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Abnormal Psychology and Clinical Psychiatry

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Research Article

Development and Implementation of an Interprofessional Workshop to Address the Professional and Emotional Needs of Clinicians Following a Patient near Fatal Suicide Attempt

Sara Figueroa, Gregory W Dalack

Correspondence Address :

Sara Figueroa
Department of Psychiatry
University of Michigan
Ann Arbor, Michigan 48109
USA
Tel: +1 734-764-0231
Email: gsrd@med.umich.edu

Received on: September 05, 2018, Accepted on: September 11, 2018, Published on: September 19, 2018

Citation: Sara Figueroa, Gregory W Dalack (2018). Development and Implementation of an Interprofessional Workshop to Address the Professional and Emotional Needs of Clinicians Following a Patient near Fatal Suicide Attempt

Copyright: 2018 Sara Figueroa, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract
Background: Coping with the loss of a patient who ends his or her life by suicide is one of the most challenging experiences faced by clinicians. A patient near fatal suicide attempt (NFSA), defined here as a suicide attempt that leads to ICU treatment, occurs frequently, is quite complicated, though important gaps in the literature exist to better address provider experiences and professional needs in these cases.
Aim: To adapt a regularly scheduled departmental postvention workshop to address clinician experiences in coping with NFSA.
Methods: The workshop agenda includes case presentations of NFSA, small group work and a final discussion in the plenary. This paper describes the development of the workshop and the pre- and post -survey responses to quantitative and qualitative questionnaires on NFSA.
Results: The survey results identified areas of distress by discipline, gender, and experience of clinicians in cases of NFSA.
Limitations: This study included a convenience sample of clinicians across disciplines.
Conclusion: The workshop surveys examined a gap in the literature regarding the potential needs of clinicians professionally and personally with a NFSA. Understanding, sharing and learning from individual clinician experiences of NFSA in a workshop setting can provide clinicians with a useful means of postvention support, education, and guidance. Such a workshop can benefit clinicians in psychiatry, and can also be broadened to any clinic, academic, inpatient or outpatient setting where patient acuity and risk for self-harm are high.

Keywords: Suicide Attempt, Near-Fatal, Postvention, Survey, Clinician Support
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Introduction
Patient-suicide events are reported by more than 50% of psychiatrists worldwide; coping with such an event is known to be very challenging, and has been associated in the literature with feelings of sadness, grief, anger, shock, dis-belief, self-blame, guilt, and anxiety [1,2]. Less information exists describing the experiences and professional needs of clinicians who have experienced a patient non-fatal suicide attempt (NFSA).
We have conducted a department wide workshop every other year to help clinicians learn from and obtain support regarding experiences with patient suicide. Feedback from a previous workshop indicated that another major challenge was managing the care of a patient who makes a near fatal suicide attempt and returns to care. We made this the focus of our most recent workshop.
There is sparse literature regarding postvention processes for a clinician after a NFSA by one of his or her patients. Originally in 1969, Edwin Shneidman, an American psychologist and suicidologist, coined the term "Postvention" [3]. He defined the term as follows:
"Interventions to address the care of bereaved survivors, caregivers and health care providers; to de-stigmatize the tragedy of suicide and to assist with the recovering process; and to serve as a secondary prevention effort to minimize the risk of subsequent suicide due to complicated grief, contagion or unresolved trauma."
The literature does speak to qualitative patient characteristics and therapeutic concerns noted in patients who have attempted suicide and have returned to treatment [4,5]. We have found no reports that specifically address the impact on the clinician, or the postvention support or training that might be needed to address the sequelae for the treating physician after a NFSA. Here, we use a postvention strategy for clinicians after a patient NFSA. We distinguished a NFSA (a suicide attempt that led to ICU treatment with eventual recovery and return to care) from self-harmful, less serious, nonfatal suicide attempts. We recognize that any attempt of selfharm that a patient may engage in is likely to cause distress in the therapist/psychiatrist. We decided that the multifactorial nature of the many different levels of self-harm added too many variables to the workshop content to adequately cover within a half-day format. Therefore, we focused on a specific, high-risk group, those with NFSA. We describe the process and content of our departmental postvention workshop on this topic and summarize responses to a survey of attitudes, feelings and knowledge that was collected from participants before and after the workshop.

Developing the Workshop

An advisory committee was constituted composed of clinicians representing all disciplines in the department (physician, social work, psychology and nursing) as well as different areas of clinical activity (adult, child & adolescent, inpatient, outpatient and clinical research). This committee met 4 times during the 6 months prior to the workshop and communicated via email to plan the content and to develop the pre and post surveys. The Michigan Medicine Internal Review Board approved the data collection plan for the surveys.
Advisory group members identified cases to present that would highlight challenges posed by a NFSA and the return of the patient to care. Special attention was given to ensure that the information was conveyed in a sensitive and informative manner. A pre-workshop survey designed to assess whether participants had attended previous retreats as well as whether they had experienced a near fatal suicide attempt by one of their patients was conducted on site. The post workshop survey was also conducted on site directly at the end of the workshop. It asked for participant feedback about the workshop, new knowledge they perceived themselves to have acquired, and their sense of how they would see themselves coping should they experience a
patient with a near fatal suicide attempt in the future. Data were collected using an audience response system which provided a report of quantitative, de- identified data in real time, allowing participants to see immediately how their responses compared to those of the entire group.
The workshop was conducted over a half day. A presentation of a brief literature review was followed by two Members of the advisory group presenting treatment cases of a patient who carried out a NFSA event. In one case the patient sought treatment elsewhere after she recovered from the attempt. The clinician involved discussed the factors perceived to be involved in that process, his feelings during the initial treatment period, patient recovery after the attempt and at termination of treatment. The clinician presented his reflections about the case and its impact on his work as a clinician. In the second case, the patient and clinician resumed psychiatric care after the critical event. This clinician discussed the care and events prior to the incident, the challenges of treatment following the attempt and his ongoing work with the patient.
Following these presentations, breakout groups were held with participants assorting into small groups of approximately 10 clinicians each. The breakout groups were led by facilitators who had a specific set of questions to guide his/her group. The focus groups met for one hour. The facilitators summarized their discussion points and the groups reconvened in plenary to share the group's results and ideas. The sharing of breakout group responses and the wrap up was led by the Chair of our department.

Break-out Group Questions

- What were some of the issues today that struck you as significant in patients that have had a near fatal suicide attempt and returned to the same provider for ongoing care?
- How would a patient near fatal suicide attempt affect the dynamics or change the treatment going forward under your continued care?
- What different feelings might you experience if one of your patients attempted suicide and survived after a near fatal experience?
- Please note main points of your group's discussion to share in the final wrap up session.

Survey Responses

Eighty-two of 87 respondents to the pre and post-surveys provided sufficient information to be included in the analysis. Overall demographic information is provided in Table 1. Our convenience sample had broad representation of professional disciplines. Participants were predominantly involved in outpatient work (72%) with more than half treating adults vs. children and adolescents. Nearly 80% had experienced patient suicide (19%), NFSA (28%) or both (30%).
We did exploratory analyses to examine differences in experience with patient suicide or NFSA by gender. (Table 2) There were no significant differences by gender, save for 2 observations: 1) among those participants who experienced a patient suicide, more men than women endorsed self-blame (50% vs 33%, p<0.05) among those experiencing a patient NFSA, more women than men endorsed feeling sadness (80% vs. 41%, p<0.05).
We broke down the data further by comparing the experience of having a patient suicide (ONLY) with that of having a near fatal suicide attempt (ONLY). There was a trend for those who experienced a patient NFSA only vs. a patient suicide only to be: 1) more likely to have been in training at the time of the experience (OR 3.12; 95% CI= 0.85, 12.4; P = 0.09); 2) less likely to have had a debriefing after the event (OR 0.28; 95% CI= 0.07, 1.09; p= 0.07); and 3) less like to report sadness (OR 0.22; 95% CI= 0.03, 1.06; p=0.08). On the other hand, those experiencing a patient suicide were significantly much more likely to report anger (OR 10.52, 95% CI= 2-83; p<0.005).
Finally, among respondents completing the post-response survey (n=82), 83% found the workshop to be helpful and 77% of the respondents indicated they learned something practical for future patient care. Eighty-three percent felt that the workshop should be repeated. Seventy-eight percent of the clinicians reported that they were very likely to reach out to colleagues after a suicide or near-fatal suicide attempt and 87% stated that they were better able to support their colleagues with such an event due to attending this workshop.

Workshop Findings

We decided to focus our most recent workshop on this gap of information related to the impact on clinicians and what professional support and guidance they may need after a patient NFSA. We included qualitative questions about patient suicide for comparison. We parceled out data related to gender to examine potential gender differences in our sample of clinicians in order to better target support and guidance for them Table 3. As noted above, we did find that there was a slight gender distinction in males who experienced self-blame more often than females when their patient completed suicide and females reported sadness more often than males in NFSA events. Moreover, providers of both genders who had experienced a NFSA only, tended to be more often in training and reported less sadness in response to that event compared to those experiencing a patient suicide only. In contrast, those who experienced suicide only were more likely to report anger. The feelings were overall very similar in type between suicide and NFSA which reinforced the idea of continuing with workshops to explore these feelings, increase awareness of the reactions of other clinicians when such an event occurs to better support them and process the events afterwards. It seems possible, given the differences that the two events (suicide vs. NFSA) are not in fact one in the same, but have differences that may reflect the potential for ongoing treatment in cases of NFSA [6-9].
Our workshop results were largely qualitative and stem from a convenience sample of small size. The mix of disciplines and years in training and experience reflected an academic department setting. We have no way of telling whether those who had experienced patient suicide and NFSA were under or over-represented among the attendees as a subset of the entire department. We did not inquire about knowledge in our preworkshop questionnaire to compare pre and post knowledge acquisition directly before and after the workshop. We plan to refine our next workshop to include a comparison of pre and post data in order to assess whether information such as strategies, skills, and awareness had increased with the participation in these workshops in addition to the sharing and emotional support that is attained.

Final Reflections

Regarding NFSA, no one is ever fully prepared to deal with such an event or to know how he/she will feel or react until it occurs. Nevertheless, the goal of these workshops is to help clinicians learn from, support one another, and provide an opportunity to share the often intense, difficult, emotional reactions to these challenging and adverse patient events that any clinician may face. Reports in post patient suicide cases demonstrate that postvention work of this type can be an important aid for clinician wellbeing and ongoing professional growth [10,11]. We anticipated that this would also be the case in NFSA events. We believe it is imperative that we continue to highlight the education and support of clinicians in suicide risk prevention, evidenced based patient care and in the postvention process in NFSA cases as well as completed suicides. Clearly, more research in this area and professional guidance for the provider is needed. We also realize that this work can be broadened to clinics of any type. Primary care, specialty clinics, as well as other non-psychiatry inpatient and outpatient settings can benefit from an increased awareness of the potential for patient self-harm, suicide attempts, the possibility of patient death by suicide, and how to manage the aftereffects of such an event. Finally, specific recommendations in the case of a NFSA that we would make include: 1. Provision of a regularly scheduled, safe setting for clinicians to explore normative clinician-survivor reactions, 2. Creation of or clearer delineation of communication channels for staff and clinicians for reporting and support resources in preparation of such an event, 3. Provision of individual supervision, consultation, and support to clinicians and staff after an adverse event, 4. Provision of a resource list (via brochure or on-line sites) which clinicians could use to access additional resources and support for self-care in the aftermath of an event. In addition, it is always prudent to be open to new ideas, with an awareness of the needs of the specific clinic population, individual clinicians and setting that you are working in to determine what postvention modalities would be most useful to them.
References
1. Hendin H, Lipschitz A, Maltsburger JT, Pollinger Haas A, Wynecoop S. Therapists' Reactions to Patients' Suicides. Am J Psychiatry. 2000;157(12):2022-2027.
2. Figueroa S, Dalack GW. Exploring the impact of suicide on clinicians: a multidisciplinary retreat model. J Psychiatric Prac. 2013;19(1):72-77.
3. Shneidman E. Postvention: The care of the bereaved. In R. Pasnau (Ed.), Consultation in liaison psychiatry. (pp. 245-256). New York.1975.
4. Douglas J, Cooper J, Amos T, et al. "Near-fatal" deliberate self-harm: characteristics, prevention and implications for the prevention of suicide. J Affect Disord. 2004;79(1-3):263-268.
5. Ramsay JR, Newman CF. After the attempt: Maintaining the Therapeutic Alliance Following a Patient's suicide attempt. Suicide Life Threat Behav. 2005;35(4):413-424.
6. Hendin H, Pollinger Haas A, Maltsberger J, Santo K, Rabinowitz H. Factors Contributing to Therapists' distress after the Suicide of a Patient. Am J Psychiatry. 2004;161:1442-1446.
7. Gulfi A, Dransart D, Heeb J, Gutjahr E. The Impact of Patient Suicide on the Professional Practice of Swiss Psychiatrists and Psychologists. Acad Psychiatry. 2016;40:13-22.
8. Yaseen ZS, Briggs J, Kopeykina I, et al. Distinctive emotional responses of clinicians to suicide- attempting patients--a comparative study. BMC Psychiatry. 2013;13:230.
9. Beautrais A. Suicides and serious suicide attempts: Two Populations or One? Psychol Med. 2001;31:837-845.
10. Ellis, TE, Patel A. Client Suicide: What now? Cogn and Behav Prac. 2012;19:277-287.
11. Wurst FM, Kunz I, Skipper G, et al. How therapists react to patient's suicide: findings and consequences for health care professionals' well-being. Gen Hosp Psychiatry. 2013;35:565-570.
Tables & Figures

Table 1: Demographic and Clinician Characteristics of Workshop Participants

Table 2: Characteristics of participants reporting a patient NFSA (n=42) by gender


Table 3: NFSA Post-workshop findings
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