journal article
LitStream Collection
Scoping Review of Postvention for Mental Health Providers Following Patient Suicide
Daly, Kelly A; Segura, Anna; Heyman, Richard E; Aladia, Salomi; Slep, Amy M. Smith
2023 Military Medicine
doi: 10.1093/milmed/usac433pmid: 36661225
ABSTRACT Introduction As suicides among military personnel continue to climb, we sought to determine best practices for supporting military mental health clinicians following patient suicide loss (i.e., postvention). Materials and Methods We conducted a scoping review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Our initial search of academic databases generated 2,374 studies, of which 122 were included in our final review. We categorized postvention recommendations based on the socioecological model (i.e., recommendations at the individual provider, supervisory/managerial, organizational, and discipline levels) and analyzed them using a narrative synthesizing approach. Results Extracted recommendations (N = 358) comprised those at the provider (n = 94), supervisory/managerial (n = 90), organization (n = 105), and discipline (n = 69) levels. Conclusions The literature converges on the need for formal postvention protocols that prioritize (1) training and education and (2) emotional and instrumental support for the clinician. Based on the scoped literature, we propose a simple postvention model for military mental health clinicians and recommend a controlled trial testing of its effectiveness. Despite over two decades of U.S. DoD–sponsored prevention initiatives,1 the annual rate of suicide among military personnel continues to climb.2 In 2020, 580 service members (SMs) died by suicide (a rate of 28.7 per 100,000, compared with a civilian rate of 13.5 per 100,000) representing an increase of 41.4% from 2015.3,4 Because of this alarming increase, there are DoD-endorsed interventions for commanders, unit members, friends, and family members impacted by an SM’s suicide (i.e., postvention).5 Notably, absent from these protocols is the provision of support for the SM’s treating mental health (MH) clinician.5–7 The occupational stressors for MH treatment providers are well established (e.g., isolation and vicarious trauma). Military clinicians’ experiences are compounded by role strain. Military MH clinicians must maintain their own readiness while serving both their patients (providing the best possible care) and the U.S. government (acting in the military’s best interest), duties that often compete. Navigating this requires frequent negotiation between the ethics and practices of psychology and of military service, an inevitable setup for moral injury when something goes wrong. Having a patient die by suicide profoundly impacts MH clinicians, personally and professionally.8–10 Across studies, clinicians have reported shock, horror, sadness, distress, guilt, and shame upon learning of a patient’s death.7,11–13 Indeed, in the immediate aftermath of a suicide, providers’ reactions are often akin to those of the deceased individual’s loved ones.14 Symptoms of post-traumatic stress disorder (PTSD) and depression are not uncommon,15–18 with one-third of clinicians still experiencing severe distress 1 year later.19 Although suicide has been described in the literature as an “occupational hazard”20–22 for MH professionals, in practice it is handled as an aberration.23 As such, following suicide clinicians report (1) feelings of responsibility, failure, loneliness, isolation, and perceived stigma and (2) having their competence questioned and fearing colleagues’ assumptions of negligence.8,24–29 In addition, clinician burnout is extremely common30 and approximately one-third consider leaving the field.31 Even among the most resilient clinicians, changes in practice (e.g., increased time devoted to undue risk assessment rather than treatment; overly lengthy, litigation-minded record keeping; and over-hospitalization) are widespread and often enduring.11,19,21 In institutional settings, clinicians’ treatment decisions, via case files, are customarily subject to a thorough review following patient suicide.32–34 Although the manifest purpose of such reviews is to generate “lessons learned” and improve ongoing patient care, clinicians often experience them as unhelpful and blaming.35 In the U.S. military, clinicians undergo a particularly intense standard-of-care review process to make a wrongdoing determination.36,37 This lengthy process has been described as unduly punitive and a significant source of fear by military clinicians.6,37,38 Moreover, research suggests that in the wake of patient suicide, a substantial portion of Air Force Medical Service clinicians feel unsupported by their units, leadership, and the MH community.6,38 In contrast, a nascent line of research has demonstrated that effectively coping with a patient’s suicide can lead to post-traumatic growth and positive changes in professional practice, including the pursuit of advanced training and treatment specialization in suicidality.25,31,39 Thus, both positive and negative outcomes are possible for clinicians after the loss of a patient to suicide. CURRENT STUDY In 1968, Edwin Shneidman coined the term “postvention” to highlight preventative interventions that can be conducted with survivors following patient suicide.9 Because of the difficulty of testing clinician postvention recommendations, there have been almost no efficacy trials. Given military health systems’ size and interest in maintaining readiness in clinicians as force protection agents, military systems would be ideal settings to test whether clinician postvention works. Thus, in this scoping review, we sought to (1) systematically identify the most promising postvention targets (i.e., practices to minimize long-term negative repercussions of patient suicide and maximize the potential for post-traumatic growth) that could be tailored to military MH settings and (2) organize them within a socioecological framework40 (i.e., clinician, supervisor, organization, and discipline). Taking a parsimonious approach, we were most interested in recommendations with the potential to simultaneously mitigate multiple adverse outcomes (e.g., PTSD, depression, burnout, and leaving the field) and promote growth among military clinicians. METHOD The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews protocol can be found in Online Supplement S1. Inclusion and Exclusion Criteria Inclusion criteria were (1) publication in English or Spanish, (2) published between January 1992 and February 2022, and (3) focused on (a) the impact/effect of patient suicide on a clinician or (b) recommendations or approaches to support providers after patient suicide. We considered studies using quantitative and qualitative methodology, as well as case reports, case series, cross-sectional, prospective, and interventional studies, clinical trials, dissertations, book or book chapters, commentaries, previous systematic or literature reviews, and editorials for inclusion. Exclusion criteria were (1) focused solely on the impact/effect of patient suicide on health care workers, without explicitly identifying needs that could be addressed, and (2) postvention for family members, peers, or friends. Article Selection Process The review protocol followed the PRISMA guidelines. The search was conducted by two Ph.D.-level authors (K.A.D. and A.S.) in January and February 2022. Three teams of at least two researchers reviewed selected articles based on the protocol. The first team independently screened titles and abstracts, indicating exclusion or possible inclusion. Then, researchers from the second team independently assessed the full text of the possible inclusion articles for eligibility. If researchers from either the first or second team disagreed about inclusion, we reached an agreement through consensus by two PhD-level coauthors. Data Extraction Five study characteristics were extracted: (1) authors and year of publication; (2) publication type (i.e., quantitative, qualitative or mixed-methods study, review, conceptual paper, theses/dissertation, book chapter, and case study); (3) sample characteristics (i.e., n, military or nonmilitary, country, and type of health care provider); (4) identified needs or types of support targeting health care providers after patient’s suicide (e.g., program, suggestion/recommendation, protocols, and training); and (5) postvention recommendations’ socioecological level (i.e., individual, supervisory, organization, and discipline). Data Synthesis and Analysis Extracted data were processed via broad, thematic qualitative analysis across socioecological levels and then summarized using a narrative descriptive synthesizing approach.41 We did not consider article bias or research rigor. RESULTS As shown in the PRISMA flowchart (Fig. 1), the initial search produced 2,374 articles for abstract review, 2,183 of which were excluded after screening. After reviewing the full text of the remaining 191 articles, 122 studies were included (see Tables I and Supplementary Table S1). Almost all of the 122 articles were in English (98.4%); three-fourths were published in the last 15 years. Most were empirical (quantitative [21.3%], qualitative [15.6%], and mixed-methods [15.6%]); 21.3% were reviews, and 12.3% were conceptual. Empirical studies sampled MH clinicians (e.g., psychologists, psychiatrists, counselors, and social workers; 63.6%, n = 56, including four with military providers), medical staff (i.e., nurses and physicians; 19.3%, n = 17), and MH residents/trainees (17.0%, n = 15). FIGURE 1. Open in new tabDownload slide PRISMA flowchart diagram for the scoping review process. TABLE I. Characteristics of the Included Studies (N = 122) . % . n . Year of study publication 1992-2007 26.2 32 2008-2022 73.8 90 Type of publication Quantitative study (n rangea = 22-713) 21.3 26 Qualitative study (n range = 4-103) 15.6 19 Mixed-methods study (n range = 25-515) 15.6 19 Narrative review 15.6 19 Conceptual paper (including postvention guidelines) 12.3 15 Case studies 6.6 8 Systematic review (n range = 10-58) 5.7 7 Personal narrative 5.7 7 Other (i.e., editorial and conference report) 1.6 2 Language of the study English 98.4 120 Spanish 1.6 2 . % . n . Year of study publication 1992-2007 26.2 32 2008-2022 73.8 90 Type of publication Quantitative study (n rangea = 22-713) 21.3 26 Qualitative study (n range = 4-103) 15.6 19 Mixed-methods study (n range = 25-515) 15.6 19 Narrative review 15.6 19 Conceptual paper (including postvention guidelines) 12.3 15 Case studies 6.6 8 Systematic review (n range = 10-58) 5.7 7 Personal narrative 5.7 7 Other (i.e., editorial and conference report) 1.6 2 Language of the study English 98.4 120 Spanish 1.6 2 Note. Percentages for the type of contribution sum more than 100% because of one study being both a systematic review and a mixed-methods study. a n range shows the minimum and maximum number of health professionals who experienced a patient/client’s suicide or received the implementation of a postvention training program for quantitative, qualitative, or mixed-methods studies. For the systematic review category, n range represents the minimum and maximum number of articles included. Open in new tab TABLE I. Characteristics of the Included Studies (N = 122) . % . n . Year of study publication 1992-2007 26.2 32 2008-2022 73.8 90 Type of publication Quantitative study (n rangea = 22-713) 21.3 26 Qualitative study (n range = 4-103) 15.6 19 Mixed-methods study (n range = 25-515) 15.6 19 Narrative review 15.6 19 Conceptual paper (including postvention guidelines) 12.3 15 Case studies 6.6 8 Systematic review (n range = 10-58) 5.7 7 Personal narrative 5.7 7 Other (i.e., editorial and conference report) 1.6 2 Language of the study English 98.4 120 Spanish 1.6 2 . % . n . Year of study publication 1992-2007 26.2 32 2008-2022 73.8 90 Type of publication Quantitative study (n rangea = 22-713) 21.3 26 Qualitative study (n range = 4-103) 15.6 19 Mixed-methods study (n range = 25-515) 15.6 19 Narrative review 15.6 19 Conceptual paper (including postvention guidelines) 12.3 15 Case studies 6.6 8 Systematic review (n range = 10-58) 5.7 7 Personal narrative 5.7 7 Other (i.e., editorial and conference report) 1.6 2 Language of the study English 98.4 120 Spanish 1.6 2 Note. Percentages for the type of contribution sum more than 100% because of one study being both a systematic review and a mixed-methods study. a n range shows the minimum and maximum number of health professionals who experienced a patient/client’s suicide or received the implementation of a postvention training program for quantitative, qualitative, or mixed-methods studies. For the systematic review category, n range represents the minimum and maximum number of articles included. Open in new tab Postvention Recommendations Extracted recommendations (N = 358) were at the provider (n = 94), supervisory/managerial (n = 90), organization (n = 105), and discipline (n = 69) levels. Supplementary Table S2 and Figure 2 summarize the recommendations; Online Supplement S2 provides comprehensive descriptions. FIGURE 2. Open in new tabDownload slide Postvention socioecological model. At the individual provider level, recommendations targeted relational support (n = 69), self-care (n = 35), preparation for the possibility of a patient’s suicide (n = 35), acknowledgment of the deceased patient’s life (n = 26), and practical elements (n = 19). At the supervisory/managerial level, recommendations focused on the supervisor–supervisee dyad (n = 87) and supervisor actions on behalf of the organization (n = 27). At the organizational level, recommendations were directed at the development of a comprehensive postvention protocol (n = 101), the creation of a workplace culture of openness and non-judgment regarding patient suicide (n = 25), and the review of investigatory processes (n = 8). Finally, at the discipline level, recommendations were aimed at suicide education and postvention implementation (n = 38), future research (n = 34), and cultural shifts (n = 15). DISCUSSION The primary purpose of clinician postvention is to mitigate adverse outcomes and bolster growth among clinician survivors. The secondary purpose is the prevention of future patient suicide loss.42,43 Commensurate with the breadth and depth of personal and professional impacts of patient suicide, concrete recommendations toward these aims have been made at all levels of the socioecological model. (Although all services have basic postvention guidelines,44–47 they are not comprehensive, focusing largely on supporting those close to suicide completers other than the clinician.) Postvention recommendations include articulated steps for both pre- and post-patient suicide loss across discipline, organizational, supervisory, and individual provider levels. We summarize these here, but because of space limitations, the specific recommendations with citations are included only in Supplementary Table S2. Discipline-wide calls for increased suicide-related training and education for MH clinicians (of all professions) at all career stages are common. Across the literature, the authors impel the MH care discipline toward a cultural shift in the way patient suicide is handled. This is operationalized via recommendations to cultivate open noncritical atmospheres around patient suicide and revise case review procedures at the organization level; foster safe environments for communication and disclose one’s own experiences of patient suicide at the supervisory level; and universal preparedness for patient suicide at the provider level. Discipline-level proposals to make clinician postvention standard practice are reflected in recommendations for the development of tailored postvention protocols, with specific roles for staff, at the organizational level; the responsibilities of supervisors to clinician survivors (e.g., extra supervision and caseload accommodations) and in carrying out their organizations’ protocols (e.g., informing all staff of the patient death) at the supervisory level; and practical elements (e.g., consultation with an attorney and update patient record) at the provider level. The individualized nature of effective postvention is widely acknowledged. At the discipline level, this is evident in suggestions that future research identifies subpopulations of clinicians who may be more vulnerable to adverse outcomes and for calls to recognize providers as survivors. The concept of individualizing postvention is reflected through recommendations for (1) at the organization level: flexible work accommodations; (2) at the supervisory level: a menu of potential support recommendations (with advice for case-by-case use); and (3) at the MH professional level: self-care, engaging personal support networks, and finding meaning in the loss. Overall, the scoped literature converges to advocate that organizations develop formalized postvention protocols with pre- and post-incident components that (1) facilitate clinicians’ training and education about suicide and (2) provide individualized emotional and instrumental support for the clinician survivor. Although the postvention recommendations are sensible, the necessity for empirical testing for both positive and iatrogenic outcomes is needed before their widespread dissemination. As a cautionary parallel, the also eminently sensible Critical Incident Stress Debriefing48 was widely disseminated to help first responders cope with trauma by immediately sharing and processing their experiences in groups. However, rigorous testing documented that rather than promote coping, Critical Incident Stress Debriefing often increased adverse effects (e.g., risk for PTSD).49,50 With that caution in mind, we selected among the simplest recommendations appropriate to be adopted in a military MH context. We prioritized recommendations from the reviewed literature that we believed (1) could simultaneously improve multiple outcomes (e.g., decreasing burnout professional inefficacy and depression and increasing post-traumatic growth) among MH clinicians, (2) could be implemented with relatively little investment, and (3) readily lent themselves to empirical testing. Recommendations for Military Clinician Postvention Distilling the scoped literature’s recommendations, we propose a two-phase approach to military MH clinician postvention (see Fig. 3). Phase I (universally implemented before patient suicide) consists of (1) comprehensive suicidology education and (2) each clinician developing a personalized postvention plan (see Online Supplement S3). Phase II (implemented after patient suicide) includes individual clinicians’ postvention plan activation and engagement of the dual-support model. A heuristic model (Figure 3) that includes (1) proximal and distal outcomes of clinician suicide loss and (2) proposed moderators (i.e., hypothesized positive impacts of prevention) that could buffer the impacts of patient suicide—should be systematically tested in a randomized controlled trial of military clinician postvention. FIGURE 3. Open in new tabDownload slide Proposed model of USAF clinician Postvention. Suicidology Education (Prevention Phase) Military suicide researcher and USAF veteran Dr. Craig Bryan51 asserts that (almost) everything we think about suicide is wrong, such as the relationship between mental illness and risk and the ubiquity of warning signs. Indeed, the most rigorous computational models of suicide completion (assessed across 14 million individuals) have positive predictive values (PPV) of <0.01.52 Meta-analyses of instruments available to clinicians for risk assessment produced a pooled PPV of 5.5% for suicide; when analyses were restricted to psychological instruments alone, the pooled PPV was 3.7%.53 Even with the best available tools (including purely computational simulation), science’s ability to predict an individual patient’s suicide is close to 0.52,54 This is the humbling, little-acknowledged reality of clinical practice. Military services need to acknowledge that suicide will never be eradicated. Efforts to reduce suicide risk are necessary; however, “zero suicide” campaigns are aspirational, unfulfillable, and may backfire when they misleadingly imply that all suicide is preventable and that someone (often a clinician) should be blamed if one does occur. The illusionary expectation of predictability is only reified by the standard-of-care review process, during which clinicians are faulted for failing to foresee what research has repeatedly found to be unforeseeable. A common theme across the postvention literature is the need for universal information regarding the ubiquity of patient suicide.7,17,55,56 Conservative estimates suggest that half of psychiatrists, one-fourth of psychologists, and one-fifth of social workers will have a patient die by suicide.29,30 Thus, all military MH clinicians should receive annual comprehensive suicidology education30,57–59 comprising (1) the nature of suicide (e.g., function of access/means, impulsivity, weak correlation between mental illness and suicide, and lack of orthogonal risk factors)51,60–63; (2) the potential and limitations of treatment (e.g., poor predictive utility of existing risk assessment measures, degree of control a provider has over patient behavior, individualized nature of effective prevention measures, and evidence base for the treatments that reduce suicide in military settings)8,11,51,64,65; and (3) common clinician impacts following patient suicide (e.g., likely personal and professional reactions, litigious and punitive experiences, case review process specifics, and typical reactions from colleagues).57,66–68 Finally, Bryan51 calls for all military MH clinicians to be trained in (1) Brief Cognitive Behavioral Therapy for Suicide Prevention and (2) knowledge of means safety (voluntary limitation of access to lethal objects [e.g., firearms and medications]). In summary, military clinicians should be educated on the best available interventions and their limitations (Fig. 3). Clearly, comprehensive suicidology education is needed by the entire MH care discipline—military and civilian—and was one of the top recommendations in a nationally representative sample of MH clinicians who have experienced patient suicide.68 It would function as informed consent regarding a critical on-the-job risk and how to mitigate the risk of (but never fully prevent) both patient suicide and its fallout. Suicidology can borrow from associated areas; for example, informing individuals of probable responses to disaster trauma has been found to be among the most effective buffers against prolonged adverse effects.69 Thus, clinicians learning about the limitations of predicting and preventing suicide can help dispel their self-perceptions of, and review boards’ expectations of, omnipotence,30,70 and buffer against burnout (i.e., emotional exhaustion and professional inefficacy) and self-blame.71,72 Patient suicide has been described as the most isolating event that can happen to clinicians,73 as discussions with colleagues about patient suicide remain taboo66 and fraught with perceived admissions of guilt for negligence.74 At an organizational level, the literature’s recommendations implicitly hypothesize that grounding clinicians in the realities of science and practice can improve the handling of suicide within clinics (e.g., reducing clinician survivors’ self-stigma and colleagues’ stigma [real and perceived]), organizations’ policies, and, if implemented broadly and continually, the discipline itself. Individual Postvention Plan (Developed in Prevention Phase, Implemented in Postvention Phase) Postvention involves universal prevention efforts for clinicians before a suicide and post-suicide mitigation efforts. Thus, several authors7,13,75,76 have recommended individual postvention plans be developed before, and activated following, a patient’s suicide. Indeed, there is some evidence to suggest that clinicians who never anticipate their own reactions to patient suicide suffer more pronounced negative effects.67,77 Creation of individualized plans requires clinicians to be knowledgeable about patient suicide and its consequences and to devise how to employ their personal resources (e.g., support systems and self-care strategies).13,75,76 Paradoxically, although 97% of practicing MH clinicians rate patient suicide as their greatest fear,73 individual preparation is rare.76 Postvention plans are hypothesized as necessary to prepare providers to enact the steps needed to take care of themselves (personally and professionally) and decrease anxiety associated with having to make quick decisions following patient suicide.75 Although used rarely with clinicians themselves, the skill of mentally preparing for crisis (during which emotions overwhelm one’s ability to engage in the best course of action) is widely used in MH treatment. One example is “Cope Ahead,” (i.e., psychological rehearsal to build mastery in the face of crisis), a core skill imparted in Dialectical Behavior Therapy,78 among the treatments with the strongest evidence base for reducing suicide.79 Another example, akin to individual postvention plans, is safety plans used with victims of intimate partner violence and suicidal patients (e.g., Victim Inventory of Goals, Options, and Risks80,81). Safety planning presents an opportunity for the individual to be given psychoeducation (e.g., common triggers and typical duration of a suicidal impulse) about the phenomena (e.g., suicidality) and strategizes personalized coping responses to effectively protect against negative impacts of future crisis events.82–84 Ultimately such plans enhance individuals’ sense of self-efficacy.82 A final example comprises other types of mental preparation for a crisis. Pre-disaster psychological preparedness plans (primarily for natural disasters in at-risk areas) and stress inoculation training (a preventative intervention applied for a host of issues from combat deployment to a potentially terminal diagnosis) have been shown to mitigate against developing anxiety, depression, and PTSD following crises.85–87,88 These approaches can be leveraged as models for how clinicians could develop individualized postvention plans. The scoped studies recommend that providers’ postvention plans include resources and skills that reflect individual characteristics and work settings (e.g., personal care needs and institution or private setting).7,13,75,76 Researchers recommend clinicians reevaluate postvention plans at least annually. To help MH professionals create a postvention safety plan, we have developed a checklist derived from the scoped literature’s recommendations (see Online Supplement S3). Future research should assess how the implementation of suicidology education and the creation of individual postvention plans (Fig. 3) impact the organizational culture around suicide (e.g., frequency of conversations about suicide, openness of clinicians to explore suicide-related fears, and new resources or strategies implemented within clinics). Bifurcated-Support Model (Postvention Phase) Social support (operationalized in countless distinct ways across scoped papers) is among the most frequent clinician postvention recommendations. This is unsurprising given extensive evidence of social support’s positive effects on emotional and physical health and its buffering impact on individual post-trauma adjustment across research foci.89 In some specialized MH settings (e.g., child protective services and training sites), clinicians can implement the scoped literature’s suggestions to use their supervisors for instrumental and emotional support following patient suicide. However, most civilian and military credentialed providers practice independently and do not have formal clinical supervision. In organizational settings (as opposed to private practice), there is often a clinician who is their commander or boss. Such superior–subordinate relationships are complicated because of the role conflicts inherent between being (1) a leader and (2) a more senior clinician who might provide emotional support and post-suicide review/supervision. Thus, scoped literature recommends bifurcated support (Fig. 3), with instrumental and emotional support roles handled by different people inside and outside, respectively, the clinician survivor’s chain of command. For instrumental support, MH clinic leaders have the responsibility to motivate, influence, and direct subordinates through assignments.90 Channeling combat and operational stress control,91 clinic leaders should be physically present, model resilience, and provide instrumental support (e.g., reduce administrative requirements and provide professional coverage) to see the clinician survivor through this crisis. Leaders who model resilience and future focus during crises enhance resilience in their subordinates.92,93 Furthermore, individuals who spontaneously mention their leaders as positive influences when describing how they coped with personal crises seem to be more resilient to their negative effects.94 For emotional support, a postvention clinician support program95 could be established. Following a patient suicide, the clinicians would be matched to a clinician survivor of equal or higher rank who volunteered to serve as a post-suicide guide. The guide should be outside of the clinician survivor’s chain of command and share their own experience and recovery, inform the clinician about the review process, and help the clinician prepare for and process the myriad meetings about the case. Ideally, this individual would be granted confidentiality and privilege so that both parties could communicate honestly about their thoughts and feelings, facilitating uninhibited emotional support. Open communication about patient suicide is thought to combat clinicians’ experiences of isolation and enable them to voice their recovery needs.13,96 Bifurcated support could also contribute to a cultural shift in the way MH patient suicides are treated by military services. Combined educational and contact-based (encountering impacted individuals) initiatives have reduced common stigmas (e.g., those about tuberculosis, leprosy, and mental illness) among health care workers.97 There is some suggestion that initiatives tend to be most effective when the stigmatized individual serves a role in developing and implementing the corrective program.98 By having another clinician survivor guide the supportive intervention, we hypothesize that the newly impacted clinician will experience less isolation, self-stigma, and perceived blame. Furthermore, the visibility of the program, headed by clinician survivors, may reduce stigma among clinicians generally. Finally, the creation of this support model would give volunteer guide opportunities for “giving back,” facilitating greater meaning-making of their own loss experiences. Meaning-making was both a common goal among clinician survivors in the scoped literature30,99,100 and a strong empirical predictor of post-traumatic growth.30,101 Testing the Proposed Model of Military Clinician Postvention Figure 3 provides a testable heuristic model of postvention based on the scoped literature. We hypothesize that prevention activities (i.e., suicidology education and development of an individual postvention plan) will increase confidence in social support, clinicians’ self-efficacy expectancies,102 providers’ knowledge of suicide prediction and intervention, and leaders’ knowledge about suicide prediction and intervention. These factors are hypothesized to buffer (i.e., moderate) post-suicide negative outcomes. Following a patient suicide and implementation of the clinician survivor’s postvention plan, we hypothesize the following proximal outcomes (compared with providers at sites without a comprehensive postvention program): (1) higher self-efficacy and perceived social support and (2) lower isolation, self-blame, perceived blame from others, and intention to leave the military MH system. We also hypothesize the following distal outcomes: (1) more post-traumatic growth and (2) lower depressive symptoms, PTSD symptoms, burnout, and leaving the military MH system. Limitations This scoping review has limitations, both implicit in the reviewed literature and attributable to our procedure. Most of the literature is anecdotal and based on a retrospective report103,104; even papers detailing the implementation of postvention programs lack outcome data beyond clinicians’ feelings about the procedures.33 This is not a criticism of the scoped research but a reflection of how difficult a phenomenon postvention is to study because it is triggered by low base-rate events. The scarcity of empirical research is what drove our decision to conduct a scoping review and include all types of literature (e.g., guidelines, studies, and letters to the editor) that could be informative in this area. A clear limitation is that this review coalesces recommendations from sources varying from a clinician’s lessons learned to a formalized, implemented postvention program. Finally, we may have missed some gray literature75; because the reviewed recommendations reached saturation, the likelihood of discovering important, undiscovered novel recommendations or findings is negligible. CONCLUSION Our proposed model consolidates the themes evident across the reviewed literature, including more (1) training and education and (2) support (emotional and instrumental) in forms that would be helpful to military MH clinicians. The most important contribution to this literature, however, is the identification of a need for a controlled trial of a postvention program to empirically test what mitigates adverse outcomes and facilitates clinician recovery. ACKNOWLEDGMENTS The authors would like to thank Lt. Col. Elisha Parkhill (who instigated this review) and Lt. Col. Eric Meyer for their insightful comments. We would like to acknowledge those who made initial inclusion determinations and conducted preliminary data extraction: John Shepherd, Ana Ivic, Vini Zaninovic, Samara Trindade, Huidi Yang, Sophia Palacios, George Ryan Ghorayeb, Lizbeth Morales, Steven Chen, Nancy Benhur, Evie Jin, Rachel Oakes, Maxine Heintz, Sherry Fung, Jennie Ochshorn, Adeen Izzathullah, and Danish Khalil. SUPPLEMENTARY DATA Supplementary material is available at Military Medicine online. FUNDING This activity was funded under subcontract 29700-0005, Item 3.3.1.1 to New York University; contract provided by the U.S. Air Force Medical Readiness Agency (AFMRA) to Cherokee Insights, LLC. CONFLICT OF INTEREST STATEMENT None declared. DATA AVAILABILITY All data are incorporated into this article and its online supplementary material. All data are freely accessible. CLINICAL TRIAL REGISTRATION Not applicable. INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS) Not applicable (review paper). INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC) Not applicable. INSTITUTIONAL CLEARANCE Institutional clearance approved. INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT K.A.D., A.S., and R.E.H. determined search terms, inclusion criteria, and the framework for data organization and analysis. K.A.D., A.S., and S.A. reviewed all sources and analyzed data. K.A.D., A.S., and R.E.H. drafted the manuscript, which was reviewed, edited, and shaped by A.M.S.S., who also helped determine the initial goals of the project. All authors read and approved the final manuscript. REFERENCES 1. Van Winkle EP , Orvis KA: Annual Suicide Report . Department of Defense; 2018 . Available at https://www.dspo.mil/Portals/113/2018%20DoD%20Annual%20Suicide%20Report_FINAL_25%20SEP%2019_508c.pdf; accessed August 16, 2022 . 2. U.S. Department of Defense . Department of Defense Releases Calendar Year 2019 Annual Suicide Report . Department of Defense ; 2019 . 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