Encountering suicide in primary healthcare rehabilitation

Article in review: Lundin, A. & Bergenheim, A. (2020). Encountering suicide in primary healthcare rehabilitation: the experiences of physiotherapists. BMC Psychiatry, https://doi.org/10.1186/s12888-020-03004-1

Summary

The World Health Organisation has recognised that suicide prevention efforts are best led by primary health care staff, who have long and close contact with the community. Despite physiotherapists being likely to encounter patients who are suicidal, we know little about how physiotherapists support and treat these patients. Semi-structured interviews were conducted with 13 physiotherapists working in a primary health care setting to document and explore their experiences with suicidal patients.

___________________________________________________________________

Physiotherapists as ‘gatekeepers’

Suicidality is not often considered in relation to physiotherapy. Physiotherapists focus on the assessment of and interventions with the body and movement, however, they also often consider anatomical, physiological, psychiatric and psychosomatic conditions.

Physiotherapists provide a range of services, including body awareness training, instructions on exercises that have been recognised to assist in the treatment of depression and mental health concerns. They may also work with patient groups known to have an increased risk of suicide, such as those with multiple sclerosis, spinal cord injury, traumatic brain injury or chronic pain, among others.

Through their work, physiotherapists may be supporting people who may be suicidal or have an increased risk of suicide. Yet Lundin & Bergenheim (2020) relate that in most instances, physiotherapists receive very little training in how to best support patients who are suicidal. In some instances, they may lack the knowledge and confidence to be able to provide support and care to those at risk.

Study Aim and Participants

Being an under-researched topic, Lundin & Bergenheim (2020) reports that the aim of this qualitative study amongst physiotherapists, was to explore the experiences of encountering and treating suicidal patients. A total of 166 physiotherapists were invited to participate, with 13 involved in the resulting study. Interviews lasting between 26 and 44 minutes were conducted, during which physiotherapists were asked a series of broad questions such as:

• Which factors do you believe are of importance for preventing suicide in the primary health care sector?
• How would you describe your current competence to respond to patients who express thoughts about suicide or who have attempted suicide?

The data was analysed using Graneheim and Lundman’s content analysis approach, a system that does not use machines or software. The material was reviewed for commonalities and patterns which were categorised and coded. Researchers sought to identify common ‘red threads’ which ran through and at the heart of the discussions. The research found one common overarching theme, five categories and 15 subcategories.

Overarching theme

While they found that the level of suicide-related knowledge varied amongst survey participants, the overarching theme was “through barriers and taboos – the physiotherapist finds a way”. Participants commonly mentioned the barriers and taboos that made it difficult for physiotherapists to provide care to suicidal people. Yet despite these challenges, they were engaged in the care of their patients and often went out of their way to make sure at-risk patients were referred and directed towards other points within the healthcare system.

Possibilities for identification 

The physiotherapists reported that they did come across patients who were suicidal, often at the first point of entry of these patients into the healthcare system. Due to the nature of their work, and the frequency with which they provide care, physiotherapists often get to know their patients well. Through building this relationship they reported that often the physical symptoms turn out to “mask” mental illness.

Obstacles in meeting suicide

In their comments classified under this category, physiotherapists spoke about their own challenges, some personal and some professional, in working with suicidal people. While many felt they had a lack of professional knowledge, which in some cases made them uncomfortable to ask their patients about suicide risk, they also described discussing suicide as “taboo” and discussion around emotional wellbeing as less palpable than the physical treatments they were trained to provide.

Workplace environment matters

Many of the physiotherapists interviewed spoke about the importance of their work in providing an environment where they could debrief and discuss concerns with colleagues. The importance of collegiality and managerial support had proven critical when there had been patients who were suicidal or when the death of a patient by suicide had occurred. Many praised their colleagues and found relief in their professional relationships.

Several also mentioned workplace practices that hindered their ability to support suicidal patients, most notably related to the lack of time to spend with patients, research information or debrief with colleagues. Supporting suicidal patients also took a toll on the health of some of the physiotherapists.

Where does the patient belong?

There was another category related to the challenges in the structure of the healthcare system, and in some cases, physiotherapists felt uneasy about what to do, and unsure how to best guide the patient through the healthcare system. They also described difficulties accessing health professionals from other specialist areas, such as psychologists.

Education and experience are key

For most physiotherapists, mentorship and guidance from seniors had been highly valued and helpful. Those who had received education in mental health reported an increased awareness of mental illness and practical tools for dealing with suicidality. Work experience, having supported a higher number of patients with mental illness and more general life experiences were seen to give physiotherapists more confidence in their capacity to support suicidal people.

How this supports suicide prevention

Lundin & Bergenheim (2020) highlighted the critical opportunity that physiotherapists hold in identifying life-threatening thinking (suicidality), behind presentations for physical health support or intervention. Researchers identified several challenges and opportunities in their practice. Whilst there were questions regarding the interpretation of interviews using the qualitative content analysis method chosen, regardless, themes are consistent with previous research and highlight the importance of suicide prevention in allied health services.