Families Experiencing Loss Due to Death by Suicide

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Regis College Master of Science in Nursing Family Nurse Practitioner Fall 2009

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  • The production of suicide survivors for each suicide is debatable since the intensity of their relationship to the decedent or perhaps the meaning of the loss to each individual play a role in how they identify themselves as a suicide survivor (Cerel et al ., 2009). Numbers may be skewed
  • You will see at the case study towards the end of this presentation just how debilitating this population’s experience is with loss by suicide
  • You will see at the case study towards the end of this presentation just how debilitating this population’s experience is with loss by suicide
  • There are over 32,000 suicides annually in the US, with an estimated 6 survivors for every suicide (American Association of Suicidology [AAS], 2008)—an overwhelming number of persons needing bereavement counseling from healthcare professionals whom the National Institute of Mental Health recognize as needing improvement in care delivery (2001).
  • Depiction of suicide rate in Massachusetts. As I mentioned before, it is estimated that there are 6 survivors for every suicide and this is an estimation. No data is available therefore it can be corroborated from suicide rates how many suicide survivors are out there.
  • Surgeon General’s definition of stigma as “’manifested by bias, distrust, stereotyping, fear, embarrassment, and/or avoidance’ of the stigmatized individual or group” (U.S. Department of Health & Human Services, 1999 as cited in Cvinar, 2005).
  • The family unit provides a “vehicle for support as a mechanism for coming to terms with finding meaning in the loss” (p. 20). The author suggests development of programs to change the social view of suicide and new therapeutic interventions that target the psychological and social effects of suicide on suicide survivors. Author’s references from mid 1990s presenting the notion that there is limited current data on the role of stigma among suicide survivors. This article puts forth the view on the importance in addressing stigma in postvention.
  • Studies have to meet seven criteria which include studies that have: (1) at least one bereaved control group, (2) reactions measured were the survivors’ subjective experience and behavior, (3) suicide survivor groups contained no survivors of other modes of death, (4) same instruments were used for both suicide survivors and controls, and (5) quantitative outcome measures were used, (6) comprehensive reporting on study measures and results, and (7) results were published in peer-reviewed journals or books
  • Identified mental health variables include general mental health, depression, post-traumatic-stress disorder symptoms, anxiety, suicidal ideation, and suicide attempts Significant differences were not found among suicide survivors and other bereaved groups. As evident, no evidence support different reactions between suicide survivors and other bereaved groups. In comparing results between recent and older studies. no differences were found. It is found that since 90% of those who die by suicide suffered from one or more mental disorders. Suicide survivors who are relatives of the deceased then have a higher level of mental disorder. Limited data is available on the increased risk of suicide attempt by suicide survivors. Nevertheless, it is found that there is an increase risk among family members of suicide completers in twin, adoption, and family studies.
  • Identified grief variables include: (1) overall grief, (2) rejection, (3) shame or stigma, (4) concealment of the cause of death, (5) guilt, (6) responsibility, (7) blaming, (8) anger, (9) loneliness or isolation, (10) social support, (11) social adjustment/ family functioning/child behavior, (12) acceptance, (13) relief shock, and (14) search for explanation.
  • A strength is found when the author state that survivors should be encouraged to seek recommended tools for coping including reading books, participating in support groups, accessing internet sites and contacting hotlines (p.241). Family resiliency in response to coping over loss through death by suicide is complex and varied therefore utilizing different tools may aid family members in one form or another. A limitation to this is that there is a gap in research on how helpful the mentioned tools are. Performing the assessment. A strength found is the mention of assessing each family member and addressing the family’s view of themselves. This is important in that each member brings on a different aspect to the direction of the treatment. Addressing how families view themselves is critical in formulating interventions.
  • Strengths/Limitations The authors exemplify the usefulness of solution-focused therapy through case studies. Though the model is practical and rational, its effectiveness is not yet supported. The authors mention the need for future research that evaluates this.
  •   Purpose To depict the usefulness of psychotherapeutic group interventions for survivors of suicide using narrative theory and structural analysis. Explanation of theory/theoretical concepts An eight-week psychoeducational support group consisting of five parts that ran two-hour sessions was held. An advanced practice psychiatric-mental health nurse and social worker facilitated the sessions in which seven members total attended all sessions. The first part of the program served as an introduction. The second part took place in weeks two through four and provided each participant the time to discuss their loss. The third part consisted of presentations about suicidology with updates on the most recent research. The fourth part focused on adaptive coping skills and strategies. The fifth part focused on termination of the group and discussing resources for ongoing support. Two types of narratives were discussed. Agentic narratives are described as “depicting events in such a way as to suggest the narrator is in control, despite disruption by traumatic life events” (p. 96). Victimic narratives are described as events “affecting the narrator’s life” and as being “controlled by outside forces” (p. 6). This study is not aimed at developing a particular form of narrative for suicide survivors but brings forth the usefulness of an approach in narrative therapy. Application to clinical practice In encouraging suicide survivors to share their personal narratives in agentic forms and motivate members of the group to provide feedback that encourages agentic narratives, survivors gained a sense of closure around the death independent of suicide. Agentic narratives reflect introspective and evaluative behavior, differentiating the actions of the decedent and the survivor. Victimic narratives shaped the control the decedent has on their life after the suicide and in turn disregards the impact of their own actions on the lives of others. The addition of a psychoeducation section in the group process brings an element to the group dynamic that maximizes the suicide survivor’s agentic narrative to move towards a “sense of the future” (p. 101). The education focuses on a neurobiological model that attributes the suicidal act to chemical changes that occur in the brain. In addition, education on adaptive coping strategies transitioned the more victimic narratives to agentic narratives. Participants saw that grief is part of resolution. The advanced practice family systems nurse may make use of this study’s approach in the clinical practice. Strengths/Limitation Motivating the use of agentic narratives as an approach in narrative therapy is depicted to have therapeutic effects on suicide survivors. Creating a support group made up of suicide survivors addresses the notion that bereavement following suicide is different from other types of death. Creating a support group that addresses their unique needs is exemplified in this study. Nonetheless, the authors note that further study is needed if agentic narratives do reflect adaptive coping. Limitations Cerel, J., Padgett, J.H., Conwell, Y. & Reed, G.A. (2009). A Call for Research: The Need to Better Understand the Impact of Support Groups for Suicide Survivors. Suicide and Life-Threatening Behavior, 39 (3), 269-281.   The wide use of support groups for suicide survivors has received little research. This article addresses the gap in research in this important tool. Since no research has been conducted on the longitudinal course of bereavement following suicide, the structuring of support groups is questionable. As the Cerel et al. (2009) state: A tension exists between the needs of survivors—who are currently in pain and looking for ways to find immediate help; and researchers—who need precise definitions to systematically study phenomenon…research should take place at several levels concurrently in order to clarify best practices. (p. 276) Some suicide survivors may seek help in the form of attending support groups at a later time as opposed to others who seek one immediately; no research is conducted about optimal timing for survivors to join a group. Factors that need addressing in structuring and framing support groups in an evidence-based way include (1) the type of facilitator that is needed to provide the best structure in support groups such as mental health professionals or a survivor leader, or combination of persons, (2) the grouping of survivor groups meaning do survivors maximize its potential if its members are all suicide survivors, (3) the re-narration of events supported to be beneficial or can they re-traumatize survivors, (4) duration of attendance, (5) rolling versus closed admission practices, setting and context, and (6) the theoretical orientations, e.g. family systems.
  •   Purpose To depict the usefulness of psychotherapeutic group interventions for survivors of suicide using narrative theory and structural analysis. Explanation of theory/theoretical concepts An eight-week psychoeducational support group consisting of five parts that ran two-hour sessions was held. An advanced practice psychiatric-mental health nurse and social worker facilitated the sessions in which seven members total attended all sessions. The first part of the program served as an introduction. The second part took place in weeks two through four and provided each participant the time to discuss their loss. The third part consisted of presentations about suicidology with updates on the most recent research. The fourth part focused on adaptive coping skills and strategies. The fifth part focused on termination of the group and discussing resources for ongoing support. Two types of narratives were discussed. Agentic narratives are described as “depicting events in such a way as to suggest the narrator is in control, despite disruption by traumatic life events” (p. 96). Victimic narratives are described as events “affecting the narrator’s life” and as being “controlled by outside forces” (p. 6). This study is not aimed at developing a particular form of narrative for suicide survivors but brings forth the usefulness of an approach in narrative therapy. Application to clinical practice In encouraging suicide survivors to share their personal narratives in agentic forms and motivate members of the group to provide feedback that encourages agentic narratives, survivors gained a sense of closure around the death independent of suicide. Agentic narratives reflect introspective and evaluative behavior, differentiating the actions of the decedent and the survivor. Victimic narratives shaped the control the decedent has on their life after the suicide and in turn disregards the impact of their own actions on the lives of others. The addition of a psychoeducation section in the group process brings an element to the group dynamic that maximizes the suicide survivor’s agentic narrative to move towards a “sense of the future” (p. 101). The education focuses on a neurobiological model that attributes the suicidal act to chemical changes that occur in the brain. In addition, education on adaptive coping strategies transitioned the more victimic narratives to agentic narratives. Participants saw that grief is part of resolution. The advanced practice family systems nurse may make use of this study’s approach in the clinical practice. Strengths/Limitation Motivating the use of agentic narratives as an approach in narrative therapy is depicted to have therapeutic effects on suicide survivors. Creating a support group made up of suicide survivors addresses the notion that bereavement following suicide is different from other types of death. Creating a support group that addresses their unique needs is exemplified in this study. Nonetheless, the authors note that further study is needed if agentic narratives do reflect adaptive coping. Limitations Cerel, J., Padgett, J.H., Conwell, Y. & Reed, G.A. (2009). A Call for Research: The Need to Better Understand the Impact of Support Groups for Suicide Survivors. Suicide and Life-Threatening Behavior, 39 (3), 269-281.   The wide use of support groups for suicide survivors has received little research. This article addresses the gap in research in this important tool. Since no research has been conducted on the longitudinal course of bereavement following suicide, the structuring of support groups is questionable. As the Cerel et al. (2009) state: A tension exists between the needs of survivors—who are currently in pain and looking for ways to find immediate help; and researchers—who need precise definitions to systematically study phenomenon…research should take place at several levels concurrently in order to clarify best practices. (p. 276) Some suicide survivors may seek help in the form of attending support groups at a later time as opposed to others who seek one immediately; no research is conducted about optimal timing for survivors to join a group. Factors that need addressing in structuring and framing support groups in an evidence-based way include (1) the type of facilitator that is needed to provide the best structure in support groups such as mental health professionals or a survivor leader, or combination of persons, (2) the grouping of survivor groups meaning do survivors maximize its potential if its members are all suicide survivors, (3) the re-narration of events supported to be beneficial or can they re-traumatize survivors, (4) duration of attendance, (5) rolling versus closed admission practices, setting and context, and (6) the theoretical orientations, e.g. family systems.
  •   Purpose To depict the usefulness of psychotherapeutic group interventions for survivors of suicide using narrative theory and structural analysis. Explanation of theory/theoretical concepts An eight-week psychoeducational support group consisting of five parts that ran two-hour sessions was held. An advanced practice psychiatric-mental health nurse and social worker facilitated the sessions in which seven members total attended all sessions. The first part of the program served as an introduction. The second part took place in weeks two through four and provided each participant the time to discuss their loss. The third part consisted of presentations about suicidology with updates on the most recent research. The fourth part focused on adaptive coping skills and strategies. The fifth part focused on termination of the group and discussing resources for ongoing support. Two types of narratives were discussed. Agentic narratives are described as “depicting events in such a way as to suggest the narrator is in control, despite disruption by traumatic life events” (p. 96). Victimic narratives are described as events “affecting the narrator’s life” and as being “controlled by outside forces” (p. 6). This study is not aimed at developing a particular form of narrative for suicide survivors but brings forth the usefulness of an approach in narrative therapy. Application to clinical practice In encouraging suicide survivors to share their personal narratives in agentic forms and motivate members of the group to provide feedback that encourages agentic narratives, survivors gained a sense of closure around the death independent of suicide. Agentic narratives reflect introspective and evaluative behavior, differentiating the actions of the decedent and the survivor. Victimic narratives shaped the control the decedent has on their life after the suicide and in turn disregards the impact of their own actions on the lives of others. The addition of a psychoeducation section in the group process brings an element to the group dynamic that maximizes the suicide survivor’s agentic narrative to move towards a “sense of the future” (p. 101). The education focuses on a neurobiological model that attributes the suicidal act to chemical changes that occur in the brain. In addition, education on adaptive coping strategies transitioned the more victimic narratives to agentic narratives. Participants saw that grief is part of resolution. The advanced practice family systems nurse may make use of this study’s approach in the clinical practice. Strengths/Limitation Motivating the use of agentic narratives as an approach in narrative therapy is depicted to have therapeutic effects on suicide survivors. Creating a support group made up of suicide survivors addresses the notion that bereavement following suicide is different from other types of death. Creating a support group that addresses their unique needs is exemplified in this study. Nonetheless, the authors note that further study is needed if agentic narratives do reflect adaptive coping. Limitations Cerel, J., Padgett, J.H., Conwell, Y. & Reed, G.A. (2009). A Call for Research: The Need to Better Understand the Impact of Support Groups for Suicide Survivors. Suicide and Life-Threatening Behavior, 39 (3), 269-281.   The wide use of support groups for suicide survivors has received little research. This article addresses the gap in research in this important tool. Since no research has been conducted on the longitudinal course of bereavement following suicide, the structuring of support groups is questionable. As the Cerel et al. (2009) state: A tension exists between the needs of survivors—who are currently in pain and looking for ways to find immediate help; and researchers—who need precise definitions to systematically study phenomenon…research should take place at several levels concurrently in order to clarify best practices. (p. 276) Some suicide survivors may seek help in the form of attending support groups at a later time as opposed to others who seek one immediately; no research is conducted about optimal timing for survivors to join a group. Factors that need addressing in structuring and framing support groups in an evidence-based way include (1) the type of facilitator that is needed to provide the best structure in support groups such as mental health professionals or a survivor leader, or combination of persons, (2) the grouping of survivor groups meaning do survivors maximize its potential if its members are all suicide survivors, (3) the re-narration of events supported to be beneficial or can they re-traumatize survivors, (4) duration of attendance, (5) rolling versus closed admission practices, setting and context, and (6) the theoretical orientations, e.g. family systems.
  • To determine if suicide survivors would seek help faster if an active postvention model (APM) were used compared to the traditional passive postvention model (PP) of referral. To determine if differences are present between individuals who receive APM compared to those who did not in terms of characteristics of suicide and decedent, clinical problems since the death, and engagement in group treatment. Explanation of theory/theoretical concepts Dataset from three hundred fifty-six suicide survivors presented at the Baton Rouge Crisis Intervention Center from 1999 to 2005 were analyzed. Participants in the APM and PP group were fairly homogenous in that most were female, only two to 2.4% were Black, and age range was 18 to 80 years old. Results show APM participants attended more support groups and were more likely to attend support group meetings. The decedents of APM recipients were more likely to have died a violent suicide method than nonviolent ones compared to PP recipients. Moreover, decedents of APM recipients had a history of receiving mental health treatment and suicide attempts. APM recipients also were less likely to receive suicide notes and were more likely to have discovered the decedent. Yet both groups experienced a previous history of suicide in their family alike. Results regarding clinical problems since the death show that APM and PP recipients showed no differences in clinical presentation. APM and PP recipients were equally likely to report problems with appetite, exercise, sleep, and concentration since the death. APM recipients were no more likely than PP recipients to report current suicidal ideation at the time of their intake. Application to clinical practice Providing an active postvention model showed recipients appearing more “tied into treatment” (p. 33). The authors also show that the sooner suicide survivors sought treatment, the less likelihood their acute problems may become chronic. It can be corroborated from this study that early assessment of suicide survivors is needed to help address the acute effects of the trauma that may be debilitating if not treated. Strengths/Limitations The homogeneity of the sample is a limitation in that it may not be a representative sample. The authors agree that the study represents a ‘self-referred’ sample and the need for a prospective study of survivors with more “finely tuned” measures of mental health is needed (p. 33). Nonetheless, the study adds to the body of knowledge on the necessary framework and construction of evidence-based postvention for suicide survivors.
  • To determine if suicide survivors would seek help faster if an active postvention model (APM) were used compared to the traditional passive postvention model (PP) of referral. To determine if differences are present between individuals who receive APM compared to those who did not in terms of characteristics of suicide and decedent, clinical problems since the death, and engagement in group treatment. Explanation of theory/theoretical concepts Dataset from three hundred fifty-six suicide survivors presented at the Baton Rouge Crisis Intervention Center from 1999 to 2005 were analyzed. Participants in the APM and PP group were fairly homogenous in that most were female, only two to 2.4% were Black, and age range was 18 to 80 years old. Results show APM participants attended more support groups and were more likely to attend support group meetings. The decedents of APM recipients were more likely to have died a violent suicide method than nonviolent ones compared to PP recipients. Moreover, decedents of APM recipients had a history of receiving mental health treatment and suicide attempts. APM recipients also were less likely to receive suicide notes and were more likely to have discovered the decedent. Yet both groups experienced a previous history of suicide in their family alike. Results regarding clinical problems since the death show that APM and PP recipients showed no differences in clinical presentation. APM and PP recipients were equally likely to report problems with appetite, exercise, sleep, and concentration since the death. APM recipients were no more likely than PP recipients to report current suicidal ideation at the time of their intake. Application to clinical practice Providing an active postvention model showed recipients appearing more “tied into treatment” (p. 33). The authors also show that the sooner suicide survivors sought treatment, the less likelihood their acute problems may become chronic. It can be corroborated from this study that early assessment of suicide survivors is needed to help address the acute effects of the trauma that may be debilitating if not treated. Strengths/Limitations The homogeneity of the sample is a limitation in that it may not be a representative sample. The authors agree that the study represents a ‘self-referred’ sample and the need for a prospective study of survivors with more “finely tuned” measures of mental health is needed (p. 33). Nonetheless, the study adds to the body of knowledge on the necessary framework and construction of evidence-based postvention for suicide survivors.
  • To determine if suicide survivors would seek help faster if an active postvention model (APM) were used compared to the traditional passive postvention model (PP) of referral. To determine if differences are present between individuals who receive APM compared to those who did not in terms of characteristics of suicide and decedent, clinical problems since the death, and engagement in group treatment. Explanation of theory/theoretical concepts Dataset from three hundred fifty-six suicide survivors presented at the Baton Rouge Crisis Intervention Center from 1999 to 2005 were analyzed. Participants in the APM and PP group were fairly homogenous in that most were female, only two to 2.4% were Black, and age range was 18 to 80 years old. Results show APM participants attended more support groups and were more likely to attend support group meetings. The decedents of APM recipients were more likely to have died a violent suicide method than nonviolent ones compared to PP recipients. Moreover, decedents of APM recipients had a history of receiving mental health treatment and suicide attempts. APM recipients also were less likely to receive suicide notes and were more likely to have discovered the decedent. Yet both groups experienced a previous history of suicide in their family alike. Results regarding clinical problems since the death show that APM and PP recipients showed no differences in clinical presentation. APM and PP recipients were equally likely to report problems with appetite, exercise, sleep, and concentration since the death. APM recipients were no more likely than PP recipients to report current suicidal ideation at the time of their intake. Application to clinical practice Providing an active postvention model showed recipients appearing more “tied into treatment” (p. 33). The authors also show that the sooner suicide survivors sought treatment, the less likelihood their acute problems may become chronic. It can be corroborated from this study that early assessment of suicide survivors is needed to help address the acute effects of the trauma that may be debilitating if not treated. Strengths/Limitations The homogeneity of the sample is a limitation in that it may not be a representative sample. The authors agree that the study represents a ‘self-referred’ sample and the need for a prospective study of survivors with more “finely tuned” measures of mental health is needed (p. 33). Nonetheless, the study adds to the body of knowledge on the necessary framework and construction of evidence-based postvention for suicide survivors.
  • For example, a four-year old may benefit from a one-on-one counseling session with their parent separate from their ten-year old and eighteen-year old sibling since the perspective of death and suicide are developmentally affected (Kaslow & Aronson, 2004).
  • For example, a four-year old may benefit from a one-on-one counseling session with their parent separate from their ten-year old and eighteen-year old sibling since the perspective of death and suicide are developmentally affected (Kaslow & Aronson, 2004).
  • With the incidence of suicide rate increasing, the likelihood that meeting a survivor of suicide is high.
  • With the incidence of suicide rate increasing, the likelihood that meeting a survivor of suicide is high.
  • The author of this report actually is affiliated at the Mclean Hospital with Harvard Medical School
  • Families Experiencing Loss Due to Death by Suicide

    1. 1. Families Experiencing Loss due to Death by Suicide: Family Systems Nursing Perspective Johana Seminiano, RN, BSN NU669-01- Family Nursing Theory Fall 2009 Professor Tucker
    2. 3. Terms <ul><li>Suicide - a conscious act of self-induced annihilation, best understood as a multidimensional malaise in needful individual who defines an issue for which the suicide is perceived as the best solution (Schneidman, 1985, as cited in Pompili, Lester, De Pisa, Del Casale, Tatarelli, & Girardi, 2009). </li></ul><ul><li>Suicide survivor - a family member or friend of a person who died by suicide (American Association of Suicidology. 2007) </li></ul><ul><ul><li>debateable </li></ul></ul><ul><li>Postvention - those activities developed by, with, or for suicide survivors, in order to facilitate recovery after suicide, and to prevent adverse outcomes including suicidal behavior (A ndriessen, 2009). </li></ul>
    3. 4. Family Systems Nurse <ul><li>The family systems nurse play an important role in postvention. </li></ul><ul><li>Individuals grieving a suicide death experience an elevated level of family dysfunction (Mitchell, Gale, Garand, & Wesner, 2003). </li></ul><ul><li>Suicide rates are twice as high in families of suicide decedents compared to families who has never experienced suicide (Mitchell, Gale, Garand, & Wesner, 2003) </li></ul>
    4. 5. Description of Population <ul><li>Suicide survivors are those who have been directly affected by a suicide loss </li></ul><ul><li>High risk for unresolved & complicated grief that if left untreated can traumatize the family system and potentially lead to generations of dysfunction </li></ul>
    5. 6. Description of Population <ul><li>90% of people who take their lives have a diagnosable and treatable psychiatric illness (AFSP, 2009) </li></ul><ul><li>In one study, 18% to 34% of suicide survivors reported maladjustment between 1 and 4 years after their loss with 2% of survivors experiencing psychiatric progression a year after the loss ( Cleiren & Diekstra 1995 as cited in Andriessen, 2009) </li></ul>
    6. 7. Incidence <ul><li>Suicide is the fourth leading cause of death for adults between age 18 and 65 years old and is the eleventh leading cause of death in the United States (National Center for Health Statistics, 2006 as cited in American Foundation for Suicide Prevention, 2009). </li></ul><ul><li>There are over 32,000 suicides annually in the US, with an estimated 6 survivors for every suicide (American Association of Suicidology, 2008). </li></ul>
    7. 8. Incidence Massachusetts Department of Public Health, Injury Surveillance Program (Sept. 2008). Suicides & Self-Inflicted Injuries in Massachusetts: Data Summary  In 2006, there were 437 suicides among Massachusetts residents; a rate of 6.8 per 100,000 residents.  The number of suicides was 2.4 times higher than homicides (N=437 and N=183 respectively) in 2006.  The total number of suicides among MA residents increased from 429 in 2004 to 469 in 2005, then decreased to 437 in 2006.  The suicide rate among MA residents is lower than that of the U.S. In 2005 (the latest statistics available nationally) the suicide rate for the U.S. was 11.0 per 100,000 residents compared to 7.3 per 100,000 for Massachusetts. Source: Registry of Vital Records and Statistics, MA Department of Public Health *Rates presented in this bulletin cannot be compared to bulletins published prior to 2008. Methods were changed to calculate rates based on all ages rather than only persons ages 10 and older which was the method previously used. Rates overall are only slightly lower due to this change. Figure 1. Suicide and Homicide Rates,* MA Residents, 1996-2006
    8. 9. Incidence Figure 2. Magnitude of Suicides and Self-Inflicted Injuries resulting in Acute Care Hospital Stays or Emergency Department Visits, MA Residents, 2006 118,000* In 2005, Samaritans organizations in Massachusetts responded to over 118,000 crisis calls. *this number includes repeat callers; individuals who contact the Samaritan hotlines more than once. 4,454 Hospital Stays for Self-Inflicted Injuries (FY2006) 437 Completed Suicides (2006) 6,969 Emergency Department Visits for Self-Inflicted Injuries (FY2006) Sources: see Methods section Massachusetts Department of Public Health, Injury Surveillance Program (Sept. 2008). Suicides & Self-Inflicted Injuries in Massachusetts: Data Summary
    9. 10. Review of the Literature <ul><li>Theoretical discussion on the role of social stigma </li></ul><ul><li>Discussion of a descriptive research on recommended family interventions </li></ul><ul><li>Discussion of an exploratory research on suicide survivors’ mental health and grief reactions </li></ul><ul><li>Clinical discussion on solution-focused therapy </li></ul><ul><li>Discussion of an explanatory research on narrative therapy </li></ul><ul><li>Discussion on a predictive research on suicide survivors seeking mental health services </li></ul>
    10. 11. Theoretical Discussion <ul><li>Suicide taboos and historical stigma. </li></ul><ul><li>Surgeon General’s definition of stigma (U.S. Department of Health & Human Services, 1999 as cited in Cvinar, 2005). </li></ul><ul><li>Suicide survivors felt blamed and avoided. </li></ul><ul><li>Survivors perceived themselves to be stigmatized or they were the objects of stigma. </li></ul><ul><li>Anger and family disintegration were found in bereaving suicide survivors. </li></ul><ul><li>Some cases saw survivors disconnecting themselves from their homes and moved to new environments. </li></ul>ROLE OF STIGMA
    11. 12. Theoretical Discussion <ul><li>Cohesive family units with good support mechanisms experienced less stigmatization. </li></ul><ul><li>The family unit </li></ul><ul><li>Development of programs for change </li></ul><ul><li>Author’s references from mid 1990s </li></ul><ul><li>Important to address stigma in postvention. </li></ul>ROLE OF STIGMA
    12. 13. Descriptive Research <ul><li>Family therapy is seen as the “treatment of choice” for suicide survivors used solely or with other adjunctive interventions </li></ul><ul><li>Five guiding approaches are used as a framework for therapists </li></ul><ul><ul><li>integrative model </li></ul></ul><ul><ul><li>systems theory </li></ul></ul><ul><ul><li>psychoeducational approaches </li></ul></ul><ul><ul><li>attachment theory </li></ul></ul><ul><ul><li>narrative models </li></ul></ul><ul><ul><li>postvention approaches </li></ul></ul><ul><li>Recommend taking to account family factors including individual families’ traditions and approaches to grieving </li></ul>FAMILY INTERVENTIONS
    13. 14. Exploratory Research <ul><li>Systematic review of studies by searching the PsychINFO and MEDLINE databases </li></ul><ul><li>Studies have to meet seven criteria </li></ul><ul><li>Only studies that utilized subscales on depression and anxiety were reported </li></ul><ul><li>Qualitative analysis of the data was conducted and results were categorized under concepts of mental health variables and grief variables </li></ul>MENTAL HEALTH & GRIEF REACTIONS
    14. 15. Exploratory Research <ul><li>Results show 41 out of 69 studies met the inclusion criteria </li></ul><ul><li>Studies show that suicide survivor groups are a heterogeneous group in that some experience a profound sense of grief and others experience relief </li></ul><ul><li>Few significant differences were found among mental health variables between survivor groups and other bereaved groups. </li></ul>MENTAL HEALTH & GRIEF REACTIONS
    15. 16. Exploratory Research <ul><li>Significant differences found in studies where instruments used targeted specific grief reactions & sensitive to variables important for suicide survivors </li></ul><ul><li>Results using specific instruments show that survivors experienced an increased level of rejection compared to other bereaved groups </li></ul><ul><li>Shame and stigma were found to be strong for suicide survivors </li></ul><ul><li>Survivors experience a low level of shock/unexpectedness, which is stated to prolong their grief experience </li></ul>MENTAL HEALTH & GRIEF REACTIONS
    16. 17. Exploratory Research <ul><li>No evidence support different reactions between suicide survivors and other bereaved groups </li></ul><ul><li>Limited data is available on the increased risk of suicide attempt by suicide survivors </li></ul><ul><li>There is an increased risk among family members of suicide completers in twin, adoption, and family studies </li></ul><ul><li>Limitation- no mention of how effective each recommendation is </li></ul>MENTAL HEALTH & GRIEF REACTIONS
    17. 18. Clinical discussion <ul><li>Solution-focused therapy is defined as a “strength-based model that helps clients resolve present problems by building on their existing resources and previously applied effective solutions” (p. 93). </li></ul><ul><li>Applicable to families coping with suicide in that it strengthens their internal coping mechanisms and past successful abilities in solving problems </li></ul><ul><li>It recognizes the notion that families know what is best for them and therefore addresses their “unique grief reactions” (p. 93) of coping with suicide. </li></ul>SOLUTION-FOCUSED THERAPY
    18. 19. Explanatory Research <ul><li>Study depicts the usefulness of narrative therapy on a psychotherapeutic group made up of suicide survivors </li></ul><ul><li>8 weeks, 2-hour sessions, 7 members in total attended all sessions, an advanced practice psychiatric-mental health nurse & social worker facilitated the sessions </li></ul><ul><li>(1) introduction, (2) weeks 2-4 provided each participant the time to discuss their loss, (3) presentations about Suicidology with updates on the most recent research, (4) adaptive coping skills and strategies, (5) termination of the group and discussing resources for ongoing support </li></ul>NARRATIVE THERAPY
    19. 20. Explanatory Research <ul><li>Two types of narratives were discussed: </li></ul><ul><ul><li>Agentic narratives are described as “depicting events in such a way as to suggest the narrator is in control, despite disruption by traumatic life events” (p. 96). </li></ul></ul><ul><ul><li>Victimic narratives are described as events “affecting the narrator’s life” and as being “controlled by outside forces” (p. 6). </li></ul></ul>NARRATIVE THERAPY
    20. 21. Explanatory Research <ul><li>Limitation on the use of narrative therapy on support groups composed of suicide survivors: </li></ul><ul><li>Type of facilitator needed to provide the best structure in support groups </li></ul><ul><li>Grouping of survivor groups meaning do survivors maximize its potential if its members are all suicide survivors </li></ul><ul><li>Re-narration of events supported to be beneficial or can they re-traumatize survivors </li></ul><ul><li>Duration of attendance </li></ul><ul><li>Rolling versus closed admission practices, setting and context </li></ul><ul><li>The theoretical orientations, e.g. family systems. </li></ul>NARRATIVE THERAPY
    21. 22. Predictive Research <ul><li>Determine if suicide survivors would seek help faster if an active postvention model (APM) were used compared to the traditional passive postvention model (PP) of referral </li></ul><ul><li>Determine if differences are present between individuals who receive APM compared to those who did not in terms of characteristics of suicide and decedent, clinical problems since the death, and engagement in group treatment </li></ul><ul><li>Dataset from 356 suicide survivors presented at the Baton Rouge Crisis Intervention Center from 1999 to 2005 were analyzed </li></ul>SEEKING MENTAL HEALTH SERVICES
    22. 23. Predictive Research <ul><li>Participants in the APM and PP group were fairly homogenous- most were female, only 2 to 2.4% were Black, age range 18 to 80 years old </li></ul><ul><li>Results show APM participants attended more support groups and were more likely to attend support group meetings </li></ul><ul><li>Decedents of APM recipients were more likely to have died a violent suicide method than nonviolent ones compared to PP recipients. </li></ul><ul><li>Decedents of APM recipients had a history of receiving mental health treatment and suicide attempts. </li></ul>SEEKING MENTAL HEALTH SERVICES
    23. 24. Predictive Research <ul><li>APM recipients also were less likely to receive suicide notes and were more likely to have discovered the decedent </li></ul><ul><li>Both groups experienced a previous history of suicide in their family alike. </li></ul><ul><li>Results regarding clinical problems since the death show that APM and PP recipients showed no differences in clinical presentation( problems with appetite, exercise, sleep, and concentration since the death) </li></ul><ul><li>APM recipients were no more likely than PP recipients to report current suicidal ideation at the time of their intake </li></ul>SEEKING MENTAL HEALTH SERVICES
    24. 25. Assessment <ul><li>Family problem of incomplete grief, unresolved grief, or ‘stuckness’. </li></ul><ul><li>Relational issues: dissatisfaction from renegotiating of relationships and reassignment of family tasks and roles, unnegotiated relationship issues, and stressed interpersonal relationships </li></ul><ul><li>Members of the family may experience problems such as behavioral disorders, compulsive disorders, anxiety attacks, suicidal ideation, sleeplessness, and decreased appetite, to name a few. </li></ul><ul><li>Family mapping—co-constructed by the family and the therapist—may be conducted to help locate trauma and loss and tracks responses of family members. </li></ul>
    25. 26. Assessment <ul><li>In addition, the following is included in the family assessment to better capture the qualities of their system: (Constance & Morrison, 2002) </li></ul><ul><ul><li>alliances and conflicts </li></ul></ul><ul><ul><li>level of autonomy of individuals and subsystems </li></ul></ul><ul><ul><li>openness and clarity of boundaries between family members </li></ul></ul><ul><ul><li>gender roles </li></ul></ul><ul><ul><li>ethnic considerations </li></ul></ul><ul><ul><li>religious orientation and spirituality of the family </li></ul></ul>
    26. 27. Assessment <ul><li>Assess the impact of the suicide, the family member’s relationship to the deceased, and perception of the deceased prior to death (Constance & Morrison, 2002) </li></ul><ul><li>An identified goal may be for the family to undergo the grief process while maintaining the integrity of the family system. Later goals may include forgiveness, restructuring of relationships, reassignment of tasks and roles, and participate in suicide prevention advocacy. </li></ul>
    27. 28. Counseling <ul><li>Response to suicide are varied and include powerful and painful emotions including stigma, blame, anger, guilt, shame, and searching for ‘why?’ </li></ul><ul><li>Framework used has to be meaningful to the family </li></ul><ul><li>Dependent upon the family’s past experience with grief and learned coping mechanisms, counseling should begin to where the family is </li></ul>
    28. 29. Counseling <ul><li>Culturally and developmentally appropriate counseling approach needs to be conducted </li></ul><ul><li>Family members may fear the realities of death and may undergo a cycle of pain and symptomatology. </li></ul><ul><li>Counseling should address ways in healthy or helpful grieving </li></ul>
    29. 30. Teaching <ul><li>Help family members anticipate and manage emotive-promoting events to help them normalize their extreme emotions and decrease anxiety so they may undertake their day-to- day activities </li></ul><ul><li>Provide tools that are fitting to each participant including relaxation techniques </li></ul><ul><li>Refer suicide survivors to sources that have the potential to satisfy their search for meaning of the loss such as support groups, family psychotherapeutic groups, psychoeducation sessions on suicide, and religious or spiritual groups </li></ul>
    30. 31. Leadership <ul><li>Need to advocate the strength of the family as a vehicle for moving its members to becoming ‘unstuck’ from their grief </li></ul><ul><li>Need to take leadership in the search for intervening effectively </li></ul>
    31. 32. Leadership <ul><li>Ensure adequate funding, gain social support, and shift social thinking surrounding suicide </li></ul><ul><ul><li>Speak at a legislative hearing to gain legislative support on acquiring funds for further research </li></ul></ul><ul><ul><li>Gain public attention on the importance of addressing factors and issues surrounding suicide </li></ul></ul><ul><ul><li>Shift social thinking on suicide by helping the media portray suicide away from the stigma suicide receives and in turn, the suicide survivors suffer </li></ul></ul><ul><ul><li>Help the profession of family systems nursing gain an awareness of their own attitudes and beliefs about survivors of suicide and gap in the body of knowledge surrounding the care of suicide survivors </li></ul></ul>
    32. 33. Case Study <ul><li>Pompili, M., Lester, D., De Pisa, E., Del Casale, A., Tatarelli, R., and Girardi, P. (2008). Surviving the Suicides of Significant Others: A Case Study. Crisis, 29 (1), pp 45-58 </li></ul><ul><li>Reports the case of a family which lost a member from suicide, depicts the deep psychache of survivors </li></ul><ul><li>Psychache- coined by Edwin Shneidman as the cause for suicide and described as the “hurt, anguish, soreness, aching, and psychological pain in the psyche (the mind)” </li></ul><ul><li>Suicide occurs when psychache is unbearable </li></ul><ul><li>Survivors experience profound grief that is often underestimated </li></ul>
    33. 35. Suicide Survivor’s Story <ul><li>http://www.youtube.com/watch?v=MvjEmRBuKiU </li></ul><ul><li>Lidia Bernik is the Director of Network Development for the National Suicide Prevention Lifeline </li></ul>
    34. 36. References <ul><li>American Foundation for Suicide (2009). Facts & Figures. Retrieved from www.afsp.org on November 11, 2009. </li></ul><ul><li>Andriessen, Karl. (2009). Can postvention be prevention? Crisis, 30 (1), 43-47. </li></ul><ul><li>Centers for Disease Control and Prevention (2001). State Suicide Prevention Planning: A CDC Research Brief . Retrieved from http://www.cdc.gov/ncipc/dvp/Suicide/state_suicide_prevention_planning.htm </li></ul><ul><li>Cerel, J., Padgett, J.H., Conwell, Y., & Reed, G.A. (2009). A call for research: The need to better understand the impact of support groups for suicide survivors. Suicide and Life-Threatening Behavior, 39 (3), 269-281. </li></ul><ul><li>Cerel, Julie & Cambell, F.R. (2008). Suicide Survivors Seeking Mental Health Services: A Preliminary Examination of the Role of an Active Postvention Model. Suicide and Life-Threatening Behavior, 38 (1), 30-34. </li></ul><ul><li>Constance, B. & Morrison, H. (2002). Survivors of Suicide: Emerging Counseling Strategies. Journal of Psychosocial Nursing and Mental Health Services, 40 (1), 28-39. </li></ul><ul><li>Cvinar, Jacqueline G. (2005). Do Suicide Survivors Suffer Social Stigma: A Review of the Literature. Perspectives in Psychiatric Care, 41 (1), 14-21. </li></ul>
    35. 37. References <ul><li>American Association of Suicidology (Jan. 2008). Survivors of Suicide Fact Sheet. Retrieved from http://www.suicidology.org/web/guest/stats-and-tools/fact-sheets </li></ul><ul><li>Pompili, M., Lester, D., De Pisa, E., Del Casale, A., Tatarelli, R., and Girardi, P. (2008). Surviving the Suicides of Significant Others: A Case Study. Crisis, 29 (1), pp 45-58. </li></ul><ul><li>Schneidman, E. S., Farberow, N. L. & Litman, R. E. (1970). The Psychology of Suicide . New York, N.Y.: Jason Aronson, Inc. </li></ul><ul><li>Sveen, C.A. & Walby, F.A. (2008). Suicide survivors’ mental health and grief Reactions: A systematic review of controlled Studies. Suicide and Life-Threatening Behavior, 38 (1), 13-29. </li></ul><ul><li>World Health Organization, Department of Mental Health (2005). Preventing Suicide: A Resource for Primary Health Care Workers (WHO/MNH/MBD Publication No. 00.4). Retrieved from www.who.int/mental_health/media/en/59.pdf . </li></ul>
    36. 38. References <ul><li>De Castro, Sahily & Guterman, J.T. (2008). Solution-focused therapy for families coping with suicide. Journal of Marital & Family Therapy, 34 (1), 93-106. </li></ul><ul><li>Horwitz, Susan H. (1997). Treating families with traumatic loss; Transitional family therapy. In Figley, C.R., Bride, B.E., and Mazza, N. (Ed.), Death and trauma; the traumatology of grieving (pp. 211-230). Washington, D.C. Taylor & Francis. </li></ul><ul><li>Kaslow, N.J. & Aronson, S.G. (2004). Recommendations for family interventions following a suicide. Professional Psychology: Research & Practice, 35 (3), 240-247. </li></ul><ul><li>National Institute of Mental Health (July 2009). Evidence-Based Prevention is Goal of Largest Ever Study on Suicide in the Military. Retrieved from http://www.nimh.nih.gov/science-news/2009/evidence-based-prevention-is-goal-of-largest-ever-study-of-suicide-in-the-military.shtml </li></ul><ul><li>National Institute of Mental Health (2001). Summary of National Strategy for Suicide Prevention: Goals and Objectives for Action . Retrieved from http://mentalhealth.samhsa.gov/suicideprevention/strategy.asp </li></ul><ul><li>Mitchell, A.M., Gale, D.D., Garand, L., and Wesner, S. (2003). The use of narrative data to inform the psychotherapeutic group process with survivors. Issues in Mental Health Nursing, 24, pp 91-106. </li></ul><ul><li>Murphy, S.A., Tapper, V.J., Johnson, L.C., Lohan, J. (2003). Suicide ideation among parents bereaved by the violent deaths of their children. Issues in Mental Health Nursing, 24 (5), 5-25. </li></ul>

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