STAFF RESPONSE TO INPATIENT AND OUTPATIENT SUICIDE: WHAT HAPPENED AND WHAT DO WE DO? J. D. Little
Inpatient or outpatient suicide may have a marked effect on the staff or therapist. After reviewing the literature, a practical, clinically-based protocol for managing such an event is described. Additionally, it places one event, the psychological autopsy, within the general context of post-suicide management. Australian and New Zealand Journal of Psychiatry 1992; 26:162-167 A recent suggestion to introduce a suicide audit to the Department of Psychological Medicine at Dunedin Hospital involved a review of the literature. Although much is written on suicide assessment, prediction, management and outcome, there is little written on the impact on the staff who have been dealing with the suicide victim. The sparsity and difficulty with which articles were found prompted this summary. It will describe the available literature and place the autopsy within the overall context of post suicide management. Further, it will propose practically based answers to two questions that staff may ask after a suicide - What happened? and What do we do?
Course of events From the isolated reports that have described what has happened following a suicide there appear to be three phases that individual clinicians pass through, and that each phase has a relatively agreed time frame [ 1,2]. They may be listed as follows: 1. Phase I occupies the initial week. It is characterised by a stunned sense of disbelief and bewilder-
Department of Psychological Medicine, Dunedin Hospital, Dunedin, New Zealand J. D. Little MBChB
ment, a general sense of loss of control and a fear that other suicides would occur immediately. 2. Starting in the first week, and continuing over the next two months, Phase I1 is characterised by turmoil. It is the most difficult stage, involving at times overwhelming feelings of anger, guilt, anxiety and depression. Staff feel exhausted and demoralised, doubting their own judgement. Personal issues, losses and conflicts may re-emerge. The rate of sick leave and absenteeism increases. 3. Phase 111 extends over 2-6 months. The intensity of the turmoil lessens and the opportunity for growth or for prolonged disability arises. This course of events is not dissimilar from that described by crisis and bereavement theory. It is proposed that management is most likely to be effective to the extent that it addresses the specific needs of each phase and Table 1 details the suggested protocol on this basis. Timing should remain flexible however, given the likelihood that individual staff members may pass through each phase at different rates.
Experiences of other therapists The experiences described by clinicians whose patients had committed suicide are also instructive. Litman [3], who personally reviewed 1000 suicides
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J. D. LITTLE
involving 200 therapists, observed the following staff reactions: 1. Feelings of professional incompetence. “Did I listen?” “Did I try hard enough to understand?” “Was there something in me that didn’t want to hear what he or she was saying?“ 2. Loss of professional standing. “Will other patients trust me?” ”Will they ask embarrassing questions’?” “Will there be reproaches from relatives or the Court?” 3. Denial. “Are you sure it was suicide?” 4. Anger. At colleagues, patient or spouse. This has been tumed against patients in the form of unwise discharges or other punitive and restrictive actions. 5. Guilt. Frequently taking the form of attributing blame for the suicide, often disguised as sophisticated psychological analysis or increased work with other suicidal patients. It is important to provide an opportunity for the individual clinician and staff member to deal with these feelings. It is equally important to limit the destructive manifestations, particularly of self blame, and criticism of colleagues. On this last point, it is useful to be reminded of an inevitable aspect to suicide.
Expectations of preventingsuicide With a high risk of suicide, it is presumed that hospitalisation will decrease that risk and suicide by an inpatient will therefore evoke a greater sense of concern. Further, Barraclough et al. [4] clearly demonstrated that treatable psychiatric disorder has been responsible for a significant proportion of suicides [4].The author does not wish to detract from the important principle that suicide may be preventable in mmy people with treatable psychiatric disorder. However, what is equally clear is that, at a population level, there is an inevitability about suicide. That is, a proportion of patients will commit suicide regardless of preventive and treatment measures. The following studies are informative. I . Hospital suicide rates are at least 5-10 times higher than the general population and over the past 75 years the frequency of inpatient suicides has been remarkably constant, despite a wide range of therapeutic ideologies and methodologies [I]. 2. Although the accuracy by which suicides may be predicted varies, Pokomy [5] prospectively studied 4800 veterans over 5 years, of which there were 67 suicides, While controlling for prevalence and using a
163
wide range of instruments, measures and risk factors, they were only able to predict 50% of the suicides. Additionally, it was at the expense of 1200 false positives. All attempts to identify specific individuals were unsuccessful. Others note some of the difficulties inherent in making such predictions [6]. 3. Chemtob C I a/. [7] studied 259 randomly selected psychiatrists. looking at suicides that took place while the patients were actively in treatment. The mean age of psychiatrists had been 50.9 years and they had been in practice for a mean of 11.3 years. Fifty percent reported having had a patient who had committed suicide at some time, and the probability of subsequent suicide was 55%. Interestingly, there was no significant relationship between the age or years in practice of those with or without a patient committing suicide. 4. Schwartzeral. [8]reviewed 1 1 suicides and found that the circumstances of each case differed from the preceding ones so much that measures taken to prevent one episode would not have prevented those that followed. This concept has been discussed in terms of crisis probability and subsequent strategies for preventive intervention. The predictability and frequency of any single crisis determines choice of strategy. Anticipatory intervention, with modification of the hazardous situation, is applicable when that situation is predictable and frequent. However, with infrequent and unpredictable situations, as in suicide, participatory intervention is the most applicable. Here the strategy is aimed at reducing the individual’s vulnerability and increasing their coping capacity with the use of interpersonal peer support (91. The concept that there is an inevitable aspect to suicide in spite of good care is an important one to discuss with the individual therapist and/or the treatment team.
staff support Phase I1 is characterised by turmoil. The prospect of a psychological autopsy appearing as an isolated but focused departmental event may represent an additional difficulty for the team who had been caring for the victim. It is suggested that an audit should be but one aspect of post suicide management, that part which specifically deals with staff education. Equally important is a second aspect, that of staff support. The author was unable to find any study pertaining to the use of a formal support system during this time,
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STAFF RESPONSE TO INPATIENT AND OUTPATIENT SUICIDE
and thus it is not clear that such a system would necessarily be more effective. However, the literature was agreed that informal peer support was found to be extremely valuable. This apparently loosely organised method should be legitimised as a valid option for providing support by and for colleagues. Additionally, it may be augmented by outlining the material presented here and separating the therapist’s responsibility to a patient from the patient’s own responsibility for his or her actions.
Audit materialand accurate recall In preparation for an audit, especially in relation to an outpatient suicide, no information is available as to the deceased’s thoughts immediately preceding the event. These Shneidman [ 121 refers to as “... private, inner, wholly psychological experiences, experienced introspectively by the individual ...” and stand in contrast to those signs that are “... perceived, inferred or assessed - by others ...” As a contributor to the Los Angeles Coroner’s Office, Shneidman comprehensively details the data that is collected, albeit retrospectively, in order to determine the answer to three questions - Why did the individual do it? How did the individual die? and What was the most accurate mode of death - accident or suicide? The outline represented a standard case history, but particular attention was paid to the following: 1 . Details surrounding the circumstances of the suicide. 2 . The victim’s personality, life style and typical patterns of reaction to stress and emotional upset, including his or her alcohol and drug use. 3. Any recent stressors or recent achievements and plans, recognising that the contemplation of suicide is usually a complicated internal debate reflecting profound psychological ambivalence. 4. Any changes in the victim’s habits, patterns or routines before death. 5 . The nature of his or her personal or professional support network and what their dreams, thoughts or fears relating to death, accident or suicide were. The information is obtained from persons that knew the deceased - the spouse, children, parents, friends, neighbours, work-mates - and an attempt is made to reconstruct the lifestyle of the deceased, focusing in particular on the period just prior to death. From this an extrapolation of the victim’s intention or behaviour is made. Shneidman cautions that the outline should
not be followed in any rigid manner. Rather, the person who conducts the interview should be sensitive to the bereaved, aware of their possible needs, while at the same time quietly listening and obtaining information that might cast light on the victim and the suicide. Data is thus collected retrospectively and often from a bereaved informant. Brent [lo] has attempted to determine the accuracy of this recall in adolescent suicides. He interviewed the parents at their homes two and six months after the event, and compared this diagnosis to the “best estimate diagnosis” summated from siblings, peers, teachers, school reports and medical records. Agreement between them was high, but parental information singly contributed more information that the other sources, although still underestimating the disorders of affect and substance abuse in their offspring. Additionally, he found that there was no difference interviewing at two or six months, suggesting the usefulness of the audit during Phase 111.
Counter-transference As it may be instructive to review the deceased’s story up to and including the suicide, so it may be informative to reflect upon the therapeutic relationship. Modestin 1141carefully studied the case histories of 149 inpatient suicides including the psychological exchanges recorded in the progress notes between patient and therapist. He suggested that 6% were ass o c i a t e d w i t h u n r e c o g n i s e d f a i l u r e s in t h e psychotherapeutic relationship. “Suicide may be an iatrogenic event ... These failings may not only be based on lack of clinical skill and knowledge, or on rational use of an inadequate technique, but also on the therapist’s insufficiently controlled counter-transference problems” [ 151. He provided a series of clinical vignettes that focused around four recurrent themes relating to an inability on the part of the therapist (1) to cope with the patient’s anger and hostility, ( 2 ) to tolerate the patient’s dependency, (3) to handle the erotic transference, and (4) to maintain a central loyalty towards the patient, especially when significant others are invited to participate in therapy. Hence therapists, attempting to contain their own anxiety and pessimism, may negate their own patient’s suicidal potential and unwittingly allow the act to occur. He suggested minimising such reactions by continued self monitoring, especially when the work is associated with the above scenarios; by supervision; and by limit-
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J. D. LITTLE
Table I .
Phase
Phase duration
Event
Agenda
Timing of event
1st week Staff
Facts As soon meeting General as possible remarks ‘Front person’ Rituals At risk patients
1st two months
2-6 months
StaffFacts patient Feelings meeting Safety Rituals
As soon as possible
Staff Specific meeting patients Underlying principles Overview of protocol
As soon as possible
Experiences From Staff meeting Expectations second week, as required thereafter Suicide autopsy
Confidentiality What happened? What can be learnt?
Decided by Unit around 3 months
ing the number of seriously suicidal patients that are treated by any one therapist at one time. Counter-transference reactions remain a potentially difficult area for a therapeutic team to consider, especially in a public forum, thus highlighting the need for constructive criticism.
Constructive criticism Grol et a1 [ 111 in a study of a GP audit, noted that 90% of their trainees participated in the review compared with only 50% of the principals. Many had felt threatened prior to involvement, but this was reduced after the first session. They emphasized the introduction of the audit early in training, and the ways in which criticism is given and received, as being essential. Comments should be detailed and based on con-
I65
crete criteria to avoid being subjective and non-committal. Comments should be positive and stimulating, emphasising strengths as well as weaknesses. Careful attention to this aspect prior to the audit maintained a sense of being open to criticism and thus open to change.
Criteria Finally. the audit is an educational opportunity in order to review policy, treatment and training. It necessarily focuses on the way suicidal patients are managed. In the GP audit cited above, the authors warn against “re-inventing the wheel” and “getting bogged down” in constructing unsound criteria which are only valid within the group that composed them. It is suggested that at a collaborative level involving all staff, clear-cut guidelines as to the assessment and management of suicidal patients be developed. Although this is beyond the scope of this article, it is usefully discussed by Morgan [ 131 and Cheung (submitted for publication) who maintain a balance between the new “open door” policy while recognising its practical limitations.
Underlying principles From the above, a number of themes can be derived that underlie staff management following a suicide. 1. There are two distinct but equally important aspects of post suicide management: (a)The psychological autopsy, which addresses staff education, and (b)Staff support, in which infornial peer support is invaluable. 2. The post suicide time is a potentially vulnerable time for all staff. (a)Discussion should focus on events, not personali ties. (b)All authors caution against meetings that focus exclusively on feelings. These consistently appear to exacerbate rather than ameliorate guilt and blame. 3 . Confidentiality - of staff and of the deceased. 4. The course of events and staff experiences are in general predictable and time limited. 5. Reconstructing the events is restricted by reliance on retrospective extrapolation. 6. The reality of suicides and suicide prevention.
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STAFF RESPONSE TO INPATIENT AND OUTPATIENT SUICIDE
It is from these that the following practical, clinically based protocol is suggested which allows for flexibility and use in a small General Hospital.
4. Finally, all the patients are invited to express their sympathy to the family and to attend a brief ward service to be arranged within the subsequent two weeks.
Protocol Stuff meeting
Phase I tiritial s r u nicetirig ~ The term “StaR’ is used here to include non-medical personnel who may have had an important relationship with the deceased. but it is important to be aware that for some, it may be their first acquaintance with death. 1. All staff can be sources of information and misinformation, and it is important to minimise confusion and rumours. Once accurate information has been obtained, details of the suicide should be communicated as soon as possible. 2. General remarks usefully include an overview of the protocol and hence an indication of what to expect. Additionally they emphasise the underlying principles noted above. 3. A “front person” should be designated to liaise with the family, police, pathologist and other involved parties. All enquiries should be directed to him or her. 4. Participation in the rituals of death (e.g. sending cards or flowers, attending the funeral) is invited. It is this factor that others have reported was the turning point when numbness ended and feelings returned. It helped to bring a psychological closure to the event. 5. A completed suicide increases the risk for other suicidal patients. In preparation for the staff-patient meeting to follow, a note should be made of those who are most vulnerable. The staff can then assess their reactions and response to the news.
Striff-patient meeting Bad news spreads quickly and the staff-patient meeting, which all should attend, should follow on as soon as possible. 1. While maintaining confidentiality, the relevant facts should be communicated to the remainder of the ward and questions answered in a matter-of-fact way. 2 . An opportunity to express feelings should be given, while monitoring those most at risk. 3. People should be told that they themselves will be safe, with staff reviewing whether or not any changes to their management are needed.
A brief meeting following the above. 1. To attend to any specific concerns regarding individual patients. 2 . To re-emphasise the underlying principles, in particular, the legitimisation of informal peer support. 3. To review the protocol, and to decide a time for the next staff meeting.
Phase I1 (1st week and up to the first two months) Staffnieetitig(s) Following any ward funeral, it is important that there is at least one further staff meeting, arbitrarily at two weeks. This is a potentially vulnerable time for all staff members. The following is suggested as contributing to staff support: 1. Utilisation of the informal network. 2 . An appreciation of what others have experienced and for how long. 3. Realistic expectations of suicide and suicide prevention. 4. Incomplete resolution of this phase leading to incapacity characterised by the personal experiences described above beyond two months, is an indication for referral. Having been made aware of the above, a therapist may recognise a problem for him or herself. Alternatively, he or she may need to be sensitively and supportively approached by another member of the Team. The referral may be directed within or outside the department, and may be that person’s supervisor, a clinician specifically interested in such referrals, or an independent therapist chosen and approached at the time. Choice is determined by personal and individual circumstances. The outpatient suicide is potentially an isolated experience for the therapist as no other clinician may have been involved in that victim’s care. It is difficult in a practical sense to provide a separate system for this situation. It is suggested however, that the individual therapist is likely to progress through the same phases as noted above, and further, that the same protocol is applicable.
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J. D. LITTLE
Phase 111 (two - six months) Over the ensuing two to six months, the intensity of the turmoil lessens. It is during this phase that the psychological autopsy is most usefully placed. The exact timing should be left to the individual Unit to choose on the basis of staff morale and when any perceived threat has abated. Where morale is low, it is suggested that the team resolve their own difficulties with the case prior to the autopsy and that the audit chairperson be made aware of this.
AudR procedure 1. Most facilities are already busy and incorporating the autopsy into an already regularly convening format, e.g. a weekly Departmental Round, may be expedient. Alternatively, a separate annual or biannual session can be introduced specifically for the psychological autopsy. 2. The chairperson may be from within or outside the Hospital, specifically interested in suicide review, appear as the weekly Departmental Round chairperson, or be chosen per individual case. 3. The general principles noted earlier may usefully serve as introductory comments by the designated chairperson. 4. A brief, 5-10 minute synopsis is then presented by a person directly involved in management. It may be either the consultant or the registrar. It addresses the question, What happened to this patient that resulted in suicide? 5. More than one case may be presented at one meeting, lessening any sense of personal failure and creating an opportunity for finding any pattern that may emerge. In addition, referral to pre-determined criteria for the management of suicidal patients allows modification where applicable, but also serves as a reminder as to what these criteria were. It is a response to the question, What can be learnt? 6. Finally, the involved team members may meet after the autopsy in order to clarify or respond to comments made.
Final remarks Suicide is a major event, not only for the family, but also for the staff who have been involved in the pre-
I67
vious care of the deceased. The psychological autopsy does not exist in isolation, but as an educational opportunity most usefully placed at between two and six months after the event. The intervening interval is important as it allows time for staff members to support one another and time for constructive reappraisal of the preceding events. It is hoped that this protocol will be of practical assistance when, following a suicide, the questions are asked What happened? and What do we do?
Acknowledgements Thanks are extended to my family, typist MaryAnne Jensen, and to my colleagues for helpful comments.
References I . Cotton PG, Drake RE, Whitaker A. Potter J. Dealing with suicide on a psychiatric inpatient unit. Hospital and Community Psychiatry 1983; 34: 55-59, 2. Hodgkinson PE. Responding to inpatient suicide. British Psychological Society 1987; 60: 387-392. 3. Litman RE. When patients commit suicide. American Journal of Psychotherapy 1965: 19: 570-576. 4. Barraclough B. Bunch J. Nelson V. Sainsbury P. A hundred cases of suicide: clinical aspects. British Journal of Psychiatry 1974: 125: 355-373. 5. Pokorny AD. Prediction of suicide in psychiatric patients. Archives of General Psychiatry 1983; 40:249-257. 6. Pallis DJ, Gibbons JS, Pierce DW. Estimating suicide risk among attempted suicides. British Journal of Psychiatry 1984: 144: 139148. 7. Chemtob CM, Hamade RS. Bauer G. Kinney B. Torigue RY. Patients’ suicides: frequency and impact on psychiatrists. American Journal of Psychiatry 1988; 145:224-228. 8. Schwartz DA. Flinn DE. Slawson PF. Treatment of the suicidal character. American Journal of Psychotherapy 1974; 2X: 194-207. 9. Schulberg HC. Sheldon A. The probability of crisis and strategies for preventive intervention. Archives of General Psychiatry 1968;
18:553-S58. 10. Brent DA. Perper JA, Kilko DJ, Zelenak JP. The psychological autopsy: methodological considerations for the study of adolescent suicide. Journal of the American Academy of Child and Adolescent Psychiatry 1988; 27362-366. I 1. Grol R. Van Eijk J, Mesker P. Schellevis F. Audit: a project on peer review in general practice. Family Practice 1985; 2:2 19-224. 12. Shneidman FS. Suicide and the psychological autopsy. International Psychiatric Clinics 1969; 6:225-250. 13. Morgan HG. Death wishes? The understanding and management of deliberate self harm. Chichester: J Wiley & Sons, 1979:70-74. 14. Modestin J. Counter transference reactions contributing to completed suicide. British Journal of Medical Psychology 19x7; 60:379-385.
Downloaded from anp.sagepub.com at University of Manitoba Libraries on June 9, 2015
Inpatient or outpatient suicide may have a marked effect on the staff or therapist. After reviewing the literature, a practical, clinically-based protocol for managing such an event is described. Additionally, it places one event, the psychological autopsy, within the general context of post-suicide management. Australian and New Zealand Journal of Psychiatry 1992; 26:162-167 A recent suggestion to introduce a suicide audit to the Department of Psychological Medicine at Dunedin Hospital involved a review of the literature. Although much is written on suicide assessment, prediction, management and outcome, there is little written on the impact on the staff who have been dealing with the suicide victim. The sparsity and difficulty with which articles were found prompted this summary. It will describe the available literature and place the autopsy within the overall context of post suicide management. Further, it will propose practically based answers to two questions that staff may ask after a suicide - What happened? and What do we do?
Course of events From the isolated reports that have described what has happened following a suicide there appear to be three phases that individual clinicians pass through, and that each phase has a relatively agreed time frame [ 1,2]. They may be listed as follows: 1. Phase I occupies the initial week. It is characterised by a stunned sense of disbelief and bewilder-
Department of Psychological Medicine, Dunedin Hospital, Dunedin, New Zealand J. D. Little MBChB
ment, a general sense of loss of control and a fear that other suicides would occur immediately. 2. Starting in the first week, and continuing over the next two months, Phase I1 is characterised by turmoil. It is the most difficult stage, involving at times overwhelming feelings of anger, guilt, anxiety and depression. Staff feel exhausted and demoralised, doubting their own judgement. Personal issues, losses and conflicts may re-emerge. The rate of sick leave and absenteeism increases. 3. Phase 111 extends over 2-6 months. The intensity of the turmoil lessens and the opportunity for growth or for prolonged disability arises. This course of events is not dissimilar from that described by crisis and bereavement theory. It is proposed that management is most likely to be effective to the extent that it addresses the specific needs of each phase and Table 1 details the suggested protocol on this basis. Timing should remain flexible however, given the likelihood that individual staff members may pass through each phase at different rates.
Experiences of other therapists The experiences described by clinicians whose patients had committed suicide are also instructive. Litman [3], who personally reviewed 1000 suicides
Downloaded from anp.sagepub.com at University of Manitoba Libraries on June 9, 2015
J. D. LITTLE
involving 200 therapists, observed the following staff reactions: 1. Feelings of professional incompetence. “Did I listen?” “Did I try hard enough to understand?” “Was there something in me that didn’t want to hear what he or she was saying?“ 2. Loss of professional standing. “Will other patients trust me?” ”Will they ask embarrassing questions’?” “Will there be reproaches from relatives or the Court?” 3. Denial. “Are you sure it was suicide?” 4. Anger. At colleagues, patient or spouse. This has been tumed against patients in the form of unwise discharges or other punitive and restrictive actions. 5. Guilt. Frequently taking the form of attributing blame for the suicide, often disguised as sophisticated psychological analysis or increased work with other suicidal patients. It is important to provide an opportunity for the individual clinician and staff member to deal with these feelings. It is equally important to limit the destructive manifestations, particularly of self blame, and criticism of colleagues. On this last point, it is useful to be reminded of an inevitable aspect to suicide.
Expectations of preventingsuicide With a high risk of suicide, it is presumed that hospitalisation will decrease that risk and suicide by an inpatient will therefore evoke a greater sense of concern. Further, Barraclough et al. [4] clearly demonstrated that treatable psychiatric disorder has been responsible for a significant proportion of suicides [4].The author does not wish to detract from the important principle that suicide may be preventable in mmy people with treatable psychiatric disorder. However, what is equally clear is that, at a population level, there is an inevitability about suicide. That is, a proportion of patients will commit suicide regardless of preventive and treatment measures. The following studies are informative. I . Hospital suicide rates are at least 5-10 times higher than the general population and over the past 75 years the frequency of inpatient suicides has been remarkably constant, despite a wide range of therapeutic ideologies and methodologies [I]. 2. Although the accuracy by which suicides may be predicted varies, Pokomy [5] prospectively studied 4800 veterans over 5 years, of which there were 67 suicides, While controlling for prevalence and using a
163
wide range of instruments, measures and risk factors, they were only able to predict 50% of the suicides. Additionally, it was at the expense of 1200 false positives. All attempts to identify specific individuals were unsuccessful. Others note some of the difficulties inherent in making such predictions [6]. 3. Chemtob C I a/. [7] studied 259 randomly selected psychiatrists. looking at suicides that took place while the patients were actively in treatment. The mean age of psychiatrists had been 50.9 years and they had been in practice for a mean of 11.3 years. Fifty percent reported having had a patient who had committed suicide at some time, and the probability of subsequent suicide was 55%. Interestingly, there was no significant relationship between the age or years in practice of those with or without a patient committing suicide. 4. Schwartzeral. [8]reviewed 1 1 suicides and found that the circumstances of each case differed from the preceding ones so much that measures taken to prevent one episode would not have prevented those that followed. This concept has been discussed in terms of crisis probability and subsequent strategies for preventive intervention. The predictability and frequency of any single crisis determines choice of strategy. Anticipatory intervention, with modification of the hazardous situation, is applicable when that situation is predictable and frequent. However, with infrequent and unpredictable situations, as in suicide, participatory intervention is the most applicable. Here the strategy is aimed at reducing the individual’s vulnerability and increasing their coping capacity with the use of interpersonal peer support (91. The concept that there is an inevitable aspect to suicide in spite of good care is an important one to discuss with the individual therapist and/or the treatment team.
staff support Phase I1 is characterised by turmoil. The prospect of a psychological autopsy appearing as an isolated but focused departmental event may represent an additional difficulty for the team who had been caring for the victim. It is suggested that an audit should be but one aspect of post suicide management, that part which specifically deals with staff education. Equally important is a second aspect, that of staff support. The author was unable to find any study pertaining to the use of a formal support system during this time,
Downloaded from anp.sagepub.com at University of Manitoba Libraries on June 9, 2015
I64
STAFF RESPONSE TO INPATIENT AND OUTPATIENT SUICIDE
and thus it is not clear that such a system would necessarily be more effective. However, the literature was agreed that informal peer support was found to be extremely valuable. This apparently loosely organised method should be legitimised as a valid option for providing support by and for colleagues. Additionally, it may be augmented by outlining the material presented here and separating the therapist’s responsibility to a patient from the patient’s own responsibility for his or her actions.
Audit materialand accurate recall In preparation for an audit, especially in relation to an outpatient suicide, no information is available as to the deceased’s thoughts immediately preceding the event. These Shneidman [ 121 refers to as “... private, inner, wholly psychological experiences, experienced introspectively by the individual ...” and stand in contrast to those signs that are “... perceived, inferred or assessed - by others ...” As a contributor to the Los Angeles Coroner’s Office, Shneidman comprehensively details the data that is collected, albeit retrospectively, in order to determine the answer to three questions - Why did the individual do it? How did the individual die? and What was the most accurate mode of death - accident or suicide? The outline represented a standard case history, but particular attention was paid to the following: 1 . Details surrounding the circumstances of the suicide. 2 . The victim’s personality, life style and typical patterns of reaction to stress and emotional upset, including his or her alcohol and drug use. 3. Any recent stressors or recent achievements and plans, recognising that the contemplation of suicide is usually a complicated internal debate reflecting profound psychological ambivalence. 4. Any changes in the victim’s habits, patterns or routines before death. 5 . The nature of his or her personal or professional support network and what their dreams, thoughts or fears relating to death, accident or suicide were. The information is obtained from persons that knew the deceased - the spouse, children, parents, friends, neighbours, work-mates - and an attempt is made to reconstruct the lifestyle of the deceased, focusing in particular on the period just prior to death. From this an extrapolation of the victim’s intention or behaviour is made. Shneidman cautions that the outline should
not be followed in any rigid manner. Rather, the person who conducts the interview should be sensitive to the bereaved, aware of their possible needs, while at the same time quietly listening and obtaining information that might cast light on the victim and the suicide. Data is thus collected retrospectively and often from a bereaved informant. Brent [lo] has attempted to determine the accuracy of this recall in adolescent suicides. He interviewed the parents at their homes two and six months after the event, and compared this diagnosis to the “best estimate diagnosis” summated from siblings, peers, teachers, school reports and medical records. Agreement between them was high, but parental information singly contributed more information that the other sources, although still underestimating the disorders of affect and substance abuse in their offspring. Additionally, he found that there was no difference interviewing at two or six months, suggesting the usefulness of the audit during Phase 111.
Counter-transference As it may be instructive to review the deceased’s story up to and including the suicide, so it may be informative to reflect upon the therapeutic relationship. Modestin 1141carefully studied the case histories of 149 inpatient suicides including the psychological exchanges recorded in the progress notes between patient and therapist. He suggested that 6% were ass o c i a t e d w i t h u n r e c o g n i s e d f a i l u r e s in t h e psychotherapeutic relationship. “Suicide may be an iatrogenic event ... These failings may not only be based on lack of clinical skill and knowledge, or on rational use of an inadequate technique, but also on the therapist’s insufficiently controlled counter-transference problems” [ 151. He provided a series of clinical vignettes that focused around four recurrent themes relating to an inability on the part of the therapist (1) to cope with the patient’s anger and hostility, ( 2 ) to tolerate the patient’s dependency, (3) to handle the erotic transference, and (4) to maintain a central loyalty towards the patient, especially when significant others are invited to participate in therapy. Hence therapists, attempting to contain their own anxiety and pessimism, may negate their own patient’s suicidal potential and unwittingly allow the act to occur. He suggested minimising such reactions by continued self monitoring, especially when the work is associated with the above scenarios; by supervision; and by limit-
Downloaded from anp.sagepub.com at University of Manitoba Libraries on June 9, 2015
J. D. LITTLE
Table I .
Phase
Phase duration
Event
Agenda
Timing of event
1st week Staff
Facts As soon meeting General as possible remarks ‘Front person’ Rituals At risk patients
1st two months
2-6 months
StaffFacts patient Feelings meeting Safety Rituals
As soon as possible
Staff Specific meeting patients Underlying principles Overview of protocol
As soon as possible
Experiences From Staff meeting Expectations second week, as required thereafter Suicide autopsy
Confidentiality What happened? What can be learnt?
Decided by Unit around 3 months
ing the number of seriously suicidal patients that are treated by any one therapist at one time. Counter-transference reactions remain a potentially difficult area for a therapeutic team to consider, especially in a public forum, thus highlighting the need for constructive criticism.
Constructive criticism Grol et a1 [ 111 in a study of a GP audit, noted that 90% of their trainees participated in the review compared with only 50% of the principals. Many had felt threatened prior to involvement, but this was reduced after the first session. They emphasized the introduction of the audit early in training, and the ways in which criticism is given and received, as being essential. Comments should be detailed and based on con-
I65
crete criteria to avoid being subjective and non-committal. Comments should be positive and stimulating, emphasising strengths as well as weaknesses. Careful attention to this aspect prior to the audit maintained a sense of being open to criticism and thus open to change.
Criteria Finally. the audit is an educational opportunity in order to review policy, treatment and training. It necessarily focuses on the way suicidal patients are managed. In the GP audit cited above, the authors warn against “re-inventing the wheel” and “getting bogged down” in constructing unsound criteria which are only valid within the group that composed them. It is suggested that at a collaborative level involving all staff, clear-cut guidelines as to the assessment and management of suicidal patients be developed. Although this is beyond the scope of this article, it is usefully discussed by Morgan [ 131 and Cheung (submitted for publication) who maintain a balance between the new “open door” policy while recognising its practical limitations.
Underlying principles From the above, a number of themes can be derived that underlie staff management following a suicide. 1. There are two distinct but equally important aspects of post suicide management: (a)The psychological autopsy, which addresses staff education, and (b)Staff support, in which infornial peer support is invaluable. 2. The post suicide time is a potentially vulnerable time for all staff. (a)Discussion should focus on events, not personali ties. (b)All authors caution against meetings that focus exclusively on feelings. These consistently appear to exacerbate rather than ameliorate guilt and blame. 3 . Confidentiality - of staff and of the deceased. 4. The course of events and staff experiences are in general predictable and time limited. 5. Reconstructing the events is restricted by reliance on retrospective extrapolation. 6. The reality of suicides and suicide prevention.
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STAFF RESPONSE TO INPATIENT AND OUTPATIENT SUICIDE
It is from these that the following practical, clinically based protocol is suggested which allows for flexibility and use in a small General Hospital.
4. Finally, all the patients are invited to express their sympathy to the family and to attend a brief ward service to be arranged within the subsequent two weeks.
Protocol Stuff meeting
Phase I tiritial s r u nicetirig ~ The term “StaR’ is used here to include non-medical personnel who may have had an important relationship with the deceased. but it is important to be aware that for some, it may be their first acquaintance with death. 1. All staff can be sources of information and misinformation, and it is important to minimise confusion and rumours. Once accurate information has been obtained, details of the suicide should be communicated as soon as possible. 2. General remarks usefully include an overview of the protocol and hence an indication of what to expect. Additionally they emphasise the underlying principles noted above. 3. A “front person” should be designated to liaise with the family, police, pathologist and other involved parties. All enquiries should be directed to him or her. 4. Participation in the rituals of death (e.g. sending cards or flowers, attending the funeral) is invited. It is this factor that others have reported was the turning point when numbness ended and feelings returned. It helped to bring a psychological closure to the event. 5. A completed suicide increases the risk for other suicidal patients. In preparation for the staff-patient meeting to follow, a note should be made of those who are most vulnerable. The staff can then assess their reactions and response to the news.
Striff-patient meeting Bad news spreads quickly and the staff-patient meeting, which all should attend, should follow on as soon as possible. 1. While maintaining confidentiality, the relevant facts should be communicated to the remainder of the ward and questions answered in a matter-of-fact way. 2 . An opportunity to express feelings should be given, while monitoring those most at risk. 3. People should be told that they themselves will be safe, with staff reviewing whether or not any changes to their management are needed.
A brief meeting following the above. 1. To attend to any specific concerns regarding individual patients. 2 . To re-emphasise the underlying principles, in particular, the legitimisation of informal peer support. 3. To review the protocol, and to decide a time for the next staff meeting.
Phase I1 (1st week and up to the first two months) Staffnieetitig(s) Following any ward funeral, it is important that there is at least one further staff meeting, arbitrarily at two weeks. This is a potentially vulnerable time for all staff members. The following is suggested as contributing to staff support: 1. Utilisation of the informal network. 2 . An appreciation of what others have experienced and for how long. 3. Realistic expectations of suicide and suicide prevention. 4. Incomplete resolution of this phase leading to incapacity characterised by the personal experiences described above beyond two months, is an indication for referral. Having been made aware of the above, a therapist may recognise a problem for him or herself. Alternatively, he or she may need to be sensitively and supportively approached by another member of the Team. The referral may be directed within or outside the department, and may be that person’s supervisor, a clinician specifically interested in such referrals, or an independent therapist chosen and approached at the time. Choice is determined by personal and individual circumstances. The outpatient suicide is potentially an isolated experience for the therapist as no other clinician may have been involved in that victim’s care. It is difficult in a practical sense to provide a separate system for this situation. It is suggested however, that the individual therapist is likely to progress through the same phases as noted above, and further, that the same protocol is applicable.
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J. D. LITTLE
Phase 111 (two - six months) Over the ensuing two to six months, the intensity of the turmoil lessens. It is during this phase that the psychological autopsy is most usefully placed. The exact timing should be left to the individual Unit to choose on the basis of staff morale and when any perceived threat has abated. Where morale is low, it is suggested that the team resolve their own difficulties with the case prior to the autopsy and that the audit chairperson be made aware of this.
AudR procedure 1. Most facilities are already busy and incorporating the autopsy into an already regularly convening format, e.g. a weekly Departmental Round, may be expedient. Alternatively, a separate annual or biannual session can be introduced specifically for the psychological autopsy. 2. The chairperson may be from within or outside the Hospital, specifically interested in suicide review, appear as the weekly Departmental Round chairperson, or be chosen per individual case. 3. The general principles noted earlier may usefully serve as introductory comments by the designated chairperson. 4. A brief, 5-10 minute synopsis is then presented by a person directly involved in management. It may be either the consultant or the registrar. It addresses the question, What happened to this patient that resulted in suicide? 5. More than one case may be presented at one meeting, lessening any sense of personal failure and creating an opportunity for finding any pattern that may emerge. In addition, referral to pre-determined criteria for the management of suicidal patients allows modification where applicable, but also serves as a reminder as to what these criteria were. It is a response to the question, What can be learnt? 6. Finally, the involved team members may meet after the autopsy in order to clarify or respond to comments made.
Final remarks Suicide is a major event, not only for the family, but also for the staff who have been involved in the pre-
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vious care of the deceased. The psychological autopsy does not exist in isolation, but as an educational opportunity most usefully placed at between two and six months after the event. The intervening interval is important as it allows time for staff members to support one another and time for constructive reappraisal of the preceding events. It is hoped that this protocol will be of practical assistance when, following a suicide, the questions are asked What happened? and What do we do?
Acknowledgements Thanks are extended to my family, typist MaryAnne Jensen, and to my colleagues for helpful comments.
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