Experiences of mental health practitioners after clients’ suicide: a qualitative systematic review protocol

Abstract

Objective:

The objective of this qualitative systematic review is to understand the experiences of mental health practitioners after clients’ suicide.

Introduction:

Mental health practitioners inevitably encounter client suicide during their careers, which can significantly affect their personal lives and professional outcomes. A deeper understanding of mental health practitioners’ experiences in the aftermath of clients’ suicide is necessary to provide effective support and assist with adaptation to this situation.

Inclusion criteria:

This systematic review will consider qualitative studies that explore the experiences of mental health practitioners, including psychotherapists, psychiatrists, psychological counselors, clinical psychologists, psychiatric mental health nurse practitioners, and social workers following clients’ suicide. Experiences may include emotional responses, coping strategies, changes in social relationships, and reflections on practice.

Methods:

This review will follow the JBI methodology for qualitative systematic reviews. The databases to be searched will include PubMed, CINAHL (EBSCOhost), Embase, PsycINFO (EBSCOhost), SocINDEX (EBSCOhost), Web of Science, CNKI, Wanfang, VIP, Bibliographia Medica Čechoslovaca, and Bibliographia Medica Slovaca. Gray literature sources will include Google Scholar and ProQuest Dissertations and Theses. Studies in English, Czech, Slovak, and Chinese will be assessed for inclusion regardless of publication date. Studies that are initially selected will be assessed for methodological quality using the JBI critical appraisal tool for qualitative studies. Then, findings with illustrations will be extracted for subsequent meta-aggregation and ConQual assessment. All the above steps will be conducted by 2 independent reviewers.

Review registration:

PROSPERO CRD42023410523

Introduction

As society develops, people’s lives are becoming more stressful, leading to serious mental health problems. According to the World Health Organization, 703,000 people die by suicide globally each year, and in 2019, more than 1 in every 100 deaths (1.3%) resulted from suicide.¹ As such, suicide prevention is an urgent but complex issue. The most basic approach to suicide prevention is mental health support, including psychotherapy, counseling, and medication, which are provided by mental health practitioners (MHPs).²

MHPs provide various forms of support, assessment, diagnosis, treatment, and interventions to individuals experiencing mental health challenges or disorders.³ These job titles and specialties can vary by country or area. However, MHPs must be qualified in the mental health field, encompassing a wide range of professionals with different levels of training and expertise. These include psychologists, counselors, clinicians, therapists, clinical social workers, psychiatrists, and psychiatric nurses. All of these professionals play a critical role in addressing psychological issues and promoting mental well-being.

The most common mental health problems among clients of MHPs include depression, post-traumatic stress disorder, anxiety, obsessive-compulsive disorders, personality disorders, schizophrenia, and substance abuse. All these clients are at high risk of suicidal thoughts, suicide attempts, and suicide.⁴

When MHPs take on the responsibility of preventing suicide, they put themselves at high risk of experiencing client suicide, which is considered an occupational hazard. Research shows the overall contact rates with mental health services in the year before suicide average 32%.⁵ Alongside this, 22% of psychologists and 51% of psychiatrists have experienced at least 1 client suicide over their career.⁶

Although MHPs are aware of this risk, they are still taken by surprise when a client dies by suicide, finding it hard to believe. Chemtob et al.⁷ found that 57% of psychiatrists and 49% of psychologists whose clients died by suicide experienced post-traumatic stress symptoms that were comparable to those experienced by clients who had recently lost a parent through natural causes. The shock of a client’s suicide can evoke emotions in MHPs such as frustration, guilt, helplessness, anger, sadness, and social withdrawal.^8–10 The emotional impact begins at some point after the client’s suicide and can last for weeks or even years.¹⁰ In addition to this emotional trauma, MHPs experience significant changes in their professional practice. A client’s suicide may lead to feelings of incompetence, professional isolation, hypersensitivity to suicidal cues, fear of litigation, stigmatization, and burnout.^11,12 For some MHPs, this impact may change the way they practice in the long term.¹³

Gulfi et al.¹⁴ found that the nature and intensity of the impact of client suicide may vary depending on the MHPs’ characteristics, their relationship with the client, and the institutional setting in which they practice. The MHPs’ reaction to client suicide also depends on whether they receive support from family, peers, and institutions, as well as understanding from the bereaved families. It has been reported that many MHPs do not receive adequate support after client suicide, especially professional help provided by the institution in which they work, such as supervision, peer debriefing, and psychological treatment.¹⁵ Sometimes, MHPs are blamed or even sued by the surviving families, making them disillusioned with their work or even quit the profession altogether.¹⁶

Although there is some understanding of the experiences of MHPs after client suicide, this understanding is based on scattered evidence from primary studies. More robust research is needed in this area, which is why we propose to conduct a systematic review. Overall, experiencing a client’s suicide may seem inevitable yet unpredictable in the career of an MHP. An inadequate response to such incidents is likely to have serious implications for MHPs, and appropriate support is necessary. To help MHPs better cope in such circumstances and to improve their mental health practice, it is crucial to comprehensively understand the experiences of MHPs after client suicide, preferably through the synthesis of qualitative evidence.

This systematic review will focus on the experiences of licensed MHPs following the suicide of a client, which is one of the most common and most impactful occupational hazard for MHPs. The experiences of trainee MHPs will be excluded in this review because they differ significantly from formal MHPs in terms of work experience, professional self-efficacy, and responsibility to clients.¹⁷ The exclusion of MHPs who had terminated the therapeutic relationship prior to their clients’ suicide is due to their relative emotional distance from the client and their relative lack of responsibility for the suicide compared with MHPs who were still in the therapeutic relationship.¹⁰ The phenomenon of suicide attempts by clients will also be excluded, as this has a very different impact on MHPs compared with actual suicide.

A preliminary search of Epistemonikos, PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted. No current or in-progress systematic reviews were found specifically exploring the experiences of MHPs following client suicide, and how this may cause personal and/or professional changes in the short and long term. Currently, only reviews not directly focused on this topic are available, including a scoping review mapping post-intervention programs for MHPs following client suicide, a systematic review on post-intervention programs for MHPs after client suicide, and 2 other systematic reviews that included only medical doctors and nurses or trainees.^18–21 In addition, a qualitative research synthesis was found on the experiences of practitioners in health, education, or social care roles following a death by suicide. However, the population inclusion criteria were too broad, and included teachers in schools and other participants who were not licensed MHPs.²² Preliminary searches have shown that there is enough primary qualitative research from different countries and areas to warrant the proposed systematic review.

Review question

What are the experiences of MHPs after clients’ suicide?

Inclusion criteria

Participants

This review will consider studies that include MHPs whose clients have died by suicide. The MHPs may include psychotherapists, psychiatrists, psychological counselors, clinical psychologists, psychiatric mental health nurse practitioners, social workers, and other practitioners who work in the mental health field with a professional license. MHPs with any professional experience, cultural background, or language will be considered. The MHPs must have been in a therapeutic relationship with the client prior to the suicide. Any non-MHPs (physical therapists, rehabilitation trainers, teachers, etc.), unlicensed MHPs (interns or trainees), or any MHPs who have terminated the therapeutic relationship with the client before the client died by suicide will be excluded.

Phenomena of interest

This review will consider studies that explore the experiences of MHPs whose clients have died by suicide. These experiences will encompass the MHPs’ perceptions of the changes and adaptations in their personal and professional lives as a result of the client’s suicide. The experiences may be either short or long term, but they must be closely connected to the client’s suicide, including emotional responses, coping strategies, shifts in social relationships, and reflections on their professional practice.

Client suicide will be defined as and limited to fatal self-injurious acts with some evidence of intent to die, regardless of the length of time the client had been treated by the practitioner, whether the client had other therapists, and how many other types of therapy the client had received. Suicide attempts, preparatory acts toward imminent suicidal behavior, suicidal ideation, self-injurious behavior, or non-suicide deaths will be excluded.

This review will include studies involving the experiences of both licensed and intern MHPs together after clients’ suicide; however, it will only utilize the data provided by the former. Studies that explore the experiences of relatives, friends, and mental health providers of a suicidal person will be included only if the results of the different respondents are reported separately.

Context

The context will be any inpatient, outpatient, or community setting in which mental health care occurs. The review will consider studies from any demographic context, with no cultural, regional, religious, or gender restrictions.

Types of studies

This review will consider qualitative studies including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, and feminist research. It will also include qualitative descriptive studies with qualitative methods, such as interviews, focus groups, or open-ended questionnaires. Studies with mixed method designs will be included, but only the qualitative data will be used. Qualitative answers from open-ended questionnaires in quantitative studies will also be included.

Methods

The proposed review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence and will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.^23,24 The review title has been registered with PROSPERO (CRD42023410523).

Search strategy

An initial limited search of PubMed and CINAHL was undertaken to identify articles on the topic. The words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a full search strategy in English for PubMed (see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. For databases in languages other than English, searches will be conducted in the corresponding language; key terms used in the searches will be translated independently by 2 reviewers, and any inconsistencies will be resolved through discussion or by a third reviewer. The reference lists of all studies selected for critical appraisal will be screened for additional studies. There will be no language or publication date limits for the search phase.

The databases to be searched will include PubMed, CINAHL (EBSCOhost), Embase, PsycINFO (EBSCOhost), SocINDEX (EBSCOhost), and Web of Science Core Collection. Mainstream Chinese databases, including China National Knowledge Infrastructure (CNKI), Wanfang, and VIP, will be searched for relevant studies in Chinese. Bibliographia Medica Čechoslovaca (Czech National Medical Library) will be searched for Czech and Slovak studies, and Bibliographia Medica Slovaca for Slovak studies. Sources of unpublished studies and gray literature will be searched via Google Scholar (first 100 results) and ProQuest Dissertations and Theses (ProQuest).

Study selection

Following the search, all identified citations will be collated and uploaded into Rayyan (Qatar Computing Research Institute, Doha, Qatar), and duplicates will be removed. Studies published in languages other than English, Czech/Slovak, and Chinese will be excluded due to the reviewers’ language limits. All data in Czech, Slovak, and Chinese will be translated into English; the original data and corresponding English translations will be reported in a table. Following a pilot test, titles and abstracts will be screened by 2 independent reviewers against the inclusion criteria. Potentially relevant studies will be retrieved in full, and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).²⁵ The full text of selected citations will be assessed in detail against the inclusion criteria by 2 independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion or with a third reviewer. The search results will be reported in full in the final systematic review and presented in a PRISMA flow diagram.²⁴

Assessment of methodological quality

Eligible studies will be critically appraised by 2 independent reviewers for methodological quality using the standard JBI critical appraisal checklist for qualitative research.²³ Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. All studies that have been critically appraised will be included in the systematic review. The results of critical appraisal will be reported in narrative format and in a table.

Data extraction

Data will be extracted by 2 independent reviewers using the standardized JBI data extraction tool. The extracted data will include specific details about the population, context, culture, geographical location, study methods, and phenomenon of interest relevant to the review objective. Findings of the authors’ analytic interpretation—usually themes or sub-themes—will be extracted verbatim. Accompanying illustrations will also be extracted verbatim, either as a participant voice or fieldwork observations from the same text. Subsequently, the levels of credibility of the findings and illustrations will be allocated based on the reviewers’ perception of the degree of support that each illustration offers for the specific finding it is associated with.²³ Two reviewers will independently rate the credibility using 3 levels: “unequivocal,” where findings are supported by an illustration that is beyond reasonable doubt and not open to challenge; “credible,” where findings are accompanied by an illustration lacking clear association, and therefore open to challenge; and “not supported,” where findings lack support from the data.

Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The entire process will be conducted using JBI SUMARI software.²⁵ All data in Czech/Slovak and Chinese will be translated into English; the original data and corresponding English translations will be reported in a table. Authors of papers will be contacted up to 3 times over 6 weeks to request missing or additional data, where required.

Data synthesis

The qualitative research findings will, where possible, be pooled using JBI SUMARI and the meta-aggregation approach.^23,25 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation through assembling the findings and categorizing these findings based on similarity in meaning. These categories will then be subjected to a synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative format. Only unequivocal and credible findings will be included in the synthesis; however, we will report the main characteristics and main findings of the “not supported” level of credibility in the related appendices.

Assessing confidence in the findings

The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.²⁶ The Summary of Findings will include the major elements of the review and detail how the ConQual score was developed. It will also include information about the title, population, phenomenon of interest, and context of the review. Each synthesized finding from the review will then be presented, along with the type of research informing it, the score for dependability and credibility, and the overall ConQual score.

Funding

This study was funded by the IGA project. Project title: Psychoterapie a umělecké terapie—syntéza vědeckých důkazů z kvantitativních i kvalitativních studií (Psychotherapy and arts therapies—synthesis of scientific evidence from quantitative and qualitative studies). Project number: IGA_PdF_2023_024. The funder will have no input into the conduct or reporting of the review.

Declarations

JD and JL are junior psychotherapists who have not experienced a client’s suicide and have not worked for any mental health institution.

Author contributions

JD and JL conceived the study and wrote the manuscript in consultation with JK. JK was involved in planning the work and revising the manuscript. NK provided critical feedback and helped shape the manuscript. ZS developed the search strategy and refined the inclusion criteria. ZM supervised the project.

Appendix I: Search strategy

PubMed

Search conducted: May 14, 2024

1. “psychotherapists” [MeSH] OR psychotherapist* [TIAB] OR “psychiatrists” [MeSH] OR psychiatrist* [TIAB] OR “mental health practitioner*” [TIAB] OR “mental health professional*” [TIAB] OR “mental health personnel*” [TIAB] OR “clinical psychologist*” [TIAB] OR “social worker*” [TIAB] OR “psychological counselor*” [TIAB] OR “psychological consultant*” [TIAB] OR “PMHNP*” [TIAB] OR “psychiatric nurs*” [TIAB] OR “mental health nurs*” [TIAB] OR MHP [TIAB] OR “mental health counselor*” [TIAB] OR “psychiatric mental health clinical nurs* specialist*” [TIAB] OR “mental health consultant*” [TIAB] (65,822)

2. “suicide” [MeSH] OR suicid* [TIAB] (122,343)

3. client* [TIAB] OR patient* [TIAB] OR customer* [TIAB] (8774565)

4. “life change events” [MeSH] OR “qualitative research” [MeSH] OR “qualitative” [TIAB] OR experienc* [TIAB] OR “mixed method*” [TIAB] OR feel* [TIAB] OR react* [TIAB] OR need* [TIAB] OR cope* [TIAB] OR coping* [TIAB] OR adapt* [TIAB] OR chang* [TIAB] OR respon* [TIAB] OR reflec* [TIAB] OR affect* [TIAB] OR support* [TIAB] OR shift* [TIAB] OR trans* [TIAB] (18,248,180)

5. #1 AND #2 AND #3 AND #4 (1516)