart Radio, Blubrry, and other podcast platforms or at: https://podcasts.apple.com/us/podcast/rmirecc-short-takes-on-suicide-prevention/id1088720858.
AFTER A LOSS: SUPPORTING SELF AND COLLEAGUES
After a patient suicide, it can be especially difficult to simultaneously process the loss while attending to professional duties. Acknowledging the multifaceted impact of this loss is a critical first step in healing, both in and outside of work. Some providers may experience the pull to isolate after a loss, especially if they are practicing in an environment where stigma exists or where there are few trusted colleagues available. Pushing gently against this desire to isolate or to avoid emotions is helpful, as is actively reaching out to colleagues after a loss (vs. waiting for the colleague to come to you). Providers often express the need for more open communication in the workplace following a suicide.25 Providing education on the impact that patient loss can have on the provider is a natural way to begin these conversations. Although the impact of a patient suicide loss can look different based on factors such as age, experience, relationship to the patient who died by suicide, and practice setting, it is recommended that supervisors and colleagues provide education about the range of emotions that providers can face after a loss (eg, sadness, guilt, anger, relief) as a critical step in encouraging open communication characterized by validation and normalization of the experience in the workplace.9,26
It is also important to examine the thoughts that surface following a patient suicide, especially cognitive biases that may oversimplify the causes of suicide.27 Allowing for extra time after a loss to engage in the normative process of exploring the “whys” is critical.26 After a loss occurs, providers may begin to overestimate the power and control they have in a patient’s life, forgetting a patient’s agency and autonomy.28 Even when working with patients with whom there is a close therapeutic relationship, it is impossible to be aware of all elements in a patient’s life that drove the desire for suicide. It is crucial not to underestimate the influence these factors may have had with respect to the decision to die by suicide. Although case reviews are a necessary professional experience to ensure care is optimized and improved, it is important not to evaluate actions previously taken through the lenses of hindsight, relying upon information known only after a suicide. For example, many case reports discuss providers looking back on a patient’s farewell at a last session, wondering if there was a signal in the patient’s goodbye that in retrospect appears different because the outcome is already known.9 After a suicide loss, striving to integrate acceptance of the uncertainty that comes with suicide loss with the mindset of growth is important. In addition to incorporating this work into reflective self-practice, supervisors and managers should also model these approaches, as this is instrumental to supporting a provider after a loss and, by extension, critical to improving care to those we serve.
Seeking support following a suicide loss is essential to personal and professional growth. Nonjudgmental and empathetic conversations with colleagues can be especially helpful, as they allow a provider to shift isolating, private experiences to a shared open experience that may foster acceptance and growth. When supporting a colleague after a loss, it is important to balance statements about medical “facts” (eg, “You did everything you could”) with empathetic acknowledgment (eg, “It makes sense that you may be questioning what it means when our patients die by suicide despite all of our efforts”). Hearing from other provider suicide loss survivors can be incredibly helpful to one’s own loss journey. Websites such as our Uniting for Suicide Postvention (www.mirecc.va.gov/visn19/postvention/) offer several resources that may be helpful for providers who want to learn more about suicide loss, including those who have experienced patient loss.
AFTER A LOSS: SUPPORTING FAMILY LOSS SURVIVORS
Reaching out to support family loss survivors after a patient suicide is important. Awareness about suicide loss, and especially the role of suicide postvention, is lacking in the general public. By supporting family and friends close to the patient who died by suicide, providers play an integral part in promoting healing for loss survivors. Furthermore, these actions are critical to mitigating the risk for negative outcomes, including suicide, in those who have been touched by suicide loss.29 In this way, providing postvention support for loss survivors continues the mission that underlined the provider’s work with the patient who died by suicide, carrying forward the tenets of therapeutic risk management.
One of the initial concerns providers experience when thinking about outreach to family members after a suicide is concern about the family’s reaction, including potential litigation. It is important to first acknowledge that the best protection against litigation occurs before a suicide (ie, meeting or exceeding the standard of care in suicide risk assessment and management, and clearly documenting those efforts).30,31 It is important to note that, when suicide postvention for families is handled well, such efforts can be of therapeutic benefit and may simultaneously mitigate the likelihood of litigation.30
Another concern commonly encountered when preparing to reach out after a suicide loss involves how to navigate legal and ethical considerations related to confidentiality/privilege and disclosure. When a suicide occurs, family members often want to “make sense” of the loss and may ask questions about what happened during therapeutic interactions. Although patient confidentiality does extend to next of kin, it is important to utilize a wise and flexible combination of compassion, support, and adherence to “first do no harm” rather than inflexibly attending to a legalistic view of what you can or cannot say to whom.30 Validating emotions, providing empathetic redirection to the natural human reaction to want to know more (vs. disclosing therapeutic content), and offering an in-person family meeting may be especially helpful.
Family outreach after a suicide loss requires preparation. This process is analogous in many ways to a provider assembling a Suicide Postvention Preparation Plan, as building a family outreach approach is easier to accomplish when not actively processing a loss. First, it is recommended that providers consult with colleagues, supervisors, and if applicable, legal counsel, as part of preparation. It is recommended that providers assemble resources such as local support groups, survivor benefits, and education about suicide loss to have on hand, and to update these resources on a regular basis. Assembling a checklist that helps guide outreach phone calls can also be extremely helpful. Recommendations for what to cover during this outreach might include the exact language with which to express condolences for the death (eg, “I am sorry for your tragic loss. Your family has been in my thoughts”), a check-in on how the person is doing to provide validation and empathy, an offer for a face-to-face meeting to provide support and resources, and contact information for resources.30,32 Although providing postvention support to family loss survivors is generally considered to be of mutual benefit to loss survivors and the provider, it is important that providers ensure that the family outreach is performed to support the needs of the family, not the provider.
Few professional experiences are as challenging, personally and professionally, as the loss of a patient to suicide. In a field where communities devote knowledge, skill, and heart to helping patients on the path to recovery, a death by suicide can send ripple effects across many individuals, communities, and systems of care. The work of therapeutic risk management, and its many benefits, continues after a death by suicide. To take good care of ourselves, our colleagues, and suicide loss survivors, incorporating proactive planning, consistent open dialog, empathetic support, and outreach after a loss is essential.
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