- Rachel Gibbons, consultant psychiatrist and chair of the Working Group on the Effect of Suicide and Homicide
Every surgeon carries within himself a small cemetery, where from time to time he goes to pray
Rene Leriche (Quoted in Do No Harm by Henry Marsh)
I was delighted to get my first consultant psychiatrist job in 2009 in an inpatient unit in inner London. In my second week, I had my first patient die by suicide. In my third week, another patient I’d treated died by suicide. In my third month, we had a very distressing and violent death by suicide of a patient on the ward. This latter death was initially treated by the police as a murder. This was a shock to me at the time, but I know now that this is not uncommon.
After my first months as a consultant psychiatrist I was permeated by the experience of suicide. I could not understand how three patients I’d treated could have died like this and felt that I must have somehow caused—or at the very least contributed to—their deaths. As a result of this belief I felt deeply ashamed, humiliated, and alone. I continued working but I was incapacitated, unable to make even the simplest clinical decision, and was terrified by every patient I had contact with. I nearly left psychiatry before my career had begun.
Many healthcare workers have been, or will be, affected by a patient’s suicide during their career. This traumatic loss has detrimental effects on the wellbeing of the workforce and staff retention, and can undermine patient care.
Nowhere to turn
In 2009 no one around me was talking about the impact that a patient death by suicide can have on clinicians. There was no help and no resources to turn to. I discovered two colleagues in similar positions and we decided to form a confidential peer support group that met monthly over the next year. Gradually, over time, I started feeling that I could continue working. This peer support group is still running 14 years later and is now being developed in other mental health settings for staff.1
After hearing from hundreds of clinicians across healthcare about the profound impact that the death of one of their patients by suicide had on them, I decided to work with colleagues to understand the scale of the problem. In collaboration with the Oxford Centre of Suicide Research, I conducted two surveys, one of psychiatrists and another of mental health professionals in general.23 The suicide of a patient had a significant impact on the emotional wellbeing of 92% of surveyed psychiatrists (105 participants), with 71% experiencing sadness, 33% fear, and 31% guilt and self-blame.2 Almost 50% (50 out of 106 participants) of mental health professionals of all professional backgrounds thought their mental health had been adversely affected by a patient’s suicide and they also reported similar feelings of sadness and culpability.3
We found that the support offered to staff after a patient’s suicide varied widely across organisations. Some reported feeling well supported by their employer, but the majority said that they received little or no support, with a few feeling blamed or even scapegoated by the organisation employing them.
The lack of support clearly has a harmful effect on the wellbeing of staff and their relationship to work and subsequent patients. This is not a cost that healthcare workers or our patients should pay. If healthcare professionals are approaching each patient with anxiety and fear, then it is unlikely they’ll be able to help reduce the psychological pain that can lead to suicide. Increasing healthcare staff’s capacity for open hearted therapeutic engagement will, however, support them in providing high quality care.
Support for all staff
Suicide is part of the human condition, and it’s important to emphasise that suicide loss is not restricted to mental health settings. Healthcare organisations should support all staff facing the fallout of suicide so that they can move forward with self-compassion and engage with future patients with empathy. Understanding, rather than blame and persecution, is needed to help everyone involved to heal.
In a step towards achieving this aim, the Royal College of Psychiatrists (RCP) published guidance for mental health organisations in January 2023 on how to support staff after the death of a patient by suicide.4 These recommendations included giving healthcare staff spaces to reflect after a patient’s suicide, adjustments to work if required, and support for the bureaucratic processes they may have to go through, including any inquiries and attending the coroners’ court. RCP suggests that all mental health organisations should employ family liaison officers, who can work with bereaved families to advocate for and support them in their grief.
These recommendations are important for all clinicians, not just those in mental health settings, and require national government support. To this end, it is encouraging that the RCP guidance was endorsed in the new national suicide prevention strategy released this month.5 The government’s new strategy offers a series of sensible recommendations that focus on reaching high risk groups and providing bereavement support. It emphasises the need to move away from tick box risk assessments towards more holistic assessment and tailored support for those who need it.
In previous years, this strategy has been a profound driver for improvements in mental health environments. Now that it has been updated for the first time since 2012, we have a real opportunity for change that must not be squandered. As the government invests in better bereavement services, we mustn’t forget that healthcare professionals also need support so that they can continue the task of caring for their patients and therapeutically engaging with those in suicidal pain and distress.
Footnotes
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If you have had a patient die by suicide please see this resource on the RCP website: www.rcpsych.ac.uk/members/workforce-wellbeing-hub/if-a-patient-dies-by-suicide
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If you’re struggling, you’re not alone. In the UK and Ireland, Samaritans can be contacted on 116 123 or email jo{at}samaritans.org or jo{at}samaritans.ie. In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counsellor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at www.befrienders.org.
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Competing interests: None declared.
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Provenance and peer review: Not commissioned; not externally peer reviewed.
