PowerPoint Presentationriversidetraumacenter.org/wp-content/uploads/2019/09/Postvention-I… · Barriers to health care Unsafe media portrayals of suicide Safe and supportive school

9/13/2019

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Responding to Sudden, Unexpected

Loss: Strategies for Supporting Schools,

Organizations, and Communities

International Association of Suicide Prevention Derry, Northern Ireland

September 2019

Presented by:

Larry Berkowitz EdD Jim McCauley, LICSW

Riverside Trauma Center

Help communities recover from the overwhelming stress caused by traumatic events by providing community outreach and counseling.

Educate communities and organizations about suicide prevention, psychological trauma, and the emotional needs of returning veterans.

We serve communities, schools, health and human services providers, organizations, government agencies, workplaces, and individuals.

We have provided trauma-related services since 1990

www.riversidetraumacenter.org



Critical Incident Responses

• Sudden/ Unexpected Deaths –Fatal Car Accidents

• Tragic Deaths of Children

• Homicides

• School Shootings *

• primarily suicide deaths • Local Disasters – Tornados, Floods

• Teacher arrested for child pornography/ sexual abuse

• Islamophobia


A world where communities and organizations provide everyone who is exposed to suicide access to effective services and support immediately- and for long as necessary- to decrease their risk of suicide, to strengthen their mental health, and to help them cope with grief.

(National Action Alliance for Suicide Prevention, 2015)

A New Vision for Postvention

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Is There a Need for Postvention?

Adolescent suicide loss survivors experience increased depression, complicated grief, PTSD. (Brent, et. al.1996)

In some settings workers exposed to suicide are 3.5 times more likely to subsequently die of suicide

(Hedstrom, et. al. 2008)

Summary of research showing 54% of attempters know at least one person who attempted or died of suicide (86% - attempt occurred more than 12 months after the suicidal behavior of the model) (DeLeo & Heller, 2008)

Exposure to suicide is a significant risk factor for suicide Contagion (Gould, 2010)


Suicide Contagion vs Suicide Cluster

Contagion:

Process by which knowledge of one suicide facilitates/influences the occurrence of a subsequent suicide.

Viewed within the larger context of behavioral contagion or social learning theory.

Also termed “modeling”

Cluster:

Excessive number of suicides occurring in close temporal and/or geographical proximity.

Gould (2010)


A study was conducted by Cerel and colleagues found: An average of 115 people are exposed when each suicide occurs. On a 5-point scale rating closeness of their relationship to the person

who died by suicide whom they knew the best, of the 115 people exposed, 71 felt some degree of closeness, 42 of those 71 felt a higher degree of closeness, and 21 of those 42 people felt a very high degree of closeness.

Perceived impact respondents felt that the suicide had on their life, of the 115 people exposed,

53 said their lives were disrupted for a short time, 25 of those 53 people said their lives were disrupted in a major way 11 of those 25 people said the suicide had a devastating effect on

their lives.

Impact for the Survivors

Cerel et al. (2017) Riverside Trauma Center

Individuals at Risk

X

Girlfriend X X Siblings

X Team-mates

Co-workers

X Ex-girlfriend Neighbors X

X “Vulnerable”

students/ adults

X Individuals with

recent losses

X Friends X

Friends on X

Social Media

Adapted from Underwood and Dunne-Maxim (1997)

X All students in

same grade

X Those who identify

in some way with the

deceased

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Domains Affected by Trauma and Acute Grief

Domain Symptoms

Emotional Shock, sorrow, anger, guilt, irritability

Cognitive/

Thinking

Confusion, intrusive thoughts, concentration

Social/Behavioral

Withdrawal, crying, fighting

Physical/Somatic

Fatigue, stomachache, startle response, sleep

Relational Withdrawal; fighting, fear of being alone; feeling

obligated to interact with people

Spiritual/

Meaning-Making

“Nothing matters.” “Why would God do this?”

“Why do I bother to do this kind of work?”


Why Grief Following Suicide Can Be

More Complicated

Shock at the sudden/unexpected death

Social stigma/shame Intense search for the

reasons “why” Police investigation/media

involvement “Could this death have been

prevented?” Ambiguity about volition of

deceased (did he/she really mean to die?)

Violence/trauma of the death

Feelings of abandonment or rejection

Fear of own self destructive impulses

Fear of possible suicidal thoughts/behaviors of others

Long delays in receiving autopsy/medical reports precludes “closure”

Anger at the deceased and/or others - Scapegoating/blaming

Adapted from Underwood (1997) & Cerel et al. (2015)


Grief Trauma

Sadness is the most common emotion. Terror/Fear is the most common emotion.

Acute grief generally runs its course over time.

With Post-Traumatic Stress lack of treatment can worsen the condition.

Pain is an acknowledgement of the loss. Pain can trigger terror and powerlessness

Generally does not attack nor “disfigure” the self-image of the bereaved.

Generally attacks, distorts and “disfigures” the self-image of the bereaved.

Generally does not involve trauma reactions like flashbacks, startle reactions, hypervigilance, numbing, etc.

Involves grief reactions in addition to trauma specific reactions like flashbacks, startle reactions, hypervigilance, numbing, etc.

Trauma vs. Grief


“What About OUR pain?”

Who else is impacted throughout a community?

Building a competent community (Kalafat)

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Think through the timeframe of the response:

Today

Rest of this week

Weekend

Services

After the funeral

One week out

Two weeks out

Timeframe of the Response

Mixed State – B. Matros


Reactions and distress may resurface during milestone moments and anniversaries.

It is often helpful to prepare the bereaved to anticipate these reactions.

Anniversaries (of birth, death, “monthaversaries”)

Milestone moments: prom, graduation, buying a new house, wedding, etc.

Anniversaries and Milestones


Promote healthy grieving Restore equilibrium and functioning/Stabilize the

environment Commemorate the deceased Provide comfort to those distressed Reduce the risk of contagion Minimize adverse personal outcomes (Depression,

PTSD, complicated grief) Use the experience/tragedy as a “teachable” moment Increase empowerment and mutual support for

organizational members

Postvention Goals


Postvention Guiding Principles

Avoid oversimplifying the causes of suicide

Emphasize the correlation with depression and mental illness

Avoid romanticizing/glorifying

Discourage focus on method

Provide structure for on-going suicide prevention efforts

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Shame – embarrassment – reduced cohesion

“This place is cursed”

“That town needs to stop killing kids”

“I go out of my way to avoid telling people where I am from.”

“The minute I can afford to move I’m leaving this hell hole.”

Impact on School/Business/

Community


Postvention Tasks

1) Verify deaths and facts surrounding the death

Superintendent/CEO/HR/ League Director

Who? When?

Confirm with family, police or medical examiner

Assume widespread rumors


“If you’re about to open your mouth to say something to make the family feel better – don’t.”

Be a “compassionate presence” – sometimes this is enough.

Representative from the school should visit with the family ASAP.

Ask the family what their understanding is of the death.

Gently encourage the family to acknowledge it as a suicide. Enlist the family in your postvention efforts

Talking with the Grieving Family


2) Coordinate internal and external resources

Crisis team (frequent mtgs)

Early Responders – police, fire, EMS, clergy

Local mental health partners/HR/ EAP’s

Other school districts

Trained clergy/ funeral home directors

External resources support those implementing the postvention plan

Postvention Tasks

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3) Disseminate accurate information

Factual, written information acknowledging suicide

Condolences to family and friends

Plans for support

Funeral plans

Changes in schedule

Announce in small groups (no public address)

Postvention Tasks


4) Support for those most impacted by the death

Follow schedule of the deceased/ work groups

Friends, family, conflicted relationships

Less obvious – administrative staff, clients, others in the community (activities, neighbors), those in remote offices who have frequent phone contact

Emphasis is on mourning the loss

Postvention Tasks


Encourage atmosphere of open expression to all reactions

Communicate facts clearly (then repeat) Initiate conversations about the deceased: facilitate

through artwork, collages, tape recording, journals Physical activity/encourage peer activities Flexibility (eg. around physical complaints) Resume routines Support rituals for the deceased Relief staff/Tutoring and temporary reduction in

work/academic load

School Response to Childhood Bereavement


Why? - making sense of the death Responsibility- guilt and blame (“tyranny of

hindsight”) Social disruption- isolation Shame- stigma, silence Anger- rejection and abandonment Trauma- shock and horror Relief- end of suffering Suicidality- why go on? Sorrow- grief and yearning

Prominent Themes for Survivors

Adapted from Jordan (2014)

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Information management – who to tell and when

Communication shutdown-trying not to upset others or manage conflict

Disruption of family rituals/ routines

Loss of cohesion

Coping Asynchrony – Differences in grieving styles/ change in availability/ different timelines

The Burden of taking care of others

The “Supermarket Aisle”

Prominent Themes for Survivors: Family

Adapted from Jordan (2014) Riverside Trauma Center

• Self Care

• Educate yourself

• Lower your expectations

• Be with people who “get it” and “get you.”

• Experiment with healing

• “Don’t waste your grief” – engage in activities that honor your loved one

• Be patient with yourself

• Have faith in your resilience • Adapted from John Jordan PhD

How to Survive


Postvention Tasks

5) Identify those most at risk

Identify with deceased (even if remote)

Feeling responsible

Recent loses

“Impressionable” students

Hx of suicidal behavior/ suicide survivor

Bracing Ourselves – B. Matros


Postvention Tasks

6) Provide opportunities for commemoration

Policy for all deaths Outside of school activities Encourage family to participate Discourage permanent memorials Encourage prevention activities and simple

activities (meals, transportation) Emphasize deceased’s life (vs. method of

dying)

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Postvention Tasks

7) Provide psycho-education on grief and suicide

Educate on depression/ grief process/ mental illness/ “perfect storm”

Encourage adaptive coping strategies

Encourage questions

Consider curricula – SOS, Lifelines, Break Free From Depression (Schools); Working Minds (workplace)

Role of Community Forums


How do we change the narrative?

Messages of hope

Encourage help-seeking

Encourage improved social support

Fight stigma about mental health challenges and asking for help

National Action Alliance: Framework for Successful Messaging: (actionallianceforsuicideprevention.org)

Messaging


Postvention Tasks

8) Casefind/Screen for depression or suicide

Consistent with public health approach Brief Screening for Adolescent Depression in

conjunction with SOS Signs of Suicide Program Mindwise.org Screening for adults “Exposed” vs. “unexposed” Prepare teachers, parents, and students for

screening event Workplace screenings more challenging Enhanced mental health resources in place

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Adult Screening


Postvention Tasks

9) Implement trauma response for second/ subsequent suicide

Increased risk of a cluster

Trauma focus ( more than one death, witness, homicide-suicide, extended publicity/ blame)

Psycho-ed around self care

Coping groups


Postvention Tasks

10) Develop linkages to resources:

Need for clinical follow-up/ on-going support

List of local resources/ publicized lists

Funding opportunities

Designated counselor in school

Project SERV

AFSP, Samaritans, The Loss Project

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Postvention Tasks

11) Evaluate postvention response

Lessons learned

Review/revise crisis plan/ protocols

Address “unfinished” business

Plan for milestones anniversary, graduation, workplace holiday party, etc.

Climbing – B. Matros


Postvention Tasks

12) Develop community/ system wide prevention plan

Community coalition/task force Resource map of community leaders/

programs/people interested in helping Proactive use of media Address risk and protective factors Resilience curriculum Means reduction Sustainability Advocacy


Examples of Risk & Protective Factors in a Social Ecological Model

Individual Societal

Community Relationship

Protective Factors

Risk Factors

Availability of Physical and mental health care

Restrictions on lethal means of suicide

Availability of lethal means of suicide

Unsafe media portrayals of suicide

Safe and supportive school and community environments

Sources of continued care after psychiatric hospitalization

Few available sources of supportive relationships

Barriers to health care (e.g. lack of access to providers or medications, prejudice

High Conflict or violent relationships

Family History of suicide

Connectedness to individuals, family , community, and social institutions

Supportive relationships with health care providers

Coping and problem solving skills

Reasons for living (e.g. children in the home)

Moral objections to suicide

Mental Illness

Substance abuse

Previous suicide attempt

Impulsivity/aggression

2012 National Strategy for Suicide Prevention Riverside Trauma Center

Dilemmas in Postvention

“We don’t think it was a suicide.” Large staff Meetings/Assemblies Notifications The “empty chair/desk” Memorials Services Rumors The Media The Diploma When the Family Shows Up

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Lessons Learned

“Exposure” to suicide is more important (and complicated) (and confusing) than “Contagion”

Think about/plan for “cohorts” “Don’t take it personally but there is no way these guys are

going to talk to you…” The use of outside resources after a suicide death is essential:

Who is taking care of the “caretakers?” (The kids are watching) Expertise Reducing the stigma with an open response

Suicide is political and often engenders blame, guilt, & anger Social Media will greatly complicate your postvention response:

Immediacy Rumors Geography


• Social Media has changed postvention

• Facebook Memorials

• Who is monitoring?

• “Worrisome” Posts

• Tips for Adolescents – Parents – Administrators

Role of Social Media in Postvention

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Postvention Models and Resources

Excellent models exist:

Underwood and Dunne-Maxim, 1997

“Connect”NAMI, NH, 2010

Brock, 2003

Kerr, Brent et al., 2003

“After a Suicide: A Toolkit for Schools,” SPRC.org

“Postvention: A Guide for Response to Suicide on College Campuses” HEMHA.org

“A Manager’s guide for Suicide Postvention in the Workplace” Suicidology.org


Riverside Trauma Center’s Postvention Guidelines

Connect

Carson Spencer Foundation

Crisis Care Network

The Loss Project

National Strategy for Suicide Prevention

Postvention Models for Agencies/

Businesses/ Communities


Responding to Sudden, Unexpected Loss: Strategies for Supporting Schools, Organizations,

and Communities

Larry Berkowitz, EdD [email protected]

Jim McCauley, LICSW [email protected]

mailto:[email protected]

mailto:[email protected]

Documents

PowerPoint Presentationriversidetraumacenter.org/wp-content/uploads/2019/09/Postvention-I… · Barriers to health care Unsafe media portrayals of suicide Safe and supportive school