You Really Never Forget It!

Article in Review: Qayyum, Z., AhnAllen, C., Van Schalkwyk, G. & Luff, D. (2021). “You Really Never Forget It!” Psychiatry Trainee Supervision Needs and Supervisor Experiences Following the Suicide of a Patient, Academic Psychiatry, DOI: 10.1007/s40596-020-01394-8

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Summary
When a person who is training to become a psychiatrist experiences the suicide of a patient, the impacts are significant. In this study by Qayyum and colleagues, trainees and their supervising psychiatrists have described how a patient’s suicide has impacted their emotional state and wellbeing, their sense of efficacy, and imparted on them a sense of responsibility for the death. However, practices and protocols following a suicide death tend to be focused on administrative and analytical actions, leading to a lack of alignment between what is experienced by professionals, and how the situation is handled.

There is room to improve supervision for trainees at personal, program and system levels.

The experiences of trainee psychiatrists
It is estimated that between 30% and 60% of General Psychiatry Residents will experience patient suicide during their residency. It has been identified that a death by suicide is like to have a greater impact on professionals during their years as a trainee compared to when they are in practice. This is a significant event in the professional lives of trainees and many factors impact the overall experience of patient death.

It is hard not to feel uncomfortable about whether it is appropriate or not to include activities to prepare trainees for potential patient death by suicide. Qayyum et al., (2021) report that some programs involve curricular to help trainees prepare for death by suicide. This includes formal lectures, workshops about coping with patient suicide or opportunities to hear from the family members of patients who have died by suicide. And while some institutions have postvention protocols in place should a suicide occur, these tend to be in a reactive rather than proactive model and administrative processes tend to be more analytical than emotionally supportive. This can lead to challenging trainees feeling both unprepared and unsupported. There is significant room to improve preparedness for trainers and the supervisor and the support they are provided, at the personal, program and at system levels.

This research has sought to address and describe the experiences of supervisors from a trainee who has had a patient die by suicide. This included examples where there was shared care between the trainee and the supervisor of the patient. The study also intended to shed some light on how trainees and supervisors experience an institutional response to a suicide event, with a view to improving trainees and supervisor experience, administrative enhancements and improved institutional response.

Method
This qualitative study was set within academic hospitals in New England in the USA. Participants were current or recent graduates of a general psychiatric fellowship who have experienced the death of a patient to suicide, or the supervisors of a trainee who met the criteria. Thirteen trainees and four supervisors participated. Three of the trainees had experienced the suicide death of a patient in more than one instance. To conduct the study, the content of the 60-minute interviews was recorded and analysed.

Findings
The analysis identified that there were certain experiences unique to trainees and unique to supervisors, but also common experiences among the two groups.

A changed perspective on self-efficacy was reported by most trainees and supervisors, leading to increased anxiety related to work and increased tentativeness about clinical decision-making. After a patient’s suicide, many study participants reported increased attention to detail in documentation, particularly in relation to the assessment of safety. Most trainees and supervisors also described a sense of responsibility, indicating their perceived inability to perform a professional duty, or other actions had contributed to the death, and supervisors bore a greater burden of responsibility.

Findings were grouped into categories related to Unpreparedness (of trainees, supervisors, programs and institutions) and Mediating/ Complicating Factors.
• Participants described an intense range of emotions, including doubt, anxiety and sadness
• Participants questioned their own clinical abilities, with some reporting it impacted their subsequent practices
• Many participants connected the suicide to their own clinical decisions and felt a degree of blame
• All trainees described a lack of awareness of the process and ‘next steps’ following a suicide
• Supervisors struggled to provide a template for how they might support trainees
• Programs did not have clear standard responses
• Systems of care did not allow for adjustments of work or load to provide space after a suicide
• Supervisors felt more able to support trainees when they had experienced the death of a patient by suicide
• A societal expectation of suicide as preventable led trainees to feel guilt and question their clinical decisions
• Participants connected the intensity of their experience to specific characteristics of the patients, such as the patient being young
• A patient suicide complicated the relationship between trainees and supervisors

All participants ascribed great significance to a death by suicide, stating it had a noticeable impact on professional lives. One of the most consistent findings was that supervisors and trainees felt there was little for them to draw on, and there was a lack of policies, procedures and program detail to deploy support. Administrative reviews, formal debriefings and root-cause analytics focus much more on system issues and do not allow trainees or supervisors to assess contributing factors beyond their control. Development and adoption of clear and concrete guidelines for psychiatry training programs are necessary; to equip trainees with the resources, knowledge and confidence they need to be able to respond to patient suicide. If improvements are not made, we run the risk of fewer trainees having the confidence and desire to qualify as psychiatrists.

While we all hope that system reviews highlight the critical importance of compassionate, person-centred care, any worker engaged in suicide prevention, whether that is in psychiatry or non-clinical roles, should have the opportunity to feel supported and understood, should a person die by suicide.