Our understanding of people bereaved by suicide (PBS) in Hong Kong and the way forward

1. Our understanding of people bereaved by suicide (PBS) in Hong Kong and the way forward By Dr. Paul WC Wong D.Psyc. (Clinical) Assistant Professor, Department of Social Work and Social Administration, and Honorary Fellow of the Center for Suicide Research and Prevention (CSRP), The University of Hong Kong Email: paulw@hku.hk

2. Outline Part one. Suicide problem in HK Part twoHong Kong PBS’ grief reactions Part three. What can we do to “help”? Part four. What can we do to “understand”? Part five. Reflections

4. Part two Hong Kong PBS's Grief Reactions

5. Empirical study on people bereaved by suicide and services for these individuals are very limited (Farberow & Andriessen, 2001). Hong Kong is of no exception.

6. What do we know about the people bereaved by suicide in Hong Kong? Based on the 150 people bereaved by suicide who participated in a psychological autopsy study (interview timing mean=7.3 months, SD=4.0)……

7. The majority of the informants were the spouses (n=37, 24.7%), parents (n=31, 20.7%), and siblings (n=44, 29.3%) of the deceased, 21 (14.7%) were children, and 17 (11.3%) were others including friends, relatives, and co-workers (Chen et al., 2006). Who were they? Chen, Chan, Wong et al., (2006) Suicide in Hong Kong: a case-control psychological autopsy study. Psychol. Med.,  36  (2006), pp. 815–825

8. Using a self-developed questionnaire. We found…. Apart from the typical bereavement reactions such as cognitive disorganized, dysphoric, somatic distress, and social and occupational disruptions, people bereaved by suicide…… Wong, Paul W. C.; Chan, Wincy S. C.; Beh, Philip S. L. (2007) . What can we do to help and understand survivors of suicide in Hong Kong? Crisis: The Journal of Crisis Intervention and Suicide Prevention, Vol 28(4), 2007

10. 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 The information seems to show that….In Hong Kong - +

11. “Postvention practices for people bereaved by suicide should not be prescriptive but instead should empower them to find their own paths” - a concluding remark from the Australian, Norwegian, Belgian, and Slovenian workforces (Grad et al., 2003) -

12. Part two What can we do to “empower them to find their own paths”?

13. Since March 2007 Postvention using a public health approach http://www.mindmap.hk/survivor/

14. Part two. What can we do to “help”? If we use suicide risk levels as an anchor, we can subdivide all existing and potential activities into three types: Universal – not all suicide survivours develop complicated grief and suicidal risk, and require additional help for their bereavement (Jordan, 2001). We suggest that some informational support and immediate help at the early phase of suicide bereavement may be useful to all people bereaved by suicide as a stress management strategy. Selective– designed for bereaved persons who are deemed to be likely to experience a complicated form of grief or suicide risk. Indicated – targeted toward people who are experiencing complications in their grieving processor expressing high suicide risk .

15. The USI Approach in Helping People Bereaved by Suicide (PBS) based on their suicide risk Indicated Selective Universal Suicide Risk

16. Universal Manual for survivours: distributed at public mortuaries and downloaded at http://csrp.hku.hk/files/70_1851_335.pdf Universal: aims to normalize feelings, provide informational support, and to enhance help-seeking behaviour.

17. Universal A website for survivours (csrp.hku.hk/sos)

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

19. Closed, six-session, CBT psychological education group? Or support group? Selective Selective: aims to identify and help those who might be at risk for complications or some level of suicide risk.

20. Things that we had to consider when planning for support groups Leadership: By who? Survivours? Mental health professionals? Volunteers? “One of the key factors that makes or breaks a support group is the facilitator” (Myers & Fine, 2006) Membership: Who attends? Children? Elderly? Spouse? Parents? Men only? There is no evidence on whether groups based on relationships are more or less helpful than those for one type of survivor (Cerel et al, manuscript). Open-Ended or Close-Ended? Also it is unknown if this type of sharing, hearing, and repeating traumatic stories may actually re-traumatize survivors (Cerel et al. manuscript)

21. The Effects of a Pilot Psycho-Educational Group based on a Cognitive-Behavioral Therapeutic (CBT) Approach for People Bereaved by Suicide in Hong Kong (unpublished data)

22. Objectives of the Group Conceptual framework: • Cognitive Behavioral Therapy (CBT) 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.

23. Methodology • Participants: • Survivors recruited with the help of Eastern District HKP (as part of the initiatives of the community-based suicide prevention programme) • Measures: • 1. Stress management (Healthy Living Follow-up Survey questionnaire) • 2. CES-D (Center for Epidemiologic Studies Depression Scale) • 3. Social Support (US NHANES questionnaire) • 4. Inventory of Complicated Grief • 5. Suicidal ideation, attempt and behavior • 6. Demographic information

24. Group Contents

25. Demographic background of the group Gender: 12 Females 5 Male Age: 33 to 73 yrs Family relationship: Parent, Spouses, Children, Sibling or Fiance “Multiple” survivors Incident taken place: 1 month to over 2 years ago

26. Depression (CES-D) Before the group (Test 1) After the group (Test 2) 6 months after the group (Test 3) (4 cases) Mean 16.85 (SD=8.68) 15.31 (SD=5.99) 13.71 (SD=3.25) Mean Difference -1.91(SD=5.02) -2.14(SD=4.45) 40 29 19 Max. scores Min. scores 8 7 10

27. Social Support (Cont’d)

28. Before the group (Test 1) After the group (Test 2) 6 months after the group (Test 3) (group 1 only) 2 0 0 Number of members with diagnosis of PGD -0.20 (SD=0.55) -0.58 (SD=0.76) Mean Difference 2.69 (SD=0.81) 2.41 (SD=0.44) Mean 2.89 (SD=0.91) Complicated Grief (Prolonged Grief Disorder)

29. Feedbacks from the Group Mutual supports and learning among survivors Normalizing their ways of expressions Increase of self-awareness Knowledge gain When should the survivors join the group? (after 1 month? 2 to 3 months?) Group and individual counseling Eagerness to help other survivors

30. Indicated Indicated: aims to help those at higher risk of suicide We hesitate to recommend any effective indicated individual interventions for suicide survivours in Hong Kong because: (1) there is still a considerable debate in finding out whether grief is a “disease” and when grief should be treated as a “disorder” (Glass, 2005); and (2) there is a dearth of empirical treatment studies for complicated grief that have been found to be efficacious (Shear et al., 2005). Despite all that, we suggest that people bereaved by suicide who have persisting symptoms and impairments which may bear some resemblance to MDD, PTSD, Pathological Grief, Adjustment Disorder, or at high risk of dying by suicide should be assessed and treated by psychiatrists or clinical psychologists (Jordan & Neimeyer, 2003).

31. Part three What can we do to “understand”?

32. Part three. What can we do to “understand”? (in an ideal situation) • We need not just to establish answers for “WHAT works for survivours?” but also “What works for WHOM?” • We need to understand: • the “course” of suicide bereavement by longitudinal research; • need to identify the features which make individuals vulnerable to, or protected from, developing severe psychological distress following bereavement by suicide; • need to explore the impact of suicide on family dynamics and family communication among Hong Kong suicide survivours because evidence from the West may not be applicable to Chinese families; • how and how much social stigmatization would affect help-seeking behaviour of survivours would be another important topic that would worth studying; and, • Most importantly, the suicide risk of people bereaved by suicide.

33. Efficacy intervention research studies Should adopt the following research designs (if possible): (1) comparisons with no treatment groups; (2) comparisons with other treatment groups; and (3) randomised assignment of survivours to interventions.

34. Reflections There are unique features experienced by people bereaved by suicide; However, not all people bereaved by suicide develop complications or suicide risk; Little, if not none, is known if the effects of any interventions reduce the suicide risk of people bereaved by suicide; Thus, without much empirical evidence, all interventions must be based on a “do-no-harm” principle (Schut & Stroebe, 2005). We should acknowledge the importance of including survivors into the work of suicide prevention with stringent ethical considerations.

35. The End Thank You http://csrp.hku.hk paulw@hku.hk