We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Hello. Thank you for joining us. I'm Umar Tosseb, a Professor of Psychology with a focus on child and adolescent mental health. Today, we're joined by Dr. Zheala Qayyum, who is a training director for the child and adolescent psychiatry fellowship programme at Boston Children's Hospital and the medical educator. She is board-certified in general psychiatry, child and adolescent psychiatry, and consultation liaison psychiatry. She received her master's degree in medical education from Harvard Medical School. Dr. Qayyum is also assistant professor [INAUDIBLE] of psychiatry at the Yale School of Medicine. Thank you so much for joining us. Thank you so much for having me. And so today, we're going to be speaking about patient suicide and the impacts on trainee psychiatrists. So I suppose my background isn't clinical. So this is something that I've never really thought of. So it's really interesting to be having this conversation with you. How much of a problem is this? So how common is it for psychiatry trainees to experience patient suicide? So I always think this is one of those things we don't talk enough about. And even though this is not something that is frequently encountered, thankfully, it's not something that happens all the time. But when it does, the impact is quite significant. And the death of a patient by suicide, especially when it's like a child or a young person, it's not only very challenging for the family and the community, but also for the clinical team that is involved in their care. So about-- depending on whatever study you're looking at, a third to 2/3 of general psychiatry trainees will encounter a patient dying by suicide during their training years. And then also, given our work with highly acute patients, this is something that we will encounter during the course of our careers as well. OK. And given that it seems to be quite prevalent, you're saying between a third and 2/3. What is currently being done to prepare psychiatry trainees for this kind of thing? So I would say not enough. We did a study, and one of the biggest things we found was that trainees generally felt very unprepared. And I think that's probably because our approach tends to be much more reactive rather than proactive. So we tend to address a patient dying by suicide when something like that happens, rather than preparing trainees, particularly those that are coming into psychiatry rotations or psychiatry training that this is something you're going to encounter during your training years and if not during your training years, this is something that's definitely going to happen over the course of your career. And then also as child and adolescent psychiatrist, I'm sure we appreciate that the suicide rates are increasing worldwide for adolescents and young adults. So over the course of our careers, this is an unfortunate event that we really have to be prepared for. And I suppose in the medical profession, in various specialties, you probably experience patients dying a lot. Why is dying by suicide within the psychiatry specialism different in terms of why does it require different levels of preparedness and support than the other specialisms? I think medical specialties do a much better job, particularly when our trainees are on the medical floors, they're in the ICU, they're on palliative care. It is discussed as a part of the culture and expectation that a patient might have terminal illness. But something trainees have pointed out is we don't always talk about psychiatric illness as terminal illness. There might be a discussion that this patient is struggling and suffering, and maybe at some point in their life they might die by suicide. But there's always this suddenness to it because you never know when that's going to happen. You're holding your breath, and there's this initial shock and devastation that comes with whenever something like this happens. I think another aspect is that OK, we don't think about psychiatric illness or we don't communicate psychiatric illnesses being a terminal illness. But then also having worked in psycho-oncology for a long time, we never had parents or families come and say that it was something that you didn't do that led to this outcome. The patient died because of cancer. How many times do we say this patient died because of depression? Or this person died because of psychosis? And that it is a part of the natural course of the illness, that an outcome like this can happen. So I think as a field, we need to do a better job of saying that trainees need to be much more prepared. You will encounter this, and how do we support both the trainees and the supervisors for such an event. So what are some of the common emotional challenges that trainees might face when they experience patient suicide? So there's a lot of emotional impact associated with a patient dying by suicide. First, there's this general sense of shock and devastation, even sometimes anger or sadness for the patient and their family. But there's also this sense of responsibility for caring and serving and healing this population. So there could be this sense of guilt and shame. Like, this happened to me. This did not happen to my colleague. This did not happen to my fellow trainee. And then also sometimes, given the suddenness of it, sometimes there could be a lot of it could be very public. There could be a lot of violence associated with the suicide itself that can be fairly traumatic and be accompanied by a lot of intrusive thoughts, a lot of self-doubt. So these changes in self-efficacy and a blow to your competence and confidence, where you start second guessing yourself, a lot of self-doubt that am I a good clinician? Am I really cut out for this? Why did this happen to me? Can I go take care of the next patient and be a good clinician for them? And then also this sense of responsibility that we are there to serve and heal our patients. So did I fail in my duty to my patients? Was it something that I did or I didn't do that contributed to this outcome? So there's a lot of, I think, emotional valence associated with an event like this. And I think you've touched on this already, the inexperienced psychiatrist or the trainee psychiatrist might have a different emotional response compared to the more experienced psychiatrist and that will be the experience. But what is it about experience that makes this thing easier to deal with as you're more experienced? Yes, exactly. I think training is a very vulnerable time in our emotional and professional development. Trainees are still getting a sense of their identity. And they may not have a lot of experience in having frameworks or scaffolding of processing difficult or adverse outcomes and experiences. And I think this is also speaks-- this also speaks to how our training is set up that a lot of times young trainees are put in the position of taking care of very acute and very ill patients at the start of their training. They're doing inpatient work, they're doing acute psychiatry. So again, there is an acuity inherent to the work that they're doing and yet they may not have the experience. But they also may not have a lot of supervisory relationships or mentoring relationships built at the start of their training years, where they can lean for support, that they can readily access guidance around how do you deal with something like this. So there's this general sense of unpreparedness that I think a lot of trainees, when we spoke to them, said, you need to inoculate us with this thing that this can happen to you. And if something like this happens to you, what do you do. Don't talk about it as a reaction, but tell us what to do, what's in store for us, what are the things we can do tangibly to take care of ourselves and also procedurally. But this is not to say that this emotional impact or difficulties only specific to young trainees, early career clinicians who haven't experienced this during their training years would have a fairly similar experience, but would be different is trainees shared that burden of responsibility with their supervisors. But if you're an early career clinician, the burden falls on you. And then also even seasoned clinicians might second guess themselves like, is this the right profession? Have I done this long enough? So a lot of times even seasoned clinicians might say this is leading to an early retirement or change how they're viewing their careers and their trajectories. Thank you. And you've talked a bit about being more proactive. So rather than waiting for patients suicide to happen before you, then help a trainee psychiatrist through this. What does being proactive look like? So, we could think about maybe the training programmes, mentoring programmes, those kinds of things. What would, in an ideal world, preparing trainees for patient suicide look like proactively before it happens? I think we're very good at training our young learners about risk assessments, how to conduct good risk assessments. But we never talk about, OK, if something like this happens, what do you do. So it does need to be earlier on in their training. I think another thing that's really important with how you process an event like this is the supervisory relationship. That is key. If you have a really good supervisor that is trusted, that has credibility, especially if they've experienced something like this in the course of their career, they can really speak to their own experience. So one of the things that might be helpful is having the people who've actually had this experience come and talk to the trainees early on in the training years, talk about their experience, demystify it, destigmatize it. And I think the other thing that it will do is it will identify who are the people in your institution or your training programme or hospital or clinic you can actually talk to because they know what it's like. You're not reaching out to someone who's going to just give you reassurance and support, but actually can speak from experience. And I think that lends a lot of credibility to that supervisory relationship. And then also it diminishes that sense of isolation that it only happened to me. It didn't happen to somebody else. And I think this is-- I thought about this when I was a young trainee, that looking at someone I admire and respect as a really good physician or clinician and say that this thing happened to them as well, and there's still such excellent clinicians and so good at what they do, I'll be OK as well. I think that is really important to convey. So you know who are the right people you can talk to who will support you through this. And what's the value of having peer support networks and peer-to-peer mentoring for this kind of thing, as opposed to a supervisor-supervisee relationship? Because I read some of your work where you highlight that both are important. So what's the value of one versus the other? I think just diminishing that sense of isolation or feeling different from your cohort and your co-trainees, knowing that there are people in your training programme who have actually had this experience. So that near-peer relationship can be very helpful. And a lot of times when we're thinking about what to do next, utilising senior trainees to support junior trainees is, I think, can help the programme itself, but also be a good conduit of information that someone is actually struggling versus not. So that if they need work accommodations, caseload accommodations, call scheduling, all those kinds of things that the peers can actually be present, pick up on those things. And if they're in a position of any administrative leadership, they can make those changes more proactively and offer that to the junior trainees or take it to the programme leadership. So again, we don't want people to feel alone during this time, because I think as good as we are in mental health at taking care of other people, we may not be the best when it comes to taking care of ourselves and having that grace and self-compassion that we too, might need explicit permission to mourn and grieve a loss like this. Because the relationship with the patient is a relationship, and the death of a patient for any reason is a loss. So hearing that explicitly, you need to take care of yourself, you have explicit permission to grieve and mourn this loss like any other, I think peers are very helpful in navigating that and providing support in the moment and being around them in their peer community so that the training does not feel isolated. And my next question is two part really. So to support trainees, supervisors probably also need training and for supervisors to be given the appropriate training. All of this happens within the context of a broader healthcare system. So how do we ensure that supervisors are adequately trained to provide this support? But how do we also ensure that happens within the system and this capacity within the system to do this kind of thing? I think you highlight a very important part, which is it's a system. An outcome like this does not happen in a vacuum and it doesn't happen because of a decision a single person made. So the reason people get the care that they get their aftercare, their treatment and the community, their support, it's a whole system. And so a supervisor needs to be prepared and supported to be able to support trainees in return by a knowing what are the administrative tasks that are supposed to happen if an outcome like this happens; what are the local laws? What are the supports available to them and their trainees within their institution? And then also this acknowledgment by the institution that we're going to own this as a system. You don't have to do this on your own. So whatever might happen, here are the supports available to you, whether it's through your medical leadership or your administrative leadership or through legal support. Because it's not a decision that you made that led to this outcome. The reason why we admit patients or discharge patients or can't keep them long enough, or that they can't get the right care after they leave the clinic or the hospital, that's not because of one person. It's whatever the system puts together. And therefore the system has to own the outcome together. No, but I think you're right. I think it is. It's that taking that responsibility of the individual and acknowledging that you exist as part of a wider system. And I think you've talked about it as a healthcare system, but also, the patients themselves live within a wider societal system and the world. So the that they take or the decisions that any individual makes in any part of life is never one person's responsibility. There's lots of other players in that as well. Exactly. And children in particular, and young people are in that ecosystem of the community that is raising them. Yeah. And so we've talked about being proactive and then we've talked about what to do if something like this happens. What about after it's happened? So how do we-- so you talked about some professional challenges like trainees questioning their competence and that denting their confidence and those kinds of things. How do you then deal with that after it's happened to build people back to the point of where they can engage again? So I think that's where supervision is really important, where I think the key elements to that supervision need to be. First, you're creating that space. Some people might not be ready to talk or process this right away. And I think one of the other key things to note is that we never know what someone is bringing into the learning environment, what previous life experiences they've had, have they had lost before, have they had some loved one die by suicide before, is that going to change how they experience this. So we don't know that. And so just creating that space as a supervisor that you can use this whenever you're ready and whenever you're available to discuss this. And the most important thing is to validate, yes, that those emotions are part of the normal process. You're going to doubt yourself, you're going to be upset and distressed, and you might have intrusive thoughts. And that's just part and parcel of how you will go through this experience. And then also creating that space so that if you're not ready for this, come talk to me later. And the key elements of that would, I think, be the validation, the humanization, diminishing the isolation and shame, but also as a supervisor, keeping a pulse on how the trainee is thinking about their competence. So do you need to constantly do some more monitoring and reinforcement of good clinical decisions so that they start feeling confident about that themselves. And also, one of the most helpful things trainees find is a very thoughtful disclosure by the supervisor of their own experience of a patient dying by suicide. Just because I think it diminishes that, oh, it happened to me. It didn't happen to anybody else. But also, it gives them a scaffolding of this is how you can then process your own experience, that it's not something that's just going to happen overnight, or you're going to start feeling better in a few weeks. This is going to be slow. It's going to take time. You might think of this often. It might come up anytime you're seeing another patient in crisis. How do you hold your own emotions and be objective in that situation. And then also without blame or shame, how do you sit with this experience. And then how do you reflect and what does it mean to you moving forward as you're going to progress in your career? What are you going to carry with you. I once had a conversation with someone who was an obs and gynae trainee and he had a difficult experience. It was traumatic in various different ways, but after the experience, he then a while later was diagnosed with PTSD. And part of it was that traumatic experience for him. Do we know whether clinicians who experience patients suicide in a psychiatry context, are they more likely to experience PTSD going forward? Can the experience be traumatic to that extent? So there is literature that supports that there could be acute stress reactions related. And a lot of trainees and supervisors who are involved in the care of the patient might experience those. However, I think with adequate support and then paying enough attention to get support and treatment if needed is critical. Again, if you sit on it and you don't process it, it's going to linger. But those intrusive thoughts tend to happen. Sometimes the suicide is very public. With the social media and all those other things, now it can be fairly public and people might have a hard time navigating that. Maintaining patient confidentiality and privacy even after the event, but then also being surrounded by it and people talking about it can be this constant stream of re-experiencing. So definitely, there is that sense of an acute stress reaction, however, does it always progress to PTSD? Not always. Again, I think this would be more in line with what are you bringing into that experience from before that might contribute or be compounded by this experience on top. And what about the process of speaking to families of the patient who died by suicide? Is it usually the trainee psychiatrist who would speak to the families about this and does that process help or can it not be helpful? I think no one should have to speak to the family without support because it's difficult. Regardless of whether you're a clinician who's in charge, you still would want to talk to them with your team. So again, having some guidance and support ahead of time, I wouldn't ever put a trainee in a position where they have to talk to the family by themselves. If they are part of the process, they're welcome to join the conversation. And I would also suggest talking to the legal department or the risk assessment folks ahead of time as well, to see do they have any guidance or reservations around this. Sometimes it can be a little more limiting to say there might be-- the guidance might be don't talk to anyone about this or you can't reach out to anybody. But in most instances, families really appreciate hearing from the clinical team and having that space where they can voice their concerns, hear a little bit about what their clinician thinks and again, maintaining the boundary of privacy and confidentiality, obviously always. But creating that space for the family can be very helpful in helping the family process what had happened. Sometimes appreciating how significant the mental illness was or how profound somebody's suffering was. And then also when they feel heard, it can minimise litigation. It might give them a space where they feel heard. And then also, sometimes if there's a longitudinal relationship with a clinical team, sometimes clinicians actually might want to go to the funeral and be part of extending that support. So I would say that most of the times talking to the family is helpful. There are instances where the family might be very upset and very distressed, and a lot of that distress might be directed towards the clinical team. And in those instances, I think it's always helpful not to put trainees in the direct line of having to have that direct encounter, but whether other people might be there to support them or take that on. You've mentioned litigation there, so I suppose we could pick up on that. So we've talked a lot about the emotional challenges that trainees might experience. Litigation, is that an additional challenge outside of the emotional challenges that trainees might experience? Absolutely, absolutely. I think as someone who's had this experience a few times, I can say that always weighs heavy, but knowing that you actually have the support of your institution is critical. And most of the times, particularly when it comes to young patients dying by suicide, we don't always appreciate the impulsivity that adolescents and young adults have inherent to their developmental stage that confers an additional risk and unpredictability. But a lot of suicide prevention is geared towards suicide prevention. We're not very good at predicting suicide. And I think this mismatch between societal expectation, yes, we're going to prevent all suicide and we're going to be able to predict. I think that causes a lot of challenges for clinicians, because you can do your best to mitigate risk factors. You can do your best to appropriately diagnose and recognise and then take adequate measures to keep the patient safe but you can't always predict. And therefore, if the benchmark is set at one suicide is too many and there can be no suicides and any time this happens, it just feels like a failure for the clinician. And that's a very difficult thing to sit with. But then also balancing that out that as physicians and clinicians, we take care of very sick patients, and death and dying is part of what we do when we take care of people in the healthcare space. So I think this is to the earlier question of do we see psychiatric illness as terminal. I think there are multiple things to think about, but I think the bottom line is no one should have to go through this alone. And there should be proper support and a team, particularly legal consultation when needed. And what are the evidence gaps in this space in terms of supporting trainees with patient suicide? So what we've talked about some good practise and what should be good practise. What are the evidence gaps? What do we not know? I think we don't have clear curricula about preparing trainees for this outcome. We don't talk about it enough at the start of their training like we talked about. And then also there could be based on the training programmes, some are smaller training programmes. They might not have the resources, they might not have the right people. So they can always draw from people in the community to come and talk to trainees and help prepare them. But I think the model that needs to change is we have to be more proactive about having this conversation at the start and make it a regular part of institutional culture. And if you have these postvention protocols, it's only as good as having it, but be regularly updating it and having a protocol. It's not helpful if you don't disseminate it regularly with all the new trainees that are coming in your new faculty, new hires, new clinicians. So postvention protocols have to be disseminated and acted on so people know who's doing what. Because the last thing you want to do is have a trainee by themselves hear this news, not know what are the supports available to them and not know what to do next. And then I think what is critical from a faculty or supervisor perspective is modelling vulnerability. Because we don't talk about it openly. We grieve in silence. We keep our shame and our guilt to ourselves and yet, this is part of what we do. And it is-- I think it was Glen Gabbard who said, "There are only two types of psychiatrists, the ones who've had a patient die by suicide and the ones who will." So I think this is something we do have to be a little more intentional and deliberate about and then see are there other things we can do in terms of preparation, curricula support and having that well delineated. And then we don't have a lot of evidence base about which of these are most effective versus not. But then also, how do you tailor these approaches to what would be best for a certain training programme in a particular culture and context. Thank you. And this is the part where we ask for a take-home message. But before I ask you for that, I'm going to tell you what I think my take-home message is from this conversation, which is really interesting to think about, which is mental illness should be and can be viewed as terminal in some cases. And thinking about it as potentially a terminal illness might change the way we approach it. So that's my-- what I've learned from this conversation or the key take-home message. But for you, what's your key take-home message for people watching this or listening to this? I think my key message is something I learned, which was sometimes you can do everything right and still have a bad outcome. And I think that's a very humbling thing to sit with that despite our best efforts, we don't come into medicine thinking, this is OK or this is going to be OK when my patient dies for any reason. But again, you only do or can do what you can do for your patient, and then sitting with your own limitations as a physician or a clinician or a human being. I think that's tough to know that, this is where my expertise ends. And then I think that's why it's particularly more difficult for trainees, because we can now better-- with experience, sit better with our limitations and understand our limitations within the system and context. But trainees might not have that frame of reference at that time. Thank you, Zheala. That's been fantastic and a really, really interesting conversation. Thank you so much for having me. Thank you. [MUSIC PLAYING]