Though the suicide of a patient is a risk and concern for any psychiatrist, the event may be particularly challenging for psychiatry residents. The nature of the psychiatric training curriculum encourages residents to learn quickly the skills necessary for competent patient care. However, in the aftermath of a patient suicide, residents may not yet possess the expertise to deal successfully with the tragedy. Support systems, such as the training program curriculum, colleagues, and supervisors, are crucial in providing guidance for residents.
The impetus for this article came from half of us experiencing at least one patient suicide by our third year of psychiatry training. Though the details of each incident varied, we all agreed that the experience was stressful and isolating. These memories prompted us first to explore our training program’s management of patient suicide and what supports were in place. We concluded that guidelines for both preparing us for a patient suicide and supporting us afterward were not clearly established. We then reviewed the literature to determine whether our anecdotes reflected the experiences of psychiatry trainees in general. In particular, we were interested in how these observations could be used by training programs to provide maximal support for residents.
This review article will highlight the incidence and impact of patient suicide on trainees. It will also review the current state of support systems in training programs. Finally, based on these results and our experiences, we will discuss suggestions for improving interventions that aim to support those affected by a patient suicide (also referred to as postvention practices).
We reviewed scientific literature from 1966 to 2006 using the keywords “patient suicide,” “residency training programs,” “psychiatry residents,” and “therapists-in-training.” The results reported were based on surveys, personal experiences, and case reports. The search focused on obtaining data on the incidence of suicide by patients of trainees, its impact on residents, current postvention practices, and recommendations for training programs.
The reported incidence of patient suicide during residency varies widely from 14% to 68% (1–7). Consistent incidence rates have yet to be established secondary to study limitations, such as small sample size and recall bias. A few studies have observed that residents early in training are more likely to encounter patient suicide. Ruskin et al. (2) found that 53% (39/74) of residents experienced a patient suicide in their first year of training. In another study, Brown (3) reported that 62% (8/13) of respondents encountered a patient suicide in the second year. No studies to date have examined reasons for this trend, but hypotheses include resident inexperience, lack of training in suicide risk assessment, severity of illness in the patient population, and frequent interruptions in patient care due to resident rotation. Most residents spend their first 2 years of training on rotations through inpatient and emergency psychiatry. As a result, psychiatrists with the least experience are paired with the most ill patients. More advanced residents may encounter fewer patient suicides because the outpatient focus in the latter years allows them to establish long-term relationships with patients who are more psychiatrically stable. Further research is needed to determine what role these factors play in the suicide of a patient.
Psychological Impact of Patient Suicide
When a resident loses a patient to suicide, a natural grieving process occurs. For some, the experience may have more profound personal and professional effects. Sacks et al. (4) observed psychiatry residents and described four phases of reactions following the suicide of a patient: shock and disbelief, acceptance of reality, self-appraisal, and working through to a resolution. Several studies have shown that these reactions are common. In Yousaf et al.’s (5) survey of 23 residents, 83% had an initial response of shock, and 70% experienced self-blame or guilt. In Dewar et al.’s (6) study of 48 residents, 31% suffered from anxiety, guilt, insomnia, loss of self-confidence, and preoccupations about the suicide. Ruskin et al. (2) found similar results in their study group of 74 residents/graduates: 69% reported a significant impact (including shock), 55% described recurrent feelings of horror, 44% had significant anxiety, and 71% felt helpless. For many, these symptoms persisted for more than 1 month.
For some residents, experiencing a patient’s suicide is comparable to trauma (4). The Impact of Events Scale (IES) quantifies symptoms of trauma, such as intrusive thoughts and avoidance, following a stressful event. In Chemtob et al.’s (7) study of psychiatrists, intrusion and avoidance scores after a patient suicide were similar to those of individuals who had experienced the loss of a parent. Ruskin et al. (2) found that nearly a quarter of their sample had mean overall IES scores that were clinically significant for stress. Twenty-two percent of residents met DSM-IV diagnostic criteria for posttraumatic stress disorder, and 20% met criteria for acute stress disorder. Yousaf et al. (5) reported similar findings: 52% of residents had total IES scores in the “clinically stressed” range, and approximately 29% of residents had significant symptoms up to 2 weeks after the suicide. Additional research to explore the role of factors, such as the nature of the suicide, demographics of the resident/patient population, and availability of support systems, is needed to elaborate further on these findings.
The psychological impact of patient suicide can also affect a resident’s professional development (3). This point is illustrated in the following personal account from one of the authors of this article (L.B.T.), written in response to the suicide of one of his patients during his first year of residency:
Initially, after the news I was shocked. Then, over the coming weeks, I felt even more guilt over the suicide, wondering what I did wrong and what I could have done differently to prevent this tragedy. I even questioned my career choice. Finally, I feel that in reaction to this suicide I became even more cautious, perhaps overly cautious, when initiating treatment plans for patients, admitting more patients from the emergency room to the inpatient unit, and keeping patients in the hospital longer before discharging them.
In the previously mentioned study by Dewar et al. (6), 39% of residents reported having problems at work. In addition to increased anxiety, they described difficulty with decision-making, and hospitalized their patients more frequently in order to prevent another suicide. Finally, up to 9% of them contemplated a career change, demonstrating the importance of recognizing the impact of suicide on trainees.
Devising and implementing a suicide postvention protocol for psychiatry training is a challenging task. The process requires balancing the educational needs of trainees with the department’s administrative interests. If resident support is underemphasized, adverse psychological impact is more likely. Following a patient suicide, residents are hesitant to seek assistance because of their sensitivity to criticism from colleagues and supervisors (2). If they also perceive a lack of support from their program, they are more likely to suffer through the experience alone and encounter the symptoms described earlier (2, 4).
Current support systems for residents appear to be minimal. Ellis et al. (8) reviewed postvention practices in U.S. psychiatry training programs and found that they were significantly lacking in formal suicide training and guidance for residents. This finding reflects a paucity of uniformly set protocols in training programs nationwide. The authors also reported a marked discrepancy between recommending and requiring postvention practices, such as supervision or individual therapy. On the other hand, programs did consistently implement critical incident reviews, suggesting an emphasis on medico-legal issues over resident support. These findings question the adequacy of support systems for residents following such an important event.
After the suicide of a patient, one of the responsibilities of a psychiatrist is to contact the family of the patient (9). This task can be especially daunting for residents because of their relative lack of experience. One of the authors of this article (S.N.) recalls the first time that she was placed in this position:
In my first year of psychiatry training, a patient committed suicide while I was on call. Since I was the in-house psychiatrist, I was asked to speak to the victim’s family members who were present. I had never even met the patient! I remember this task being quite scary, and I felt truly unprepared and unsure of what to say or do in this situation.
This review found only one study that specifically explored psychiatrists’ contact with the families of patients who committed suicide. In that report, Brownstein (10) surveyed 10 psychiatrists and 32 psychiatry residents about their experience with patient suicide. In the first part of the survey, they were asked about their interactions with the patient’s family after the suicide. Only one out of 12 providers contacted the family, and this psychiatrist cited fear and a sense of obligation as reasons for reaching out to them. Some of the reasons given by the providers who did not contact the families included “I had never met them before,” and “I thought they would blame me and be angry with me.”
Brownstein also surveyed the families of the patients about their interactions with the psychiatrist. Only three of the families had contact with the psychiatrist, but almost all of them wanted to be contacted. Reasons hypothesized by the families to explain the lack of contact included guilt, fear, and lack of concern by the psychiatrist. Eight of the families felt that the psychiatrist was partly responsible for the suicide.
Despite the limitations of this survey, the results indicate that psychiatrists do not usually contact families after a suicide; however, families wish to be contacted. It is important to offer families the chance to process their reactions to the suicide, since they are at risk for pathological grief reactions, depression, and suicide. Brownstein recommends that any program in suicide care provide guidance in how to work with families. In particular, residents could benefit from training in speaking with families, understanding their reactions, attending funerals, and reviewing autopsy reports (9).
In today’s medico-legal climate, it should be noted that the desire to talk to the patient’s family may unfortunately have legal consequences. Communications with the family regarding the suicide may be discoverable in legal proceedings. At the same time, talking to the family may actually lower the chances of litigation. This dilemma, and the lack of clear guidelines on how to proceed, adds to the confusion during an already stressful time. Questions about legal issues should be directed to a qualified professional, such as risk management or an attorney.
Supervisors play an essential role in providing guidance to residents throughout this process. Residents report that increased distress is associated with a lack of support from their supervisors (11). When supervisors share their sense of responsibility and guilt, residents feel relieved and less isolated (4). They can normalize the experience and reduce the stigma of suicide by talking about what happened to other residents in similar circumstances. Some authors recommend that the supervisor contact the resident immediately after the suicide to offer emotional and professional support (2, 4). After checking in with the resident, issues to address include reviewing the case and preparing for the critical incident review. In particular, supervisors should explain the purpose, procedures, and possible outcomes of the meeting. Residents should be reassured that the meeting is not meant to be a witch hunt, but an opportunity to review the care that was provided. Supervisors can outline some of the questions that will be asked and role-play with the resident on how to answer them (12). Whenever possible, the supervisor should attend the meeting for additional support.
Supervisors can also offer a referral for personal therapy as a means for further assistance. Aside from the obvious benefit of giving the resident another outlet for working through, statements that the resident makes about the case with his or her therapist are guarded by doctor-patient rules of confidentiality (12).
The Role of Training Programs
There is currently no requirement by the Residency Review Committee that education about suicide, also called suicide care, be taught in psychiatry training programs. Although emergency psychiatry is a required rotation, there are no specific guidelines for suicide education (13). In his proposal for a curriculum on suicide care, Lomax (14) recommends that this topic be recognized as a core component of psychiatry education.
Surveys of psychiatry training programs have found great variability in suicide care education and practices following the suicide of a patient. In Pilkinton and Etkin’s (1) survey, only one-third of residents received education on the impact of suicide on trainees, and one-third of program directors reported having a policy in place in the event of patient suicide. Ellis et al. (8) found that only one-half of training programs provided residents with advance guidance for a possible patient suicide, and even fewer programs outlined postvention protocols.
A curriculum in suicide care is essential for preparing residents for future work with suicidal patients, but little has been written about its implementation into resident education (14). Even fewer proposals for such a curriculum are based on direct research. There are two studies that specifically examine the resident experience of patient suicide and propose corresponding components for a curriculum. Ellis et al. (8) surveyed 166 child and adult psychiatry programs about suicide care education and postvention practices. The results of their survey indicate that most programs provide this training through seminars and clinical supervision, which may be superficial in nature. Ellis suggests that “skill-building workshops” be used in conjunction with lectures to allow residents to directly practice skills under live supervision.
Brown (3) surveyed 39 psychiatry graduates about their experience with patient suicide during residency. He proposed a five-phase scheme for training program preparation and response to this event based on the survey results. Brown emphasized that while most programs use critical incident reviews after a patient suicide, it is important that they be an opportunity to address residents’ emotional and educational needs, instead of trying to assign blame to one party.
Finally, residents typically turn to their colleagues for support before looking to their supervisors or training director. Thus, training programs should work to foster peer, mentoring, and supervisory relationships. They also need to disseminate information about the availability of personal therapy and employee assistance programs, of which many residents are unaware (1).
Though much has been written about the assessment of suicide risk, relatively little attention has been directed to the psychiatrist’s experience of patient suicide. Even less literature describes the impact on psychiatry residents, and the studies that do exist provide mostly observational data, raising many questions without answers. The patients that psychiatry residents treat are among the most ill and are at the highest risk for suicide. Studies indicate that up to 68% of psychiatrists experience the suicide of a patient while in residency. Unfortunately, residents have very little preparation for dealing with the tragedy. Most training programs do not have protocols in place for preparing residents for the possibility of patient suicide or managing the events afterward. Common reactions to suicide include feelings of guilt, anger, inadequacy, and isolation. Without intervention, symptoms can be enduring on a personal and professional level.
The recommendations described in this article vary from individual work with mentors to the implementation of protocols on an administrative level. Based on the limited data available and our personal experiences, suicide care education and individual supervision should be components of every training program. In the first year of residency, trainees should receive general education about suicide. This information can be effectively conveyed through lectures and open discussion in small groups. In particular, residents should hear about risk assessment, the possibility of losing a patient to suicide, reactions that they can expect to have, and issues that they will face afterward.
Once a resident experiences a patient suicide, his or her mentor, supervisor, or training director plays an essential role in providing support. This person should therefore be someone whom the resident knows reasonably well and trusts. The mentor should immediately arrange a meeting to debrief and process the event. Subsequent meetings should address other complicated issues, including how to talk to the family and whether to attend the funeral. The mentor should assist in preparing for the critical incident review and attend whenever possible.
Finally, the training program should delineate a protocol for the events following a patient suicide. It should address administrative issues, such as who should be notified, whether a critical incident review will occur, and who will attend. Consistent implementation of such a protocol helps to decrease confusion during an already stressful time.
In summary, dealing with the suicide of a patient is an important aspect of psychiatry training. Residents, however, need more guidance and support to navigate this challenge. Ultimately, it is the process of working through such an experience that enables a psychiatrist to grow both personally and professionally.