The impact of the suicidal intervention on professionals
Schroth (2019) state, “The overall goal of suicide prevention is to reduce risk factors and promote resilience” (cited in CDC, 2018, p.27). In this essay, I will discuss the personal impact of suicide in a professional context and reflect on how risk may be mitigated by protective factors.
In the US, Over the past 10 years, more than 2,800 suicides have occurred in the workplace (Schroth, 2019, p.27). In New Zealand, 538 people died by suspected suicide in 2021/22 (Mental Health Foundation,2023). According to Lyra, McKenzie, Every-Palmer and Jenkin (2021) “The Mental health professionals (MHPs) group includes psychologists, psychiatrists, social workers, and nurses. Of the seven papers, four reported the prevalence of exposure to suicide among MHPs. The prevalence of exposure to at least one suicide ranged from 32% to 46.6% with professionals experiencing an average of around 4 suicides throughout their career” (p.5).
According to Al-Mateen, Jones, Linker, O'Keefe and Cimolai (2018), “Suicide is a trauma to almost all who know the decedent” (p.624), “Clinician reactions can be categorized as traumatic loss/grief, interpersonal relationships, and professional identity concerns. The loss is not only of the patient but of the sense of safety in the treatment framework” (p.625) and “Most noted that the suicide affected both their professional and personal lives, with 45% reporting effects lasting more than a month” (p.625).
When mental health professionals (MHPs) had “indirect trauma” by the client’s suicide, they have the risk of having “secondary traumatic stress (STS) when they got the adverse impact of helping or wanting to help traumatised people, triggered by secondary trauma exposure” (Wymer, Guest, Deaton, Newton, Limberg & Ohrt, 2020). However, Wymer et al. (2020) believe that compassion satisfaction is one of such mechanisms, conceptualised as the reflection of the efficacy that the workers perceive as a result of their work” (cited in Figley, 2002a). Although, there is the concern of getting compassion fatigue (CF). For example, Sprang, Clark, and Whitt Woosley, (2007) warn, “CF signifies more progressed psychological disruptions. This term can be used interchangeably with secondary traumatic stress disorder (STSD) and is considered to be less stigmatizing (cited in Figley,1995). The proposed continuum of responses ranges from compassion satisfaction to compassion stress and ends with CF” (cited in Figley,1995; Stamm, 2002b). Moreover, Sprang et al., found “A study of community mental health workers found that 17% met criteria for STSD and 18% exhibited significant but subclinical levels of psychopathology” (cited in Meldrum, King, & Spooner, 2002).
Here, I assume MHPs may be exposed to suicidal ideation by the above discussion. In fact, Lyra et al. (2021) argue, “Mental health professionals (especially psychiatrists) and first responders themselves also have high rates of suicide. One of the explanations for the higher rates of suicides among these professions is their higher levels of occupational-related psychological distress, and for first responders, work-related Post Traumatic Stress Disorder (PTSD)” (p.2). Besides, when MHPs get the impact of repeated empathic engagement with trauma survivors and associated cognitive, schematic, and other psychological effects they may experience countertransference reactions to include the term ‘Vicarious trauma (VT)” (Lyra et al., 2021; Sprang et al., 2007).
It is notable that female therapists, younger aged therapists, and those who work less than 5 years or between 11 and 20 years significantly experience severe distress, hypervigilance of potential suicide cues, sadness, shock, feelings of guilt, and doubt of their professional knowledge and skills (Al-Mateen et.al.,2018; Lyra et al., 2021; Sprang et al.,2007). Furthermore, Al-Mateen et al. (2018) discover, “They were also more likely to seek support from peers’ supervision than male psychiatrists and psychologists” (p.624). Additionally, Sprang et al.(2007) note, “A higher educational degree, less clinical experience, and a higher percentage of clients with PTSD predicted higher levels of CF and burnout” (p.271). At this point, I was questioning if MHPs’ cultural identities may influence the bereavement of the client’s suicide. Al-Mateen et al. (2018) answered, “A study of Thai psychiatrists found cultural differences in clinician response to patient suicide based not only on individual and regional religious beliefs but also on regional perceptions of the suicide and its causality. Compared with studies of US, Scot, Australian, and German psychiatrists, the Thai psychiatrists endorsed less anger, and none considered changing professions or stopped seeing suicidal patients. An individual’s personal and professional life experiences also affect their reactions to a patient’s completed suicide” (p.624). When we see our gender, age group, length of work, qualifications, and cultural differences, I also had a question about the geographical impact on MHP because New Zealand is a such small country and I have uncountable experiences of service limitation in the rural area when I worked at Ministry of Social Development. Sprang et al. (2007) discover that clinicians who were working in rural locations were more likely to suffer burnout than those in highly metropolitan locations. “Limited resources, geographical isolation, few colleagues (limited peer support), and highly demanding caseloads create a ‘‘perfect storm’’ of burnout risk among rural clinicians” (p.273).
As a consequence of these impacts, as Lyra et al. (2021) found, “Other professional implications include the questioning of confidence in career choice, which may impact occupational retention. In respect of re-assessing career choices, questioning one’s career choice is not limited to health professionals, and has been observed in other professions that deal with emotionally sensitive content, for example, suicide researchers” (p.2).
In contrary to this, Solin, Tamminen, and Partonen, (2021) emphasize, “Social work professionals, when compared to other profession groups, estimated most increase in their competence in the three quarters of the training areas. These training areas were risk and protective factors, raising concerns and confronting suicidal patients and lastly treating suicidal ideation in primary health care and the associated referral processes” (p. 334). It may help these vulnerable MHP groups to enhance their competencies to deal with suicide work.
After finding the risk of suicide and vulnerable groups among MHPs, from here, I will see the actual impact on them. In a result of the client’s death by suicide firstly, some MHPs experienced severe distress, depression, guilt, inadequacy, anxiety, anger, sorrow, sympathizing, helplessness, sadness, shock, surprise, feelings of blame, hopelessness, self-doubt, and grief (Al-Mateen et al., 2018; Lyra et al.,2021; Smith, Kleijn & Hutschemaekers, 2007) Secondly, Lyra et al. (2021) state, “Their professional reactions ranged from increased awareness of suicide risk, reduced professional confidence, fear of publicity and litigation, increased referrals to psychiatrists, and sadness at work” (p.5). Thirdly, Qayyum, AhnAllen, Van Schalkwyk & Luff (2021) argue, “All participants, trainees and supervisors, ascribed great significance to the suicide of a patient as a notable life event emotional impact, in their professional lives, which resulted in changes in self-efficacy and a sense of responsibility for the suicide of the patient” (p.281). Qayyum et al. (2021) explain that “changes in self-efficacy were reported by most trainees and supervisors, resulting in anxiety and tentativeness around their work and clinical decision-making after the death of a patient by suicide” (p.281). Fourthly, Al-Mateen et al. (2018) describe the changing in their behaviour at their workplace as “They had increased anxiety and irritability at work, were more distant from patients, had a desire to change jobs, and avoided patients with substance abuse issues” (p.625). Lastly, it is remarkable that some MHPs show a wide range of distress. For instance, Al-Mateen et al.(2018) point out the four factors of distress at their workplace;
1. Failing to forcibly hospitalize a patient who then completed suicide.
2. Having made a treatment decision that the clinician thought contributed to the suicide. (such as allowing a patient to go out on a pass or giving in to parental pressure to discharge an adult patient from a group home despite an active plan)
3. Feeling blamed by the hospital administration for the suicide.
4. Fear of a lawsuit.
They explain their loss of client contributes to their sense of safety in the treatment framework (p.625). In other words, the four factors raise questions within the MHP on whether they have the confidence to keep working in a distressed environment with a lack of safety. If so, how can MHPs process their clients’ bereavement by suicide? According to Schroth (2019), “In the event that an occupational suicide occurs, ensure that there is a supportive structure in place to assist employees who are having a difficult time dealing with the situation” (p. 29). It is obvious that de-briefing and peer support will help them. For instance, Al-Mateen et al. (2018) state, “Some noted improvement in their clinical documentation and greater likelihood of seeking support from colleagues, including via peer supervision” (p.625). Lyra et al.(2021) also say, “The type of support received by these MHPs in their day-to-day work was described as informal peer-support, including debriefing” (p.5). Schroth (2019) suggest that “debriefings should include an overview of the incident (withholding private details and information), what was done correctly, what could have been handled better, and how the response can be improved if a similar situation occurs”(p.29).
However, Qayyum et al. (2021) added that “Some trainees also commented on being aware of their supervisor’s own struggles with the death of the patient by suicide. Some trainees reported that they felt they needed to comfort and support their supervisors as they navigated the process together. Some trainees stated that processing with a grieving supervisor had been helpful” (p.285). This statement helped me to be aware of my own professionalism and independence and how to engage with my trauma work. As Smith et al. (2007) say, “The acknowledgment of situation-specific reaction patterns and the recognition of one’s personal therapeutic style may help therapists to cope with therapeutic difficulties” (p.39).
I believe it is important to understand the MHP’s limitation on a personal to professional level because now, I have a clear picture of how risks are mitigated by protective factors and some tools to use in achieving these mitigations. Al-Mateen et al. (2018) observes, “[the] realization of one’s own limits allows for cessation of self-blame and enables the bereaved to realistically assess his or her responsibility” (p.623). To set up this realization, Wymer, et al. (2020), suggest, “All participants counsellors acknowledged the need to balance their emotional demands and expenditure, and limit their exposure to indirect trauma in order to sustain their empathic energy. The term, “empathic stamina” arose from the interpretation of participant counsellors’ description of those factors as a dynamic and continuous process” (p.304).
From the above discussion, additional training may help MHPs to prevent risks. Actually, Sprang et al. (2007) say, “Additionally, training experiences potentially created peer support and even transitory support from colleagues that were protective against CF and burnout, especially for those clinicians working in isolated settings” (p.272-273). Additionally, Solin, Tamminen, and Partonen (2021) say, “The erroneously held beliefs of primary healthcare professionals and their lack of knowledge, experience, and expertise in confronting suicidal patients may be prove to be fatal to suicidal patients” (p.335). If we could get the additional trauma and suicide training, then how does the organization could gain the safe work environment? Schroth (2019) propose, “Studies show that a healthy work-life balance may reduce stress and increase job satisfaction, performance and productivity (cited in Shalini & Krishna,2017). Organizations can work to improve this balance by implementing benefits that allow employees to balance work and personal demands (e.g., telecommuting, flexible work options, and time to allocate toward fitness activities; Shattell, 2017). Organizations can also integrate work-life principles into policies and programs to make them official” (p.28).
In this essay, I reflect on how risk may be mitigated by protective factors. I discovered that I still maintain a strong motivation to continue working in trauma and suicide work even though there are a number of risks which I discussed here. Interestingly, the result of interviewing counsellors by Wymer et al. (2020) found that trauma counsellors perceived trauma counselling work as involving both challenges and rewards (p.302). They continue, “Having the view that trauma counselling work is purposeful influenced the sense of value in engaging in the work and an overall sense of commitment” (p.302). Finally, Wymer et al.(2020) conclude, “Participant counsellors reported that being able to facilitate the empowerment of clients was a powerfully rewarding aspect of the work. Reciprocally, counsellors also gained a sense of empowerment and validation in their own work through supporting the clients’ journey” (p.302). I found the evidence and resources to keep working safety through this essay.
References
Al-Mateen,C.S., Jones,K., Linker,J., O'Keefe,D., & Cimolai,V. (2018).Clinician Response to a Child Who Completes Suicide. International Journal of Clinical Pharmacy, 27(4): 621-635.http//doi.org/10.1016/j.chc.2018.05.006
Figley, C. R. (1988). Victimization, Trauma, and Traumatic Stress. The Counseling Psychologist, 16(4), 635–641. https://doi.org/10.1177/0011000088164005
Lyra, R., McKenzie, S.K., Every-Palmer, S.,& Jenkin,G. (2021) Occupational exposure to suicide: A review of research on the experiences of mental health professionals and first responders. PLoS ONE 16(4), e0251038 https://doi.org/10.1371/journal.pone.0251038
Mental Health Foundation. (2023). Statistics on suicide in New Zealand: What does the data tell us? Retrieved from https://mentalhealth.org.nz/suicide-prevention/statistics-on-suicide-in-new-zealand
Qayyum, Z., AhnAllen,C.G., Van Schalkwyk,G.I., & Luff,D. (2021). "You Really Never Forget It!" Psychiatry Trainee Supervision Needs and Supervisor Experiences Following the Suicide of a Patient. The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry,45(3),279-287. http//doi.org/ 10.1007/s40596-020-01394-8
Schroth, L.A. (2019). Workplace SUICIDE PREVENTION. Professional Safety; Des Plaines,64 (9),27-29.
Smith,A. J. M., Kleun,W.C.,& Hutschemaekers,G.J.M. (2007) Therapist reactions in self-experienced difficult situations: An exploration.Counselling and Psychotherapy Research, 7(1), 34-41, DOI: 10.1080/14733140601140865
Solin, P., Tamminen, N., & Partonen, T. (2021). Suicide prevention training: self-perceived competence among primary healthcare professionals. Scandinavian journal of primary health care, 39(3), 332-338. http://doi/org/10.1080/02813432.2021.1958462
Sprang, G., Clark, J. J., & Whitt-Woosley, A. (2007). Compassion fatigue, compassion satisfaction, and burnout: Factors impacting a professional's quality of life. Journal of Loss and Trauma, 12(3), 259–280. https://doi.org/10.1080/15325020701238093
Wymer,B.,Guest, J.D.,Deaton,J.D.,Newton,T.L., Limberg,D., & Ohrt,J.J., (2020). Early career clinicians’ supervision experiences related to secondary traumatic stress when treating child survivors of sexual abuse. The Clinical Supervisor 39(2), 284-305. https://doi.org/10.1080/07325223.2020.1767253
