Master Thesis
The impact of patient suicide on PTSD symptomatology among mental health professionals
Katharina Verzak S2106302
Master Thesis Clinical Psychology
Supervisor: Dr. J.F. van den Berg & S. Struijs Leiden University
14-07-2019
Authors Note: This study made use of the dataset based on the research that was done in collaboration with Claudia Berwers, who designed and sent out the questionnaire to over 2000 mental health
Abstract
Background: Patient suicide is a common experience amongst mental health professionals (MHPs) which often causes strong reactions. Often these reactions closely resemble posttraumatic stress symptoms. However, to date no study has investigated the association between patient suicide and posttraumatic stress specifically. This study examined the link between patient suicide and posttraumatic stress among MHPs as well as possible interaction effects of self-confidence and perceived social support with patient suicide in predicting posttraumatic stress.
Methods: In this observational cross-sectional study 437 questionnaires were answered by professionals from different facilities of a Dutch mental health institution. The questionnaire consisted of the PCL-5, which assessed self-reported PTSD symptoms and a distress
questionnaire (4DSQ). MHPs were also asked to rate perceived social support and their confidence in dealing with patient suicide on a 4-point Likert-Scale.
Results: Results did not show a significant association between patient suicide and self-reported PTSD symptoms. Social support but not self-confidence was negatively related to PCL-5 scores. No interaction effects of social support or self-confidence with patient suicide in predicting PCL-5 scores were found.
Discussion: In this sample patient suicide was not significantly linked to higher PTSD symptoms among MHPs indicating that MHPs handle patient suicide well. However, more exploration of the quality and quantity of symptoms following patient suicide could be done by future research to determine whether these results are due to a lack of an association or rather methodological issues of this study.
Introduction
“When I got the call that Susan had committed suicide, I refused to believe it. Even after hearing that she had hanged herself in the bedroom, that the police had been there and that the medical examiner had take her body away, I said, “Are you sure she is really dead?” Once the truth sank in, my next feelings were of panic, fear, followed at various times by confusion, shame, doubt sadness and relief – to name just a few emotions I experienced. When I put down the phone I realized I had no idea what to do next” – Kayla Miriyam Weiner, PhD, Psychologist and Psychotherapist (Weiner, 2005, p. 1)
Suicide is a common phenomenon. Every year nearly 800 000 people, that is one person every 40 seconds, commit suicide. In 2016 alone in the Netherlands more than 1800 people committed suicide and the numbers continue to grow every year (Centraal Bureau voor de Statistiek, 2017) .
Approximately one third of deaths by suicide come from people receiving mental health treatment (Huisman, van Houwelingen, & Kerkhof, 2010). Therefore, many mental health care professionals (MHPs) experience the loss of a patient by suicide. The exact numbers vary across studies, settings and professions. A national survey in the late 1980s found that 51% of psychiatrists and 21% of psychologists have reportedly lost at least one patient in their career to suicide (Chemtob, Hamada, Bauer, Kinney, & Torigoe, 1988; Chemtob, Hamada, Bauer, Torigoe, & Kinney, 1988). A recent review that examined 32 studies across the world showed that 70% of mental health professionals had at least one patient who committed suicide throughout their career (Séguin, Bordeleau, Drouin, Castelli-Dransart, & Giasson, 2014).
Losing a patient to suicide is an emotional experience that has been described as severely distressing or even traumatic for MHPs throughout the literature with some researchers even referring to patient suicide as an occupational hazard (Chemtob, Bauer, Hamada, Pelowski, & Muraoka, 1989; Chemtob, Hamada, Bauer, Torigoe, et al., 1988; Ellis & Patel, 2012; Séguin et al., 2014; Weiner, 2005; Wurst et al., 2010). For instance, one study found that therapists who have experienced patient suicide showed subjective stress levels that were comparable to the ones of people who have recently experienced the loss of a parent (Chemtob et al., 1989; Chemtob, Hamada, Bauer, Kinney, et al., 1988).
A wide range of emotions such as described in the opening of this paper are common among MHPs who experienced patient suicide. On a personal level these reactions often include feelings of sadness, shock, anger, grief, betrayal and denial (Chemtob et al., 1989;
Draper, Kõlves, De Leo, & Snowdon, 2014; Ellis & Patel, 2012; Kleespies, Penk, & Forsyth, 1993a; Séguin et al., 2014). Many other reactions closely resemble posttraumatic stress symptoms. Guilt and self-doubt are not uncommon but also irritability, sleeping problems and heightened awareness to trauma reminders (i.e. suicidal cues) are often reported (Alexander, Klein, Gray, Dewar, & Eagles, 2000; Gulfi, Castelli Dransart, Heeb, & Gutjahr, 2010). Additionally, feelings of loneliness or being isolated are frequently mentioned in MHPs self-reports after patient suicide (Ellis & Patel, 2012; Wurst et al., 2010). On a professional level common reactions include feelings of inadequacy, self-doubt, embarrassment and
incompetence (Draper et al., 2014; Ellis & Patel, 2012; Séguin et al., 2014). Moreover, many MHPs report behavioral changes, particularly in their work methods. This includes increased record keeping, increased focus on suicidal cues and increased peer consultation. Some MHPs report avoiding suicidal or high risk patients and exhibit resistance to treat such patients. (Alexander et al., 2000; Chemtob, Hamada, Bauer, Torigoe, et al., 1988; Draper et al., 2014; Séguin et al., 2014).
The role of social support
After a patient suicide, many MHPs have actively sought peer and social support from family and friends but also from colleagues, supervisors or other MHPs (Alexander et al., 2000; Kleespies, Smith, & Becker, 1990). In one study in Switzerland social support emerged as a key factor in predicting the severity of distress and therefore the impact of patient suicide on MHPs. MHPs who reported that they sought out and received sufficient social support showed significantly lower stress reactions and were therefore less negatively impacted by patient suicide than MHPs who reported a lack thereof (Dransart, Heeb, Gulfi, & Gutjahr, 2015). Furthermore, perceived social support has specifically been linked to PTSD symptoms. A meta-analysis of 77 studies found that among 11 examined risk factors, lack of social support (the authors did not differentiate between actual social support and perceived social support) emerged as one of the strongest predictors of posttraumatic stress symptoms together with trauma severity and subsequent life stress (Brewin, Andrews, & Valentine, 2000).
Perceived social support has also been investigated in the context of posttraumatic growth. Posttraumatic growth is defined as “experience of positive change that occurs as the result of a struggle with highly challenging life crises” (Tedeschi & Calhoun, 2004, p. 1). In a review of several studies Tedeschi & Calhoun conclude that perceived social support
resource of coping with the aftermath of a traumatic event and thereby decreasing traumatic symptoms (Tedeschi&Calhoun, 2004).
The role of self-confidence
Evidence suggests that less training in dealing with suicidal patients might be related to an increased severity of posttraumatic stress after losing a patient to suicide. Following patient suicide, less experienced therapists or therapists in training show stronger emotional reactions and more severe distress than their more experienced counterparts (Kleespies, Penk, & Forsyth, 1993b). Having learned that their patient committed suicide many MHPs point out that they would like to have more training in working with suicidal patients and managing patient suicide (Alexander et al., 2000). But how do experience and training affect the severity of posttraumatic stress following patient suicide?
One possible explanation of how experience and training affect the severity of
posttraumatic stress in MPH’s after patient suicide is provided by Bandura’s social cognitive theory of posttraumatic stress. According to this theory coping self-efficacy plays a key role in dealing with trauma (Benight & Bandura, 2004). They define coping self-efficacy as “the perceived capability to manage one’s personal functioning and the myriad environmental demands of the aftermath occasioned by a traumatic event”. According to Benight & Bandura this belief directly affects the severity of experienced posttraumatic stress following many different types of trauma (Benight & Bandura, 2004). Building upon this theory other studies identified resilience, in which one major component is self-mastery, as one major protective factor against posttraumatic stress in several trauma contexts (Day & Kearney, 2016). Apparently, an important aspect in coping with traumatic events is the belief that one can cope with the challenges faced with the event (i.e. patient suicide). In our study this belief is labeled “clinical self-confidence”. To date the relationship between clinical self-confidence and posttraumatic stress in the context of suicide has been largely uninvestigated. Therefore, this study aims at exploring the possible link between these two variables.
Research Question and Hypotheses
This study investigates the relationship between experienced patient suicide and posttraumatic stress symptoms such as intrusions, avoidance, mood disturbances and reactive behaviors in MHPs. The main examined hypothesis states that there is a positive relationship between experiencing patient suicide and self-reported PTSD symptoms among MHPs. Moreover, this study aims to look at factors that possibly positively influence that relationship. Therefore, it investigates possible relations between clinical self-confidence and
PTSD symptoms assuming that a) there is a negative correlation between self-confidence and self-reported PTSD symptoms and b) there is an interaction effect between self-confidence and patient suicide in explaining the variance on PTSD symptoms.
Given the relations of social support in coping with suicide and its associations with posttraumatic stress, this study also investigates whether perceived social support is indeed related to PTSD symptoms. This study examines the hypothesis that there is a) is a negative correlation between self-confidence and self-reported PTSD symptoms and b) there is an interaction between perceived social support and patient suicide in explaining the variance of PTSD symptoms following patient suicide.
Methods
Design, Participants and Procedure
This is an observational cross-sectional study. An online questionnaire was sent out to about 2000 mental health professionals working for Parnassia Group (a mental health
institution in the Netherlands). Confidentiality and anonymity were assured, and the participants had to provide informed consent before starting the questionnaire. After two weeks all the MHPs received a reminder about the study.
Instruments
Demographics. The used online questionnaire was a self-report measure that
containing items assessing demographic variables (age, sex), professional characteristics and experiences (educational level, occupation, work setting, training in suicide prevention, experiences of patient suicide and suicide of a loved one).
Distress. Experiences of distress and common psychopathology after suicide were assessed using 16 itemsof the Dutch version of The Four-Dimensional Symptom
Questionnaire (4DSQ). The 4DSQ has shown reasonable reliability scores (α = .94 for the distress scale of the Dutch version and α = .90 for the distress scale of the English version). The questions referred to experiences in the week prior assessment. Questions such as “During the past week, did you feel tense?” and “During the past week, did you have
difficulties getting to sleep?” were rated on a 0-4 Likert scale with 0 indicating the lowest and 4 indicating the highest frequency of the experienced complaints (0=never, 1=sometimes, 2=regularly, 3=often, 4=very often or constantly). All responses were summed up to form one main score for distress. The distress scale’s validity has been tested and shown to have reasonable construct validity (Terluin et al., 2006). The researchers who developed the
instrument describe distress as an underlying factor indicative of any psychological diagnosis. The distress score has shown high correlations with other psychological diagnoses (especially depression and anxiety) indicating good criterion validity (Terluin, 1996, 1998; Terluin, Willem, Schaufeli, & De Haan, 2004).
PTSD symptoms. For assessing PTSD symptoms, the Dutch version of the PTSD checklist of the DSM-5 (PCL-5) was used (Boeschoten et al., 2015). It is a short 20item self-report measure that orients itself along the DSM-5 symptom clusters (American Psychiatric Association, 2013). Items such as “In the last month, how much were you bothered by repeated, disturbing, and unwanted memories of the stressful experience?” or “In the past month, how much were you avoiding external reminders of the stressful experience?” were rated on a 5-point Likert scale ranging from 0= not at all to 4= extremely. Scores were summed up and a maximum possible score was 80. A cut off score of 33 is suggested based on the current evidence to make a provisional diagnosis of PTSD (Weathers et al., 2013). The PCL-5 has shown to be a reliable screening measure for posttraumatic stress with internal consistency scores of α = .96 and a test–retest reliability of r = .84. It has also demonstrated good construct validity by showing a high correlation (r = .87) with the earlier version PCL-C (Bovin et al., 2016). Moreover, a large body of research has consistently shown its reliability in of the previous version based on the DSM-IV (Blevins, Weathers, Davis, Witte, & Domino, 2015; Bovin et al., 2016; McDonald & Calhoun, 2010).
Self-confidence. Self-confidence was assessed by three items that are based on the statements of ‘provider confidence’ by Oordt, Jobes, Fronscesca and Schmidt on a 0-4 Likert scale (0=not at all,1= a little, 2=moderately, 3=quite a bit, 4=a lot). Given the
operationalization of self-confidence in this study only the item: “I am confident in my ability to successfully treat suicidal patients.” was used for the statistical analysis. (Oordt, Jobes, Fonseca, & Schmidt, 2009).Although this item seems valid on face value the reliability and validity of this construct have not been examined. Therefore, results must be interpreted with care.
Social Support. Perceived social support was measured by two items asking the participants whether they experienced support after patient suicide in their personal and professional life (i.e. “Did you experience support in your work environment after the suicide?” and “Did you experience support in your personal life after the suicide?”). The items were rated on a 0-4 Likert scale (0=not at all,1= a little, 2=moderately, 3=quite a bit, 4=a lot) and summed up. This resulted in a total score ranging from one to eight in which the score one indicated the lowest and a score of eight indicated the highest possible level of
perceived social support. Similar to the measures of self-confidence the item that was used to measure social support has not been examined for reliability and validity and has to be interpreted with caution.
Statistical Analysis
First a descriptive analysis was carried out. To investigate the relationship between patient suicide and PTSD symptoms a simple linear regression-analysis was performed with the experience of patient suicide (yes/no) as the independent variable and the PTSD
symptoms as the dependent variable.
To examine the relationship between self-confidence and PTSD symptoms,
correlations between scores on these two variables were analyzed. The main effect of patient suicide (yes/no) on PCL-5 scores has already been investigated in the main hypothesis. Secondly, a simple linear regression with self-confidence as the independent variable and the PCL-5 scores as the dependent variable was carried out. Subsequently a multiple regression model was examined including patient suicide and self-confidence as main effects as well as the interaction of suicide and self-confidence as independent variables. PCL-5 scores were put in as the dependent variable.
To investigate the relationship between perceived social support and PTSD symptoms the correlations of these two variables were examined. Analogue to the above-mentioned interaction analysis three regression models were analyzed to determine whether there was an interaction effect of perceived social support and patient suicide in predicting PTSD
symptoms. The first model was equivalent of the one for the main hypothesis. A second model included perceived social support as the independent variable and PCL-5 scores as the dependent variable. Lastly, the third model included patient suicide, perceived social support and the interaction of patient suicide and perceived social support as independent variable and PCL-5 scores as the dependent variable. All analyses were performed using IBM SPSS 23.
Results
Over 2000 questionnaires were sent out to a randomly selected sample of MHPs working at a Dutch mental health institution (ParnassiaGroup) and 472 questionnaires were sent back. (Some of the non-returned questionnaires were due to MHPs being out of office or non-updated contact information). 35 participants have not completed any of subsections of the questionnaire (e.g. neither had they completed the distress questionnaire nor the PCL-5). They were therefore excluded leading to a remaining sample of N = 437 mental health
professionals (e.g. clinical psychologists, GZ-psychologists, psychiatrists, basic psychologists, nurses etc.) from seven different mental health facilities (inpatient and outpatient facilities). The participants age varied between 20 and 70 years (M = 42.32, SD = 11.66). 76% (n = 332) of respondents were female and 24% were male (n = 105). In this sample 211 MHPs reported that they had experienced the loss of a patient to suicide and 226 had not. The PCL-5 questionnaire was completed by 425 MHPs and showed fairly low scores (M = 4.81, SD = 5.72, min = 0, max = 43). PCL-5 scores were non-normally distributed with a skewness of 2.67 (SE = .12). The positive skew was similar in the group of MHPs who have experienced patient suicide and the ones who have not. Self-reported clinical confidence showed a mean score of 4.56 (SD = 1.15) and perceived support was reported with a mean of 4.32 (SD = 1.57). Both variables were normally distributed.
Table 1
Characteristics of the sample (N = 437)
Total M (SD) N % Gender Female Male 332 105 76 24 Age 42,32 (11,66) 437 100 Profession
Specialist in clinical and/or clinical neuropsychology 28 6,4
Psychologist with post-master qualifications 76 17,4
Psychologist 97 22,2
Psychiatrist 48 11
Addiction medicine specialist, geriatric physician 8 1,8
Master advanced nurse practitioner 17 3,9
Social psychiatric nurse / in training to master advanced 49 11,2
Socio-Pedagogical Care worker or other applied sciences 11 2,5
Nurse 27 6,2
General Practitioner in training / Postgraduate House Officer/ Senior House officer
21 4,8
Trainee/ Intern Other 1 50 0,2 11,4 Work setting Inpatient facility 32 6,8 Outpatient facility 394 83,5
Inpatient and outpatient facility
Experiences with suicide Suicide of a loved one Suicide of any patient Suicide of own patient (yes)
PTSD symptoms (PCL-5)
Distress (4DSQ)
Self-confidence
Perceived social support
4.81 (5.72) 5.90 (5.23) 2.24 (0.65) 4.33 (1.57) 35 164 261 211 424 416 420 325 7,4 37,5 59,7 48,3
Patient Suicide and PTSD
A simple linear regression was carried out to examine whether PTSD symptoms (i.e. PCL-5 total scores) were associated with the reported experience of patient suicide. Patient suicide (yes/no) was used as the independent and the PCL-5 total score as the dependent variable. Even though patient suicide is a group variable, regression analysis had been chosen over a simple t-test to directly see the direction of the relationship. MHPs who had
experienced patient suicide scored higher on the PCL-5, however this effect was
nonsignificant (R2 = .00, β = .18, t (423) =.33), p = .74). To make sure that these effects were not due to non-normality the same analysis was carried out using a newly created variable using a square root transformation of the PCL-5 scores. The results did not show any
significant differences in PCL-5 scores between both groups (R2 = .00, t (423) = .21, p = .83). Since the distribution of PCL-5 scores was highly positively skewed the transformation might not have sufficiently corrected for problems with non-normality. Therefore, a third analysis has been carried out using the sample distribution (n = 1000) with a 95% confidence interval. The results between group differences remained nonsignificant (p = .85). Similar results amongst these three analyses showed that the skewness and therefore the violation of the
normality assumption did not explain the lack of differences between groups. This was to be expected due to the large sample size. In sum, these results do not support the hypothesis that there is an association between patient suicide and self-reported PTSD symptoms.
Patient suicide and self-confidence
PCL-5 scores tended to be higher for MHPs with decreasing clinical self-confidence. However, the correlation was very small and therefore not significant (r = -.03, p = 0.54). These results do not support the hypothesis that there is a correlation between self-confidence and PCL-5 scores.
The main effect for patient suicide on PCL-5 scores has already been described above. In the second model with self-confidence as the independent and PCL-5 scores as the
dependent variable, no significant association was found (R2 = .00, β = -.27, t (419) = -.62, p = .54). In the third model self-confidence and patient suicide and the interaction effect of these two were used as independent and PCL-5 scores as the dependent variables. The interaction effect between reported patient suicide and the self-confidence measure in predicting PCL-5 scores was non-significant (R2 = .00, β = .31, t (417) = .71, p = .48). Results were similar when using the sampling distribution of 1000 with a confidence interval of 95% (β = .30, p = .48). Also for the complex model (including both main effects and the interaction effect) these results did not significantly change when the PCL-5 scores were substituted with the
transformed PCL-5 scores as the outcome variable for the multiple regression model (R2 =
.00, β = .09, t (417) = .97, p = .33). These results do not support the hypothesis that there is an interaction effect of patient suicide and self confidence in explaining the variance in PCL-5 scores.
Patient Suicide and Perceived Social Support
Perceived support was negatively correlated with PCL-5 scores (r = -.23, p = .00), which supports the hypothesis that there is a relationship between perceived support and self-reported PTSD symptoms.
In a regression model with perceived social support as the independent variable and PCL-5 as the dependent variable there was a significant amount of variance of PCL-5 scores explained by perceived social support (R2 = .53, β = -.82, t (323) = -4.27, p = .00). In the following regression analysis, adding patient suicide and the interaction of patient suicide and perceived social support to the previous model, a significant amount of variance in PCL-5 scores was explained (R2 = .07, F (3, 321) = 8.05, p = .00). However, the interaction effect
between patient suicide and perceived social support was not significant (β = .34, t (321) = -1.69, p=.09). Therefore, the data do not support the hypothesis that there is an interaction effect between patient suicide and perceived social support in association with PCL-5 scores. For the analyses looking at perceived social support no further analyses using transformed PCL-5 scores, or the sampling distribution were performed. The analysis of the interaction was analogue to the one examining self-confidence and as previously shown adding running these analyses did not significantly change the results.
Table 2
Results of regression analyses on the interaction effect of perceived social support and self-confidence on the association between patient suicide and PTSD symptoms.
B SE T P
PTSD symptoms (n=425) (Intercept)
Experienced patient suicide Self-Confidence (n= 421) 4.72 0.18 0.39 0.56 12.26 0.38 0.00 0.74 (Intercept) 4.77 0.29 16.73 0.00
Experienced patient suicide 0.13 0.29 0.45 0.65
Self-Confidence -0.30 0.44 -0.68 0.50
Interaction 0.31 0.44 0.71 0.48
Perceived Social Support (n=325)
(Intercept) 4.71 0.32 14.79 0.00
Experienced patient suicide 0.50 0.32 1.57 0.12
Perceived Social Support -0.80 0.20 -3.98 0.00
Interaction -0.34 0.20 -1.69 0.09
Discussion
The aim of this study was to investigate the relationship between patient suicide and self-reported Posttraumatic Stress Disorder (PTSD) symptoms among mental health
professionals (MHPs). Additionally, this study examined possible interaction effects of clinical self-confidence and perceived social support in association with self-reported PTSD symptoms after patient suicide. Contrary to the hypotheses in this study’s sample the
experience of patient suicide was not associated with higher self-reported PTSD symptoms. Moreover, no relationship was found between clinical self-confidence and PTSD symptoms scores as well as no interaction between patient suicide and self-confidence in association with PTSD symptoms. The negative correlation between perceived social support and PTSD symptoms indicates that higher social support is related to lower PTSD symptoms among MHPs. The hypothesis that there is an interaction effect between patient suicide and perceived social support was not supported by the data.
One possible explanation for the lack of an association between patient suicide and PTSD symptoms is that MHPs in the Netherlands cope well with the aftermath of patient suicide. This might include factors such as a high level of support (i.e. collegial, legal, personal), which has shown to be linked to lower stress reactions (Séguin et al., 2014). It would be interesting take a closer look at how people in the Netherlands follow up on and cope with patient suicide (i.e. do they take time off, are they offered group support, counselling or are there other potential supporting factors).
Furthermore, it could be that MHPs show complaints that are not diagnosable as PTSD but show in different types of pathology. The question then is, are these reactions pathological and just differ in quality than hypothesized in this study (e.g. anxiety or depression), do they differ in quantity (e.g. MHPs show higher levels of distress after patient suicide but they only reach subthreshold level) or are the effects are not captured by this study due to its design that assesses MHPs reactions to patient suicide retrospectively (see limitation section). In order to find answers to these questions more research would have to be done that assesses the
experience of patient suicide of MHPs in the Netherlands that also looks at potential protective factors and coping strategies that are commonly applied by MHPs in the Netherlands.
As some of the most frequently mentioned factors associated with PTSD symptoms social support has been investigated. Looking at the main effect perceived social support indeed showed a negative correlation between perceived social support and PTSD symptoms meaning that MHPs who experienced more (subjective) social support tend to report less PTSD symptoms. These results are consistent with the findings in the literature (Brewin et al., 2000), therefore strengthening the evidence current evidence based by replicating findings in a new context (i.e. MHPs as suicide survivors). This means that monitoring and providing support for MHPs at mental health institutions could potentially be beneficial to improve the quality of mental health care by supporting MHPs in the process of coping with the loss of their patient and as a result being able to provide high quality care for their patients. However,
more evidence is needed to determine whether there is not just a correlational but also causal relationship between support and MHPs reactions to patient suicide.
The results showed no interaction effect of social support in the association between patient suicide and PTSD symptoms. Previous research has shown that perceived social support can be helpful in coping with traumatic events and predicted lowered PTSD
symptoms (Brewin et al., 2000; Scarpa et al., 2006). These findings could not be replicated by this study in the context of PTSD symptoms that are associated with patient suicide, which means there is more need in finding out how support could potentially be related to PTSD following patient suicide.
This study found no significant association between self-confidence and self-reported PTSD symptoms following patient suicide. Moreover, in contrast to the hypothesis no interaction effect has been found between patient suicide and self-confidence in association with PTSD symptoms. This means based on this study MHPs self-confidence seems unrelated to the severity of PTSD symptoms experienced after patient suicide. The role of MHPs self-confidence in coping with posttraumatic stress following patient suicide has not been investigated so far. This study tried to fill this gap. However, the concept of self-confidence was only been assessed by one item. The idea of looking at self-confidence was based on previous literature that states that less experienced MHPs and MHPs with less training in treating suicidal patients are more strongly affected by patient suicide than their more
experienced colleagues. Moreover, some literature suggests that self-efficacy and self-mastery and resilience are factors that can help in coping with patient suicide (Benight & Bandura, 2004; Day & Kearney, 2016). The concept of clinical self-confidence was examined as a possible underlying mechanism of these variables. For the future, more research should be done on how the concepts of self-mastery, resilience, experience and training are linked to self-confidence before using this as a variable within a study like this. There is a need for a clearer idea of the underlying mechanism at hand and the concept that plays a role in these aforementioned findings. Moreover, validated measures that capture this concept would yield more accurate and informative results. It might be an interesting topic for future research to look into these concepts and how they relate to posttraumatic stress amongst MHPs. For example, a factor analysis could be used to determine what the common underlying
component of these factors is. Finding this underlying mechanism could be useful developing strategies and eventually even trainings that target these mechanisms and improve MHPs skills in coping with patient suicide, hence improving the quality of care they provide. Limitations
The cross-sectional observational design of the study allowed for the investigation of a large and diverse sample of MHPs of different professions, backgrounds and experience as well as different types of facilities. The analyzed sample turned out to be well balanced in with regard to gender, age and experienced patient suicide (yes or no). However, the chosen methods also come with limitations that need to be taken into consideration when interpreting the results.
MHPs who experienced patient suicide did not report significantly more PTSD symptoms than MHPs who did not experience patient suicide. Even though these results do not support the tested hypothesis, they make sense considering that the sample in this study consisted of a working population. This study looked at an overall healthy population in which one would not expect to find many people with PCL-5 scores that are above the cut-off score for a provisional diagnosis for PTSD. The results suggest that not more MHPs meet the criteria that warrant a PTSD diagnosis following patient suicide compared to MHPs without that experience. However, these data do not allow any conclusions about whether MHPs experience posttraumatic stress in general. MHPs might differ in quantity of their reactions but these might still be similar in quality. For instance, MHPs with patient suicide might still show complaints that resemble PTSD symptoms, but these might be symptoms at a
subthreshold level that are not captured by the PCL-5.The lack of findings would be due to the operationalization of posttraumatic stress as meeting the diagnostic criteria of the DSM-5 for PTSD rather than the absence of posttraumatic stress all together. The instrument that was used to assess PTSD symptoms (PCL-5) has shown good psychometric properties (Bovin et al., 2016). However, to date no studies have investigated its sensitivity in non-clinical samples. Generally, in this sample PCL-5 scores have been low, which could partly account for the lack of a difference between the two groups.
Moreover, the results of this study suggest that there is a correlational relationship but no inference about a causal relationship between experienced support and PTSD symptoms following patient suicide can be drawn based on this study. The design poses the question of directionality, which in this context means that support does not necessarily lead to lower PTSD symptoms but it could also be that people who experience higher levels of PTSD symptoms are more likely to seek out and receive social and professional support.
Additionally, there might be other variables that affect both the levels of experienced support amongst MHPs after patient suicide as well as their reported PTSD symptoms. These could be factors such as a less stressful work environment that facilitates teamwork, close relationships with colleagues and supervisors, lower overall stress levels or even more training in assessing
and handling suicidal patients of MHPs in these facilities that also make MHPs less likely to develop psychopathological complaints. These potential factors would need to be assessed more closely to draw further conclusions. There are other possible confounders that have not been controlled for and that might account for the lack of explained variation (such as time passed, healing process, development of coping mechanisms, other traumatic events). For example, in the questionnaire MHPs stated whether they had experienced patient suicide and how many patients they have had lost to suicide, MHPs were not asked how much time has passed between their (most influential) experience of patient suicide and the assessment of PTSD symptoms or things that they did in order to deal with the aftermath of patient suicide. The PCL-5 is a questionnaire that assesses PTSD symptoms present at the time of filling in the questions and does not consider PTSD symptoms in the past (i.e. frame of reference is the last month). For some MHPs experiences of patient suicide might have been quite recent whereas for others this experience could have been a long time ago. They might have met the criteria for PTSD at a previous point but have managed the symptoms have disappeared or reached a subthreshold level before the moment of assessment. Therefore, (e.g. self-doubt guilt) might have been experienced but retrospectively and not at the time the participant filled in the questionnaire.
Future research
Future studies might look into different ways of assessing posttraumatic stress in a healthy population to apply these measures to MHPs who have experienced patient suicide. Additionally, other measures assessing different types of psychopathology as well as other distress measures could provide more information of the types of complaints that are commonly experienced among MHPs.
Moreover, based on previous literature and this study, social support seems to be an interesting factor to look at as a potential protective factor for MHPs who experienced patient suicide. Generally, more exploration of potential protective factors on a personal level such as resilience, confidence, training in dealing with suicidal patients as well as on a professional level (e.g. work environment, social and professional support in dealing with the aftermath of patient suicide) could shed a light on how MHPs deal with patient suicide. This would help to identify variables that are potential targets for intervention to help MHPs in coping with patient suicide while still being able provide high quality care for their other patients. This could be done by conducting more qualitative research to identify potential variables of interest or using methods such as factor analysis to determine underlying mechanisms (e.g. as described above in the context of self-confidence) that could be possible targets for
intervention that help to at improve support (at the work) and facilitating functional ways of coping with patient suicide. These could then be tested in a study by comparing the
intervention and non-intervention groups in relation to MHPs reactions to patient suicide. Conclusion
This study put the experience and reactions of MHPs into the context of posttraumatic stress by asking a large and diverse sample within a Dutch mental health institution about their experience on patient suicide. It assessed self-reported PTSD symptoms, experienced social support and self-confidence in relation to patient suicide. Although no link has been found between patient suicide and self-reported PTSD symptoms this study can help seeing patient suicide in a new context (i.e. patient suicide in relation to the effects of mental health of the care providers) and spark ideas for future research. The results of this study raise the question of whether MHPs might be experiencing complaints that resemble PTSD symptoms that are at subthreshold level, whether their reactions are of a different type than investigated in this study or whether MHPs in the Netherland are not significantly affected by patient suicide. This study did not find a relationship between self-confidence and PTSD symptoms following patient suicide, which could be due to the operationalization of self-confidence in this study and potentially a different mechanism might be active. However, higher
experienced social support was associated with lower levels of self-reported PTSD symptoms. This finding is in line with the literature, therefore strengthening current evidence. Social support could be a potential target for future interventions that help MHPs in coping with patient suicide.
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