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Citation: Tamworth, M.; Killaspy, H.;
Billings, J.; Gibbons, R. Psychiatrists’
Experience of a Peer Support Group
for Reflecting on Patient Suicide and
Homicide: A Qualitative Study. Int. J.
Environ. Res. Public Health 2022,19,
14507. https://doi.org/10.3390/
ijerph192114507
Academic Editors: Karl Andriessen,
Karolina Krysinska and
Yossi Levi-Belz
Received: 18 August 2022
Accepted: 4 November 2022
Published: 4 November 2022
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4.0/).
International Journal of
Environmental Research
and Public Health
Article
Psychiatrists’ Experience of a Peer Support Group for Reflecting
on Patient Suicide and Homicide: A Qualitative Study
Millie Tamworth 1,* , Helen Killaspy 1,2 , Jo Billings 1and Rachel Gibbons 3
1Division of Psychiatry, University College London, London W1T 7NF, UK
2Camden & Islington NHS Foundation Trust, London NW1 0PE, UK
3Royal College of Psychiatrists, London E1 8BB, UK
*Correspondence: millie.tamworth.20@ucl.ac.uk
Abstract:
There is a lack of support for mental health professionals who experience a patient suicide
or homicide. This is despite a high likelihood of such an occurrence and the heavy professional and
personal toll the experience can take. We conducted 15 interviews with members of a facilitated
peer support group run for consultant psychiatrists who have experienced a patient homicide or
suicide. Our interviews explored the trauma of the experience as well as the effectiveness of the
group in helping the clinician heal. Our results echoed previous research that the experience can be
profoundly traumatic. A professionally facilitated, consultant-only peer group specifically dedicated
to suicide and homicide were the key components helping participants to process their grief. Mental
health trusts should consider setting up facilitated peer support groups for clinicians who experience
patient suicide or homicide.
Keywords:
psychiatrists; mental health practitioners; peer-support; postvention; suicide bereave-
ment; qualitative research
1. Introduction
There is limited understanding of what kind of support is helpful for clinicians after a
patient suicide or homicide. This is despite the fact that the impact of losing a patient in this
way can be prolonged and profound [
1
]. In the field of suicidology, it has been suggested
that coping with bereavement after a suicide can be complicated by higher levels of stigma
and associations of blame [
2
]. In an effort to deepen our understanding of what support
is needed, we conducted a qualitative evaluation of a peer support group for consultant
psychiatrists who had experienced a suicide or homicide by a patient under their care.
In England, between 2008 and 2018, 1/3 of suicides were carried out by people under
the care of mental health services, equating to 1271 suicides per year [
3
]. Typically, these
patients were under the care of a multi-disciplinary team including a consultant psychiatrist,
a psychologist, nursing staff, trainees and allied health professionals [
4
]. The total number
of consultant psychiatrists in England as of September 2020 was 4452 [
5
]. Based on the
yearly average of 1271 suicides, each psychiatrist has a one in three chance of losing a
patient in this way every year. Put differently, over a 15-year career, the average consultant
psychiatrist will experience five patient suicides although that number will vary depending
on the area of specialty. Rates of homicide carried out by patients are lower, averaging 54
a year [
3
], but the personal and professional repercussions of such an event appear both
more common and more severe. In a survey assessing the impact of patient homicide on
forensic psychiatrists, 81% of respondents said the experience had impacted their mental
health, 25% of which described it as ‘very significant’ [6].
The impact of patient suicide is more widely covered than homicide, due in part to its
higher frequency. A recent systematic review outlined the different ways that psychiatrists
are affected by patient suicide, whilst Mezey et al. carried out a survey looking at the
Int. J. Environ. Res. Public Health 2022,19, 14507. https://doi.org/10.3390/ijerph192114507 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022,19, 14507 2 of 16
impact of homicide on the care team [
6
,
7
]. Both papers highlight the emotional effect on
the individual (such as guilt, shame, blame and anger) and the impact on their professional
practice (such as taking on lower-risk patients, prescribing more antidepressants). The
severity and duration of these impacts depends on several factors, including the psychia-
trist’s personality traits, the nature of the therapeutic relationship they had with the patient
and the manner of their death [
7
]. Sandford et al. found that the most significant risk factor
for a negative impact was fear of blame or self-blame [
7
]. Previous research has also found
feelings of stigma and persecution to be prevalent [
6
,
8
]. To that end, the psychiatrist’s
experience echoes the wider literature on experiences of suicide and homicide bereavement.
To date there is little evidence as to what organisational and cultural factors may
moderate the impact of a patient suicide or homicide on professionals. Sandford et al.’s
study noted that informal support was deemed most helpful, but it was unclear whether
formal support was considered inadequate or required more individualisation [
7
]. It has
also been noted that the evidence base for what types of interventions are useful for those
impacted by suicide more widely is underdeveloped [9].
Research on specific occupational groups exposed to suicide found that, in the case
of ambulance workers, a combination of time pressures and a macho culture prevented
people seeking support [
10
]. The study also found that there was limited opportunity for
staff to process their own distress but when afforded the means to do so, staff supported
one another. For psychiatrists, the likelihood of seeking support needs to be framed in the
context of clinical responsibility. The death of their patient by suicide may implicate and
stigmatise them in a way that is less the case for doctors working in other specialties [8].
Campaigns and initiatives such as the ‘zero-suicide policy’ differ in their capacity to
motivate workforces, depending in part on implementation. Zero-suicide can be construed
positively, as an aspirational goal underlying concrete objectives of delivering reliable and
consistent healthcare [
11
]. Conversely, the same policy can be presented as an absolute
target or key performance indicator. Such policies can be unhelpful in exaggerating the
degree to which health professionals can prevent these kinds of tragic incidents and risks
implying that a ‘failure to prevent’ a suicide equates to it being the healthcare professional’s
fault [
2
,
12
]. In the wake of a traumatic death, the difficult emotions that arise and the fact
that the patient is not there to speak for themselves, means clinical responsibility and blame
can conflate [6]. In this context, seeking support can be challenging [12].
The group is run out of an NHS Trust in London and operates an open membership,
meaning any consultant psychiatrist is welcome to attend regularly, intermittently or as
a one-off. The group was founded 12 years ago by two consultant psychiatrists. Today it
is facilitated by one of the group founders who is also a trained psychotherapist. Group
membership has grown, and a typical session is now eight to ten people. Five to seven
of these are ‘core’ (regular) members, one of whom is the group facilitator; the remaining,
non-core participants might attend following a relevant experience. The group meets every
three months face to face for two hours.
Group sessions are loosely based on the Balint model [
13
] and use a psychoanalytical
framework. Consultants share their experience of the event and their reaction-described by
the group facilitator as a “stereotyped pattern of response”-with the rest of the group. They
then listen to other members discussing what they have shared. This ‘stepping back’ gives
the presenter space to observe their case from an objective viewpoint, uncoloured by their
own interpretations and judgements.
A facilitated conversation is then held by the group who consider and reflect on
what they have heard. The intention is to bring together multiple perspectives, provide
emotional understanding, containment, and an alternative narrative to self-recrimination.
Through a combination of the group’s collective memory and members’ own experiences,
the presenter’s experience is ‘metabolised’ within the group and ‘handed back’ in a man-
ageable form.
Our research had three research objectives:
•To investigate the experiences of psychiatrists after a patient suicide or homicide.
Int. J. Environ. Res. Public Health 2022,19, 14507 3 of 16
•
To investigate the ways in which the group may be helpful to its members and ways
in which it may be improved.
•To understand key elements of the group structure and the role of the facilitator.
2. Methods
2.1. Study Design, Participants and Procedures
The study procedures were approved by the University College London Research
Ethics Committee (Ref. 20423/001). Consultant psychiatrists who were attending or had
previously attended the group were asked if they were happy to be contacted by the research
team. Willing participants were sent the Participant Information Sheet and Consent Form.
They returned an electronically signed consent form to the principal researcher (MT) before
the interview. The topic guide (Supplementary Materials) for the interview was drafted by
the research team in consultation with the Royal College of Psychiatrists’ working group
on patient suicide and homicide, which comprises psychologists, psychiatrists, academics,
psychotherapists, and family members with lived experience of losing someone to suicide.
MT conducted all the interviews, most of which took place remotely via Microsoft Teams.
All the interviews were audio recorded and transcribed verbatim.
2.2. Analysis
Our study adopted a reflexive thematic analysis approach, whereby researcher sub-
jectivity is regarded as an analytic resource [
14
]. Three members of the research team
(MT, JB, HK) conducted the coding and reflexive analysis. HK is a member of the peer
support group and subsequently, we ensured the transcript excerpts selected for her input
guaranteed the anonymity of the participating member. Participants had been made aware
that HK was part of the research team and would have access to participant data and
consent was given on this basis. HK did not partake in the interview process. The fourth
research team member, RG, is a founder of this peer support group. RG participated in the
interview process and therefore did not partake in the analysis. Transcripts were imported
into NVivo Pro V12 and a preliminary coding frame was developed. MT conducted initial
coding before allocating two transcripts each to HK and JB, who coded these independently.
The team then met for further refinement into a coding framework. Coding was done
collaboratively, consisting of an interactive process between data, interviewer, and research
team. Our purpose was to develop a rich and nuanced reading of the data rather than seek
consensus on meaning.
Reflexive thematic analysis is an ongoing and iterative process that does not lend
itself well to the concept of data saturation [
15
]. Our decision about how many people to
interview was a function of the finite nature and specificity of the sampling pool rather
than a need to reach data saturation. Our results take into consideration and give the
reader an indication of when perspectives were unanimous and when opinions varied.
Consistent with the principles of reflexive thematic analysis [
15
], it would be nonsensical
to cite frequencies of responses. The interview process in reflexive thematic analysis is
necessarily open and evolving, and not every participant is asked the exact same question
at the same point in the interview. Certain participants may choose to give certain examples,
but this decision could be as much a function of the stage of the conversation as it is an
indicator of the relative importance of the topic in question. Our intention in using reflexive
thematic analysis was to capture the breadth of experiences and responses, a single point
of view is as valid as one which is shared by many [14].
2.3. Reflexivity
Reflexivity is the process of actively recognising your own personal situation as the
researcher and the impact this may have on data interpretation [
16
]. It enables the reader
to consider the researcher’s perspective as a factor in how the research was constructed,
and hence the validity of the analysis [
17
]. The research team had four authors, MT, JB, HK
Int. J. Environ. Res. Public Health 2022,19, 14507 4 of 16
and RG. Each encompassed different career stages, clinical specialties and academic areas
of interest.
MT is a mature student studying an MSc in Clinical Mental Health Sciences. She has
research interests in experiences of vicarious trauma across different occupational settings.
This subject matter was interesting to MT who sought to better understand society’s coping
mechanisms for dealing with the pain of suicide-seemingly through silence or by turning
away- and how this contributes to the trauma, isolation and experience of stigma for those
left behind [10].
JB is a Consultant Clinical Psychologist with over 20 years of experience working in
the NHS. An associate professor, she is an experienced academic in all areas of trauma
and in the writing of qualitative research. HK is a consultant psychiatrist with expertise
in psychosis. A professor with a background in quantitative and qualitative research, her
areas of academic interest are services and interventions for people with complex mental
health problems. She is also a member of the support group studied in this research. RG
is a consultant psychiatrist, psychotherapist and Chair of the Patient Safety Group and
Working Group on the Effect of Suicide and Homicide on Psychiatrists at the Royal College
of Psychiatrists. She was one of the three founding members of the peer support group
following early career experiences of losing patients to suicide. JB, HK and RG all have
lived experience of patient suicide and/or homicide.
2.4. Quality and Validity
The quality of this research was based on the Standards for Reporting Qualitative Re-
search Framework (SRQR) [
17
]; conceptual and design thinking for thematic analysis which
formed the foundation of our methodological approach [
16
]; and the Oxford Handbook of
Qualitative Research [18].
Subjectivity lies at the heart of reflexive thematic analysis. Our aim was less to control
bias than to explore the complexity of human experience and allow the reader to reflect
on researcher perspective as part of their own conclusions [
16
]. Nevertheless, we have
sought to be rigorous, transparent and trustworthy in the reporting of our findings [
17
],
routinely reflecting on our assumptions, expectations and choices throughout the research
process [19].
We contacted 19 past and present members out of a total of 50, 15 of whom agreed
to be interviewed. Whilst results are not necessarily generalisable beyond the sample, the
participants were sufficiently diverse in ethnic diversity, clinical specialty and experience
for us to capture a range of views. Those interviewed included male and female members,
the group founders, regular and infrequent attenders, former regular attendees and those
who had attended only once.
3. Results
Eight females and seven males took part. Areas of specialty and membership status
are presented in Table 1. Interviews took place between June and September 2021 with each
lasting 45–60 min. Findings were organised into separate domains based on the research
objectives. Within each domain, inductive themes were identified (Table 2). Our results use
pseudonyms to ensure anonymity.
Int. J. Environ. Res. Public Health 2022,19, 14507 5 of 16
Table 1. Demographic Information of participants.
Participant Membership Status Specialist Area
001 Present Eating Disorders
002 Present Rehabilitation Psychiatry
003 Present Old Age Psychiatry
004 Present Assessment
005 Present General Adult Psychiatry
006 Present Acute Care
007 Present General Adult Psychiatry
008 Present Acute Care
009 Present Personality Disorder Unit
010 Past Acute Care
011 Past Acute Care
012 Past Perinatal
013 Past General Adult Psychiatry
013 Past Psychiatric Intensive Care
015 Past Early Intervention Services
Table 2. Themes and sub-themes by research objectives.
1. The Experience of Psychiatrists After a Patient Suicide or Homicide
1.1 Responsibility
1.1.1 Uniqueness of consultant’s role
1.1.2 Types of responsibility
1.1.2.1 Team
1.1.2.2 Clinical
1.1.2.3 Formal
1.2 Support
1.2.1 Attitudes towards seeking support
1.2.2 The support available
2. The value of the group to its members
2.1 Different uses for different people
2.1.1 An alternative perspective
2.1.2 Leaving it behind
2.2 A three-stage journey
2.2.1 Shedding
2.2.2 Safety
2.2.3 Post-traumatic growth
2.2.3.1 Regaining the capacity to think
2.2.3.2 Changes in work behaviour
2.2.3.3 Changes in clinical practice
3. Group structure and the role of the facilitator
3.1 Membership structure
3.1.1 Core members
3.1.2 Non-core members
3.2 Facilitation: what’s important?
Int. J. Environ. Res. Public Health 2022,19, 14507 6 of 16
3.1. The Experience of Psychiatrists after a Patient Suicide or Homicide
3.1.1. Responsibility
Uniqueness of the Consultant’s Role
The amount of responsibility held by consultants on behalf of the rest of the team is
felt particularly acutely after a suicide or homicide. Consultants described feeling.
“
. . .
isolated. You’re working very closely in a team; you feel very supported on the one
hand, but you are the only consultant.” (Michael)
with an overwhelming sense of responsibility from being
“
. . .
the only consultant psychiatrist in a team. [You] have unique experiences in having
to be the certain decision-maker
. . .
Ultimately in these sorts of situations, if you go to
Coroner’s Court, you’ll be the person that’s there. There are different expectations of
you–of what you should know.” (Patricia)
Types of Responsibility
Participants described three different responsibilities after a patient suicide or homi-
cide. These related to the team, clinical decision-making and the formal responsibilities
following a serious incident.
Team responsibility.
Most participants agreed that, after a serious incident, they felt
inhibited by their position of responsibility within the team when it came to processing
their own emotions. Participants often used the word ‘containment’ to describe a process
of actively managing other team members’ anxiety and uncertainty through listening and
facilitating or leading on decision making.
“The role of the consultant is to contain a team that is under stress so that the team is
functional at times of very high workload. I try to contain the distress of junior doctors
and nurses when I can.” (Nina)
Peter described the challenge of having to healthily process his own emotions but in a
safe and contained way.
“Imagine going into a debrief and the consultant breaking down in front of everyone. It
would make the whole team even more unsettled. You are expected, by virtue of your
senior role, to keep things going
. . .
but there is a balance between this and showing your
vulnerable side.”
Clinical responsibility.
Participants described how decisions around patient safety
are often taken in a culture of unrealistic expectations about what is controllable. They
described their role as that of a ‘super-hero’, a belief held sometimes by themselves and
often by those around them, that they should always be able to save patients.
Comparing a severely unwell psychiatric patient to someone with terminal cancer,
one participant pointed out that the idea that the psychiatric patient might die would be
unthinkable to most people whereas this would be an accepted reality for the cancer patient.
Another compared psychiatrists to ICU doctors:
“I don’t think society expects them to save everyone. The approach to psychiatry is very
different. We should have predicted everything.” (Nina)
Many found these expectations particularly challenging after a serious incident and
described a process whereby clinical responsibility could easily be conflated with self-
blame.
“It’s very difficult to differentiate how much of it is your blame and how much of it is
professional. Initially, my professional integrity felt threatened. Then personal things
come in as well. And this is when things start to merge.” (Adam)
These feelings were rarely alleviated by the knowledge that, clinically, reasonable
decisions had been taken.
Int. J. Environ. Res. Public Health 2022,19, 14507 7 of 16
“On an intellectual level I know these things can happen. But some part of you, some-
where, believes that if we do all the right things, it won’t. I thought, ‘There must be
something wrong with me.’” (Anne)
Formal responsibilities.
As part of the investigation, psychiatrists are usually re-
quired to attend the Coroner’s Court. Generally, this experience was described as extremely
challenging. The fact of being a witness rather than the accused rarely tallied with the
experience, and the presence of a jury added to feelings of culpability.
“It really feels like you are in court and someone will determine whether you are guilty or
not guilty. Well, I mean, who else will have a jury unless you are accused of something?”
(Jenny)
Many described the experience of being cross-examined by representatives of the
deceased’s family, sometimes with no mediation from the judge, as very exposing.
“The relatives, the solicitor of the relatives, they come and don’t always see you as the
witness for information. Their attitude can be quite hostile.” (Peter)
3.1.2. Support
Following a homicide or patient suicide, the support psychiatrists were offered de-
pended on the organisation they were part of as well as factors such as resource constraints.
Attitudes towards Seeking Support
All interviewees valued receiving support after the incident, with informal support
(such as from peers) being the most common. Regarding the acceptability of seeking
support, the consensus was that, whilst it was getting easier to do so, this remained
difficult.
“It might not necessarily be a conscious ‘you’re weak if you get help’ because that goes
against what we would be telling anybody else, but yeah, you should be fine and just
manage these things.” (Michael)
Some participants described a ‘stiff upper lip’ culture in their NHS Trust where these
kinds of incidents were considered part of the job and having a forum to discuss their
impact was seen as “sitting around talking about it”. Conversely, the Trust affiliated with
this group was seen as more open and progressive regarding consultant support by virtue
of its hosting of the peer group. More recent consultants explained this had been helpful in
overcoming any perceived ‘wrongness’ in needing support.
“It was an utter relief to see people who have been consultants for 15 to 20 years and who
are still so deeply affected by the loss of a patient
. . .
Pain is a human response and there’s
nothing wrong with me.” (Anne)
The Support Available
Most psychiatrists had attended some kind of team debrief following an incident,
though the form this took varied widely. Team debriefs were considered helpful in terms
of feeling collegiate with the team who had experienced the tragedy, but many participants
felt constrained in processing their own emotions at these meetings because of their role as
emotional containers for the team, as detailed earlier in Section 3.1.1.
Other forms of support that participants mentioned included reflective practice groups,
peer groups and Balint groups, again with variation in availability between employing
organisations. Often policies about the support that was available contrasted with reality:
“On paper you’re supposed to have a peer group, a supervisor, someone you can go to
clinically
. . .
But the reality of the situation is you are so clinically inundated there’s no
time to be accessing those sorts of support, and the people we are getting support from
are themselves inundated and overspent.
. . .
personally, I felt trapped in the deep end.”
(Anne)
Int. J. Environ. Res. Public Health 2022,19, 14507 8 of 16
One consultant explained how shortages of skilled facilitators meant sessions were
often cancelled, whilst others remarked it could impact how they were run. One described a
Balint group they had attended as “a 15 min presentation and discussion, nothing more than
that”, whilst clinicians using support structures to meet CPD requirements was mentioned
by several consultants. Asked whether they could have brought the subject of patient
suicide to these other forums, it was thought theoretically possible but practically unwise.
Many support structures that were described tended to focus on clinical decision-making
but were not considered safe or appropriate places to discuss the consultant’s emotional
response and experience of a patient suicide or homicide.
“The support was there but it was
. . .
very procedural. It’s all very business-like and
there’s no emotional connection
. . .
no sharing of that kind of level of emotional response
to the work that we do.” (Michael)
3.2. The Value of the Group to Its Members
3.2.1. Different Uses for Different People
Participants used the group in two key ways.
An Alternative Perspective
Participants with an interest or training in psychotherapy tended to show a particular
curiosity about the acts of suicide and homicide and the human response to it. This was
discussed in different ways but underlying each was a belief that, to truly process the
experience and accompanying emotions, one must go beyond medical discourse and
instead query human decision-making behind the taking of a life, be it one’s own or
another’s. One member spoke of the common tendency to try to comprehend the act within
the Western-medicine framework of ‘illness. They felt that, while removing the suicidal act
from our understanding of ‘normal’ human behaviour may feel less painful, it prevents
true understanding and healing.
“Helping professions want to be seen as dealing with illness, not people acting out in
a very destructive manner. So [the group] was about legitimising thinking negatively
about suicide.” (Ben)
Many, not all, considered this psychoanalytical lens an important input to the wider
grieving process.
The factor valued by all members was a separate and safe space where it is permitted
to question ‘What if no one did anything wrong and this still happened?’ and consider an
alternative narrative to self-blame. Consultants described how, by stepping away from
their everyday environment, they could distance themselves from artificial constructs such
as omnipotence or the superhero narrative. In the context of a patient suicide or homicide,
these constructs were contributing to the sense of self-blame and were prohibiting grief.
“You don’t see the madness because you are part of it. And then you start to reflect
. . .
but you cannot reflect and question until you get space.” (Jane)
It was felt to be important that the space was dedicated solely to processing sui-
cide and homicide experiences, enabling members to discuss subjects that might be too
uncomfortable to raise in mainstream support environments.
“Our natural tendency is to not want to go near it because it’s too distressing. People
will, unless the group is about this and only this, talk about other things.” (Elizabeth)
Leaving It Behind
Some participants attended the group only a few times. These participants described
how they used the group as a place to share the ownership of an experience, before
depositing the pain as a form of closure.
“Once I had processed it and thought about it a bit, I didn’t really want to keep talking
and I just wanted to forget about it, to the extent that I could.” (Nick)
Int. J. Environ. Res. Public Health 2022,19, 14507 9 of 16
Those with less interest in psychotherapy still found value in the interpretative frame-
work. Jane, a core member, described members’ different purposes in attending as a
contributing dynamic to its workings:
“I think some come because they just need to leave it with us. Putting it down and leaving
it there and going away.”
Interviewer: “And that’s enough?”
“That’s enough. I think that’s a very common and even helpful, reasonable thing to do.
It’s a gift to us and provides material to work with. It’s a gift to them because they can
come in green and go out pink. They can just go and get on with things.”
3.2.2. A Three-Stage Journey: Shedding, Safety and Growth
Participants described a three-step process of healing encompassing the temporary
shedding of their professional responsibilities, containment by group members and the
opportunity for personal growth.
Shedding
The group invites its members to step outside the hierarchy of the medical profes-
sion and, in doing so, deconstruct their beliefs about responsibility. Core member Sally
explained:
“In being a consultant, a superhero is the role you have to enact even if you don’t feel it.
When you come into this group, you don’t have to do that, it’s safe to take your hat off.”
All participants agreed that shedding responsibilities was possible because the group
is only open to peers (fellow consultants).
“I try to contain the distress of junior doctors and nurses when I can. But I need to be
contained as well
. . .
We cannot have the people I am supposed to contain in the same
room as people tasked with containing me.” (Nina)
Participants highlighted two tensions to the group structure. First, other team members
apart from the psychiatrist need support too. Second, the consultant-only aspect was
described by the group facilitator as a “
. . .
a difficult balance, there’s something about the
omnipotence of us trying to be omnipotent.” In other words, restricting the group to senior
clinicians gives it an implied superiority that risks endorsing the superhero narrative they
are trying to escape.
Safety
Participants described the confidential exchange of personal experience as key to
feeling safe in the group. In the act of presenting, a consultant shares ownership of their
experience and its accompanying grief.
“The loneliness of the experience is shared. It is validated, it is acknowledged. The
loneliness is not just yours, somebody else is owning it as well.” (Adam)
Having shared their account, the presenter listens to others discuss it. Members
bring personal experiences as well as reflections from past group discussions, and newer
participants begin to see a commonality of experience and feelings. Unanimously, members
spoke of how important the sense of sameness was to feeling validated and contained.
“There’s something quite shameful for clinicians in a death by suicide. So, I think that the
most helpful thing was hearing from others, recognising feelings and normalising them.”
(Laura)
Post-Traumatic Growth
All participants felt that attending the peer group sessions had enabled self-growth.
Three main areas of self-growth were described.
Int. J. Environ. Res. Public Health 2022,19, 14507 10 of 16
Regaining the capacity to think:
Participants reflected on how the opportunity for
growth came once they felt safe in the group setting. With their emotions validated, they
now had at their disposal a new framework for interpreting what happened, in which they
were not cast as playing a central role.
“The blame narrative does not disappear. However, you can reflect better on what your
role is and not what you fantasise your role to be.” (George)
Within this safe space, there is a renewed ability to adopt a thinking mind. This was
felt to be as much a function of the sense of separateness, safety and sameness as it is of the
actual exchange with other members explored in the previous section.
“We could only move when this absolute terror about suicide-hat we were to blame for
it-could reduce. It was only through having the space to think about it that gradually
curiosity emerged.” (Jenny)
Changes in work behaviour:
Participants described a greater awareness of their daily
environment. For some core members, the ability to continue working effectively in acute
areas rests on regularly attending the group.
“Without the group I don’t think I would be continuing, certainly not as healthily.”
(Patricia)
One non-core member who worked in an inpatient ward described a new readiness
to take time off and to work from home more regularly to help manage their tendency to
overwork. The most consistent change outlined was in team communication, specifically
breaking down hierarchies that impeded communication.
“It certainly has changed how I function in terms of openness
. . .
and how we check in
with each other on an ongoing basis. I was keen to break down this whole, you know,
consultant superhero narrative. I don’t think it does anyone any good.” (Anne)
Changes in clinical practice.
Regarding changes to clinical practice, seemingly di-
verse responses centred on an underlying intention that clinical decisions should not be
influenced by fear of recrimination and blame.
“
. . .
to not be scared to listen to your intuition. To practice in a way that feels right
rather than in a way that’s guided by concerns that something awful is going to happen
which will end your career.” (Patricia)
Many other consultants talked about prioritising instinct over ‘the training manual’
and allowing more nuanced risk formulation. Peter described this as.
“
. . .
a case of how you think about the risks with the patient, which isn’t reflected on the
medical notes, on the risk assessment tool, on what the expectation is from the Trust.”
3.3. Group Structure and Facilitator
3.3.1. Membership Structure
The group operates with open membership and has different types of members. Core
members are those who attend regularly; non-core members attend episodically or as a
one-off.
Core Members
At the time of writing, there are five to six core members who attend the group
regularly, many of whom have a background in psychotherapy. Core members described
their role as upholding an alternative framework of thought to the one brought by the
consultant who is sharing. George, a core member, explained his purpose as
“
. . .
bringing a different perspective to suicide, which steps away from something purely
psychiatric—where we can get a little bit stuck in thinking
. . .
‘What was the diagnosis?
Was the medication the right thing?’-and towards
. . .
‘What is [an] event like suicide
like? What are the energies harnessed?”
Int. J. Environ. Res. Public Health 2022,19, 14507 11 of 16
This sense of stepping outside the medical formulation and into questioning underly-
ing responses to the experience was a consistent theme.
“A key role of a core member is to provide the emotional containment so the other person
can process; to investigate what the hooks are in that case that make the pain so unbearable
and the loss so profound
. . .
It’s not a clinical learning, it’s something much more
. . .
[It’s] about the emotional structure of how we deal with this very difficult professional
issue.” (Nina)
Another role was described as holding the collective memory of the group. By sharing
the similarities of past cases, core members could show that the emotional experience is
not unique.
“You find yourself having similar sort [s] of explorations. The themes about responsibility
and roles etc come up again and again.” (George)
As noted in Section 3.2.2., a sense of ‘sameness’ is critical to feeling validated and
safe. Core members described experiencing ongoing reassurance from regularly attending
the group and hearing other people’s cases. One explained how seeing reactions in other
people helped them understand their own weak points better, which amounted to an
iterative learning process.
“You have the opportunity to digest your own episodes, again and again through new
perspectives. Even if you don’t present, your own experience is still being re-evaluated.”
(Adam)
Non-Core Members
At the time of writing, the group hosts two to three visiting members. Generally, we
found that core members had stronger psychoanalytical interests than members who came
less regularly. These differences were commented on by non-core members.
“The people that attend regularly have been going for longest, [they] are more attuned
to the implicit rules of the group [and] the styles of interpretation that are likely to land
well.” (Nick)
A sense of “us and them”, particularly when first attending, was mentioned. One
participant (now a core member) described his first visit as
“
. . .
not easy. Relationships were already established. The way they were talking about
things, the jargon, the facial expressions, the exchange of ideas
. . .
I thought, “Well, if I
had to present a case, how would I feel?” (Adam)
However, this did not seem to impact the effectiveness of the group.
“
. . .
there’s two subgroups within the group. It’s probably a little bit of an awkward mix
but it doesn’t preclude it from being useful.” (Nick)
Whilst some visiting members described feeling safe reasonably quickly, it was rare
that people had felt comfortable presenting their experience without having first attended
as a listener.
3.3.2. Facilitation: What’s Important
Participants were asked whether the group facilitator should be from outside the Trust
and whether it was important they had psychoanalytical training. The current facilitator
has knowledge of the Trust but does not currently work in it. All participants knew the
facilitator in a professional capacity outside the group. This familiarity appeared more
important than either of the above questions.
“I have never thought about it their position within [the Trust], it feels so natural they
are there.” (Adam)
“Inside is better. The support you need is also about trust and understanding the
institutional dynamics at play.” (Jenny)
Int. J. Environ. Res. Public Health 2022,19, 14507 12 of 16
Regarding psychoanalytical training, many of those personally inclined to that way of
thinking answered in relation to the importance of employing a psychoanalytical lens.
“Absolutely critical [a psychoanalytical lens]. It creates the framework in which difficult
things can come to the surface, things that you know were not visible before.” (Peter)
“It allows the group to be held and to keep the group going in a way that progresses and
furthers that kind of psychoanalytic stream of conversation.” (Anne)
The skill and experience of the facilitator was recognised by all participants and was
an important factor in their decision to attend. It was described by many participants as
paramount to feeling safe:
“I wouldn’t feel comfortable and contained if it was just a Joe Bloggs psychiatrist facilitator.
I wouldn’t feel safe in that space.” (Michael)
“I think [they] are very skilled in facilitating. I think without them it might feel different.”
(Laura)
4. Discussion
4.1. Summary of Research Objective and Results
Our study had three research objectives:
•To investigate the experience of psychiatrists after a patient suicide or homicide
•
To investigate the ways in which the consultant peer group may help its members and
ways in which it may be improved
•To understand key elements of the group structure and the role of the facilitator
Our data revealed that a sense of fellowship is critical to allowing psychiatrists to
first grieve and then grow after experiencing a patient suicide or homicide. It showed the
impact of these events depends on several factors including the circumstances surrounding
the suicide or homicide, the psychiatrist’s sense of their therapeutic alliance with the
patient, the manner of the death and the approach taken in the subsequent investigation
and coroner’s inquest. Our findings in this regard were broadly consistent with research
conducted previously [
7
] although we note that research on the investigative and inquest
experience is lacking. Despite the range of potential factors associated with our participants’
experiences, we identified common emotional responses of psychiatrists including feelings
of acute guilt or shame. Within the peer group setting, this commonality becomes evident
through the intimate act of sharing one’s own experience and through the collective history
of the group shared by core members.
4.2. The Experiences of Psychiatrists after a Patient Suicide or Homicide
The important difference between this support group and other support structures
was in providing separation from the conventional clinical framework of thought which, in
the context of a suicide, can trap the consultant in a narrative of self-blame. Therefore, this
support group was described as helping consultants in a way that other forms of support
do not. It does so by being a space dedicated to the processing of the experience of suicide
or homicide and by offering a different lens through which to view the experience.
Our participants described the difficulty presented by the superhero narrative that
can be held by themselves and society. Whilst the superhero narrative is not confined to
psychiatry; its falsity can be accentuated by the experience of a patient suicide or homicide.
Gorkin has written about how the extent of a clinician’s belief in their omnipotence can
shape their trauma after a suicide [
20
]. Expectations of clinical omnipotence was also
reported in a recent meta-synthesis of 10 papers exploring the impact of patient suicide
across doctors and nurses [
21
]. This paper noted differences in blame attribution between
doctors and nurses. Doctors reported looking inwardly whereas nurses looked to external
factors. Other research is less clear-cut about the personal impact of patient suicide on
clinicians [
22
]. The varied findings alert us the individual nature of the experience and the
Int. J. Environ. Res. Public Health 2022,19, 14507 13 of 16
multitude of factors that can determine how a suicide or homicide impacts a clinician [
23
].
This goes beyond personality to include contextual and environmental factors [7].
Plakun and Tillman describe a twin bereavement of personal and professional identity
for psychiatrists after a patient suicide [
24
]. In our interviews, we explored the differences
between a psychiatrists’ personal, professional and organisational self to gauge the different
types of blame felt by participants. We found that many psychiatrists experienced a
blurring of these domains that added to the challenge of grieving. One such context is the
relationship between the psychiatrist and the patient’s family after a suicide or homicide.
This can be very strained with families often needing to assign blame [
25
] at precisely
the time when the psychiatrist’s personal self is seeking absolution. Currently there is no
communication protocol for the family and medical team in the aftermath. More could be
done to protect both the psychiatrist and family in these circumstances.
4.3. The Support Available
Previous research has shown that psychiatrists can be reluctant to seek support after
a patient suicide or homicide [
6
,
26
]. Brooks et al. [
27
] have identified multiple barriers to
doctors seeking help for mental health including anticipated negative career implications
from either taking time off work or in disclosing their condition. The paper discusses
doctors feeling shame, embarrassment, and a sense of weakness in the role reversal implied
of becoming ‘the patient’.
The feedback from our participants echoed these findings but working in psychiatry
introduces another layer of complexity, and the experience of a serious incident, yet an-
other. Participants described psychiatry as having an unspoken cultural resistance toward
professionals getting support for themselves, though the extent of this resistance depends
on the specific trust and area of specialism. The silence over the issue of support captures
the contradictory position of being in a profession which upholds the value of managing
one’s mental health but not feeling able to seek it out for themselves. The sense of ‘not
feeling entitled’ (to support) may become more prevalent when a psychiatrist graduates to
a consultant role and their responsibilities-team and clinical-grow. We have discussed how
in the case of a patient suicide or homicide it is common for psychiatrists to feel that they
are to blame personally. A further issue then may be that the clinician fears that admitting
the need for support is tantamount to an admission of professional guilt. More needs to
be done to understand this tension. What our research does make clear is that there is no
other situation where the responsibility of containment is so crucial to the wellbeing of
your team yet currently, many psychiatrists do not feel able to access the tools that will
enable them to do so.
Our study suggests that many other existing forms of support inadvertently magnify
rather than challenge the collective silence around suicide. Our participants identified
the group being only open to consultants as an important contributor to its effectiveness.
This structure was described as enabling clinicians to escape the burden of the superhero
narrative and find sanity by doing so. That said, not opening the group to a wider range of
clinicians also risks endorsing the ‘superhero’ narrative they are trying to escape as well as
perpetuating the myth of clinical omnipotence. Research on the potential pitfalls of peer
groups should be noted [
28
] and degree of choice in support is important. Future research
should compare peer groups to other interventions [29].
4.4. Opportunities for Growth
Post-traumatic growth refers to positive psychological change that may co-exist with
significant psychological distress after a shattering of fundamental assumptions [
30
]. Many
participants pointed to examples of growth, including more realistic appraisal of what
they could impact and what they could not, and passing on these insights to clinicians
moving into a consultant role. Changes to clinical practice was a complex topic in our
interviews, but any such changes reported seemed to be the result of growth and entailed a
subtle alteration of perspective in relation to responsibility and team interaction. However,
Int. J. Environ. Res. Public Health 2022,19, 14507 14 of 16
growth only became possible once the consultant was released from feelings of blame
and could reflect analytically on what had happened. Past research has described how
experiencing patient suicide without getting the right support can lead to inhibited clinical
decision-making and more defensive practice [7,31].
The need to be more accepting of the possibility of patient suicide has been discussed
in past research [
7
,
22
]. This issue can be explored in relation to risk assessment-an area of
change reported by many of our consultants who spoke of allowing greater intuition and
focusing on the clinical encounter. The predictive value of suicide risk assessments is far
from clear. One study of suicide risk assessment tools looked at 156 different types used in
85 NHS organisations. Of these, 85% were tick-box checklists which have been shown to be
ineffective in predicting suicide [
32
,
33
]. Another study [
34
] looked at the effectiveness of
risk assessment in discerning the odds of suicide across low-risk and high-risk inpatient
populations. This meta-analysis found that over a 20-year period, the pooled odds ratio of
suicide in the high-risk group compared with low-risk group was 7.1 but with an extreme
level of between-study heterogeneity. The authors argued the heterogeneity limited any
certainty that a similar result would be found across other inpatient populations. Our study
gives warning that that distilling the complexity of suicide risk in this way can reinforce
false notions about the ability of clinicians to be able to control and prevent such incidents.
It also risks shutting down genuine communication between mental health professionals
and the patient [35].
4.5. Strengths and Limitations
Little is known about what the most effective interventions are for supporting indi-
viduals who experience the death of a patient by suicide or a homicide by a patient under
their care. This study adds to the research in the field and enriches overall understanding.
Most group members were interviewed, enabling the accumulation of a wide range of
perspectives from clinicians of different career stages, areas of psychiatry and genders. The
qualitative approach taken enabled us to explore the “phenomenological complexity” of
the experience [
12
]. We examined individual experiences of trauma and the effectiveness
of this intervention in helping clinicians recover. Our conversations also explored other
forms of support offered, and their respective merits and shortcomings.
However, this was a small-scale, qualitative study, and findings may not be trans-
ferrable to other settings. Additionally, whilst good understanding into why the group
is only open to consultants was gained, more research is needed on the experiences of
other team members and alternative support mechanisms that could be helpful. Finally,
the study only interviewed participants of the peer group, which introduces self-selection
bias. Whilst participating consultants were asked their views on the limitations of the
group, the perspectives of those who chose not to attend the group are essential to fully
understanding pitfalls.
4.6. Clinical Implications
Our findings demonstrate the potential benefits of providing a facilitated peer support
group for consultant psychiatrists. Whilst this study focused on consultant psychiatrists
there is no reason to consider that such groups would not be useful to other professional
groups as well. Further research is needed to understand whether support groups that
include a range of different professionals would be feasible or as well attended and effective
as the group studied in this project.
Clearly this is not the only potential staff intervention needed following these kinds of
serious incidents and other structures, such as receiving specific support and guidance to
navigate the subsequent formal process that follow a patient suicide or patient perpetrated
homicide are likely to be needed. Further research is needed to clarify the kinds of assistance
and guidance staff may benefit from.
Int. J. Environ. Res. Public Health 2022,19, 14507 15 of 16
5. Conclusions
This study builds on previous research showing that the experience of a patient homi-
cide or suicide can be profoundly distressing to psychiatrists and confirms the complexity of
the grieving process in tragic situations such as these. Ensuring that clinicians have access
to appropriate support is crucial and this study identified many benefits of a facilitated con-
sultant psychiatrist peer support group. Our study has helped to expand the understanding
of the underlying causes of this distress and how the structure and facilitation of a peer
support group can address them. Further research is needed to investigate the effectiveness
of this and other forms of support for clinicians and what kind of support works for whom
and why. What we do know at this juncture is that actively supporting psychiatrists, by
addressing the stigma they face and the sense of blame they feel, is extremely important for
their mental health and well-being, and ultimately their capacity as professionals.
Supplementary Materials:
The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/ijerph192114507/s1, Interview Transcript.
Author Contributions:
Formal analysis, M.T., H.K. and J.B.; Investigation, M.T., H.K. and J.B.;
Methodology, M.T. and J.B.; Supervision, H.K., J.B. and R.G.; Writing—Original draft, M.T.; Writing—
Review and editing, H.K., J.B. and R.G. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement:
The study was conducted in accordance with the Declaration
of Helsinki, and approved by the UCL RESEARCH ETHICS COMMITTEE (protocol 20423/001 date
of approval 10 June 2021).
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the
study.
Acknowledgments:
We would like to thank all the members of the peer support group who gave up
their time to take part in this research. We would also like to thank the Suicide Working Group for
providing invaluable guidance on the design of this study.
Conflicts of Interest: The authors declare no conflict of interest.
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