Improving Support of Residents
After a Patient Suicide:
A Residency Case Study
Christina Mangurian, M.D., Elizabeth Harre, M.D.
Aaron Reliford, M.D., Andrew Booty, M.D.
Francine Cournos, M.D.
sional life. A substantial portion of psychiatrists in general
practice (15%–68%) will experience at least one patient
suicide during their careers (1, 2), and approximately one-
third of psychiatric residents experience a patient suicide
during residency (3). A patient’s suicide frequently leads
the treating psychiatrist to experience considerable stress,
guilt, shame, anxiety, and even PTSD-like symptoms of
intrusion, hypervigilance, depersonalization, and avoid-
Residents, at the early stage of their careers, are
uniquely vulnerable to stress from this event (5). A patient
suicide may cause the resident to doubt his or her clinical
skills, the decision to enter psychiatry, and previous treat-
ment decisions (5). Residents may also feel anger toward
their supervisors for providing inadequate guidance, and
co-residents may feel relief that they were not the treating
resident (6). However, in their positions as trainees, resi-
dents have a unique opportunity for personal and profes-
sional growth at the time of such an event (7, 8). None-
theless, in one study of Canadian medical students and
residents (9), of whom nearly two-thirds had encountered
at least one suicide, only one-third had received any for-
mal education regarding the impact of suicide on residents.
It is ironic that we as psychiatrists, particularly attuned to
the needs of others, often avoid discussing these issues
he suicide of a patient is arguably the most traumatic
event that can occur during a psychiatrist’s profes-
with colleagues, especially given the potential distress
such events may cause.
We each experienced the suicide of one patient during
our residencies at Columbia and discovered several defi-
ciencies in our methods for dealing with them. The com-
posite patient described in Appendix 1 illustrates some of
these problems. First, we found a lack of basic knowledge
by residents in several areas, including the expected emo-
tional responses, the frequency of patient suicides during
residency, and helpful institutional procedures that a res-
ident could access. Second, we noted isolation and lack of
emotional support and appropriate mentorship for the af-
fected resident. Finally, there was a lack of institutional
support and constructive, noncritical reviews of suicide.
To address these problems at our institution and the call by
Academic Psychiatry for developing supportive and edu-
cational interventions for residents experiencing patient
suicide (10), we describe here the interventions we devel-
changes, development of a crisis support team, and a for-
mal review of the event, and other constructive and repar-
ative measures we have taken.
Gitlin (8) recommends that courses be provided to res-
idents early in training, before they experience a patient
suicide, and that they be exposed to modeling by senior
residents and/or seasoned faculty who have had the expe-
rience of patient suicide themselves. We have done this at
our institution and now have an experienced faculty mem-
ber conduct an anticipatory seminar class in which post-
graduate year one (PGY-1) residents learn statistics about
Received October 16, 2008; revised February 1, 2009; accepted February
27, 2009. Drs. Mangurian, Harre, Reliford, and Cournos are affiliated
with the Department of Psychiatry at Columbia University in New York
City; Dr. Booty is affiliated with the Department of Psychiatry at the
University of California, San Francisco. Address correspondence to
Christina Mangurian, M.D., 1051 Riverside Dr., Box 100, New York,
NY 10032; email@example.com (e-mail).
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278http://ap.psychiatryonline.orgAcademic Psychiatry, 33:4, July-August 2009
how common patient suicide is during residency, typical
responses of residents after patient suicides, and useful
coping strategies. This seminar also provides an important
forum for residents to voice their fears about such an
event. Then, during the PGY-2 orientation, we outline
resources available to residents after a patient suicide. This
information has been compiled into a “Resource Guide for
Residents After a Patient Suicide” that is available on our
residency website as well as the APA website (11). This
packet includes typical responses to patient suicide, sug-
gestions for ways to cope, suggested questions for super-
visors during this process, logistical practices of each
clinic or inpatient unit, listing of risk management orga-
nizations and terms that residents might encounter, an-
swers to common legal questions, and references from the
literature to help a resident after the event. This resource
also lists peer and faculty who are available to residents
and specifies which of them have personally experienced
patient suicide. This specification was included to mini-
mize isolation and model that a successful future is pos-
sible after this event (8).
Crisis Support Team
To address the initial isolation and lack of emotional
support and mentorship in these situations, we developed
a formalized institutional response to facilitate a resident’s
personal and professional development and enhance learn-
ing, growth, and functioning after a patient suicide.
Emulating similar models at institutions including Bay-
lor and Stanford, we formed a crisis support team to be
activated immediately upon discovery of the suicide of a
patient currently or recently within the care of a resident.
The team consists of resident “buddies” and faculty men-
tors who themselves have either lost patients to suicide or
undergone training in this area and who coordinate with
one another to provide emotional support to affected res-
idents. The team may also collaborate with the House Staff
Crisis Service, so that, when appropriate, formal counsel-
ing can also be provided, free of cost.
The crisis support team at Columbia is activated when,
in response to a suicide of a resident’s patient, the chief
resident contacts the head of the team, who selects a
resident buddy and faculty mentor to assist the affected
resident. The buddy and mentor will, in a coordinated
fashion, arrange to meet with the resident to determine
how they may best provide nonintrusive emotional sup-
port. We replicated key features of the Baylor program,
including helping residents in concrete ways, such as ex-
plaining unit procedures after a suicide, offering time
away from work, and accompanying the resident to related
meetings (e.g., risk management). Mentors will continue
to contact the resident for a period of time after the suicide.
The frequency and duration of these meetings is deter-
mined by the resident and mentor and tailored to the needs
of the resident. We are also considering expanding the
purview of the team to include situations in which trainees
are assaulted by patients, stalked, or named in malpractice
suits or other potentially traumatic events.
Since its inception approximately 2 years ago, the crisis
support team has been invoked three times, once for a
suicide and twice for suicide attempts. In each case, resi-
dents reported feeling supported. We have found that res-
idents elicit this support under various circumstances. For
example, one resident may have treated the patient weekly
for several months, whereas another resident may have
evaluated the patient only once in the remote past. We
view this as an important aspect of this crisis support team,
as it tailors support during this difficult experience to fit
the specific resident’s needs and personal experience.
At our institution, we know of two suicide attempts that
were not brought to the attention of the crisis support team.
Eliciting this kind of support after a patient suicide is an
individual decision. Some residents prefer not to use a
service like the crisis support team and to rely on their own
resources. Nevertheless, we cannot anticipate who will
find this helpful or not; which highlights the importance of
offering this service to all affected residents as opposed to
requiring participation. We believe it is instrumental that
all residents are aware of the existence of this crisis sup-
port team, so we have been making presentations at ori-
entations, anticipatory suicide classes, related presenta-
tions, and resident lunches. We are also tracking the
utilization of the crisis support team for future evaluation.
Morbidity and Mortality (“M&M”) Meetings
To address lack of institutional support, we have created
a formal, noncritical review process. We believe there is a
need for such standardized “postvention” measures after a
suicide to minimize the psychological impact on residents.
Critical reviews and “psychological autopsies” in psychi-
atry have been shown to facilitate examination of the
events and have a valuable focus on education and mod-
eling. However, as implemented thus far, such meetings
have not addressed the unique emotional impact of patient
suicide on a psychiatric resident and have emphasized
medico-legal issues and blame at the expense of providing
support (3, 12). As noted by Fang et al. (13), if resident
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279 Academic Psychiatry, 33:4, July-August 2009 http://ap.psychiatryonline.org
support is underemphasized, adverse psychological impact
is more likely.
Interestingly, there is only one published report of a
traditional psychiatry morbidity and mortality conference
at an academic medical center (14). Emphasis was on
formal structure, regular meetings, monitoring clinical
outcomes, and quality assurance. Although the authors
mentioned several of the problems we have encountered,
specifically resident concerns about patient confidentiality,
litigation, and feeling emotionally overwhelmed and de-
moralized, there was no discussion of how these important
concerns were addressed or how much focus they received
in these meetings. At Columbia, we are starting to imple-
ment regular reviews of adverse events (suicide and other
violence), focusing on quality assurance, education, and
structure. However, we are also striving to address the
emotional impact on the treating resident in an environ-
ment with resident-selected, supportive clinicians who are
open about their own experiences with patient suicide.
Ideally, these regular reviews could also provide support
to all staff who are affected by patient suicide, including
attending supervisors, nursing staff, social workers, occu-
pational therapists, and therapy aides.
Unfortunately, in carrying out these meetings, the first
problem we encountered was confidentiality. Given that an
academic psychiatry department is a small community and
that suicide is a rare but highly visible event, even pre-
sentation of minimum material could allow for inadvertent
identification of a patient. Another major concern was
potential vulnerability to litigation. Although the law var-
ies from state to state, we have been hampered by the lack
of privilege of those in attendance at our meetings because
there is an official incident review committee that reviews
adverse hospital events. These meetings were put on hold
until the litigation issue could be resolved.
We learned that sufficient privilege and protection from
litigation can be obtained by subsuming these meetings
under the rubric and jurisdiction of the quality assurance
departments at each hospital. We have named the body
conducting these meetings the crisis support committee,
which oversees all activities of the crisis support team.
Both the committee and team are led by the same senior
resident who has experienced a patient suicide. All activ-
ities of the crisis support committee and activities of the
crisis support team will be regularly monitored by the
quality assurance department. In our facility, sufficient
privilege is maintained only if all attendants are designated
as medical staff. It is our recommendation that any pro-
gram considering instituting a similar committee should
consult extensively with its quality assurance department
to ensure adequate compliance with specific institutional
and state regulations.
We hope that the crisis support committee will institute
regular, monthly meetings focusing equally on education,
prevention, and quality assurance and on the provision of
the necessary suicide “postvention” supportive elements
that would lessen the emotional impact of a patient’s sui-
cide on a resident and provide formalized institutional
support through a noncritical review process.
Workshops and Publications
Gitlin (8) recommends reparative and constructive be-
haviors as a means of coping after a patient suicide. We
believe these are most useful after the resident has had
some distance from the suicide itself. At Columbia, we
followed this recommendation to the fullest by putting our
energy into implementing the programs mentioned earlier.
We also presented “Impact of Patient Suicide on Psychi-
atry Residents: A Workshop Discussion” at the 2007 APA
meeting, and five residents and two faculty members
shared their stories. More than 50 participants came to
hear about our experiences and share their own. This
workshop minimized the isolation of attendees and gave
them a place to share with others who have gone through
the same experience. At the end of the workshop, attend-
ees had the following suggestions: reduce clinical respon-
sibilities of residents after the event, consider a crisis
support team, provide direct supervision during risk man-
agement interviews, and reconsider whether the primary
attending should be the main supervisor and source of
support for residents in this situation. We used many of
these recommendations to create the crisis support team as
described earlier. We hope to hold this workshop yearly in
an effort to minimize isolation within the larger psychiat-
Finally, writing this article helped each of us heal and
grow a little more from this difficult experience. We hope
that it will be helpful to others as well and that the expe-
rience of patient suicide can be used to improve patient
care and better support other residents who face this dif-
ficult experience. We also hope to encourage other insti-
tutions to enhance the support they provide to residents
who experience the suicide of a patient. By responding to
the trauma that a resident experiences when a patient
commits or attempts suicide, programs will not only be
offering support, but they will also be modeling less stig-
matizing attitudes toward the psychological vulnerabilities
SUPPORTING RESIDENTS AFTER A PATIENT SUICIDE
280 http://ap.psychiatryonline.orgAcademic Psychiatry, 33:4, July-August 2009
that we study and treat in others but have so much diffi- Download full-text
culty in acknowledging among ourselves.
At the time of submission, the authors disclosed no competing
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APPENDIX 1. Composite Case of a Patient Suicide
Mr. Brown, 56 years old, was admitted to the general inpatient psychiatry unit of a major urban teaching hospital with a recurrence of
major depression with psychotic features. He was treated by Dr. Smith, a second-year resident on her first psychiatry rotation, under the
supervision of an attending psychiatrist. During the course of his 3-week hospitalization, Mr. Brown improved significantly with
electroconvulsive therapy, pharmacotherapy, and supportive psychotherapy and was discharged to the care of his outpatient psychiatrist
on the last day of Dr. Smith’s rotation. A week later, on a different rotation, Dr. Smith received a page from her former attending. His
voice sounded distant. “I thought you would want to know . . . we got a call a few days ago. Mr. Brown jumped off of the roof of his
apartment building early Monday. He’s dead.”
The attending told her that he would be in touch about a “Q and A.” Dr. Smith’s hands were shaking, and her mind was blank. “This
is what it feels like to be in shock,” she thought. She left a message for her boyfriend and went to the bathroom to compose herself.
Afraid of how she would be viewed by other residents and the department, she told no one what had happened.
Later that day, the unit chief from her old rotation called Dr. Smith to “touch base.” “Do not blame yourself,” he told her. He referred
to staff meetings addressing the suicide that had already occurred since Dr. Smith had rotated off the unit. Later, her residency director
paged Dr. Smith to ask, “Why didn’t you tell us about the patient suicide sooner?”
Dr. Smith did not sleep well that night. She lay awake, sad, disbelieving, and horrified. She felt guilty, as if she had failed Mr. Brown
and his family. She dreaded facing her fellow residents, supervisors, and residency director. She also felt an uncomfortable anger at Mr.
Brown, who had destroyed her treatment and hard work and put her in this situation. She questioned herself: Did she have bad
judgment? Had there been warnings that a “better” doctor would have noticed? Was she in the wrong field? Did she want to be in a
field in which she could work her hardest and still have such an outcome? She wondered what she should do. Should she call Mr.
Brown’s family? Should she apologize? Should she have gone to his funeral? She worried about being sued. That night, and for several
days after, she could not stop picturing Mr. Brown in the plaid shirt he had worn on the day of discharge.
About a month after hearing the news, Dr. Smith attended a case review on the unit by hospital administrators. She was quiet as the
attending and head nurse answered questions. She felt sick to her stomach. She thought about calling the therapist she had seen in
medical school, but her new rotation was busy, and leaving the unit was difficult. Her boyfriend and parents were supportive but had no
experiences from their own lives to allow them to be helpful. Dr. Smith felt alone.
Dr. Smith continued on to her third year of residency, treating predominantly outpatients. She continued to feel anxious when treating
suicidal patients, although less so with time. However, each anniversary of her patient’s death continues to give her pause.
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