Postvention FOR SUICIDE LOSS SURVIVORS DR. SAMAN YOUSUF 20 JUNE 2011.

PostventionFOR SUICIDE LOSS SURVIVORS

DR. SAMAN YOUSUF

20 JUNE 2011

What is postvention?

o Postvention refers to activities and strategies undertaken after a suicide death to reduce associated trauma

o Postvention responses aim to:• provide bereavement support

and advocacy for those affected by the suicide

• prevent further suicide events including contagion suicides and suicide clusters

Why postvention?

o Bereavement supporto Nature of bereavement different for suicideo Intentional nature of suicideo Stigma o Fear of others in family committing suicide

o Prevention of further suicideso All exposed are at increased risko Suicide clusters refer to ‘a group of suicides

or suicide attempts that occur closer together in time and space than would normally be expected in a given community’

Core principals of postvention

o “Do no harm”

o Response to needs of o INDIVIDUALo FAMILYo SCHOOLo COMMUNITYo STAKE-HOLDERS OF THE COMMUNITY

o Avoid glorification and minimize sensationalism

o Identify individuals who may be at risk of harming themselves

The Survivors

o For every life lost to suicide, 6-12 people are affected (Edwin Schneidman, 1983)

o Survivors often experience a wide range of grief reactions, including some or all of the following:

o Shock, numbness or disorientation o Trouble with concentrationo Symptoms of depressiono Anger : deceased, a family member, therapist or

selfo Relief, particularly if the suicide followed a long

and difficult mental illnesso Guilt, including thinking, “If only I had.…”

These feelings usually diminish over time

o Other reactions that may stay…

o Feelings of abandonment and rejectiono Bewildermento Loneliness and social isolationo Difficulty trusting otherso Relationships with others negatively affectedo Depressiono Heightened suicide risk

o Gender differences in coping with suicide (Davis, C and Hinger, B 2004)

o Men: getting back to routine, outside activities/sports

o Women: reading, seeking counseling or support groups and doing volunteer work

o What helps survivors in coping with the loss?

o Davis and Hinger (2004)

o Immediate support following suicideo Informal support provided most comforto Practical support was helpful – eg. helping with

funeral arrangementso Emotional support – ‘just having someone to listen’o Honest, open interactionso Support groups with other survivors of suicideo Professional therapyo Supportive school and workplace

o Unhelpful experiences

o Lack of communication from clinicians and other health professionals

o Lack of compassion and understanding

o Unrealistic expectations of process and time of grieving

o Special times of need

o Holidayso Anniversaries of the event

“…Since [my husband’s] suicide, I felt increasingly isolated from my friends and family. They had no idea what I was going through, all their well-intentioned advice and words of comfort seemed ignorant at best and tinged with cruelty at worst… I thought about the singular bond suicide survivors share with one another. Even though each of our situations is unique, we all experience similar stages in our grieving. When we meet someone else who has been there, it makes our personal chaos and isolated secrecy seem a little less frightening.”

CARLA FINE in BOOK:“No Time to Say Goodbye: Surviving the suicide of a loved

one”

o Supportive counseling close friendso Psychological debriefing whole schoolo Crises/gate keeper training school

personnel

o Evidence?o No protective effect against suicide or attempts

o Serious negative effects of debriefing in a study (Callahan 1996)

o Gatekeeper training effective in increasing knowledge about crises intervention among school personnel

School-based

SR OF POSTVENTION STRATEGIES – Nova Scotia 2010

o Outreach at scene of suicide to survivorso Support groups for widows/widowers or

parentso Support groups for other adult survivorso Support groups for children and adolescent

survivors

o EVIDENCE?o No protective effect on number of suicides or

attemptso Outreach helped survivors to seek a support and

seek helpo Nurse-led group counseling for spouse survivors

reduced psychological distress in both short and long term(one year)

o Parents – lowered distress 6 months

Family-focused

SR OF POSTVENTION STRATEGIES – Nova Scotia 2010

Sudak et al 2008:

“Suicide and Stigma: A review of the literature and personal reflections”

Academic Psychiatry

Community-based

o Media reporting guidelines for suicide and suicide attempts

o Multi-component intervention including schools, media and health services

o EVIDENCE?o Responsible media reporting shows promising

resultso Further investigation required to show if community-

based programs are effective independent of socio-historic factors

SR OF POSTVENTION STRATEGIES – Nova Scotia 2010

The case of Hong Kong

o Information for people bereaved by suicide – gathered from the psychological autopsy study of Hong Kong

(Chen, E. Y. H., Chan, W. S. C., Wong, P. W. C., et al. (2006). Suicide in Hong Kong: A case-control psychological autopsy study. Psychological Medicine, 36(6), 815-825)

Who were they?

• Spouses (n=37, 24.7%)• Parents (n=31, 20.7%)• Siblings (n=44, 29.3%)• Children (n=21, 14.7%) • Others including friends, relatives or co-workers

(n=17, 11.3%)

Items Strongly Disagree

n(%)

Disagree n(%)

Neutral n(%) Agree n(%) Strongly Agree n(%)

Perspective on Suicide

Suicide is a kind of relief for the deceased 53(35.3) 13(8.7) 11(7.3) 23(15.6) 48(32.0)

I think that his/her suicide is pre-determined by fate and nobody can prevent it from happening.

49(32.7) 13(8.7) 19(12.7) 23(15.3) 43(28.7)

Stigmatization

I will not tell other the reason for his/her death.

36(24.0) 26(17.3) 24(16.0) 14(9.3) 47(31.3)

I fear that others may think I will follow his/her steps (committing suicide).

70(46.7) 9(6.0) 15(10.0) 10(6.7) 43(28.7)

Psychological

I am lonely. 63(42.0) 16(10.7) 19(12.7) 15(10.0) 32(21.3)

I am anxious. 36(24.0) 13(8.7) 32(21.3) 28(18.7) 36(24.0)

I am miserable. 39(26.0) 14(9.3) 25(16.7) 25(16.7) 42(28.0)

I feel comfortable for there is someone who listens to my sharing.

28(18.7) 13(8.7) 40(26.7) 21(14.0) 44(29.3)

Social adjustment

I visit relatives and friends. 8(5.3) 8(5.3) 15(10.0) 23(15.3) 89(58.7)

I get along with family. 4(2.7) 3(2.0) 15(10.0) 33(22.0) 87(58.0)

I show empathy and support to my family. 56(37.3) 24(16.0) 30(20.0) 30(20.0) 86(57.3)

I cannot cope with daily routines. 87(58.0) 19(12.7) 12(8.0) 15(10.0) 10(6.7)

About 30% are lonelyAbout 40% are anxiousAbout 45% are miserable

About 74% visit relatives and friends

About 80% get along with family

About 16.7% cannot cope with daily routines

Wong, P.W.C., Chan, W.S.C., and Beh, P.S.L. (2007). What can we do to help and understand survivors of suicide in Hong Kong? Crisis, 28, 183-189

Their reactions of participating in the study…

Nearly 90% of the suicide informants were positive about having been initially approached to participate

More than 50% of the deceased informants found that it was helpful to talk about the suicide deaths at the interviews

66.1% of the control informants reported that they had a better understanding of the control subjects

More than 90% of all informants did not regret to participate in the study

CSRP planning…

o UNIVERSAL

o Informational support to normalize feelings and enhance help seeking in general

o Immediate help in early phase of bereavement

MANUAL FOR SURVIVORS DISTRIBUTED AT PUBLIC MORTUARIES

A website for survivors (in progress)

http://www.goodwillmusic.com/sur2/

“留給最愛的說話 /The Belated Dialogues between the Suicides and Their Families”

– a book on people bereaved by suicide

o SELECTIVE

o Bereaved persons who are likely to suffer complicated grief or suicide risk

o Closed, 6-session, group CBT?

o INDICATIVE

o Targeted towards people who are suffering complications of grief or have a high suicide risk

o Psychiatric referral indicated for people who have signs of depression, PTSD, Pathological grief, Adjustment disorder

o The Impacts of a Pilot Psycho-Educational Group based on a Cognitive-Behavioral Therapeutic (CBT) Approach for People Bereaved by Suicide in Hong Kong

o Participants:o People bereaved by suicide recruited with the help of

Eastern District HKP (as part of the initiatives of the community-based suicide prevention programme)

Test 1 CBT Group Test 2 6 months Test 3

o Major aim:

To help suicide survivors understand their grief and normalize the ways in which it manifests by providing support and education in a safe environment

o Objectives:

- To develop a mutual-support platform and network for participants;

- To enhance participants opportunities to discuss their painful feelings in a constructive and safe manner

- To equip participants’ a list of life-skills to adapt to the changes and tackle future challenges

- If possible, to develop a group of survivors as being one of the workforce for suicide prevention in Hong Kong

Theme Contents

1 Introduction Lecture on suicide in Hong Kong

2 Psychological Needs Lecture on stages of suicide bereavement

3 Guilt and self blame(negative thoughts)

Concept of ABC

4 Letting go Focus on the “present”

5 Goal setting Steps to set goals

6 Closing session Acknowledge the continuous support among the group

o Results and conclusions:

An average decrease of depression scores after the group. Yet individual members reported higher scores in Test 2. It may due to the increased awareness of ones’ emotions

Two members were diagnosed with Prolonged Grief Disorder in Test 1. They reported fewer symptoms after the group

Fewer members reported needs of extra emotional supports after the group

More awareness of community resources / professional help

The group may elicit thinking about the death related issues. However, less frequently the members thought that family and friends will be better if they die or will commit suicide if they know the method

Role of culture

o Culture penetrates the total experience of grief and suicide survivors

o Meaning attached to death

o Meaning attached to suicide

o Role of religion

Eg. Excess and incongruence of emotions (i.e., happiness, anger, worry, desire, sadness, fear and fright) is considered as pathogenic in the Chinese tradition

THANK YOU