Postvention and Healing After a Patient Suicide

Name: Postvention and Healing After a Patient Suicide
Uploaded: 2023-11-01T17:16:35.8533333Z
Duration: 59 min 26 s
Description: YCSC Grand Rounds October 31, 2023 Christine Yu Moutier, MD Chief Medical Officer American Foundation for Suicide Prevention

November 01, 2023

YCSC Grand Rounds October 31, 2023

Christine Yu Moutier, MD
Chief Medical Officer
American Foundation for Suicide Prevention

Information

ID: 10930
To Cite: DCA Citation Guide

Download Transcript

00:00Good afternoon, everyone.
00:02Welcome to Grand Rounds.
00:05Forgive us, we're slight little delay here,
00:09but we have a brand new
00:11AV system that is great.
00:13We have a really spectacular
00:17presenter today and a spectacular
00:20presenter and discussant.
00:21So Julie, this was your idea.
00:23Do you want to tell us all
00:25sorts of wonderful things
00:26about our magnificent speaker?
00:28Absolutely. So hello dear friends.
00:32For those of you who don't know me,
00:35I'm Julie Chilton.
00:36I was a a graduate in 2012
00:39from Yale Child Study Center.
00:43And now I'm in North Carolina in
00:46private practice and I'm a part
00:48of the Grand Rounds committee.
00:50And luckily, they they allowed
00:52me to put forward one of my
00:54favorite people on the planet,
00:56Doctor Christine Moutier,
00:58who I actually met long
01:01before I met any of you all,
01:04when I was a wee Med student
01:07in San Francisco.
01:09And Doctor Moutier was not yet the
01:11Chief Medical Officer for the American
01:14Foundation for Suicide Prevention,
01:16but instead doing important
01:19work at UCSD in San Diego,
01:23taking care of the trainees and
01:26medical students all their well-being
01:28needs and and a psychiatrist herself.
01:31And she was lovely enough to join
01:36me in presenting a documentary
01:39on medical student health issues
01:43and and suicide at an APA meeting
01:48probably in 2001 or 2002.
01:51And since then,
01:53I've been a big fan and have followed
01:56her career and attended several
01:59presentations and really benefited
02:02from so many of the resources the
02:05that the American Foundation for
02:07Suicide Prevention provides for.
02:09For both families who have gone
02:13through a loss of of a child or or
02:18other family member as well as tool
02:22kits that they put together for
02:25medical schools and residencies.
02:28And communities who have experienced
02:30a loss of a loved one or a trainee
02:34or or a friend to suicide.
02:38And so I won't.
02:39I won't spoil all of the the good
02:43things that she might tell you about
02:46by going on and on about the AFSP.
02:50But we're also fortunate because one
02:53of my other heroes and Mama Hens, Dr.
02:58Steuby,
02:59is going to be joining us to
03:03talk more about how some of the
03:06resources that the AFSP has and
03:10and how to help trainees and and
03:13clinicians who lose patients to
03:16suicide get through that aftermath.
03:19She will be joining us to discuss
03:22ideas with Doctor Mutier towards
03:24the end of our talk today.
03:25So Doctor Mutier,
03:28welcome.
03:30Thank you Julie. It's such a joy to see
03:35you again and to join the department
03:38here with with I I'd say that no
03:42matter what your role is right now,
03:45if you're in training or if you're in
03:48practice and what discipline you're in.
03:50I've designed this talk with
03:52Doctor Stubby with you in mind,
03:55and although it it will focus on
03:57loss of a patient to suicide,
04:00I will start out actually with
04:02a broader frame.
04:03So let me just share my screen
04:05so we can get into that.
04:10OK, let's see here.
04:13Let me try to get that minimized.
04:17OK. Does that look OK to everybody?
04:21You can see my slides and.
04:22OK and and is Doctor Stubby on
04:25Zoom or in the the real life room?
04:30I'm in the real life room.
04:32OK, perfect. But we can hear you great.
04:33OK, thank you so much.
04:35So I am so excited to to talk to
04:39you today about a very serious
04:42topic and to have the pleasure of
04:44having Doctor Stubby join me as
04:47well for some discussion and we
04:50will also try to leave time for
04:52anything that's on your minds.
04:54This is meant for you.
04:57I will just add to Julie's
04:59introduction of my background that
05:02I am somebody who now publicly
05:05talks about my own lived experience
05:08of mental health experiences and
05:12also related to suicidal ideation.
05:15I In the course of my career,
05:17I had the tragic experience of losing
05:23a medical student I had worked closely
05:25with to suicide while I was a resident.
05:28And then over a period of 15 years,
05:32as I became, you know,
05:34on the faculty at UCSD and a Dean in
05:36the medical school, I was Dean for
05:39medical education and student affairs.
05:41There were 13 more physicians who died by
05:43suicide at UCSD over that period of time.
05:46All different specialties and
05:47for that reason, combined with,
05:51you know,
05:51my own kind of lived experience
05:53of what a culture,
05:55what a work environment and a learning
05:58environment have to do with one's
06:00ability to seek support and and
06:03really take care of our own mental
06:05health and take care of each other.
06:06That really developed my interest
06:09in suicide and suicide prevention.
06:12So let me go ahead and from
06:16there get into this.
06:19My only disclosure actually is that I'm
06:21focused full time as the Chief Medical
06:24Officer at the American Foundation
06:26for Speech Prevention on Suicide.
06:28We are the leading private funder
06:30of all global suicide research.
06:33We're very proud of that,
06:34but we engage a grassroots
06:37community of chapters nationwide.
06:39We license the interactive screening
06:41program and I did publish a book for which
06:45I receive royalty and Doctor Stubby does
06:47not have disclosures relevant to this talk.
06:50So just a word more about AFSP,
06:53this is our mission,
06:55save lives and bring hope to
06:57those affected by suicide.
06:58And the work that we are doing now has been,
07:03has had the benefit of you know 30 plus
07:08years of not only funding the research,
07:11but being engaged in local grassroots
07:14communities across all 50 states.
07:17It really keeps us honest in
07:19terms of science meeting,
07:21real life implementation and all
07:23of the challenges around that.
07:26We are an organization that also
07:28is a leading voice on the hill for
07:30Fed federal and and also state
07:33advocacy and that's it's really
07:35an incredible marriage of a blend
07:38of science best practice.
07:40All comers in terms of clinicians,
07:42other professionals and families,
07:44and many of us of course wear many
07:47different hats as it pertains to
07:50suicide in terms of personal and
07:52professional ways that we touch this issue.
07:58It has been a very exciting time of
08:01culture change around the nation,
08:03which we can talk about
08:05as well if there's time.
08:07So this is my general framework for the talk.
08:10I want to talk first about suicide
08:12bereavement and in order to do that
08:15I'll spend just a few minutes talking
08:17about how a modern day integration
08:20of of scientific findings can help
08:24the the community at large. But.
08:27But for those of you who haven't had
08:29any updates recently on suicide,
08:32there are some kind of modern
08:34ways of thinking about suicide
08:36that I'll just touch upon and then
08:39we'll we'll talk about and.
08:40And again,
08:41the understanding of suicide in this
08:43talk is really in the framework of why
08:46that is so important to people who are
08:49going through the experience of suicide,
08:50loss.
08:51And then we'll focus the last
08:53half of the talk on the loss of a
08:57patient to suicide and and a bit
08:59about that and what can be done to
09:01support all of us who go through
09:03that type of experience as well.
09:06So first just thinking about the topic
09:09of suicide, loss and bereavement.
09:12So it turns out that many more individuals
09:17and families in our American Society,
09:20our population,
09:21have been affected by suicide
09:24than we probably ever imagined
09:26by our recent Harris polls.
09:29At AFSP,
09:30it's 54% of adults who are surveyed
09:35by a Harris Poll method when asked
09:39identify as someone who has either
09:42experienced suicide loss in their life.
09:44Now that doesn't necessarily
09:45mean a family member,
09:46but some type of experience with
09:49suicide loss or lived experience which
09:51can be defined as you yourself have
09:54had experiences of being suicidal or
09:57attempting living through suicidal
09:59experiences or that of a loved one.
10:02So,
10:03so these personal experiences are
10:05far more commonplace than we probably
10:08realized because stigma kept things
10:10so shrouded in silence for a long time.
10:14So a great colleague and and hero of mine,
10:18Doctor Kathy Scheer,
10:20who focuses on grief research
10:23and who designed the complicated
10:25grief therapy that's so,
10:27so effective for complicated grief.
10:30She said something that that
10:32really just brings it home,
10:34which is that grief is the form love
10:36takes when someone you love dies.
10:38And that means that it's,
10:42it's, it's a profound and and by the
10:45way universal experience because all
10:47of us will be bereaved at some point
10:50by losing a loved ones and colleagues
10:53and friends at some point in time,
10:55not necessarily to suicide,
10:57but, you know, to to death.
11:01And thinking about how is suicide
11:06loss fitting into the context of
11:09overall experiences of grief.
11:10And what I would say is,
11:12well, first of all, at AFSP,
11:14in our research grants program,
11:16we have a long running priority on
11:20study of suicide, loss and healing.
11:23And that's because it's been an understudied
11:26area of of the topic of suicide,
11:29a very important one.
11:30And and so the research is growing around
11:34this topic of suicide bereavement.
11:37There are obviously a very complex range of
11:42emotions that occur with any type of grief,
11:44but specifically and maybe a
11:47bit more so with suicide loss.
11:50And and I won't go into all of that,
11:53but just to say that part of what we
11:57do at AFSP in our loss and healing work
12:00is we convene suicide loss survivors.
12:03In fact, on November 21st,
12:05it's the International Survivors
12:06of Suicide Loss Day.
12:07Every day, every year,
12:09annually on the Saturday before Thanksgiving,
12:11we convene several 100 sites around
12:14the world that host a program
12:16that's like a day long program that
12:19we help support And and it brings
12:22together mostly newly bereaved
12:24people and it gives them a chance to,
12:29you know,
12:30to frame their loss to shed as much
12:32stigma as possible and to connect
12:34with other suicide loss survivors.
12:36And so we know that experiences
12:39of even not just yearning for the
12:42the loved one who has died,
12:44not just extreme sadness and grief,
12:48but also sometimes guilt.
12:50But but even things like relief,
12:52all of those experiences can be intermingled.
12:55And it's a complicated type of grief,
12:58partly because of stigma,
13:00partly because I think our human
13:03mind craves an understanding of
13:05why that that loved one died,
13:08especially when their struggles
13:09were not known to the family.
13:11But even when they were known,
13:14it still can feel like like the death
13:17of that loved one can feel blindsiding,
13:21even when you knew and the family was
13:24aware that there were mental health
13:26struggles or suicidal experiences.
13:30So the search for the the the why
13:32did the did the they take their
13:35life can be a huge part,
13:37especially of the early journey in
13:41suicide loss and bereavement and and
13:44there's nothing wrong at all with
13:46that search for why in in about 30%
13:49of cases of suicide loss survivors it
13:53it turns into a case of complicated
13:55grief or prolonged grief disorder.
13:58And in those instances it's very
14:00important as clinicians to recognize
14:02that as such because that's not
14:05the same as depression.
14:07It's not the same as regular healthy
14:10grief and there are now treatments.
14:12Again,
14:13thanks to doctor shears work to address
14:17complicated grief more specifically.
14:19So that's one of many clinical sequelae
14:22that I would say we need to be on
14:25the lookout for because it is true
14:28that after experiencing the suicide loss,
14:31death of a loved one,
14:32there are a number of mental health
14:36and physical health sequelae that
14:38are that the risk is increased for.
14:41And let me just kind of advance to this
14:44slide to show you that a study by Yates
14:47Conwell and Annette Erlingson that
14:50that looked at about 15,000 spousal
14:54suicide loss survivors in Denmark.
14:57You know, one of the countries
14:58that keeps track of all of their
15:00medical records so carefully.
15:01So between 1980 and 2014,
15:04there were about 15,000 individuals
15:06who lost a spouse to suicide.
15:09And what you see here is just
15:11one example from their findings,
15:13which are the health outcomes that were
15:15increased for men who were bereaved
15:18by spousal suicide versus men who were
15:20bereaved by any type of spousal death.
15:23And this is at a five year mark after
15:25the loss of that spouse And you
15:28can see that PTSD is far elevated.
15:30Anything that's to to the right of
15:33that number one means that it is over
15:37represented in this group of men
15:39and you can see that suicide is also
15:42the risk of suicide is increased.
15:45So that's just one study,
15:48it's it's one of few studies though
15:50that really specifically looks at the
15:53health sequelae after suicide loss.
15:55So, you know,
15:57so I would say that as clinicians,
16:00part of what I would plant the seed
16:03for is to always be on the lookout
16:05when your patient happens to be
16:07a suicide loss survivor,
16:08even if that's not the reason that
16:11they're presenting in the current time frame.
16:13That's something to note in terms
16:16of a significant type of loss that
16:19can impact other health outcomes,
16:21physical health outcomes as well
16:23as mental health outcomes as well
16:25as the risk of suicide.
16:27It's part of the reason that we have
16:29a saying in the field of suicide
16:32prevention that post prevention is
16:34a form of prevention because by
16:36supporting suicide loss survivors we
16:38can also reduce their risk of suicide.
16:41And by the way,
16:42in the movement of suicide prevention,
16:44so many of us are suicide loss survivors
16:47also now joined by people with lived
16:50experience who are carrying the torch.
16:52So there's a there's an energy that
16:55can be funneled towards prevention
16:57and advocacy as well when lost
17:00survivors are given the opportunity
17:02to connect and heal.
17:04We say healing is a journey because
17:05there's really not an end point.
17:07It's an ongoing process.
17:08You don't get over your the loss
17:12of your loved one.
17:13And so there's some things
17:15that would that would also,
17:16I would just want to sensitize clinicians
17:19to in their work with suicide loss
17:22survivors That because we've heard,
17:24you know,
17:25terrible stories about loss survivors
17:27sometimes going to therapy and the
17:30therapist with all good intentions
17:32probably saying things like,
17:33well, you should be farther along
17:35in your healing by now.
17:36You should be over it by now.
17:38You know,
17:38technically it's now six months
17:40or 12 months and that is,
17:41that is not correct.
17:43And it is highly jarring and insensitive
17:46to somebody who's bereaved by suicide.
17:49OK,
17:50So now let's turn our
17:51attention just very briefly,
17:53'cause this is the focus of our talk.
17:55But there is a reason that the science
17:59around suicide and understanding
18:01suicide is so important in the
18:04healing process after suicide loss.
18:07Because for those of the, you know,
18:10the average person out there in
18:12society hasn't necessarily yet had
18:14the opportunity to really take that
18:16moment and deeper dive to understand
18:19what science tells us about suicide.
18:21Which dispels so many myths that are
18:24still prevailing and really lingering
18:26around in media and in the way that many,
18:29many people, even clinicians,
18:31almost unconsciously think about suicide.
18:34So I'll just start by saying there's
18:36a lot of scientific work going on.
18:39I just came from Barcelona where we
18:41gathered up 600 of the leading suicide
18:44researchers from 32 different countries.
18:46And those disciplines range from
18:49neurobiological to genetics to
18:51clinical to community cultural
18:54and and epidemiological type of
18:56researchers and computer scientists
18:57like everything in between.
18:59And we really need cross disciplinary
19:02research and we're getting much more mature
19:04as a field of of scientific inquiry.
19:07All of that boiled down,
19:09you know,
19:09there's a million different findings.
19:11But if I had to sum it up in one statement,
19:13I would say the finding is
19:15that while complex,
19:16suicide is a health issue
19:18and a health outcome.
19:20And these are just some of my favorite
19:23little snippets of top findings in
19:25in the scientific literature that
19:27some are very new around epigenetics,
19:29around the genetics of suicide risk,
19:31going even outside just the genetics
19:34for mental health conditions,
19:36the role of shame, humiliation,
19:39rejection,
19:39psychological traits matter as well as
19:43biological markers that that are still,
19:45you know, being searched for.
19:47We we can't predict short term
19:49risk for suicide yet,
19:51but it's we're getting a
19:53little closer in the field.
19:55Mental health treatment matters a whole lot.
19:58Peer support and even just
20:01dialoguing about and opening up
20:04about what you're experiencing.
20:06So don't don't be confused between
20:08the topic of suicide contagion,
20:10which is a real phenomenon,
20:13and talking about suicide
20:14in ways that are hopeful,
20:17or asking an an individual who
20:18may be suffering and at risk if
20:21they're having thoughts of suicide.
20:22Those latter 2 are safe to do.
20:25They are important to do as
20:27part of suicide prevention.
20:28Contagion is a whole different set up,
20:30where suicide and the means for
20:33suicide are being portrayed by
20:35media after celebrity death or
20:37in entertainment content or in
20:39the aftermath of a colleague in a
20:42workplace or in a school setting.
20:44That's why postvention also is so important,
20:47because it helps the leadership
20:48know what to do,
20:50how to communicate and how to
20:52help the community to grieve.
20:54So we're we're always looking at
20:58the trends in suicide and I would
21:00just point out that the trends in
21:03suicidal behavior and ideation
21:04can look very different than the
21:07trends in suicide mortality.
21:09So sometimes people are kind
21:11of conflating all of that.
21:13But it is important to note that
21:15in this
21:16YRBS data set that came out last
21:18year looking at a 10 year trend,
21:21what you saw was that in 2021 some things
21:25are changing for black and brown youth.
21:28And of course we've known that LGBTQ
21:30youth for we've known for a long time
21:33that they are much more likely to
21:35have suicidal thoughts and behavior
21:37than than their heterosexual matched
21:39or cisgender matched young people.
21:46This is my visual that
21:47that Jill Harkavy Friedman,
21:49who runs our research at AFSP and
21:51I came up with about 10 years ago
21:54that really tries to synthesize
21:56OK of all the incredible and
21:58amazing findings in the literature.
22:00What can we say about what amounts to
22:03suicide risk and protective factors?
22:05And the key thing here is that
22:07for any instance of suicide,
22:09psychological autopsy methods show
22:11that there are between 7:00 and
22:1512:00 identifiable risk factors going
22:18on preceding that person's death.
22:21So the idea that but something
22:23happens in their environment and
22:25their current life circumstances,
22:26and that's what leads to suicide
22:29is not correct. It.
22:31Life events and losses,
22:33break UPS, financial strain,
22:34all of those things are important.
22:36They can be seen sometimes
22:39as precipitating events,
22:40but not as a sole cause,
22:42because of course,
22:43the majority of people who experience
22:45those kinds of stressors are resilient,
22:47do not go on to consider suicide
22:49or die by suicide.
22:51So it is this underlying
22:53convergence of biological,
22:55psychological,
22:55social and environmental factors
22:57that we can become so much smarter
23:00about as clinicians and as a society,
23:03because those are opportunities
23:04for prevention and intervention.
23:06If we're able to recognize suicide
23:08risk long before a person even becomes
23:11suicidal, that is now possible to do.
23:14The access to lethal means has
23:15a lot to do with suicide risk,
23:18and that's why that's sitting
23:20there with that red sort of arrow.
23:23So again,
23:25suicide risk and protective
23:27factors are multifaceted.
23:29They interact with each other
23:31and we can look at suicide from
23:34a societal standpoint as a major
23:36public health issue because it
23:38is a complex health outcome.
23:40And that means that we can take
23:43a primary prevention,
23:44a universal strategies around
23:47educating all citizens.
23:49You know,
23:50embedding certain evidence based
23:53interventions even into K through
23:563rd grade school settings that
24:00like the good behavior game,
24:01has been shown to decrease suicidal
24:03behavior and other outcomes 15
24:05years later for children who
24:08are exposed to that classroom
24:10management style of system versus,
24:12you know,
24:12all the way up the ladder of
24:14the public health model,
24:15which I won't go into detail.
24:17Why are we talking about
24:19this about suicide loss?
24:21We're talking about it because in
24:23that search for why it really helps
24:26to have at least some basic AB
24:29CS around understanding suicide.
24:31In in these slightly more nuanced
24:34and accurate and complex ways,
24:37our lexicon has had to change.
24:38Because we used to say things like
24:40commit suicide as if it's a sin or a crime,
24:43which in fact decriminalizing
24:45suicide is still a major advocacy
24:47effort in other countries.
24:49So we we are still stuck in
24:51some Stone Age ways of thinking
24:53that it's a an issue of moral
24:55or characterological deficiency
24:57or a sin those are not correct.
25:00That is not shown by the science at all.
25:03And so instead of saying commit suicide,
25:05we recommend language like died
25:07by suicide or other plain
25:09language. Ended her life,
25:10killed himself. Those are fine.
25:12We had an advocacy win with The Associated
25:14Press style book that they made this
25:17official change for journalists to
25:19stop using the phrase commit suicide.
25:22So you'll see that trend hopefully
25:25more and more the CDC and SAMSA and
25:29we at FSP have summed up what we can
25:32could consider evidence based suicide
25:35prevention strategies for communities.
25:37So this is not talking about
25:39just clinical strategies.
25:40The clinical piece is kind
25:41of embedded in some of this.
25:43But if you look at this,
25:44this is really about at a societal level.
25:46If we increase access to mental health care,
25:49if we infuse the new relatively
25:51new evidence based steps into
25:54clinical practice like screening,
25:56suicide risk assessment,
25:57which is still the probably the
25:59weakest point, safety planning,
26:01lethal means counseling,
26:03CBTDBT,
26:03all of the things that have
26:05evidence we know that we can reduce
26:07suicide risk for a population.
26:09Reducing access to lethal means is something
26:12that it can happen on a policy level.
26:13It also can happen in your work
26:16with a patient who's at risk.
26:18It also can happen with your
26:20neighbor or in your own home if
26:22a family member becomes at risk.
26:23I tell parents and people if their loved
26:26one is struggling and has become suicidal,
26:28the first thing to do,
26:30in addition to letting them know that
26:32your love for them is unconditional
26:34and you're going to help them
26:35get the help that they need.
26:39And I also advise people about how
26:41to make the home relatively secure
26:43from lethal means, 'cause that is,
26:45that is a key step in reducing the risk
26:48of people who are going through a a
26:51brief period of time of suicide risk.
26:53Clinicians need to get much more
26:55engaged in lethal means counseling,
26:58including in emergency departments
26:59and primary care.
27:01I think in mental health care,
27:02hopefully we're we're a bit more advanced
27:04than those other areas of medicine.
27:09So for a suicide law survivor,
27:11the word even the phrase suicide
27:15prevention can be a little bit triggering.
27:19And it's tricky because I'm
27:23often asked by law survivors,
27:25does suicide prevention,
27:26does that phrase mean that my
27:29loved one didn't have to die,
27:31That every case of suicide can be prevented?
27:34And what I would say is that
27:37suicide prevention in my mind
27:41is talking about the many,
27:43many steps we have yet to take
27:46as a society to reduce suicide
27:48mortality in our nation.
27:50It does not mean that this complex health
27:53outcome is preventable in every case.
27:58So that's one thing to note.
28:01Another thing to note,
28:03especially for us as clinicians,
28:05the issue of short term risk prediction
28:08and the fact that we're not able to
28:11predict who will die and when seems to be
28:15a bit of a hang up in my humble opinion.
28:18Whereas I look at cardiologists,
28:20I look at primary care and they
28:22have no problem with the fact that
28:24they cannot predict who will die by,
28:26you know, cardiac or even cancer or
28:30other types of leading causes of death.
28:34It does not stop them from aggressively
28:37identifying those who are at risk
28:39going after the, the,
28:41you know, changeable,
28:42modifiable risk factors.
28:44And also at the public health level,
28:46educating everybody about the AB,
28:48CS of cardiac health and so forth.
28:51So I want to just advise all of us to be
28:54really careful about not conflating the
28:57concepts of prediction and prevention.
29:00We don't have to be able to predict
29:02in order to reduce risk overall.
29:05And like I mentioned earlier,
29:08it doesn't mean that it will always work.
29:11And that is a sobering thought.
29:14I think we as clinicians think we have
29:16a lot more power than we do sometimes,
29:19'cause remember also our patients
29:20spend an enormous amount of time
29:22outside our scope of influence.
29:24And so that's why actually engaging
29:26families and having a more holistic
29:29approach to suicide prevention
29:31is important when possible.
29:32Think about this too,
29:33that with regard to heart disease
29:35and diabetes and again other
29:37leading causes of death,
29:38there are no evidence based
29:40treatments or interventions that
29:42work for all patients in every
29:45instance that just doesn't exist.
29:47So don't let that stop your your
29:50work and your search for how to
29:54continue to work to reduce suicide
29:57risk amongst your patients.
29:59OK.
30:00Let me speed up a little bit because
30:03I also want Doctor Stubby to have some
30:05time to talk about her experiences.
30:07So we're going to turn our attention
30:10now to this topic of clinicians and the
30:14experience of suicide loss of a patient.
30:17So the prevalence for clinicians in
30:20experiencing loss of a patient to suicide,
30:24they're they're kind of estimates
30:25and different stats when you look
30:28in different research studies.
30:29But what I would say summing up
30:31is that probably at least half of
30:34psychiatrists will experience the loss
30:36of a patient to suicide over their career.
30:38It's a bit more front loaded during training.
30:42And also other mental health clinicians,
30:44psychologists,
30:45social workers,
30:46counselors will also have some
30:49prevalence of experiencing the loss of
30:52a patient to suicide when it occurs.
30:56It has the potential to have
30:59tremendous outcomes and impact on
31:02us personally and professionally.
31:05And so I'm not going to go into
31:07all the findings,
31:08but but I what what I want to say is
31:12that it's far more impactful than
31:14we might think in our cerebral,
31:17you know, zipped up clinician identity.
31:21If you haven't gone through that
31:23or if you haven't
31:24paid attention to the literature on this,
31:26it it is along the lines
31:29of the loss of a person,
31:31someone in your personal life.
31:34You know, that kind of grief can can be
31:37the level of impact psychologically,
31:39personally as well as professionally.
31:42And because there was so much shame
31:45around suicide and frankly stigma even
31:49within health systems and within the
31:52fields of psychiatry and psychology,
31:54until I'd say, you know,
31:56really recent decades is,
31:57is the scientific effort really shedding
32:00a light on this as a health issue.
32:04And so that kept so many experiences
32:07just locked on lockdown so that people
32:10weren't feeling able to to process
32:13that experience of loss and potentially
32:16mitigate the the kind of harmful,
32:18potentially damaging effects
32:20on us as clinicians after
32:23experiencing the loss of a patient.
32:25Now we're not going to be able to go into
32:29any kind of breakout groups in this session,
32:32but I did want to just pose some
32:34questions to you to just have
32:36percolating in the back of your mind.
32:38And Doctor Steuby and I will
32:41stay on the Zoom for, you know,
32:44after the talking case,
32:45anyone wants to engage in any,
32:47you know, more kind of intimate
32:49conversation about this.
32:51But if you are somebody who has
32:55experienced loss or loss of a
32:58patient to suicide or the loss
33:01of a loved one to suicide,
33:03those are experiences that
33:05that obviously shape our lives.
33:08And I specifically wanted to have
33:11us collectively think about what are
33:14the activities and interventions
33:16that have been the most useful
33:19and the most helpful to you.
33:21And you know,
33:22maybe we can talk about that because again,
33:24there's a small literature around that,
33:26but not a not a ton to go on.
33:31What we do know is that in
33:35the aftermath of suicide,
33:37there is an an action that can be taken,
33:41a series of actions called postvention,
33:43which is so in the context of
33:47AK12 school or a medical school.
33:51When a student,
33:52or a staff member for that matter,
33:54dies by suicide,
33:55then the leadership has a responsibility
33:58to help create an environment
34:00through communication and through a
34:03series of activities that facilitate
34:06the community's healthy grieving
34:08process and that reduce the risk
34:11of contagion and reduce the risk of
34:13effects of unaddressed trauma on
34:16the community and and particularly on
34:19vulnerable members of the community.
34:22And so this is a very detailed,
34:24this is a very action plan of you
34:27can look at it as a crisis response
34:30plan in a way where a team gets
34:33together and meets every day for a
34:36period of at least a couple weeks
34:38and is carrying out the steps of
34:40that post vention plan and keeping
34:42an eye out for any members of the
34:44community that may be vulnerable now.
34:47So in the aftermath of a patient loss,
34:50patient death to suicide,
34:52we can look at the post vention
34:54period in a in a slightly shifted way,
34:57customized to setting where the goal
35:00then is really to give those members
35:03of the team the support that they
35:07need and the time off that they needed.
35:10Anything that could be helpful in
35:13the most optimal and goal being
35:15that they're processing it through.
35:18They have a chance to reflect that
35:20They're not feeling a sense of
35:22blame or shame where they need not,
35:25but they're still going through
35:26all of the the appropriate steps.
35:28So we'll get into some of that
35:32and and I'm going to ask Doctor
35:34Steuby to comment on on some
35:36of this in just a moment.
35:37But postvention strategies in the,
35:39let's say a clinical training
35:42program could look like embedding
35:46suicide prevention education,
35:48certainly as part of the routine
35:51education and including in that the
35:54topic of patient suicide and almost
35:56in a way framing in advance of any
35:59suicide deaths that may occur.
36:01For those trainees,
36:03how we might understand the topic
36:06of suicide and patient suicide
36:09and the postvention response
36:11protocol is really to destigmatize
36:13and frame the loss For the team.
36:16For those who are grieving to
36:18provide debriefing opportunities,
36:20to really again provide a safety
36:24net to reduce the risk of of trauma
36:27and contagion and to take proactive
36:30steps to create a culture of support.
36:34So these are things that are
36:36easier said than done at UCSD.
36:38Way back when in about 15 or 20 years ago,
36:42I had the opportunity to engage
36:45with a small group in the residency
36:48training program where our residents
36:51really led the way on developing
36:53the UCSD residency training program
36:56suicide loss protocol that that
36:58was put into place and it consisted
37:00of actual steps and checklists
37:02for each member of the team.
37:04So the chief resident was making sure
37:06that some steps are being followed.
37:08The attending this,
37:09engaging with nursing staff,
37:11a whole team approach.
37:15OK, now there are important ways
37:17to talk about suicide that I've
37:19just gone a little bit into.
37:21This is from the the safe
37:23messaging guidelines for media.
37:25But because a suicide death can have
37:29a ripple effect in a community and
37:32sometimes the media does get involved,
37:36it's important to be at least aware that
37:39that there are there's guidance for how
37:41to talk to the media about a suicide.
37:44So please know that the URL is
37:46down there at the bottom and anyone
37:48can have access to my slides too.
37:50By the way, at AFSP we had helped
37:54create the first tool kit for schools.
37:57That's the one on the left that we Co
38:01created with the Suicide Prevention
38:03Resource Center and the EDC.
38:05Then we customize that tool kit for
38:08other settings that you see here and
38:10we worked with other groups to do that.
38:13Interestingly,
38:13when it comes to patient suicide,
38:17there isn't a zipped up toolkit that
38:20I'm aware of that's so kind of packaged
38:23up and therefore many places are
38:25kind of making their own versions.
38:28OK, let me just quickly go through
38:30this and then turn it,
38:31turn it over to Doctor Stubby to
38:34make comments on on any of it.
38:36So there are these like specific
38:38steps to take for the team or for
38:41a residency training program,
38:43a clinical training program.
38:45Sometimes risk management of the
38:48hospital needs to be involved.
38:50Offering a meeting with the family
38:53of the deceased patient is an
38:55important consideration.
38:56We can talk more about that because
39:00there are some nuances around that,
39:02but I will tell,
39:03I will just state my opinion which
39:06is that we should offer that rather
39:09than being concerned either because
39:12of fear of you know,
39:15legal action or fear of issues
39:20around confidentiality.
39:21All of those things can be managed.
39:24And actually by doing that it's a
39:26way for the the team to have that
39:29but but importantly to offer to the
39:32family to have more information and
39:34framing of their loved ones loss and
39:37you can do that without betraying
39:39confidentiality believe it or not
39:41and in many cases of course the
39:44patient was OK with the family being
39:47engaged so so that that's a bit of
39:50a nuance there case reviews should
39:52occur just like normal but needs to
39:55be done in a way that's supportive
39:57non judgmental and and not blaming.
40:01And then offering ongoing support
40:03or debriefing at UCSD,
40:05we made sure that trainees could
40:07meet with someone who wasn't a core
40:10faculty member so that they could
40:12have some just sort of privacy around
40:15their experience of debriefing through
40:17that experience of patient suicide.
40:20That was not necessarily considered
40:22therapy either.
40:23Those might have been a couple
40:25sessions that that trainees
40:26would engage in to to debrief.
40:30So these are some of the goals
40:32again for postvention steps.
40:35Maybe I will at this point invite Doctor
40:38Stubby to to speak on any of this.
40:41This was a slide that she provided as well.
40:44Doctor Stubby,
40:47let me just see what comes next.
40:49OK yeah, we're almost to the end here. Is
40:53there a way for me to see this?
41:03So maybe I'll just start talking here.
41:07So we've always looked at suicide prevention.
41:12How do we assess, how do we manage in the
41:17emergency room, outpatient, etcetera.
41:20But actually, it was Doctor Julie
41:23Chilton who brought up the idea that
41:26we don't talk about postvention.
41:29So it's only been in the last
41:32maybe five years that we've added
41:34this to the curriculum,
41:35thinking about how do we manage
41:39issues when kids don't get better.
41:42So there's a lot of grief.
41:44There's a lot of stress,
41:46there's a lot of shame that comes
41:49from individuals not getting
41:51better or dying by suicide.
41:54So, yeah,
42:01no, this, this is, this is the
42:05wrong slide. I want the one with the
42:10oh, Christine. There, there, that
42:12perfect. OK Like that. She can see.
42:15Forget about this mic. OK,
42:17Dorothy, just talking to this mic.
42:19Yeah, there we go.
42:22So everyone wants to know exactly what to
42:25do in the instance of a patient suicide.
42:28So having a plan before is
42:31always really important and even
42:33people in private practice,
42:34they may not think of this,
42:36but it's really important to put
42:38together a plan in the unfortunate
42:43situation that a patient may die.
42:46So here is sort of the plan that Doctor
42:50Agarwal and colleagues put together
42:53for residency training programs
42:56when a patient dies by suicide.
42:59So the initial response is
43:03to inform supervisors,
43:05inform training directors and then we
43:11will mobilize a larger group of support.
43:15The primary response then is supervisor,
43:21resident, discuss,
43:23then we go past that to emotional response,
43:29talking to families,
43:34Risk management is always informed
43:37very early and making sure that we
43:41have immediate support for residents,
43:43including having them take
43:45some time off if they want.
43:47Some people want time off,
43:49some people don't.
43:53I guess I want to say a
43:55word about toxic shame.
43:57Losing a patient to suicide is one of the
44:02like nightmares for anyone in mental health.
44:05We in order to do our work,
44:09we need to feel like we can
44:12really make an impact. And we can.
44:15We can make a really positive impact.
44:17We can help decrease suicides,
44:21but we can't prevent them all.
44:24So because we have that idea,
44:27then if a patient does die by suicide,
44:32ergo we have failed.
44:35We did something wrong and
44:38there's a lot of shame.
44:40There's a lot of worry.
44:41What will people think?
44:42Will they think that I'm awful?
44:44Am I going to get sued?
44:45What's going to happen?
44:47And then the culture of medicine is
44:51morbidity and mortality conferences.
44:53Those are, you know,
44:55when things go wrong, you look at,
44:57you know what went wrong,
44:58how do you do it better?
45:00And that is an important thing to do.
45:02But calling it morbidity and mortality
45:08really can focus on who did things wrong.
45:13And so it's really important to both learn
45:16are there things that we can do differently,
45:19while supporting and reassuring that
45:22sometimes we're going to lose someone
45:26to suicide no matter what we do?
45:29I wanted to say a word
45:31about families as well.
45:33Speaking of toxic shame,
45:35the idea of meeting with a family when
45:39you were the clinician and the person
45:43has died and you feel really responsible,
45:47you feel really upset.
45:49It is really important to engage the family
45:54for the family's sake and for your sake.
45:58Families typically know that they have
46:02a loved one that has been suicidal,
46:05probably for a while,
46:08and they may also be feeling toxic shame.
46:12Probably occasionally there's even more
46:16guilt that goes around when you say,
46:19oh, thank God, I've been dealing with
46:22them all this time and it's over.
46:26No one will ever say that,
46:27but there may be that and people feel
46:31extremely guilty over that as well.
46:33So really thinking about how complex it is,
46:36how to bring families in and support,
46:39and as a training program,
46:42as an institution,
46:44how do we support every single member
46:48of our group if they do happen to
46:52have a patient die by suicide or
46:55have some other really bad outcome?
46:58And for those of you who have,
47:02I hope that you've had that support
47:04that you need.
47:05I hope you've been able to go through
47:07that grieving process because so many
47:10people will just live with it for years
47:13as sort of a badge of shame and concern.
47:17And the other thing that was
47:19alluded to is the idea of how
47:22does it change your practice?
47:24So the next person you see in the emergency
47:29room who says I'm feeling suicidal,
47:32it's going to be a natural reaction
47:35not to want to take any risk.
47:37And I think that that's OK for a while,
47:42but obviously we don't want to
47:44put people in the hospital that
47:46don't need to be in the hospital.
47:49So the idea of it changing,
47:52decreasing our ability to really
47:55think objectively and putting
47:58more of a fear mindset.
48:00So those are my comments at this point,
48:03but these are what we have put together.
48:07And I know the outpatient clinic also
48:10has a real protocol for postvention,
48:14postvention for patients or postvention.
48:18God forbid that any of
48:20the clinicians might die.
48:24Thank you, Doctor Stubby.
48:26That's really helpful.
48:31Yeah. On the topic of, you know,
48:35not wanting to take the risk after
48:38losing a patient to suicide,
48:40what I will say is that the challenge
48:43in in the suicide prevention
48:46movement today is really important.
48:49And it's that there's a there's a
48:52belief and I think it's somewhat
48:55data-driven that we've been relying
48:59on sort of hospitalization as a as a
49:03two prong thing either go home or be
49:04hospitalized rather than looking at all
49:06of the interim steps that can be taken.
49:09And so there's a there is something
49:11of a movement within the lived
49:14experience community that feels that
49:16involuntary hospitalization has been
49:18over utilized and has been potentially
49:21traumatizing and unhelpful for some
49:25that that is really a challenge.
49:26I think where where we need to go
49:29next in our field is to really be
49:32developing and evaluating more tools
49:34for inpatient at as well as with with
49:37suicide risk reduction in mind knowing
49:39that the post discharge period is
49:42actually the most high risk period
49:45for people who were hospitalized
49:47for suicide related reasons.
49:48So
49:51OK, so let's let's wrap up and really
49:54open it up to any questions or comments
49:57which we really would welcome.
49:59So I'll just kind of wrap up our our
50:03formal part of our talk by saying that
50:06there that the steps of postvention
50:08after suicide loss of a patient are
50:11are very important to go through.
50:13As Doctor Stuby said, it's really ideal
50:17to have your protocol outlined, you know,
50:20at a time when you're not in the crisis mode,
50:22because this is something that requires
50:24things to really be thought through.
50:26If you have yet to develop it in in your
50:29training program, anyone who's here,
50:32then be sure to engage the trainees
50:35themselves as well so that they can
50:37weigh in on what how engaging in,
50:41you know, in support, debriefing,
50:43time off, etcetera,
50:44because it's nuanced how people
50:47perceive those this protocol.
50:52OK, so in summary, suicide loss is a
50:56unique and profound type of bereavement.
51:00The understanding of suicide it can
51:03be a critical part of helping lost
51:06survivors to heal and maybe moving on
51:09into other actions like advocacy which
51:12can also be part of the healing process
51:15and also very important for the suicide
51:18prevention field and supporting clinicians.
51:21Experience after patient suicide is
51:24critical and and again because it suicide
51:30in a state of rising public health crisis.
51:34From a statistical standpoint,
51:36the base rate is still low and so
51:38we don't encounter this every day,
51:39thank goodness.
51:40But it's all the more reason to have
51:43your your supportive steps outlined in
51:45advance in order to optimize outcomes
51:48for clinicians, trainees, and families.
51:52Here are some resources that Doctor
51:55Stubby was is recommending.
51:57The one that I'm in I I would,
51:59I don't.
51:59I don't know what video that is of me.
52:03But on our AFSP website we have many,
52:06many resources for lost survivors as well as
52:11our chapters even offer clinician training
52:14on suicide bereavement on that topic.
52:16And then I've just put together some
52:19of my favorite articles on this topic,
52:22including Doctor Stubby's recent one
52:25called When Prevention Is Not Enough.
52:27I really,
52:27really loved her article that
52:29she wrote for Focus.
52:30That was a special issue of Focus that
52:33I guest edited on the topic of suicide.
52:36OK,
52:36and I will stop there and
52:38invite questions or comments.
52:51I I would like to add a few words
52:56and and I unfortunately two years ago
53:03lost my first patient to suicide and
53:07it was especially traumatizing for me
53:10having lived through my older sister's
53:14suicide in 1993 when she was 20.
53:17I was 19 and my younger sister was
53:2417 and of course I think we're we're
53:28caught because while you know we want to
53:32obviously do everything to help the family.
53:34What we hear from our malpractice insurance
53:37is do not reach out to the family.
53:39At least that has been my experience
53:41and and the
53:44circulating wisdom in the in
53:47the psychiatric community.
53:49And I will say I did reach out to PRMS,
53:54my malpractice provider and explained
53:56that I also did want to reach out to
54:01the family and and they were, you know,
54:06said said be careful about that,
54:09but weren't as anti as I had been told.
54:12And I was also curious because I said,
54:14you know, knowing the literature
54:16and what happens to clinicians,
54:18physicians who lose somebody to suicide.
54:24And you have a vested interest
54:26now in my mental and physical
54:28health considering you are,
54:30you know, responsible kind of for,
54:33for my continued good medical care.
54:37Do you have any resources for
54:40psychiatrists who go through this to
54:43keep them up and running and in and
54:46doing a good job And they said why?
54:49No, we've never even heard of that.
54:52And witness,
54:53if you find resources,
54:56would you bring them to us?
54:58We don't offer that at all.
55:00So I would put that in in Doctor mutier's
55:05ear as a a potential way of finding
55:10those psychiatrists who really are
55:12struggling after the death of a patient.
55:16And then I will also say that I
55:21personally benefited from some
55:23of the American Foundation for
55:26Suicide Prevention's resources and
55:30activities after my sister died.
55:34Strangely,
55:34my sister and I,
55:36we just wanted to talk to someone
55:38the day after she died that
55:39could understand our experience.
55:41We even reached out to somebody we
55:43didn't know who who was the older
55:45sister of of a girl in our high
55:47school who had died by suicide,
55:49thinking 'cause we we just were so lost.
55:54And that need to kind of have
55:57some people who might understand
55:59was so strong for the two of us
56:03in our teenage years.
56:05Also,
56:05my parents had the wisdom of having
56:08my older sister's psychologist come
56:10to the house prior to the funeral and
56:13and help us talk through it and why.
56:15And my sister and I had questions
56:19we weren't comfortable asking my
56:21parents because we didn't want
56:23to make them feel bad or guilty.
56:26That really that psychologist
56:28could help us work through.
56:31Then my dad and I several years later did
56:35the Out of the Darkness walk in Chicago,
56:38where, you know,
56:39through the night,
56:40I think we walked 12 miles or so
56:43with other survivors and really got
56:47some meaning and sense of connection.
56:51I also participated in the Suicide
56:53Loss Survivors Day when I was
56:56a medical student at UCSF,
56:58which was helpful and in the
57:01immediate aftermath, You know,
57:03in 1993,
57:04my parents didn't and I don't
57:06didn't know about AFSP.
57:08My parents went to Compassionate
57:10Friends a support group for for parents
57:14what what I now offer residency when
57:20when when they're coming up with a
57:25postvention protocol is giving our residents,
57:30our clinicians ideas of what
57:32they could offer.
57:33You know the AFSP website has
57:37a support group by zip code.
57:42You know,
57:43find a support group page for
57:46you can offer to parents telling them
57:49about things later on, what when
57:52they're after that more acute period.
57:55But but while we feel so helpless and and so
58:02like we didn't do enough,
58:04there are still ways that
58:06you can help a family even
58:08after your patient is gone.
58:11So thank you so much Doctor
58:13Moutier and and Doctor Stuby.
58:16I'm so grateful to you both.
58:20Thank you Doctor Chilton and
58:22thank you so much for sharing
58:24your your both your professional
58:27and personal journey with this.
58:30I think it's when we,
58:33when we go through these experiences
58:36and we have the opportunity to process
58:40and kind of come back to center,
58:43it does give us a new lens on things
58:46and many of us do get involved.
58:48It's you know, I'm devoting my whole career.
58:50I've been at AFSP for 10 years now and
58:53it is a privilege and and there's so
58:56much hope actually for change to come
58:59and greater investments on the part of
59:01our federal government and so forth.
59:03A lot is changing.
59:05So I really thank you all and you
59:08know thank you for for devoting
59:10the time and and your work with
59:13patients more than anything else.
59:15So thank you and and again I'll
59:16I'll stick around.
59:17I know people have to go on to
59:19their next meetings and things,
59:20but I'll stay on in case anyone
59:22wants to engage further.
59:25Thank you so much. Thank you so much.