Working with Those Bereaved by Suicide in the Clinical Setting

1. Working with Those Bereaved by Suicide in the Clinical Setting Doreen S. Marshall, PhD AFSP VP Programs

2. My experiences with survivors • My own experience • Support group facilitator • Clinician • Outreach/postvention support • Consultant • Researcher • VP Programs AFSP

3. Reality • Most clinicians have not had any coursework related to bereavement or trauma, let alone suicide bereavement. • Many of us will be impacted at some point by an attempted or completed suicide in our clinical practices. • Many of us will learn about the needs of survivors by workingwith survivors.

4. The Experiences of Survivors of Suicide

5. Survivors of Suicide • Survivors—Who? • Anyone affected by a loss by suicide • Clinical literature addresses a number of people who could be considered survivors: • Family members (spouses, parents, children, siblings, significant others) • Friends (limited attention) • Peers (mostly in school settings) • Professionals (mental health clinicians) • Clients (mental health professional suicide)

6. Discussion questions • Do you think loss by suicide is different from other types of loss? • What issues may be faced by survivors that are unique concerns?

7. The “Why” of Suicide? • Constellation of factors • Cup analogy • Role of perceived burdensomeness, thwarted belonging, acquired capability • Majority of suicides are related to some emotional or mood problem, such as depression or bipolar disorder, though not all. • The Survivor may have their own “why” for the suicide…

8. Survivors of Suicide • What’s different about suicide grief? • Experience more frequent feelings of rejection from others • Perceived responsibility for the death • The “double bind” of anger • Misinformation and prevailing beliefs about suicide • Relief as a possible reaction (and then experiencing shame for feeling relieved)

9. The impact of suicide • Suicide impacts individuals, families, and communities. • Suicide Bereaved families often face challenges that are different from other deaths. • They may be unsure as to what to tell others about the death • They may question whether to have a public funeral. • They may experience intrusion by those investigating the suicide. (Source: Clark, 2001)

10. Survivors of suicide and related clinical issues

11. Conceptualizing loss by suicide… • Complicated grief reaction? • Post-Traumatic Stress Disorder? • Acute Stress Disorder? • Bereavement? • Comorbidity of other clinical concerns? • Question: How do you define the level of intervention needed? What aspects of the survivors’ experience can inform your assessment?

12. Conceptualizing loss by suicide • Things to consider: • What was the nature of the relationship between the survivor and the deceased? • How long ago was the loss? What is the survivor’s personal history of loss? • Did the survivor participate in a ritual (such as a funeral or memorial service)? • Is the survivor experiencing a traumatic response? • Has the survivor ever been suicidal? Clinically depressed?

13. Conceptualizing loss by suicide • If traumatic symptoms are present, are those symptoms most intense just following the loss and begin to gradually lessen? • Is the survivor engaging in avoidant behaviors? • Is the survivor hypervigilant or have an exaggerated startle response? • Is emotional constriction (numbness) present? • Did he or she find the deceased’s body? Was the suicide completed in their presence?

14. Conceptualizing loss by suicide • What situational factors surrounding the death may complicate the survivor’s experience? • What questions are unanswered for the survivors? • Does the survivor of suicide have other mental and/ or emotional problems (previous to suicide loss)? • How public was the suicide? • Has the suicide resulted in additional stressors beyond the loss itself? • Is this the first suicide that the survivor has experienced?

15. Conceptualizing loss by suicide • How does culture play a role in the survivor’s experience? • Has the survivor’s “life role” changed as a result of the suicide? • How likely is the survivor to seek professional help? • How do spiritual beliefs factor into what the survivor is experiencing? Can the survivor find comfort in these beliefs? • Does the survivor have support from others? Can he or she acknowledge the death by suicide with others?

16. Conceptualizing loss by suicide • Does the survivor feel responsible for the suicide? Was he or she “blamed” for the suicide? • Is relief a component of the survivor’s emotional experience? • Were mental health providers involved in the deceased’s treatment? • What was the quality of the interactions with professionals after the loss?

17. Conceptualization • Considering the answers to these questions will give you an indication of the overall clinical picture.

18. Conceptualization • Bereavement? • Is the survivor having a normal reaction to an abnormal event? • Caution against pathologizing survivor • Many survivors do not receive any treatment and manage to cope with the loss

19. Conceptualization • Comorbidity? • Given that risk of suicide is higher in those exposed to the suicide of a loved one, assessing suicide risk in survivors may be important. • Other comorbid concerns that may complicate treatment: • Substance abuse • Mood disorders • Anxiety disorders/PTSD

20. Activity • Consider each of the following clinical scenarios. • What special concerns may be unique to this individual’s experience? • What would this individual share in common with other survivors? May not have in common? • If this person were your client, where would you start clinically? What might be some goals for your work with this client?

21. Clinical situations • Client #1 • Client is a 38 year old woman whose husband has died by suicide. Client reported that husband was abusive toward her and had significant problems with alcohol which contributed to the abuse. Client reports significant financial distress as a result of his death. Client also has a three year old son and is currently in conflict with her husband’s family, who blames their pending separation for the death.

22. Clinical situations • Client #2 • Client is a 28 year old woman whose mother completed suicide when the client was 12 years old. Client was not told at the time that her death was a suicide. She recently learned this, following the suicide of another family member. Client notes that other family members (father, grandmother) still refer to her mother’s death as a “tragic accident” but do not acknowledge her death to be a suicide.

23. Clinical situations • Client #3 • Client is a 50 year old man whose 26 year old son completed suicide six months ago. He reports that his son had suffered from bipolar depression since his early teens and he had been in mental health treatment for most of the time since then. He reports having anger at the mental health system for “failing him”. His death was a murder-suicide where he also killed his girlfriend.

24. Strategies for working with survivors in the clinical setting

25. Exploring your own beliefs about suicide • Importance of being aware of your own beliefs, biases, experiences related to suicide. • If you are not aware of these, they may impact your clinical work (and you may not even know it). • Survivors often report that clinicians have said/done things that indicated a general lack of understanding about the issue of suicide loss.

26. Remember the basics… • No two people grieve alike. • Support often dwindles in the months following the death, as opposed to the early weeks. • Anniversaries, holidays and other special days are likely to be difficult for the client. • Suicide has different meanings across cultures, communities, families and individuals. • Don’t assume. Learn. • Use your knowledge about suicide to help inform the survivor. Answer questions when you can and use other resources.

27. Intervention Strategies 1. First things first. 2. Survivors often struggle with the “why” of suicide and this is a normal part of ascribing some meaning/gaining understanding of the event. 3. “You don’t have to know all of the details to heal.”

28. Intervention Strategies 4. Be very aware of how the survivor is coping—what strengths, resources, support is already in place. 5. Be aware of complicating factors when traumatic symptoms, suicidality or comorbidity exists. 6. Don’t assume that a support group will be the “right” place for your client. While support groups are beneficial to many, not everyone benefits from a support group. 7. Explore a wide range of feelings with your client (again, don’t assume)

29. Intervention Strategies 8. Guilt is a “normal” reaction to suicide loss. Allow your client to struggle with this if appropriate. 9. Remind your client that you can have regrets but not be responsible for the death. 10. Explore the meaning and use of rituals. 11. Help your client ask others for what they need. 12. Learn about the origins of suicide stigma 13. Don’t idealize the deceased. Help survivors see the humanness of their loved ones.

30. Intervention Strategies • Things to consider: • Timing of treatment • Appropriateness of modality of treatments • Cultural norms of seeking assistance • Other resources for survivor support • Situational factors that may impact treatment

31. Assessing suicide in the survivor • It is not uncommon for survivors to ask themselves the question of whether or not they would ever attempt suicide. • Routine suicide assessment is important for standard of care, given increased risk. • Important to consider survivor’s previous risk (previous attempts, previous clinical concerns)

32. Basics of Suicide Assessment • Assessing risk: • Person’s risk relative to others • Is this person more at risk for suicide than others? • Person’s risk relative to themselves (over lifespan) • Is this person more at risk for suicide at this time than in previous times in their lives?

33. Standard of Care for Assessing Suicide • Assessing intention • Assessing history of suicide and treatment • Assessing family history of suicide • Assessing for access to means • Discussing safety plans • Documenting all of the above, including follow up contacts.

34. Suicide bereavement resources

35. Suicide Resources for Clinicians • Journals: • Suicide and Life-Threatening Behavior • Omega: Journal of Death and Dying • Crisis • Films: • The Journey film series (AFSP) • Clinician-survivors listserv •  Please email Vanessa McGann at VLMcGann@aol.com if you would like to join)

36. Survivor resources • Survivors of suicide support groups • General bereavement groups (e.g. Compassionate Friends) • Online support groups (FFOS, POS, Alliance of Hope) • Memory Quilts • Community support/outreach teams • Connection to national/state organizations

37. Resources for clients • Books: • My Son, My Son, Iris M. Bolton • How to Go On Living When Someone You Love Dies, Therese Rando • Silent Grief: Living in the Wake of Suicide, Christopher Lukas & Henry Seiden • The Gift of Second: Healing from the Impact of Suicide, BrandyLidbeck • No Time to Say Goodbye, Carla Fine

38. Resources for clinicians • Books • Lay My Burden Down, Alvin Pouissant • The Noonday Demon, Andrew Solomon • Night Falls Fast, Kay Jamison • Therapeutic and Legal Issues for Therapists Who Have Survived a Client’s Suicide, Editor Kayla Weiner • Voices of Healing and Hope: Conversations on Grief after Suicide, Iris Bolton

39. National Organizations • American Foundation for Suicide Prevention • www.afsp.org • Support group listing • International Survivors of Suicide Loss Day • Survivor materials • Survivor Outreach Program • Digital Memory Quilt • American Association of Suicidology • www.suicidology.org • Healing After Suicide Conference

40. For more information… • Doreen S. Marshall, VP Programs • Afsp.org/suicideloss • dmarshall@afsp.org

41. In closing… • Know that you are in a position to help loss survivors. • Survivors need clinicians who understand the unique aspects of loss by suicide and are willing to learn about the individual survivor’s experience. • Know that suicide prevention, intervention and postvention are national priorities and that others are also working to save lives. • Take care of yourself! Working with suicide loss survivors in the clinical setting is difficult work!

42. Thank you!