Suicide of a patient affects 31–61% of psychiatry residents during training [1, 2]. Psychiatry trainees have greater negative impact than practicing psychiatrists [3, 4]. Timely oversight and support from supervisors is identified as an important and safe place to explore and process the difficult experience of patient loss due to suicide, in the clinical setting or outside it [5]. Supervisors have greater experience and knowledge that they can draw upon to provide this type of supervision, which can have a positive impact on resident experience and learning. Although the quality of supervision around such an event and the strength of the supervisory relationship have been identified as factors which may influence the trainee experience [5, 6], the key components of what such supervision entails remain unclear.

The American Psychiatric Association (APA) provides basic but important information about “Helping Residents Cope with a Patient Suicide” [7]. It addresses the common reactions trainees can expect to experience after the suicide of a patient, promoting seeking supervision to help with coping, along with questions for the supervisors and resources. However, the focus in systems and medical education as reflected by APA continues to remain on robust suicide assessments, and there is dearth of literature on how to effectively support trainees after the death of a patient by suicide.

Programs need to consider a range of factors to ensure that trainees are optimally prepared and supported following the death of a patient by suicide. These include knowledge of institutional policies and state laws regarding patient suicide, explicit efforts to prepare both the trainees and faculty, consideration of the formal procedures that follow such an event, attention to trainee wellness and support in the days following, and a well-developed process for debriefing and peer supervision.

A challenge exists in balancing any potential medicolegal ramifications of patient suicide and the need for supporting the trainee. This may discourage trainees from discussing the case broadly or in detail. However, this does not preclude the trainee being supported by the program or access additional support for their experience and emotional reactions. Much can be accomplished without disclosing confidential case-related material, the flexibility of which may also differ depending on state laws.

Empirically derived, practical approaches to improve the programmatic and supervisory support of psychiatry residents and fellows facing this challenge are needed [8]. These guidelines were derived from an empirical qualitative research project, which explored the perspectives of both trainees and supervisors. The suicide of a patient was a notable experience in the professional lives of trainees and supervisors, having significant emotional impact including shock, shame and guilt, changes in self-efficacy, and a sense of responsibility for the death of patient [6]. Although these recommendations need to be further studied and assessed for their impact on these challenges, the goal of this paper is to provide a starting point to better support programs and supervisors with the complex task of helping trainees navigate this process.

Enhance Preparedness

Prepare the Trainees

Normalize Early

Trainees need to hear from their supervisors at the outset of their training that the death of a patient due to suicide is a reality encountered by most psychiatrists.

Introduce Trainees to Faculty with a Similar Experience

Facilitating a safe and open discussion around the experiences of faculty whose patients died from suicide not only allows for greater reflection on this challenging outcome, but also serves to connect trainees with mentors they may access if faced with such an outcome. If programs do not have supervisors willing to share or have not had such an experience, then psychiatrists or other mental health clinicians in the community can be invited to consult for the training program, or available material such as “collateral damages”—video vignettes can be utilized [9].

Add to Formal Curriculum

Trainees should receive formal didactics, including case discussion, in advance of patient suicide. Having knowledge of what to expect both emotionally and administratively—including addressing areas of concern such as medico-legal ramifications—are extremely important. Previously proposed curricula such as by Lomax (1986) focus on not only preparation but also the aftermath, emphasizing individual supervision and small group meetings [10].

Prepare the Faculty

Supervision of Trainees

Faculty development should focus on informing supervisors about how to supervise trainees in the event of a patient suicide.

Navigation of Administrative Processes

Educating supervisors ahead of time about the administrative proceedings that occur within the institution in the immediate aftermath of patient death by suicide is important. This will assist them in supporting trainees through this process along with the formal and informal debriefings, meetings with risk management and legal department, and Morbidity and Mortality conferences. Program directors and supervisors should become familiar with the institutional guidance and risk management requirements in the event of patient suicide.

Formal Procedures

Notification Process

Designate the Notifier

Trainees should ideally receive the notification of the patient’s death by suicide from a supervisor or training director.

Provide Support

It is best when the notification of patient death is delivered in person directly to the trainee. However, when the notification of the patient’s death by suicide comes from indirect sources such as e-mail messages, voicemails, risk management, electronic health record notifications, etc., it is helpful to ensure the trainee also receives contact from supervisors who reach out, offer support, and check-in with the trainee as well as provide guidance about next steps.

Policy and Postvention Protocol

Develop Policies and Procedures

Although some programs have clear policy on responding to patient suicide, this is not always the case. Policies should focus on transmission of information and guidance about how the trainee involved in the patient’s care will be notified and by whom. Postvention protocols have been implemented in some US psychiatry training programs that establish line of communication from the first person to hear, to the attending psychiatrist and program director, who can then deliberate on how the trainee can be best supported [11].

Policies should include instructions for trainees about who to contact for additional support, guidance about the administrative procedures, obtaining supervisory support for communications with the patient’s family, and maximizing support for the trainee from internal and external resources, including chief residents.

Institutions should have guidelines in place regarding contact with the patient’s family which the supervisors should gain knowledge about. Families appreciate the opportunity to be heard, and have permission to process the event and to grieve [12, 13]. Contact should be initiated proactively especially if consent exists and if not, families can still be heard without confidential information being disclosed. Some families may be angry, reluctant to engage or raise the possibility of lawsuits, in which instance it is helpful to engage the assistance of the institution’s risk management, patient relations, and legal department (Table 1).

Table 1 Helpful tips for trainees for talking to the family
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Disseminate and Revisit

It is important to ensure that when these policies exist, they are disseminated and implemented consistently. These policies should be revisited periodically and new trainees and faculty are educated about them during the orientation or onboarding process

Formal Debriefing Processes

Trainee Involvement

Formal debriefing proceedings can be an important learning experience for trainees, but it is critical that guidance be given around what to expect during meetings with risk management, hospital attorneys and internal reviews or audits [6].

Support the Trainee and Team

Simple interventions such as someone other than the trainee being designated to present the case at morbidity and mortality conference/root cause analysis meetings may alleviate anxiety. Additionally, the support and appreciation of the efforts of the clinical team by institutional leadership is valuable in creating a sense of shared responsibility while taking care of high-risk patients [6]. It is also important to support faculty members, since there may be distress that is communicated as thoughts of early retirement and expressed dissatisfaction with their career [14].

Ensuring Trainee Wellness

Take a Moment—Pause

Acknowledge

In high-volume patient care environments, trainees may experience a culture of “business as usual.” In the event of patient death by suicide, it is important to create a safe space within the day’s workflow to acknowledge the event. Providing time for the trainee and supervisor to regroup and reset before returning to their obligations is critical [6].

Accommodations in Workload

Create the Opportunity for Self-care

It is a key responsibility of the program to provide the trainee with the allowance of taking time off, creating modifications in non-critical work obligations when possible, and considering changes in impending on-call shifts.

Offer Accommodations Proactively

Not all trainees will require work modifications—but most are appreciative when they are offered, and appreciate not having to be the ones to ask [6].

Identifying Supports

Immediate Supports

Program directors and supervisors should assess available supports for the trainee within the trainee’s peers, family, and outside friends. They should connect the trainee with an appropriate supervisor who has experienced a similar event [6]. This may not always be the attending involved in the specific case.

External Supports

Program directors are also instrumental in assisting trainees in accessing additional support with outside psychotherapists if indicated.

Peer Support

Minimize the Sense of Isolation

It is helpful for trainees to connect with peers who have experienced the death of a patient due to suicide. Allowing trainees with a similar experience to provide peer support may reduce the sense of isolation [6]. This may be of benefit for trainees who are reticent about discussing their experience. Hearing from others, including peers and supervisors, may facilitate further dialog.

Group Process

Trainees can utilize group meetings with their peers and/or case conferences as venues to process the experience of having a patient die by suicide with their peers [11]. Having others lead the discussion can allow the trainee to sit back, process, and share when they are ready to do so [6].

Periodic Check-ins

Program directors and supervisors should have an explicit strategy for checking in with the trainee, particularly as their experience may evolve over time. An effort should be made to sustain engagement even when trainees rotate off service. The program director should lead the process of identifying which faculty member is best suited to provide this supervision, and remain engaged in the process themselves [6].

Guidelines for Supervisors

The relationship between the trainee and supervisor plays a vital role in how the death of a patient by suicide is processed by the trainee. The supervisor creates a safe space that allows for validation of the emotions resulting from this experience, processing of the event and subsequent learning. Supervision may also provide guidance for trainees to feel empowered in asking the program for additional support if needed.

Create the Space

The space for discussion, reflection, and processing created for the trainee by the supervisor is perhaps the most crucial aspect of supervision. It is important to consider that different trainees will have their own way of making sense and dealing with patient suicide. However, structure and initiative from the supervisor may facilitate a more meaningful dialog. The trainee can then utilize this safe space based on what they need and the challenges that arise.

Validation

Humanizing the experience of patient suicide by the supervisor in a way that the trainee feels they are not the only ones to feel the way they do is very important. Supervisors should acknowledge and validate the feelings of guilt, shame, and self-doubt commonly experienced by psychiatrists after patient suicide [2]. A critical piece is the reassurance the supervisor provides the trainee that they are “good doctors,” even while they question what could be done differently in the future [6].

Processing

The supervisor’s supportive presence can allow for the trainee to process patient suicide and the loss that accompanies it. Supervisors can facilitate how the trainee understands their expectations of themselves, ensuring that they can safely explore and appreciate their own limitations. Some important considerations follow.

Review of Case

Some trainees find it helpful to have a thorough review of the case and documentation in a supportive manner by the supervisor. They can alleviate the trainee’s excessive sense of responsibility and concerns about potential liability with evidence.

Restoring Confidence

It is important for supervisors to reaffirm as much as possible that the outcome was not the trainee’s fault when applicable. Outside of gross negligence, patient death by suicide is complex and ultimately the burden of responsibility is shouldered by the institution and supervisors, not the trainee. Framing patient suicide in the context of the severity of the illness utilizing a medical model such as those used for terminal illness can be useful [15]. It is valuable when the supervisors can alleviate trainee anxiety such as being dismissed from the residency program, medico-legal ramifications, and the burden of responsibility attributable to the trainee role by addressing them clearly.

Supervisors should also monitor trainee hesitation, self-doubt, and tentativeness around clinical decision making following the death of a patient by suicide and support them while they regain sense of competence and confidence in their abilities [6].

Thoughtful Disclosure

One of the most helpful and important aspect of supervision is the thoughtful disclosure of the supervisor’s own experience of patient death by suicide. Trainees find it valuable to see a supervisor they respect and admire acknowledge similar feelings of shame, guilt, and self-doubt. A supervisor’s disclosure helps to relieve the sense of isolation experienced by the trainee, and also provides them with a framework in which to explore and process their own experience [6].

Grief and Mourning

It is invaluable when the supervisor acknowledges it as a painful experience and unequivocally permits the trainee to grieve and mourn this loss. It is helpful to frame this as a loss like any other, as trainees often express feeling sad that their patient is no longer in this world, and some think more of mortality often adding to the distress. Supervisors should highlight that this grieving process can take time and does not subside right away [6].

Self-compassion

Supervisors should emphasize the importance of self-compassion to help trainees with their self-critical thoughts. It is important to ensure that the trainee is taking care of themselves and being kind to themselves. The supervisor is well positioned to support the trainee in advocating for the supports and accommodations they need [6].

Learning

Reflection

Supervision allows time for reflection and learning that is embedded in the experience. Supervisors can facilitate this process while supporting the trainee in navigating the delicate balance of not blaming one’s self but learning.

Meaning

Periodically revisiting and assessing what form and meaning this event has taken in the life of the trainee, and what can they take with them that will help them in the future.

In summary, program and institutional preparedness to respond effectively in the event of patient death by suicide is key in supporting the trainee and supervisor impacted by this event. Within this framework of programmatic support, the trainee and supervisor can process and work through the deeply emotional impact in supervision. The authors hope that these guidelines can inform policies and postvention protocols within residency and fellowship training programs (Table 2).

Table 2 Helpful tips for program directors and supervisors
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