Navigating the ripple effects of suicide

For decades, researchers and clinicians widely cited a figure suggesting that every suicide death leaves behind roughly six survivors, an estimate often traced to pioneering suicidologist Edwin Shneidman but that predated any empirical basis. In 2018, Julie Cerel, PhD, and her team at the University of Kentucky’s Suicide Prevention and Exposure Lab published a landmark epidemiological study demonstrating that a single suicide impacts approximately 135 individuals, a finding that changed the field’s understanding of how many people are exposed to a death by suicide each year.

That work prompted Cerel to shift her research focus from bereavement to suicide exposure, to better serve and capture the full population of people affected by suicide. “We found that knowing someone, especially being close to someone who has died by suicide, becomes a risk factor for a person’s own mental health behaviors and future suicidal ideation,” she said. “We proposed the idea that suicide survivorship exists on a continuum. There is a handful of people—mostly family, close friends, or clinicians—who are profoundly influenced and identify as survivors for the rest of their lives.”

Cerel talks about the need for a broader approach to suicide prevention, intervention, and postvention in reducing people’s risk for suicide, talking with patients about exposure to others suicide, and providing the kind of support clinicians need if they lose a patient to suicide.

About 10 years ago, when I was president of the American Association of Suicidology, I realized we were failing to do prevention in a way that helps people long before they become suicidal. I came up with an idea for a universal preventative intervention, called code red, where everyone, not just those already known to be at risk of suicide, engages in preparedness, centered on the philosophy of planning long before someone has their “worst day.” We need to integrate this type of prevention upstream so that people understand that while a suicidal crisis won’t strike everyone, we must be prepared for a mental health crisis the way we ask everyone to be prepared for a fire, a tornado, or a natural disaster.

This is a universal approach meant for everyone, even those with no history of mental illness or past attempts. It involves training facilitators to work in group settings—like schools, workplaces, and youth organizations where it has been piloted—to help individuals map out who they will talk to, what distractions relax them, and establish that if these strategies fail, the 988 Lifeline is always there. These plans cannot be static; they must be actively updated as people’s lives change and evolve. Talking about suicide in this context doesn’t create more risk. Rather, avoidance is the real risk. People hesitate to ask about suicide because they fear “planting the idea,” but that hesitation prevents intervention.

Many states pass unfunded mandates requiring a certain number of hours of suicide prevention training for teachers or clinicians, but the programs that are most effective can be expensive, and there still isn’t enough research on them.

In terms of best practices, I recommend clinicians pursue training in established, evidence-based intervention models like cams (collaborative assessment and management of suicidality), DBT (dialectical behavior therapy), or cognitive behavioral therapy. I highly recommend cams because it is accessible and teaches clinicians how to work collaboratively with a patient in crisis, rather than immediately jumping into a defensive risk-management mindset where the automatic first choice is hospitalization.

We know that the highest risk period for suicide is often immediately following an inpatient admission. People are often terrified to admit they are experiencing suicidal thoughts to clinicians or crisis lines because they fear an armed officer will show up at their door or they will be hospitalized against their will, causing them to lose their autonomy. There needs to be more alternatives to traditional emergency departments, such as psychiatric emergency “EmPATH” (emergency psychiatric assessment, treatment, and healing) units, where patients can have downtime without having their clothes, shoes, or devices taken away, allowing space for clinicians to use motivational interviewing and cams.

Clinically, we don’t always know ahead of time where people who have lost a loved one are going to fall on the survivorship continuum. So, clinicians must explicitly ask their patients about exposure to suicide and treat it as a significant risk factor among many others. Historically, when people have gone to a health care provider, they checked a box for a “family history” of suicide. What we now know is that family history alone doesn’t capture the whole risk; the question really needs to be: “Have you been close to someone that has died by suicide?”

When a patient answers yes, clinicians must query further to understand how that loss contributes to current symptoms. Is that death something that plays into their mind constantly, or have they started viewing suicide as a viable coping mechanism because they lost someone they care about? A veteran once told me, “I never really thought about suicide, and then he did it. And I thought, if he couldn’t handle his problems, how could I possibly handle mine?” That kind of identification—with a celebrity, a peer, a family member—comes up repeatedly, and clinicians need to be looking for it.

Practicing professionals need to be prepared for the reality that, regardless of your setting, you will encounter suicidal patients, and despite your very best efforts, you might lose a patient to suicide. Most clinicians receive no training in graduate school on how to navigate these losses.

Worse, institutional systems often respond by sending clinicians to morbidity and mortality conferences, which are recurring meetings held by medical centers to identify adverse outcomes and modify behavior, that hyperfocus on blame and what the clinician did wrong. This process can induce intense guilt and has been known to drive skilled professionals to leave the field entirely. The fear of losing someone can scare clinicians into adopting overly restrictive practices—the moment they hear the word “suicide,” they panic and hospitalize the patient instead of treating them. Clinicians need to understand that they are not alone, and workplaces and supervisors must proactively establish postvention plans before a loss occurs.

And organizations need to offer blame-free consultations, ensure proper legal documentation protocols are understood, and allow clinicians to take time off or ramp their caseloads back up slowly. Just as we use universal safety planning for patients, we need to implement a plan for postvention for clinicians so they know who to contact and how to preserve their own resilience in the face of a professional tragedy.