Suicide Intervention Presentation, Nov. 8, 2012
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Suicide Intervention Presentation, Nov. 8, 2012

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Cleeve Briere, Coordinator, Crisis Management Service, Assistant Director, Saskatoon Crisis Intervention Services in Saskatoon spoke to SIAST Faculty and Staff about dealing with crisis of suicide.

Cleeve Briere, Coordinator, Crisis Management Service, Assistant Director, Saskatoon Crisis Intervention Services in Saskatoon spoke to SIAST Faculty and Staff about dealing with crisis of suicide.

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  • 1. We are not researchers, but practitioners, and our offerings are grounded in work experience and tempered with recourse to the literature.
  • Suicide gains meaning in several dimensions and we’ll go through a few The continuum from noble to ignobleAfter Socrates was convicted of two impious crimes: corrupting Greek youth and challenging the orthodoxy of beliefsHe was defiant at his trial, received the death penalty and rather than escape Athens as he ostensibly could have done, he decided to accept his fate: a) A philosopher should not fear death b) whereever he might go his questioning of all things would place him in the same conflict as in Athens and c) it would breach his principles regarding a citizen’s submission to the city state. He willingly drank the hemlock that killed him. (Death for a set of principles) Sue Rodriguez, with a debilitating terminal illness, amyotrophic lateral sclerosis, wanted to pre-plan her own death, an assisted suicide.The Supreme Court of Canada denied her request.In 1994 she died with the assistance of an anonymous physician. (Planned personal death but with the hope others would gain the right to assisted suicide)
  • Before Christianity , Greek and Roman cultures had moral space for suicideSamurai culture permitted suicide (seppuku) as a means of atonement for failure or as a form of protestMore recently in WW2 kamikaze pilots willfully sacrificed themselves by crashing into shipsIn India, the Sati custom expected women to self-immolate on the funeral pyre of their husband. Now outlawed.Islam prohibits suicide: what about the suicide bomber? Section 241 of the Can. Criminal Code considers it an offense either counsel suicide or to aid or abet suicideThe penalty is imprisonment for up to 14 years
  • My most difficult work experience - The burn unit at VGH : grown men crying in pain, knowing that the treatment of burns actually creates another equally painful donor site. Feeding burnt babies, infants,...witnessing the whimpering cries of desperation. The penultimate context of an inability to consoleFeelings of helplessness as a helper.These are for the most part people who had no means to commit suicide although their anguish was palpable. And while they may think of suicide they are seemingly driven to return to life. I tell this as it invoked in me thoughts of how one might entertain suicide as a form of relief.But this is the ground that informs those pursuing “assisted suicide” and euthanasia permissive policiesSwitzerland permits assisted suicide, I am troubled that they seemingly permit it only for those with protracted mental illness. My research may be incomplete.None of this territory is easy
  • All medical workers confront failure in their treatments, they even count their failure rates.Those of us who work with suicidal people must recognize that we too encounter a failure rateI mention this not to excuse malpractice or lesser practice in our helping efforts, but to acknowledge a dreadful reality that accompanies work with suicidal peopleWhat are the protectants at Kelsey for counsellors? What is the organizational culture around staying healthy?
  • Most of our focus with suicide is secondary prevention with an individual. The person is already thinking suicide and we try to assist the person with alternate optionsThe family bears a remarkable burden of shame and guilt in our society when a family member completes a suicidePrevention at the school, community, provincial, national and international levels are developing.We will share one model of a post-secondary institution’s strategy regarding suicide
  • This fact has especial significance for those of us in the fieldRapid safety assessments are paramountWeapons? Everything in a kitchen is arguably a weapon. Do not meet in a kitchen.
  • Multiple self-mutilations over several years. To end uncontrollable sensations running up and down the arms“Banging and Bumping”Parental funeral: deep arm wound, little bleedingMatter of fact referral to ER for wound stitchingRecall in hospital where a pathological culture of self harm occurred amongst adolescents. They were jamming sewing needles deep into their arms requiring surgical renewal. It had changed from a means of attending to highly uncomfortable feelings to a pathological means of group formation and acceptance.
  • Gender – MaleAge - 65 years – USA findings Marital status – single, widowed, divorcedEthnicity – Caucasians, Alaskan Indians, Native AmericansSexual orientation – gay, lesbian, bisexualSubstance use history – presentPrior suicide history – present, including aborted or interrupted attemptsPhysical illness – present, attention to chronic illness and chronic painPsychoses – present, especially command hallucinations
  • Psychological factors – hopelessness, impulsivity, aggression, hostility, anxietyHistory of self- mutilation – presentPsychiatric diagnosis – pay specific attention to major depressive disorder, biploar disorder (depressive or mixed), schizophrenia, subsstance use disorders, or personality disorders, particularly those in DSM- IVR as Cluster B- PD’s Social Factors – Lack of economic supports, drop in socioeconomic status, domestic partner violence, recent relationship problems, recent stressful event, recent loss, religious or cultural acceptance of suicideFamily history – positive history of suicideTherapeutic relationship – poor or lacking
  • Children - living in the homeLife satisfaction – positiveReligious beliefs – negative view of suicideCultural beliefs – negative view of suicideCoping skills – good with futuristic thinkingSocial supports – positive social supportsReality testing ability – positiveTherapeutic relationship - good
  • In a public place, in the home, in a vehicle, with someone, by yourself...Mental status: General behaviour and attitudeBehaviour and motor activitySpeech and languageFeeling, affect, and moodThought content and processesIntelligence and cognitionPerception and sensory experiencesImpulsivityJudgement and insight Mental Status Assessment: This is a biggie and we go through them one by one. It will take some time but I consider knowledge of this fundamental to assessing a client, in a non-crisis situation. Note that it does not specifically ask for substance use which is now mandatory for a good mental status exam. General appearance and attitude: Appearance includes physical characteristics, mannerisms, facial expression, clothing, and grooming. Attitude refers to how the client relates to the examiner and how the client comes across.Behaviour and motor activity: Includes physical activity, body movements, gestures, posture, and gait. Note the quantity and quality of the activity. Speech and language: Addresses fluency in English or another language and which is primary. Determine if the loudness and speed is consistent with the cultural group of origin. Note unusual speech patterns and how talkative the client is. Feeling, Affect and Mood: This concerns the emotions and mood that the client verbalizes and that the clinician observes and the observed affect. Determine whether the affect matches the feelings (is it appropriate?). Does the client shift quickly from one feeling state to another? i.e. Labile? The affect is the expression of the mood. Feels happy, therefore is singing. Thought content and processes: This addresses the themes and preoccupations evident in the client’s talk. Note unusual or unrealistic ideas. Describe the quality of the client’s thinking in his or her speech. Intelligence and cognition: The client’s general level of intelligence and intellectual functioning. Assess abstract thinking apart from education and culture. Evaluate orientation, memory, and consciousness. Perception or Sensory Experiences: This refers to the client’s ability to accurately perceive and process environmental stimuli. It explores whether the client has hallucinations, illusions, depersonalization, and/or derealization. Impulsivity: Is the client able to control aggressive, sexual or other impulses. Judgment and Insight: This addresses the client’s ability to distinguish among thoughts, feelings, and actions; to examine alternative solutions to a problem; and assume responsibility for and understand the consequences of his or her own behaviour. Ask whether the client has suicidal or homicidal ideations; and the extent to which the client acknowledges the presence of problems and his or her own role in their development
  • 1. Likelihood of concurrent disorders by diagnosis:Bipolar Disorder 61% Schizophrenia 47%Panic Disorder 36%Obsessive Compulsive 32%Affective Disorder 32%Anxiety Disorder 15%2. In the USA (2011) approximately 90% of all individuals who completed suicide met criteria for 1 or more diagnosable psychiatric conditions. Mental health conditions most strongly associated with fatal and nonfatal suicide attempts include depression, bipolar disorder, schizophrenia, posttraumatic stress disorder, and alcohol(Drug information on alcohol) and/or drug use disorders.
  • Prochaska and colleagues developed this Stage Model of ChangePrecontemplative: “not ready to change”: Validate lack of readinessEncourage re-evaluation of current behaviourEncourage self-exploration, not actionExplain and personalize the riskContemplative: “thinking of changing”Encourage evaluation of pros and cons of behaviour changeRe-evaluation of group image through group activitiesIdentify and promote new, positive outcome expectationsPreparation: “Ready to change”The client needs encouragement to evaluate pros and cons of behaviour changeThe therapist needs to identify and promote new, positive outcome expectations in the individualEncourage small initial stepsThese individuals have take some actions the past year such as joining a health education class, consulting a counsellor, talking to their physician, buying a self-help book, or relying on a self-change approachThis group of individuals are suitable for actions-oriented programs for smoking cessation, weight loss, or exercise programs4. Maintenance : “Staying on track” 1. plan for follow-up support 2. Reinforce internal rewards 3. Discuss coping with relapse5. Relapse: “Fall from grace” 1. Evaluate trigger for relapse 2. Reassess motivation and barriers 3. Plan stronger coping strategies6. Denning, Patt; Little, Jeannie; and Glickman, Adina: Over the Influence: The Harm Reduction Guide for Managing Drugs and Alcohol. Guilford Press: New York, 2004.
  • 1. Remember that you cannot counsel someone who is inebriated.
  • There are several models but this one is perhaps the best visual display of the components. ParadigmHoff’s Model robustly explains the origins of crisis and the potential of either positive or negative outcomes
  • The circle represents Tao - the undifferentiated Unity out of which all of existence arises. The black and white halves within the circle represent Yin-qi and Yang-qi - the primordial feminine and masculine energies whose interplay gives birth to the manifest world. One could not exist without the other, for each contains the essence of the other. Night becomes day, and day becomes night. Birth becomes death, and death becomes birth (think: composting). Along with noticing the "waves" of our daily experiences (e.g. thoughts, emotions, sensations & perceptions), we also stay tuned into the "ocean" out of which those waves arise, and into which they dissolve, continuously.It is this thinking which gives rise to the idea that crisis can only be understood as a time of danger and opportunity – one cannot exist without the other.As helpers our job is to assist the person in crisis (our client) to find the opportunity or opportunities that allow her or him to deal with the danger appropriately.
  • This is the Hoff Paradigm that sets out an explanation of the dynamics of crisis.Paradigm: an outstandingly clear or typical example or archetypeA paradigm is essentially a model, both aim to explain how matters unfold and proceedThis model invites our attention to move from:The origins of the crisisThe personal manifestations of the crisisThe aids to positive resolution of the crisisThe duality of outcomes:Positive crisis resolutionNegative resolution
  • The intertwined circles relate that the origins overlap; they may provide doorways to resolution. The following examples are not exclusive.Examples from the class: Situational States: (Please give some examples)Material: fire, natural disaster (tsunami, hurricane, flooding)Personal/Physical: heart attack, dx of fatal illness, loss of limb, body disfigurement from accident or diseaseInterpersonal: divorce, loss of loved one, SIDS deathTransitional States: (Please give some examples)1. Universal life passages such as the Erikson stages of development that may or may not resolve positively, the challenges for everyone2. Nonuniversal life passages such as student to worker, to homemaker, to immigration, to retirement5. Social/Cultural: (Please give some examples) 1. job loss stemming from discrimination due to age, gender, race, disability, or sexual identity. 2. deviant acts of others that violate social norms: rape, robbery, incest, marital infidelity, physical abuse 3. socially tolerated violence against children and women
  • Emotional :Anxiety: is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either the absence or presence of psychological stress, anxiety can create feelings of fear, worry, uneasiness and dread.[3] Anxiety is considered to be a normal reaction to a stressor. It may help a person to deal with a difficult situation by prompting one to cope with it. When anxiety becomes excessive, it may fall under the classification of an anxiety disorder.[4] The intensity and reasoning behind anxiety determines whether it is considered a normal or abnormal reactionDepression2. Biophysical Upsets: 1. upset stomach, perhaps to point of vomitting 2. disturbed sleep 3. loss of appetite3. Cognitive: 1.Feels unduly responsible for the crisis situation eg in SIDS death or that her beating was justified and unable to decide what to do4. Behavioural Changes: 1. alcohol or other substance abuse, 2. abuse of children 3. excusing partner violence5. Gather information through the lens of these factors to make your assessment
  • Emotional :Anxiety: is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either the absence or presence of psychological stress, anxiety can create feelings of fear, worry, uneasiness and dread.[3] Anxiety is considered to be a normal reaction to a stressor. It may help a person to deal with a difficult situation by prompting one to cope with it. When anxiety becomes excessive, it may fall under the classification of an anxiety disorder.[4] The intensity and reasoning behind anxiety determines whether it is considered a normal or abnormal reactionDepression2. Biophysical Upsets: 1. upset stomach, perhaps to point of vomitting 2. disturbed sleep 3. loss of appetite3. Cognitive: 1.Feels unduly responsible for the crisis situation eg in SIDS death or that her beating was justified and unable to decide what to do4. Behavioural Changes: 1. alcohol or other substance abuse, 2. abuse of children 3. excusing partner violence5. Gather information through the lens of these factors to make your assessment
  • What do mean here? This are types of intervention strategies that you may draw from.Traumatic Situations: Grief work: Bereavement is the response to any great loss. Grief work takes time.Grief work is a process of suffering that a bereaved person goes through on the way to a new life without the lost person, status or object of love. Grief includes numbness and somatic distress (tightness in the chest, need to sigh, shortness of breath, lack of muscular power)Grief includes pining and searching, anger and depressionA final turning to recovery
  • 1. Remember that there is no magic timeline to complete the personal work required for each of these steps
  • Material support: think of people who bring platters of food upon hearing of a death. Some offer assistance with transportation, other tasks associated with a tragedy, such as clean-up after a suicide or murderSocial Support: Inviting the survivor to a small gathering of friends or acquaintances, inviting out for a walk , to a garage sale, to a movie, to a soccer game, to a play, to accompany to churchCrisis Counselling: Decision counselling focuses on the client making decisions after clarifying what problem she thinks most important. With the client the crisis counsellor helps develop what options may be available to attend to that problem. It involves some after care or follow-up.Cultural Values/Social structuresThis level of intervention involves forms of social change. For example, violence against women originates in a paternalistic view of women and their roles that include obedienceI have not spent time on this form of intervention. Community development activities and strategies lead to change in social values. Can you think of some of these activities occurring where you live ?5. Transition States: From worker to student, new immigrant, from rural student to urban institute or college or university.
  • With negative resolution you can see in the diagram that the client returns to the crisis origins state.You can also see that it is possible for a client to go directly from manifesting crisis to negative resolution status. In practise, this means the person is essentially back at the starting point and may have to repeat the process more than once

Suicide Intervention Presentation, Nov. 8, 2012 Suicide Intervention Presentation, Nov. 8, 2012 Presentation Transcript

  • SIAST Kelsey Campus November 8, 2012
  •  Your questions Crisis Management Service, Saskatoon November 8, 2012 2
  • Mobile Crisis Service 933-6200Crisis Management Service 933-8234 103 506 25th Street East Saskatoon
  • Cleeve BriereCoordinator, Crisis Management Service Assistant Director Saskatoon Crisis Intervention Service cbriere@saskatooncrisis.ca Crisis Management Service, Saskatoon November 8, 2012 4
  • TO THEFROM THE NOBLE IGNOBLE, CATASTROPHIC o Socrates (399 BC) o Life is ..."solitary, poor, nasty, brutish, and short.” Thomas Hobbes , Leviathan, 1651 o Sue Rodriguez (1994) o Accidental o Altruistic suicide o Recreational drug use o For the benefit of others o Sharing needles (Is this suicide?) o Suicide by Police Crisis Management Service, Saskatoon November 8, 2012 5
  • MORE TOLERANCE LESS TOLERANCE Greek & Roman  Christianity o Moral space for suicide o An offense against God• Japan o Samurai era • Islam o Seppuku o Prohibited (Quran 4:29-30) o Kamikaze pilots • Canada• India o Criminal (Sec 241 C.C.C.) o Sati Crisis Management Service, Saskatoon November 8, 2012 6
  •  “the will to live”; transcendence; the unexplained mystery Biological, spiritual, cultural impulses The ultimate in pain and anguish “Assisted suicide” Euthanasia Crisis Management Service, Saskatoon November 8, 2012 7
  •  10/day die by suicide 50/day self harm Completed suicide 3:1 (Men:women) More women attemptA preventable epidemic Crisis Management Service, Saskatoon November 8, 2012 8
  •  Sigmund Freud committed suicide with morphine following an inoperable cancer Aggression turned inward Imbalance between Eros (life instinct)and Thanatos (death instinct) has severely fallen out of favour Crisis Management Service, Saskatoon November 8, 2012 9
  • Crisis Management Service, Saskatoon November 8, 2012 10
  •  There is a mortality and morbidity rate when working with suicidal persons Some die In other words, sometimes, despite our best efforts, our interventions fail With suicidal death there is, for the intervener, a risk of transforming into personal failure Families often experience this impact Crisis Management Service, Saskatoon November 8, 2012 11
  •  With Mental Disorder - 90% With Depression – Highest With Personality Disorder Substance Abuse Crisis Management Service, Saskatoon November 8, 2012 12
  •  Individual Family Community o the SIAST community o the Kelsey community Province National International Crisis Management Service, Saskatoon November 8, 2012 13
  •  Suicide is a form of homicideA murder of the self The direction of the anger may change Murder-suicide Crisis Management Service, Saskatoon November 8, 2012 14
  • “Suicide is not chosen, it happens when pain exceeds resources for coping with pain” The Samaritans www.metanoia.org/suicide Crisis Management Service, Saskatoon November 8, 2012 15
  •  Suicide attempt, gesture or self- harm/mutilation that does not result in suicide Strongest predictor of future completed suicide More frequent among adolescents and young adults About half of all completed suicides are preceded by parasuicide Crisis Management Service, Saskatoon November 8, 2012 16
  •  Distinguished by its utility o Relief of unbearable feelings o Feelings of unreality o Feeling of numbness• Not intended to kill• Client examples Crisis Management Service, Saskatoon November 8, 2012 17
  •  See Handout Crisis Management Service, Saskatoon November 8, 2012 18
  •  Sex (1) Age (1) Depression or hopelessness (2) Previous attempts or psychiatric care (1) Excessive alcohol or drug use (1) Rational thinking loss (2) Separated, divorced, or widowed (1) Organized or serious life threatening attempt (2) No social support (1) Stated future intent (2) Crisis Management Service, Saskatoon November 8, 2012 19
  •  Add all scores If score < 6: Consider outpatient management • Have friends or family stay with client • Remove weapons and medications • Arrange follow-up within 24 to 48 hours Crisis Management Service, Saskatoon November 8, 2012 20
  •  If score > 6: Consider psychiatric consult or admission Crisis Management Service, Saskatoon November 8, 2012 21
  •  Identify risk and protective factors Assess current presentation of suicidality Assess suicide history Substance Use – present and past Crisis Management Service, Saskatoon November 8, 2012 22
  •  Assessfor hopelessness, impulsivity, aggression, agit ation Psychiatric diagnosis? Psychosocial stressors Religiousand spiritual beliefs about death and suicide Management Service, Saskatoon November 8, 2012 Crisis 23
  •  Gender Age Marital status Ethnicity Sexual orientation Substance use history Prior suicide history Physical illness Psychoses Crisis Management Service, Saskatoon November 8, 2012 24
  •  Psychological factors History of self-mutilation Psychiatric diagnosis Social Factors Family history Therapeutic relationship Crisis Management Service, Saskatoon November 8, 2012 25
  •  Children LifeSatisfaction Religious beliefs Cultural beliefs Coping skills Social supports Reality testing ability Therapeutic relationship Crisis Management Service, Saskatoon November 8, 2012 26
  •  Location – where are you? Mental status Physical status Substance use and abuse Weapons Crisis Management Service, Saskatoon November 8, 2012 27
  •  Take all suicide “talkers” seriously When uncertain of your assessment, consult a senior colleague or psychiatrist’ Involve natural supports Re-assess regularly Crisis Management Service, Saskatoon November 8, 2012 28
  •  Document • Suicide risk assessment s • Comprehensive physical assessments • Natural supports concerns • Previous psychiatric history • Previous treatments, include key clinical decisions • Discharge plan, include who is to follow-up Crisis Management Service, Saskatoon November 8, 2012 29
  •  Training staff improves staff performance, better referrals, improves overall care Applied Suicide Intervention Skills Training (ASIST) – foundational Access to MH clinician to follow-up at ER presentations Timely clinical supervision and support for staff Culturally appropriate services Educational information about suicide Crisis services Crisis Management Service, Saskatoon November 8, 2012 30
  •  Informed consent Mental Health Services Act • Involuntary Detainment Health Information Act and Confidentiality Crisis Management Service, Saskatoon November 8, 2012 31
  •  Our mostly modern contribution Crisis Management Service, Saskatoon November 8, 2012 32
  •  Includes drugs of abuse, prescribed medications, toxin exposures Substance use disorders • Dependence • Abuse Substance induced disorders • intoxication, withdrawal, delirium, persistent dementia, • Amnesia, psychoses, mood disorder, anxiety disorder Polysubstance abuse Concurrent disorders Crisis Management Service, Saskatoon November 8, 2012 33
  •  Do not attempt to counsel clients “under the influence” Instead pursue physical safety planning Recall the Maslow hierarchy of needs to guide your intervention Crisis Management Service, Saskatoon November 8, 2012 34
  • Crisis Management Service, Saskatoon November 8, 2012 35
  •  First order symptoms – Physical (2) • Insomnia • Vivid dreams • Nausea • Diarrhea • Headache • Elevated vital signs • Cravings Crisis Management Service, Saskatoon November 8, 2012 36
  •  Second order symptoms – defense structures • Rationalization – makes irrational excuses to explain behaviour • Justification – Statements that justify the individual’s actions • Minimization – Making light of the extent and severity of the illness • Externalization – Blaming others for the progression of the disease Crisis Management Service, Saskatoon November 8, 2012 37
  •  Third order symptoms- feelings/emotional responses • Anger that the individual is unable to ever drink safely again • Fear of potential consequences of past actions and what the future may hold Crisis Management Service, Saskatoon November 8, 2012 38
  •  Third order symptoms- feelings/emotional responses (2) • Loss associated with substance use ( job, family, financial stability, sense of self) • Guilt over things done while drinking and using • Shame over what the individual perceives they have become Crisis Management Service, Saskatoon November 8, 2012 39
  •  Psychosocial and lethality assessment Psychological contact, relationship and rapport Establish dimensions of problem, help client connect the dots Focus on here and how – connect substance use activity to current crisis Encourage feelings and emotion Explore and assess past coping attempts Crisis Management Service, Saskatoon November 8, 2012 40
  •  Restorecognitive functioning by developing a plan • Focus on specific event that led to crisis • Let client self-define the specific meaning o f the crisis event, how it conflicts with goals, beliefs, and self-expectations • Know your local substance use treatment continuum (detoxification, social detoxification, outpatient counselling, inpatient treatment, maintenance) Crisis Management Service, Saskatoon November 8, 2012 41
  •  Restorecognitive functioning by developing a plan • To develop cognitive mastery • Need to restructure , rebuild, replace irrational beliefs and erroneous cognitions • Provide new information about recovery through counselling, homework assignments, referral to support groups Crisis Management Service, Saskatoon November 8, 2012 42
  • Lee Ann HoffCrisis Management Service, Saskatoon November 8, 2012 43
  • Crisis Management Service, Saskatoon November 8, 2012 44
  •  To assist the person to return to their pre- crisis level of functioning To achieve growth and development With an enhanced coping repertoire Crisis Management Service, Saskatoon November 8, 2012 45
  •  Situational • Material • Personal/physical • Interpersonal loss  Transitional • Life passages Social/Cultural  Values  Socialization  Deviance  Conflict Crisis Management Service, Saskatoon November 8, 2012 47
  •  Emotional  Cognitive • Anxiety • Interference in usual • Fear problem solving ability • Anger • Guilt • Shame  Behavioural Changes Biophysical upsets Crisis Management Service, Saskatoon November 8, 2012 48
  •  Emotional  Cognitive • Anxiety • Interference in usual • Fear problem solving ability • Anger • Guilt • Shame  Behavioural Changes Biophysical upsets Crisis Management Service, Saskatoon November 8, 2012 49
  •  Traumatic situations • Grief work • Material aid • Social support • Crisis counselling Cultural values/Social Structure social change strategies Transition States contemporary rites of passage Crisis Management Service, Saskatoon November 8, 2012 50
  •  Acceptance of the pain of loss Openexpression of pain, sorrow, hostility, and guilt Understanding of the intense feelings associated with loss Resumption of normal activities and social relationships without the person lost Crisis Management Service, Saskatoon November 8, 2012 51
  •  Material Support Social Support Crisis Counselling Cultural values/Social structures  Social change strategies Transition States Crisis Management Service, Saskatoon November 8, 2012 52
  • Negative outcomes Emotional/mental disturbance Violence against others Self destruction Addictions Crisis Management Service, Saskatoon November 8, 2012 53