Death by suicide poses a profound challenge to both the family members who survive and the treating psychiatrists. In this paper, we describe a unique pilot intervention to address these issues in the education of psychiatry residents.

A significant proportion of psychiatry residents lose a patient to suicide during residency training, with estimates ranging from 14–68 % [1]. Patient suicide results in residents experiencing grief, shock, anger, and guilt [2, 3]. At the same time, when a patient dies by suicide, the family must navigate a unique bereavement process. Those who have lost a family member to suicide experience frequent feelings of rejection, responsibility, shame, and stigma [4]. Almost all families of patients lost to suicide wish to be contacted by the treating psychiatrist [5]. However, few psychiatrists or psychiatry residents contact families, and fewer still attend the funeral of their deceased patients [1, 6].

The Accreditation Council for Graduate Medical Education program requirements in adult psychiatry do not specifically mention suicide, suicidal patients, or families of suicides among the topics that programs must cover. Furthermore, there are few guidelines about how to prepare residents for the possibility of a patient’s suicide or about how to support residents afterward, resulting in great variability in the curricula regarding suicide [1]. A survey in 2003 revealed that only a third of residents reported receiving formal education on patient suicide [6].

In an effort to address these deficiencies, we created a pilot educational event in which a panel of people who have lost family members to suicide presented their experiences to our residents. We predicted that this event would affect attitudes towards suicidal patients, understanding of their family members’ experience, and intended management of suicidal patients. In particular, we hypothesized that this program would increase the residents’ inclination to involve family members in the care of suicidal patients and increase their likelihood to interact with families after a death by suicide.

Methods

A panel of three presenters from the Dallas chapter of the American Foundation for Suicide Prevention provided an educational program for UT Southwestern psychiatry residents on November 9, 2011. The program director and chief residents met with the speakers in advance to discuss our educational goals and to hear a description of their intended presentations. During the program, each presenter discussed the experience of losing a family member to suicide—a child, a spouse, and a parent. Each spoke for approximately 20 minutes; their narratives included details of the patient’s illness and attempted interventions by the family member and treatment teams. The speakers described their grief after the loss, how they mourned, and how other people in their lives responded to their grief. The speakers described feelings specific to a loss to suicide, such as their anger at the patient and their own subjective guilt. Each speaker also recommended potential best practices for clinicians when working with family members who have lost someone to suicide.

This study was designed to examine the impact of this conference as part of a psychiatry residency training program. To this end, all psychiatry residents in attendance were asked to complete a brief survey. The questions in the survey examined the general benefit of attending the program, the perceived change in residents’ attitude towards suicide and survivors of suicide loss, and the anticipated change in managing suicidal patients in general and in specific aspects. Residents were given space to comment on each question. Representative responses are included in the results. Those were selected based on their ability to reflect the general consensus of the submitted comments. The survey items are available by correspondence with the authors. Survey responses were anonymous and free from any identifying information. This study was exempted from review by the institutional review board at UTSW.

Results

Thirty four (n = 34) of 44 UTSW psychiatry residents completed the survey. About a third (29.4 %) of the respondents reported having encountered patient suicide during their residency training.

Most of the residents (91.2 %) found this program to be successful in communicating the experience of suicide loss survivors, and the same number agreed that future colleagues would benefit from attending similar educational programs. One resident commented, “I have never heard stories like these. Fascinating, heart-breaking and very helpful.”

The majority of residents (64.7 %) agreed to a subjective sense of a change in attitude toward suicide after attending the program. Most residents (91.2 %) agreed that they are now more likely to believe that the loss of loved ones poses a specific grieving challenge to the survivors. One resident wrote, “I never realized what an important role the family plays and how helpless and confused they feel.”

The majority of residents (73.5 %) agreed that this program would change their future management of suicidal patients. Further, residents agreed that they would be more likely to involve families in the care of suicidal patients (85.3 %), to call families after a patient suicide (85.3 %) and to refer families to support groups (94.1 %). There was a less consensus about the idea of attending the funeral after a patient suicide, with similar proportions of residents strongly agreeing (35.3 %), agreeing (26.5 %), feeling neutral (20.6 %), and disagreeing (17.6 %) that they would do so. One resident noted, “I feel this would be a case by case basis and my decision would not be based on this program.”

Discussion

This study assessed the impact of a pilot educational program on psychiatry residents’ attitudes and understanding of the nature of grief in families of suicides and their clinical management of suicidal patients. Psychiatry residents found the program to be helpful and would recommend such programs to future colleagues. Overall, the survey data suggested perceived changes in the attitudes of residents towards suicidal patients and in their understanding of the uniqueness of the grief experience for family members. The data also suggest planned changes in residents’ future involvement of family members in the care of suicidal patients and their likelihood of reaching out to support the families in cases of death by suicide. In contrast, residents were less convinced that they would attend funerals in the future, perhaps because they anticipate survivors may confront or blame them.

This study has some limitations, particularly that the intervention and study were limited to one residency training program. The survey was administered after the residents had attended the educational program and no data were collected prior to the program, so we were not able to report preintervention and postintervention comparisons. We acknowledge that each suicide loss survivor’s story and experience is unique and having a limited number of presenters in this educational program inevitably provided an incomplete and subjective experience. Another limitation is that it is possible that residents may feel pressured to answer in a “politically correct” way, which may overestimate acceptance of the program. Since the program was arranged by the program director as a special event, there may have been a placebo effect, where the residents feel that the program had a positive impact because they expect it to have such an impact.

Notwithstanding these limitations, the data collected in this study are encouraging and suggest that educational programs focused on patient suicide from the surviving families’ perspective may have a positive impact on attitudes and future practice of residents. A follow-up survey would ideally be done a few years after such a program to detect any long-lasting effects on management of suicidal patients, interactions with families, and general attitude towards suicide. Our residency training program is actively collaborating with the Dallas Chapter of the American Foundation for Suicide Prevention to explore the possibility of including similar programs in our curriculum annually.

We recommend that other training programs try to replicate this educational program. Future studies should consider including multiple sites, pretesting as well as posttesting, and validated measures that capture changes in attitudes towards suicide. Having speakers who represent the range of relationships and treatment experiences is optimal, but, in our opinion, less important than the preparation and educational skill of the individual presenters. Consideration should also be given to addressing the medicolegal implications of contact with family in terms of confidentiality obligations. Should the positive impact on residents still be demonstrated when the study has been replicated on a larger scale, this would suggest that similar educational programs would be an essential component of the suicidology curriculum of psychiatry residency training programs.

In summary, this report suggests that educational approaches that emphasize the subjective experience of suicide loss survivors can have an impact on psychiatry residents and might be of benefit to incorporate into suicidology curriculums alongside theoretical and clinical aspects of managing those patients and their families.

Implications for Educators

• This article highlights the importance of teaching psychiatry residents about the unique grief experience of family members who lost loved ones to suicide.

• Understanding the surviving families’ perspective may increase residents’ involvement of family members in the care of suicidal patients and may change resident attitudes toward suicidal patients.