Addressing the Aftermath of Suicide: Why We Need Postvention

Table 1 – A selected list of postvention resources

Table 2 – A summary of Shneidman’s 8 principles of postvention

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Matthew D. Erlich, MD, for the GAP Committee on Psychopathology

Suicide is increasingly a part of the national conversation. Deaths from suicide are now at their highest level in 30 years. Suicide is the 10th leading cause of death in the US-well ahead of deaths by homicide, which ranks 17th. In 2014, 43,773 people are known to have killed themselves, and there are likely more suicides that go unrecognized.¹ More people die by their own hand than in auto accidents.

Attempted and completed suicides ripple throughout the community, affecting family and friends, community workers (such as police officers and teachers), and clinicians. Former NIMH Director Thomas Insel, MD, noted that with every suicide, there are 11 victims-the person who died and the 10 caregivers devastated by the loss who are themselves at risk.^2,3 For those grieving in the wake of suicide, there are relatively few resources.

Interventions that occur after a suicide are called “postvention”-a term originated by Edwin Shneidman in 1968 at the first conference of the American Association of Suicidology.

Postvention addresses the care of bereaved survivors, caregivers, and health care providers. It aims to destigmatize the tragedy of suicide, promote survivor recovery, and strengthen suicide prevention efforts by providing multiple resources to the survivors-including behavioral health, psychosocial, spiritual, and public health services.⁴ To many, postvention is a secondary prevention effort, with the goal of assisting in recovery and mitigating trauma.^5,6

Here, we briefly review the literature on postvention efforts. We consider the effects on the victim’s caregivers-especially the behavioral health providers who care for a patient who commits suicide. We also provide current resources to help manage survivors’ and caregivers’ emotions and dread.

Selected types of postvention efforts

Postvention efforts have been developed to address a broad array of responses to a suicide. Table 1 lists selected resources. Most organized efforts focus on the family and friends of the survivor. Fewer efforts address the emotional toll on other caregivers.

A 2015 RAND report for the US Department of Defense highlights the dearth of scientific evidence on how to best respond to a completed suicide, best manage survivors’ grief, and monitor caregivers’ risk for self-harm.⁷ Despite their heterogeneity, postvention resources can be organized into 3 groups:

• Active, early postvention approaches

• Therapy-centered techniques

• Containment strategies

These groupings, although not mutually exclusive, reflect the dominant themes of postvention responses and are described briefly below.

Postvention “first-responder” approaches. In the first few days after a suicide, there is immediate need for practical resources by caregivers to guide the survivors with the complicated tasks involved with the end of life after suicide. Active postvention approaches help improve survivor welfare, averting crises and assist with destigmatization.

In a Baton Rouge crisis intervention center, researchers followed 2 cohorts of suicide survivors between 1999 and 2005. One group received an active model of suicide postvention with guidelines and interventions; the other group received “treatment as usual” postvention. An active model of postvention led to earlier treatment for survivors and improved attendance at survivor support group meetings.⁸ Such early triage efforts function as a form of crisis intervention to manage current grief and to proactively address and anticipate future concerns.

Many organizations and state agencies now recognize that an early postvention response is a critical community responsibility. For example, The Local Outreach to Suicide Survivors (LOSS) is a peer-led program in which a team that includes a caregiver-survivor offers immediate support to survivors, from counseling to helping clean a victim’s home. At national LOSS conferences, members hone their skills and collaborate to improve postvention practices. Several states now incorporate LOSS programs into their postvention practices, and the use of LOSS programs is expected to grow.

The Samaritans of New York center (http://samaritansnyc.org/) offers both a suicide prevention hotline as well as a confidential hotline in which trained counselors provide ongoing support to survivors. These operationalized, triage, or immediate crisis intervention approaches are increasingly seen as best practices to ensure that survivors are not left alone with the tragic aftermath of suicide, the stigma of having a loved one commit suicide, and the often overwhelming practicalities of managing a traumatic loss.

Therapies to comfort the survivors. Grief counseling, narrative approaches, various therapies, and support groups are also available. The management of healing is an essential process both for survivors and professionals who work with them. Beyond concerns regarding professional liability and how this affects mental health workers’ response, there is a lack of expert consensus on managing the loss of a patient. The literature regarding how trainees and their supervisors manage a suicide when it occurs in the educational environment exists, mostly in the form of guidance articles and anecdotal pieces.

Questionnaires in Great Britain and Ireland, for example, showed that among the many trainees who experienced a patient suicide, 51% reported moderate emotional impact, 24% had a severe emotional impact, and 9% considered a change in career.⁹ Such findings have been replicated elsewhere and training programs have responded accordingly with enhanced supervision and modification of their procedures to comfort affected trainees and their colleagues.

For non-clinician caregivers, coping and postvention strategies are more diffuse. There is a dearth of expert consensus, evidence-based guidelines, or rigorous studies. Although a description of the range of therapeutic treatment approaches that constitute survivor therapy is beyond the scope of this article, such therapies range from individual to group support, from passive reading to active role-playing; and from “The Girlfriends’ Guide to What to Expect When Your Girlfriend’s Grieving” to academic guidelines.¹⁰

Containment to prevent contagion. The most standardized and widespread current postvention approaches have been developed to manage adolescent suicides in academic settings. Many of these protocols are rooted in the contagion risk that adolescent survivors may be at some risk of attempting suicide in the aftermath of an adolescent suicide. This phenomenon is well documented and awareness is critical.¹¹ Postvention measures are primarily focused on initial containment of the tragedy and mitigating potential contagion among vulnerable individuals.

Thorough and informative protocols are available. These are intended to help identify at risk adolescents, to provide psychoeducation about warning signs that other adolescents and teachers can learn, and to delineate grief management techniques. One prominent example of this is the Texas Suicide Prevention Toolkit (http://www.texassuicideprevention.org/) that includes a glossary, FAQs, mnemonics to teach risk assessment, and practical guidelines.¹²

Another containment postvention resource helps manage the aftermath of suicide in the workplace. First-aid interventions in work environments involve training managers and human resource personnel to set a respectful tone, to listen to (and elicit) the emotions of coworkers, and to provide practical resources for both inside and outside the work environment. Some of these protocols provide guidance for managing law enforcement authorities and maintaining a dignified, coordinated message to coworkers.¹³

Community members are survivors too

A variety of community members are affected by suicide. They include first responders, educators, coworkers, public service workers, religious leaders, and law enforcement personnel. The relationship may have been a close one (ie, a teacher/student) or it may not have existed (eg, a dead stranger discovered by a subway worker). Available resources for community workers have focused on delivering postvention to family and friends (eg, suicide in a school or workplace setting). However, few resources focus on community workers themselves, the emotional toll the suicide has exacted, or how to best support survivors.

The behavioral health care provider as a survivor

Roughly half of all individuals who complete suicide saw a health care provider in the month before their death, and a quarter had a behavioral health encounter.¹⁴ More than 35 years ago Shneidman¹⁵ delineated 8 principles of postvention to guide the clinician in the aftermath of a suicide (Table 2). While his principles were initially developed for behavioral health, they remain relevant and broadly applicable to all clinicians. Other than Shneidman’s principles, there is a dearth of rigorous research and studies on behavioral health professionals who are survivors of suicide (see “A Suicide Survey,” page 1).

Conclusion

The role of the behavioral health provider in postvention can be critical to other survivors and the community as a whole in reducing morbidity and mortality, increasing suicide prevention and postvention awareness, and destigmatizing the act of “taking one’s life.” Until suicide is no longer a societal issue, postvention efforts are relevant-and a necessity in the aftermath of suicide. All survivors will benefit from continued advocacy for an approach that incorporates postvention into the suicide prevention framework to enhance awareness, continue research in this underfunded area, increase funding for postvention efforts, and increase knowledge of how to implement best practice postvention strategies.

Disclosures:

Dr. Erlich is Assistant Professor of Clinical Psychiatry, Columbia University College of Physicians & Surgeons. He reports no conflicts of interest concerning the subject matter of this article.

This article is from the Psychopathology Committee of the Group for the Advancement of Psychiatry (GAP). The authors are Matthew D. Erlich, MD, Lisa B. Dixon, MD, MPH, David A. Adler, MD, David W. Oslin, MD, Bruce Levine, MD, Jeffrey L. Berlant, MD, PhD, Beth Goldman, MD, MPH, Steve Koh, MD, MPH, MBA, Michael B. First, MD, Chaitanya Pabbati, MD, and Samuel G. Siris, MD. Dr. Adler is co-owner of Health and Productivity Sciences; Dr. First receives royalties from APPI Press. The GAP, American psychiatry’s think tank, informs and educates mental health professionals, policy makers, and the public at large.

References:

1. Tavernise S. Sweeping pain as suicides hit a 30-year high. NY Times. April 22, 2016: A1.

2. Insel T. Director’s Blog: A new research agenda for suicide prevention. NIMH RSS. http://www.nimh.nih.gov/about/director/2014/a-new-research-agenda-for-suicide-prevention.shtml. Accessed June 30, 2016.

3. Andriessen K. Can postvention be prevention? Crisis. 2009;30:43-47.

4. Aguirre RTP, Slater H. Suicide postvention as suicide prevention: improvement and expansion in the United States. Death Studies. 2010;34:529-540.

5. Jordan JR. Bereavement after suicide. Psychiat Ann. 2008;38:679-685.

6. Seeman MV. The impact of suicide on co-patients. Psychiat Quart. 2015;86:449-457.

7. Ramchand R, Ayer L, Fisher G, et al. Suicide Postvention in the Department of Defense: Evidence, Policies and Procedures, and Perspectives of Loss Survivors. http://www.rand.org/pubs/research_reports/rr586.html. Accessed June 30, 2016.

8. Cerel J, Campbell F. Suicide survivors seeking mental health services: a preliminary examination of the role of an active postvention model. Suicide Life. 2008;38:30-34.

9. Foley SR, Kelly BD. When a patient dies by suicide: incidence, implications and coping strategies. Advan Psychiat Treat. 2007;13:134-138.

10. Sparrow G. The Girlfriends’ Guide to What to Expect When Your Girlfriend’s Grieving. http://www.sprc.org/sites/sprc.org/files/library/gfriendsurvguide.pdf. Accessed June 30, 2016.

11. Brock SE. School suicide postvention. In Brock SE, Lazarus PJ, Jimerson SR, Eds. Best Practices in School Crisis Prevention and Intervention. Bethesda, Maryland: National Association of School Psychologists; 2002: 553-575.

12. Texas Suicide Prevention Council and Texas Youth Suicide Prevention Project. Coming Together to Care: A Suicide Prevention and Postvention Toolkit for Texas Communities. Texas Suicide Prevention Council; 2012.

13. Carson J Spencer Foundation, Crisis Care Network, National Action Alliance for Suicide Prevention and American Association of Suicidology. A Manager’s Guide to Suicide Postvention in the Workplace: 10 Action Steps for Dealing with the Aftermath of Suicide. Denver, CO: Carson J Spencer Foundation; 2013.

14. Ahmedani BK, Simon GE, Stewart C, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014;29:870-877.

15.Shneidman E. Postvention: The care of the bereaved (from Consultation-Liaison Psychiatry), Suicide Life-Threat Behav. 1981;11:349-359.