Psychiatric Bulletin (2002) 26: 50-52. doi: 10.1192/pb.26.2.50
© 2002 The Royal College of Psychiatrists
Psychiatric Bulletin (2002) 26: 50-52
© 2002 The Royal College of Psychiatrists
The impact of suicide on community mental health teams
findings and recommendations
Stuart Linke, Consultant Clinical Psychologist,
Jenny Wojciak, Trainee Clinical Psychologist and
Samantha Day, Trainee Clinical Psychologist
Camden & Islington Mental Health Services NHS Trust, Department of
Clinical Psychology, Charterhouse Building, Highgate Hill, London N19
3UA
See pp. 44-49 and pp. 53-55 this issue. 
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Abstract
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AIMS AND METHOD
The study investigated the personal impact of patient suicides on the
members of community mental health teams and the sources of support utilised
for coping with adverse effects.
RESULTS
Forty-four questionnaires were returned. Eighty-six per cent of staff
reported having had at least one patient suicide, with an average of 4.2
suicides. The majority of staff reported that patient suicides had significant
adverse effects on their personal and professional lives. Some of the effects
were long-lasting (greater than 1 month). Staff found that peer support,
reviews, dedicated staff meetings and support from senior colleagues were of
most value.
CLINICAL IMPLICATIONS
Staff require skilled and dedicated support following a patient suicide in
order to minimise its detrimental effects on personal, professional and team
functioning.
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Introduction
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Community Mental Health Teams (CMHTs) are at the heart of the modern mental
health service. Stress among the staff of these teams is a concern both in its
own right as an occupational health issue and also because it is likely to
have a detrimental effect on the functioning of a team. Mental health nurses
have been found to experience greater stress in community settings than their
hospital-based colleagues (Carson et
al, 1995; Prosser et
al, 1996). Patient suicide is a significant contributor to
staff stress. It has been shown to affect adversely the health and well-being
of consultant psychiatrists (Alexander
et al, 2000), psychiatric trainees
(Dewar et al, 2000),
clinical psychologists (Bucknall &
Unsworth, 1997) and nurses
(Cooper, 1995), with some staff
displaying symptoms of depression, anxiety and post-traumatic stress
disorder.
A patient's suicide can adversely affect not only the individual staff
members but also the functioning of a unit, such as a psychiatric ward, in
which the staff member works (Kayton &
Freed, 1967). In a similar way a suicide by a patient may have a
detrimental effect on a CMHT as a whole. Although there have been many studies
of the effects of a suicide on individual professional groups, there have been
none on multi-disciplinary CMHTs. Studies of this kind may be of value because
they indicate the type of support that could be helpful for such teams in
order to reduce the adverse impact of disturbing events such as a patient
suicide.
The present study aimed to investigate the effect of patient suicide on the
members of multi-disciplinary CMHTs in inner-city London.
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The study
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All 77 members of five CMHTs were sent confidential questionnaires. The
CMHTs covered the London Borough of Islington, which is an inner-city area
with high levels of social deprivation and mental health problems. The
questionnaire was based closely on that used by Alexander et al
(2000) in their study of
consultant psychiatrists' responses to suicide. The questionnaire was adapted
for a multi-disciplinary group. The questionnaire had two sections: the first
asked about personal non-identifying information and the second asked about
the ‘most distressing’ suicide. There was also space for free text
responses, and additional comments were invited. The questionnaires were
administered and analysed by two trainee clinical psychologists who had no
other connection with the service (J.W. and S.D.), which helped to preserve
the anonymity of the responses.
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Results
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Forty-four completed questionnaires were received (a response rate of 57%).
Some staff were absent during the data collection period so we cannot be
certain that all team members received their copy of the questionnaire. This
may account for the rather low response rate. Twenty-eight of the respondents
were female, 14 were male and two did not complete that item of the
questionnaire. The majority of the respondents were either community
psychiatric nurses (18) or social workers (15). Of the remainder, two were
psychiatrists, four were clinical psychologists, two were occupational
therapists, two were managers and one was an administrator. The mean number of
years since qualification was 12.9 (s.d.=9.2) and the mean number of years in
the current post was 3.8 (s.d.=4.7).
Thirty-eight (86%) of the respondents reported that they had experienced at
least one patient suicide in their career, with an average of 4.2 (s.d.=5.1)
suicides. Twenty-eight team members (64%) had experienced a patient suicide in
their current job.
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The effects of a patient's suicide
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Staff were asked about the effects of the most distressing suicide. Many of
the respondents reported that it had a noticeable impact on both their
personal and professional lives (see Table
1).
Staff reported experiencing a range of symptoms and emotions following a
patient's suicide (see Table
2). Some of these symptoms were transient, however 15 (40%)
acknowledged symptoms that persisted for over 1 month. The effects on
professional life also were long-lasting and 17 (45%) reported adverse effects
lasting longer than 1 month. Some of these effects were serious enough to
influence professional behaviour in negative ways, such as avoiding clients
who abuse alcohol and drugs, increased anxiety at work, irritability with
employers, increased distance between self and clients and an increased desire
to change jobs. A small number of staff, however, reported positive effects
such as improved notekeeping and an increased likelihood to seek support and
peer supervision from colleagues. Only three respondents (7%) took time off
work following a patient's death.
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Support following a suicide
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Staff were asked what ‘support’ meant to them. Twenty-three of
the respondents defined support primarily as having time to talk and having
someone to listen. Six appreciated skilled supervision on the case, five felt
that receiving acknowledgement of the impact of the event was important while
not being blamed and four valued having time off.
The most common source of support was from immediate colleagues, followed
by partners, friends and family (see Table
3). Where special staff meetings to discuss the suicide and
provide support were held, they were generally viewed as being of value, but
there was some comment that they must be handled carefully. Staff closely
involved with clients who have killed themselves often feel judged and
vulnerable to criticism. In this context, official enquiries into the
background on the suicide were viewed equivocally. Although an attempt to gain
an understanding of the suicide and learn from it was valued, there was
considerable unease about the manner in which formal investigative enquiries
are conducted.
Thirty staff recommended that in future special meetings to discuss a
suicide could be helpful and, most importantly, that senior staff should
publicly acknowledge how disturbing a suicide can be for teams and team
members. Thirty-one of the respondents, a majority, had felt inadequately
prepared for dealing with a suicide by their initial professional training
(although they all felt trained in risk assessment) and would welcome further
help in this regard. In particular, developing an attitude of acceptance that
suicides are likely to happen in CMHT work and that they are not always
preventable was thought to be helpful.
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Discussion and recommendations
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The multi-disciplinary group of staff sampled in this study reported a high
incidence of patient suicide during their careers and in their current posts.
Although the study sample was small it is clear that, as with other groups of
mental health workers, these suicides had a significant detrimental effect on
the personal and professional lives of CMHT staff. The incidence of suicide,
however, appears to be higher than that reported by consultant psychiatrists
(Alexander et al,
2000) and psychiatric trainees
(Dewar et al, 2000)
and results in a similar degree of distress. This may not, however, reflect a
greater number of suicides overall, but is more likely to be a result of
multi-disciplinary teamwork in which cases are shared. This sharing of cases
makes support from colleagues more possible than working single-handed, but
also means that a patient suicide affects a greater number of people. The
effect of this can be very uneven. In one of the teams, for example, there had
been several suicides in close proximity. One of the patients was well known
to all members of the team, whereas the other patients were known to only the
particular members of staff who were the patients' key workers. This is a key
issue that needs consideration when providing support to a team following a
suicide.
There is little published on team support following serious incidents such
as suicide. Recommendations for individual support have included discussion
with colleagues, attending patients' funerals, detailed case reviews, special
staff meetings and training in the likelihood and expectation of suicide as a
normal part of the mental health worker's role (as part of initial and ongoing
training). All these were confirmed in the present study. Suggestions for team
support have included holding special staff meetings and the use of the
specific technique of psychological or critical incident stress debriefing
(Farrington, 1995). This is now
considered a controversial technique because in some cases routine
psychological debriefing may cause more harm than good. A more appropriate
form of intervention is a dedicated team review that focuses on establishing
and sharing the facts of the case, normalising individual responses to the
situation (by, for example, describing the findings of studies such as this
one) and allowing staff to offer support and encouragement to each other. Care
must be taken, by an experienced group facilitator, to ensure that the
expression of strong emotions such as guilt, shame, fear and grief are
contained and normalised, rather than encouraged or explored in depth.
Support by senior members of the team and management was considered by our
respondents to be particularly helpful. Dewar et al
(2000) reported that trainee
psychiatrists valued the support and guidance of their consultants. Similarly,
CMHT members greatly appreciate comments from senior colleagues acknowledging
the impact of a suicide. There are often formal enquiries into the background
to a suicide and there is a risk that these can add to the trauma for staff if
they are not handled sensitively. It is in the interests of good team
functioning that the issues of professional responsibility and good practice
are highlighted and examined in a context that supports rather than threatens
staff, during a time that is already highly stressful with raised personal and
professional vulnerability.
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Acknowledgments
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We are grateful to Professor Paul Bebbington for his helpful comments on an
earlier draft of this article.
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Abstract
Introduction
