Consortium for Defense Psychology

By Andrew Devendorf, Ph.D. 

Losing a patient to suicide is among healthcare providers’ greatest fears. But most providers are not prepared for navigating this nightmare. This can worsen the aftermath of a suicide—making it more confusing, more chaotic, and more painful. Everyone loses in this situation: providers, their colleagues, their organization, and, of course, the surviving loved ones.

Over a series of posts, I aim to demystify this important yet underdiscussed area. My hope is to alleviate some anxieties by answering some basic questions. 

These include:

• How common is it for a provider to lose a patient to suicide? 
• What is it like to endure this nightmare? 
• What are some effective ways to cope with it? 
• How can organizations provide postvention support? 
• What are the potential legal concerns of losing a client to suicide (e.g., malpractice)?

This post will address the first 2 questions.

Statistics of Suicide Loss Among Providers
Suicide is a leading cause of death in the United States. It is the 2nd leading cause of death for people ages 10-44, and the 8th leading cause of death for people ages 45-64. Many providers know these statistics, and they recite them for public health awareness. But most do so without knowing that, they too, may be affected by these tragedies.

Unfortunately, losing a patient to suicide is not an uncommon experience. A systematic review of 41 studies, across 15 countries, found that 1 in 2 healthcare professionals experienced a patient suicide across their career. When broken down by specialty, 37% of psychologists, 73% of psychiatrists, and 87% of general practitioners lost a client to suicide over their career. Among trainees, about 1 in 6 psychologists reported losing a client to suicide during their one-year clinical internship, and about 1 in 2 psychiatrists reported losing a client to suicide during their residency.

I think it’s importance to contextualize these rates and their interpretation, as they can be scary. First, these rates represent suicide loss across a provider’s career—and providers may see hundreds or thousands of patients across their lifetime. The fact remains that the likelihood of losing a given patient is still very low, so providers need not be concerned when working with a patient with suicidal thoughts. Second, these rates do not capture the level of closeness or proximity of the patient-provider relationship. For instance, the high rate of patient suicides among general practitioners is likely related to their high case load. They are more likely to see patients in brief primary care appointments rather than a long-term psychotherapy context.

A Nightmare for Providers
A patient suicide can be a tremendous loss for a provider. Like any loss, there’s no right or wrong way to grieve a patient suicide, as each one is different. On a personal level, experiencing a patient suicide simply hurts because our patients matter to us. Particularly when we develop longstanding relationships with them, such as in psychotherapy, we get to know intimate aspects of their lives.

On a professional level, we strive to provide the best care. We see people when they are struggling, when they need our help. And, if a patient dies by suicide, we might perceive it as a personal failure. In fact, even among providers who are trained in suicide prevention, research shows that they may feel a sense of responsibility, or a lack of competency, after a patient suicide. Furthermore, providers may experience a storm of thoughts and feelings related to the tragedy. I outline some common reactions below.

Thoughts, Images, and Concerns: 
“I must have done something wrong.”
“I should have seen the signs.”
“Could I have prevented this?”
“Did I miss something?” 
Replaying sessions in one’s head
Doubting one’s competence
Concerns about not knowing what to do next

Feelings: 
Guilt, self-blame 
Shame, embarrassment 
Grief, profound sadness
Confusion, shock, disbelief
Anger (at self, client, or system)
Fear of judgment, litigation, and working with future suicidal clients

Behaviors:
Withdrawing from colleagues
Second-guessing oneself 
Avoiding suicide-related topics
Over-documenting future cases
Difficulty returning to work
Hypervigilance with other clients
Changes in sleep or appetite

While I have not experienced a patient suicide, I can identify somewhat with the nightmare. I lost my brother to suicide in 2017. This loss hit me with unrivaled pain, confusion, and self-doubt. I replayed every scene with him, especially the times that he confided in me about his chronic depression. I interrogated myself, asking, "Did I do enough?" “Did I say the right things?” and "Why didn’t he feel comfortable reaching out to me?” I was not his therapist, but I was about to embark on my training as a psychologist, and my mission was to specialize in suicide prevention. Losing him made me question my ability, “Would I be capable of treating suicidal ideation?” “Would I be able to handle it?” and “Would I be able to make a difference, or would I fail my patients?”

The Need for Proactive Postvention Support
Postvention is a coordinated approach to providing support for people impacted by a suicide loss. The core components include psychoeducation, social support, and structural support (e.g., at the workplace). Postvention efforts (ideally) give a roadmap for navigating the personal (e.g., emotional), professional, legal, and administrative complications after a suicide. There should be risk management and communication protocols across all parties involved; this includes the provider, their supervisor, their team, their organization, and the patient’s loved ones.

Postvention should be proactive—not reactive. The immediate aftermath of a suicide loss can be an emotionally charged time. Preparing a plan prior to a loss can help decrease the anxiety associated with having to quickly determine necessary action steps following a suicide. It can also reduce administrative confusion and thus allow attention to be placed on the human impact.

It can be useful for providers to treat suicide postvention like fire preparation: fires are unlikely to happen, and yet, everyone should always be prepared for one. Like fire preparation, providers and their organizations should develop a proactive plan for a patient suicide. This can be a usable electronic document that is accessible to everyone in the organization. Plans could be organized into sections for the relevant audience (e.g., staff, trainees, leadership, family members) and by action items for the pertinent topics (e.g., “Communicating with Family,” “Supporting Oneself,” “Liability and Malpractice Information”). Of course, making a plan is just the first step. No different than a firedrill, organizations should hold re-occurring trainings and reminders about postvention protocols. Put simply, suicide postvention is an ongoing discussion.

Stay Tuned… 
Suicide postvention deserves more attention. And so, in later posts, I will get deeper on suicide postvention for providers.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of War.

Andrew Devendorf, Ph.D., is a Military Mental Health Psychologist with the Henry M. Jackson Foundation for the Advancement of Military Medicine. He serves as a subject matter expert in suicide prevention for the VA SAFEGUARD project.

References
Jupina, M., Mercer, M., Weleff, J., Hackett, L., Nunes, J. C., Sebastian, D., & Anand, A. 
(2024). Prevalence of patient suicide and its impact on health care professionals: A 
systematic review. Psychiatric Services, 75(10), 999-1008.
Spruch-Feiner, A., Labouliere, C. D., Brodsky, B., Green, K. L., Brown, G. K., Vasan, P.,
... & Stanley, B. (2022). Effects of patient suicide on professional practice among mental
health providers. Journal of Psychiatric Practice, 28(3), 184.

56.0% vs. 47.3%  
 

The percentage of veterans who report using mental health care versus non-veteran use, according to a study published in the journal Psychiatric Services -- Mental Health Care Use and Barriers Among Veterans and Nonveterans With Suicidal Ideation: Findings From a National Survey.

However, nearly one-third of both veterans and nonveterans reported unmet mental health needs. Veterans were less likely than nonveterans to endorse cost as a barrier to care (APR=0.65) but were more likely to endorse confidentiality concerns (APR=1.65). Fear of involuntary hospitalization and stigma were common in both groups.

By Kristyn Heins, Ph.D.  

The Suicide Prevention and Response Independent Review Committee (SPRIRC) identified a number of recommendations for improving suicide prevention efforts. Some of these included increasing suicide prevention training, improving access to resources, and promoting lethal means safety. The Consortium for Defense Psychology (CDP) has spent the past year targeting a few of these recommendations and increasing the effort to improve suicide prevention services.

One of the most notable efforts was the increase in offered trainings of Cognitive Behavioral Therapy-Suicide Prevention (CBT-SP). The CDP offered 69 CBT-SP trainings over the last 12 months. The two-day immersive training includes education on terms and theory, a specific focus on lethal means safety, and detailed review of the evidence based therapy. Participants engage in polls, small group discussions, and have opportunities to role play these new skills. Once someone has finished the two-day training, they are encouraged to engage in free CBT-SP consultation which is offered twice a week by CDP subject matter experts.

The CDP has also worked to engage adjacent providers, not just training therapists. The suicide prevention training for mental health technicians (MHTs), which is an interactive, instructor-led course, includes role play activities to reinforce learning in each of the key skills. The course provides an overview of the basic components of CBT-SP and how a MHT can support a patient engaged in CBT-SP. Additionally, a separate training tailored to prescribers provides education on the essential skills associated with suicide prevention. This includes safety planning and LMSC, while also providing modules on DOW recommendations and best practices for prescribing medication to patients experiencing increased suicide risk.

The CDP continues to evolve in how we are reaching providers. Over the past year a number of CDP Presents, our monthly webinar series, focused on suicide prevention. Inspiring presentations included navigating suicide in context of romantic relationships, Dialectical Behavioral Therapy for suicide prevention, and prevention of harmful behaviors. One of the most engaging methods of reaching providers is through the Practical for Your Practice podcast. Episodes included topics like navigating multiple presenting problems that contribute to suicide risk, personal experience of suicide loss, and firearm safety.

The CDP considered how various presenting concerns can contribute to suicide risk. Knowing that suicidal thoughts do not develop in a vacuum, we considered what other diagnoses we should be addressing. This year marked the re-launch of CBT for Chronic Pain. There were nine Cognitive Behavioral Therapy-Chronic Pain offerings this past year, each with a substantial number of actively engaged participants. The CDP has also incorporated training on Posttraumatic Stress Disorder evidence based therapies, understanding that traumatic experiences can contribute to the development and maintenance of suicidal thoughts.

We are excited for the next year and our continued push to train providers in evidence based therapies. In addition to our current efforts, we are incorporating a number of alternative learning opportunities including asynchronous training and microlearnings. We look forward to working towards the goal of expanding suicide prevention efforts and supporting our service members and veterans.

Interested in our work? Ready to join the effort? See our training calendar for a complete list of course offerings at https://cdp.usuhs.edu/training-schedule

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of War.

Kristyn Heins, Ph.D., is a Licensed Professional Counselor serving as a Military Mental Health Counselor for the Consortium for Defense Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this role, she supports the CDP’s efforts of training clinicians in evidenced-based practice focused on suicide prevention.