While society has grown more open to discussions centering around suicide – both its prevention and its impact on survivors – the subject remains fraught among mental health clinicians who have treated people who have died in this manner. The death of a client by suicide can elicit in providers shock, profound sadness, guilt, anger, and anxiety, the intensity of which may rival the welter of emotions felt following the death of a family member. Many clinicians, especially trainees and early-career therapists, experience dual bereavement in such circumstances: mourning the patient coupled with loss of professional self-perception as competent and capable. Some clinicians decide to leave the field entirely following a person in their care dying by suicide (Ellis and Patel, 2012).
Leadership within mental health organizations should develop clear policies and procedures that address suicide postvention, which staff can refer to when a patient dies by suicide. Because suicide is infrequent, many organizations lack these written structures, leaving staff to attend to grief in a haphazard manner at precisely the time when guidance is vital. This article outlines three fundamental components of suicide postvention: staff support, administrative tasks, and learning.
Staff Support
According to Anderson, 2007 and Alexander, 2005 (as cited in Ellis, 2012), mental health professionals often describe feeling isolated from colleagues in the wake of a death by suicide. Fear of judgment, blame, and inadequacy can overtake clinicians, especially among staff who overestimate their ability to control outcomes, hold themselves to perfectionist standards, or overly invest their own self-worth in their clients’ wellbeing (Ellis & Patel, 2012). Prompt social support in which condolences and reassurance are offered from supervisors, mentors, and members of senior leadership can help mitigate the alienation clinicians encounter in the days and weeks following a death. It is paramount that the intent of these communications is to comfort the staff member, avoiding dissection of the record and possible missteps in treatment or safety planning. Examining the treatment course for lessons that could bolster suicide prevention within the organization will come later.
Debriefing in more depth with a supervisor–allowing space for discussion of the particulars of the case from the therapist’s perspective and the emotional ramifications of the loss– is recommended. Several conversations of this type may need to occur over weeks to ensure that the therapist has a forum to process how the tragedy has impacted their approach to therapeutic work, especially with clients who express suicidal ideation. These encounters can also help to identify staff members who may be vulnerable to complicated or prolonged grief, specifically those who have lost a family member or friend to suicide, have more porous boundaries between their personal and professional lives, or cloak their genuine feelings about the event out of fear or shame (Ellis & Patel, 2012). Linking the staff member to speak with a senior practitioner who has experienced the loss of a patient to suicide can help attenuate the isolation that many clinicians feel, giving them a longer view of how tragedies can deepen one’s understanding of the work, especially the limits of professional influence. Leadership should ensure that staff members are apprised of any employee assistance benefits offered by the organization so they can obtain, if needed, professional care and address any personal resonances a client’s death carries for them that would not be appropriately discussed in a workplace environment.
Administrative Tasks
A complicated yet unavoidable dynamic occurs following a patient’s suicide; staff reeling from the emotional fallout of the death must also contend promptly with numerous administrative and reporting responsibilities to regulatory bodies. Depending on the size of the organization and the scope of its services, these requirements may be difficult for staff to decipher and follow, especially if they have never submitted such reports in the past, compounding the stress experienced by staff members designated to fulfill this task. Leadership, specifically in compliance departments, can ease this burden by delineating very clearly in advance how and to whom deaths should be reported, as well as a timeframe for sending these communications and follow-up measures. Supervisors and managers may have more experience in these administrative domains, but they, too, can benefit from stepwise workflows pertaining to actions that must be taken following a death by suicide. While they may not have treated the client directly, they bear responsibility for supporting those staff who knew the client well, responding to staff distress, and serving as liaisons to more senior leadership, all of which require substantial emotional resources. Clear direction regarding administrative responsibility and pressure increases the likelihood that reporting processes will be completed correctly.
In some instances, such as residential settings, it is possible that a staff member may need to notify the client’s family of the death. Imparting this news may magnify many of the feelings already experienced by staff. Leadership should be cognizant of this difficulty and help the designated staff member prepare to make this call.
Organizational Learning
Gleaning lessons from suicide deaths is a vital part of postvention. Done with thoughtfulness, in a manner that eschews blame, examining the treatment course carefully can strengthen an organization’s capacity to prevent future deaths while still respecting clinicians’ sensitivities around the event. Reviews should not be completed in a cursory manner that glosses over missteps, as individual mistakes often stem from systemic processes that need refining (Ellis & Patel, 2012). For example, does the organization maintain clear directives about reaching clients who are transitioning from one level of care to another when deaths by suicide are statistically more likely to occur? Does staff know how to develop safety plans in a collaborative manner with clients so that the document becomes a true resource? Do risk assessments incorporate multifactorial elements that can contribute to suicidality, such as past attempts, substance abuse, and physical pain? A thorough analysis of the case with an eye toward identifying gaps such as these can galvanize improvements across the organization.
Who conducts the review and which sources are used in gathering information varies depending on the nature of the organization. Hospitals typically follow established Morbidity and Mortality protocols, while smaller institutions need to develop their own procedures that best suit their capacity (Ellis & Patel, 2012). Appointing a clinical leader who is not directly connected to the case to conduct the review ensures a measure of objectivity, which is necessary. Leaders might opt for the review to consist solely of a close examination of the chart or include conversations with treating clinicians and their supervisors, which can add more nuance and subtlety to understanding the treatment course, though care should be taken to approach these conversations in the spirit of learning and improvement, not criticism.
Formal reports should include the following elements: a description of the client’s initial assessment and diagnosis; a narrative of the client’s course; discussion of precursors, stressors, and chronology of events preceding the death; and reference to conversations held with relatives that occurred following the client’s passing (Ellis and Patel, 2012). Clinical leaders should use this information to generate ideas for systemic improvement, comparing the findings between reviews to identify commonalities and ameliorate clinical and operational weaknesses in suicide prevention.
Knowledge about suicide postvention should be conveyed before clinicians need to rely on it. Having a codified approach to response to suicide helps sustain and care for staff and wrestles from tragedy ideas for improving care for clients most vulnerable to it.
Andrew Pearson, MD, is Chief Medical Officer of The Jewish Board. He can be reached via email at apearson@jbfcs.org.
Reference
Ellis, T. E., & Patel, A. B. (2012). Client suicide: What now? Cognitive and Behavioral Practice, 19(2), 277–287. https://doi.org/10.1016/j.cbpra.2010.12.004
