Postvention

1. 20 JUNE 2011 Postvention FOR SUICIDE LOSS SURVIVORS DR. SAMAN YOUSUF

2. What is postvention? • Postvention refers to activities and strategies undertaken after a suicide death to reduce associated trauma • Postventionresponses aim to: • provide bereavement support and advocacy for those affected by the suicide • prevent further suicide events including contagion suicides and suicide clusters

3. Why postvention? • Bereavement support • Nature of bereavement different for suicide • Intentional nature of suicide • Stigma • Fear of others in family committing suicide • Prevention of further suicides • All exposed are at increased risk • 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’

4. Core principals of postvention • “Do no harm” • Response to needs of • INDIVIDUAL • FAMILY • SCHOOL • COMMUNITY • STAKE-HOLDERS OF THE COMMUNITY • Avoid glorification and minimize sensationalism • Identify individuals who may be at risk of harming themselves

5. The Survivors • For every life lost to suicide, 6-12 people are affected (Edwin Schneidman, 1983) • Survivors often experience a wide range of grief reactions, including some or all of the following: • Shock, numbness or disorientation • Trouble with concentration • Symptoms of depression • Anger : deceased, a family member, therapist or self • Relief, particularly if the suicide followed a long and difficult mental illness • Guilt, including thinking, “If only I had.…” These feelings usually diminish over time

6. Other reactions that may stay… • Feelings of abandonment and rejection • Bewilderment • Loneliness and social isolation • Difficulty trusting others • Relationships with others negatively affected • Depression • Heightened suicide risk • Gender differences in coping with suicide (Davis, C and Hinger, B 2004) • Men: getting back to routine, outside activities/sports • Women: reading, seeking counseling or support groups and doing volunteer work

7. What helps survivors in coping with the loss? • Davis and Hinger (2004) • Immediate support following suicide • Informal support provided most comfort • Practical support was helpful – eg. helping with funeral arrangements • Emotional support – ‘just having someone to listen’ • Honest, open interactions • Support groups with other survivors of suicide • Professional therapy • Supportive school and workplace

8. Unhelpful experiences • Lack of communication from clinicians and other health professionals • Lack of compassion and understanding • Unrealistic expectations of process and time of grieving • Special times of need • Holidays • Anniversaries of the event

9. “…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”

10. School-based • Supportive counseling  close friends • Psychological debriefing  whole school • Crises/gate keeper training  school personnel • Evidence? • No protective effect against suicide or attempts • Serious negative effects of debriefing in a study (Callahan 1996) • Gatekeeper training effective in increasing knowledge about crises intervention among school personnel SR OF POSTVENTION STRATEGIES – Nova Scotia 2010

11. Family-focused • Outreach at scene of suicide to survivors • Support groups for widows/widowers or parents • Support groups for other adult survivors • Support groups for children and adolescent survivors • EVIDENCE? • No protective effect on number of suicides or attempts • Outreach helped survivors to seek a support and seek help • Nurse-led group counseling for spouse survivors reduced psychological distress in both short and long term(one year) • Parents – lowered distress 6 months SR OF POSTVENTION STRATEGIES – Nova Scotia 2010

12. Sudak et al 2008: “Suicide and Stigma: A review of the literature and personal reflections” Academic Psychiatry

13. Community-based • Media reporting guidelines for suicide and suicide attempts • Multi-component intervention including schools, media and health services • EVIDENCE? • Responsible media reporting shows promising results • Further investigation required to show if community-based programs are effective independent of socio-historic factors SR OF POSTVENTION STRATEGIES – Nova Scotia 2010

14. The case of Hong Kong • 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%)

16. 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 About 30% are lonely About 40% are anxious About 45% are miserable About 74% visit relatives and friends About 80% get along with family About 16.7% cannot cope with daily routines

17. 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

18. CSRP planning… • UNIVERSAL • Informational support to normalize feelings and enhance help seeking in general • Immediate help in early phase of bereavement MANUAL FOR SURVIVORS DISTRIBUTED AT PUBLIC MORTUARIES

19. A website for survivors (in progress) http://www.goodwillmusic.com/sur2/

20. “留給最愛的說話/The Belated Dialogues between the Suicides and Their Families” – a book on people bereaved by suicide

21. SELECTIVE • Bereaved persons who are likely to suffer complicated grief or suicide risk • Closed, 6-session, group CBT? • INDICATIVE • Targeted towards people who are suffering complications of grief or have a high suicide risk • Psychiatric referral indicated for people who have signs of depression, PTSD, Pathological grief, Adjustment disorder

22. The Impacts of a Pilot Psycho-Educational Group based on a Cognitive-Behavioral Therapeutic (CBT) Approach for People Bereaved by Suicide in Hong Kong • Participants: • People bereaved by suicide recruited with the help of Eastern District HKP (as part of the initiatives of the community-based suicide prevention programme)

23. 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 • 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

25. 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

26. Role of culture • Culture penetrates the total experience of grief and suicide survivors • Meaning attached to death • Meaning attached to suicide • 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

27. THANK YOU