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Helping All Who Are Exposed: A New View of Suicide Loss

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A new conceptual framework proposes that offering assistance to people in the aftermath of suicide ought to include everyone who is exposed to a fatality (Cerel, McIntosh, Neimeyer, Maple, & Marshall, 2014). This view, if adopted by the field, would significantly expand, focus, and strengthen the delivery of postvention services. The graphic above illustrates how the proposed categories are nested within one another and describes each one: Suicide Exposed, Suicide Affected, and Suicide Bereaved Short-Term and Long-Term. Delivering services and support based on this perspective would reach many people whose needs are currently not being addressed (or addressed only marginally); and, just as importantly, doing so would help grief support practitioners and researchers clearly identify different populations in need and tailor interventions to assist them effectively. Determining how a particular individual might be categorized would not be linked to the person’s designation, role, or relationship in reference to the deceased. Rather, each person’s reaction to the death would determine the category into which he or she would be classified.

The Grief After Suicide blog post about this essay is at http://bit.ly/falloutsuicide.

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Helping All Who Are Exposed: A New View of Suicide Loss

  1. 1. 1 "Helping All Who Are Exposed: A New View of Suicide Loss" is based on Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines (2015), by the Survivors of Suicide Loss Task Force (bit.ly/sosl-taskforce) of the National Action Alliance for Suicide Prevention. The original document is available free for download at bit.ly/respondingsuicide. Helping All Who Are Exposed: A New View of Suicide Loss Special report❋ A new conceptual framework proposes that offering assistance to people in the aftermath of suicide ought to include everyone who is exposed to a fatality (Cerel, McIntosh, Neimeyer, Maple, & Marshall, 2014). This view, if adopted by the field, would significantly expand, focus, and strengthen the delivery of postvention services. The graphic above illustrates how the proposed categories are nested within one another and describes each one: Suicide Exposed, Suicide Affected, and Suicide Bereaved Short-Term and Long-Term. Delivering services and support based on this perspective would reach many people whose needs are currently not being addressed (or addressed only marginally); and, just as importantly, doing so would help grief support practitioners and researchers clearly identify different populations in need and tailor interventions to assist them effectively. ❋ The source document for this report is Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines, by the Survivors of Suicide Loss Task Force of the National Action Alliance for Suicide Prevention. The use of the Action Alliance logo is intended to credit the SOSL TF as the author of the source document. May 13, 2015
  2. 2. 2 Determining how a particular individual might be categorized would not be linked to the person’s designation, role, or relationship in reference to the deceased. Rather, each person’s reaction to the death would determine the category into which he or she would be classified. In order to better understand the framework, let us consider the hypothetical example of a married man with children, who died by suicide at his workplace. The categories around which the framework is structured make it possible to organize everyone who experienced the suicide into a hierarchy that accounts for each person’s reactions and needs in specific ways. Suicide Exposed Everyone who experiences any connection whatsoever to the deceased or to the occurrence of the suicide would initially be categorized as Suicide Exposed. This would include, in our example, the man’s family, friends, colleagues, neighbors, and members of his faith community. Also included would be the professionals who cared for him before his death and those who, afterward, assisted with the funeral. In addition, members of the public who learned about and reacted to the death would be among those categorized as Suicide Exposed. People who remain in this category would be people who have little or no problematic reaction to the suicide or who experience transitory shock, disquietude, or short-term, low-level sadness over the death or its effects on the deceased’s loved ones. But they would experience no significant or lasting disruption of their functioning or well- being. Their reactions would be self-limiting or require only informal assistance from those in their natural circles of support. But those originally categorized among the Suicide Exposed who have a more palpable reaction to the suicide would be placed into one of the additional categories, below—and, if their reactions fluctuate in intensity or quality, also could be classified successively in more than one other category. Suicide Affected Those categorized as Suicide Affected are differentiated from the Suicide Exposed by the increased severity of their reaction to the death. They are differentiated from the Suicide Bereaved Short-Term and Long-Term in the nature of their reaction (namely, even if their reation is severe, it is not primarily focused on grief and loss). Included in this category in our hypothetical case would be the custodian who found the deceased’s body— who was a Vietnam veteran and was having flashbacks related to the death scene that interfered with his ability to function. Another person categorized as Suicide Affected would be a fellow employee, a young woman who did not work directly with the deceased but who suffered from depression and, after the death, experienced a major depressive episode accompanied by suicidal ideation. People categorized as Suicide Affected likely would benefit from some kind of assistance or support, which may be informal help from their social and family networks or from community-based programs, or it may be formal
  3. 3. 3 clinical treatment from a professional. The effects of the exposure could be mildly, moderately, or severely troublesome and could be short-term or longer-term—but people’s struggles would not be directly related to bereavement over loss of the personal relationship with the deceased. Suicide Bereaved Short-Term The Suicide Bereaved Short-Term are people who, beyond having a connection to the deceased and/or to the death, are experiencing a grief reaction to the loss (for example, separation distress or other bereavement- related emotions such as guilt, shame, or anger). This might involve a relatively typical course of grief✜ or a higher level of distress for a longer period of time (perhaps for several months or a year). Regardless of the details, at some point in time, the Suicide Bereaved Short-Term are those who are able to integrate their experience of loss into their life. In the case of the man who died by suicide at his workplace, the members of the deceased’s immediate family would be among the Suicide Bereaved Short- Term as would members of the deceased’s extended family who experienced a grief reaction to his death. It would also include a close colleague who worked regularly with him for many years and noticed, before his suicide, that he was having psychological difficulties and tried to help him. Also, because of the closeness of the relationships involved, the man’s lifelong primary care physician and a high school friend who grew up with the man and stayed in touch with him would be categorized as Short-Term Bereaved. People in this category may need a great deal of assistance and support, including professional counseling; they may go to great lengths to cope with their grief on their own or with only the help of their most intimate family and friends; or they may cope with the loss through means that are not readily apparent to others. Most—even over the span of their lifetime—will feel occasional pangs of grief, periodically yearn for the company of the deceased, and at times lose themselves in memories or regrets about the deceased. But—however painful their journey might be—they recover all of their functioning and heal from their grief much the same as the majority of people do after experiencing the death by any cause of someone to whom they are emotionally close. Suicide Bereaved Long-Term People who continue to suffer significant aftereffects from the death for an extended period of time and who do not experience a reasonable restitution of their normal functioning would be categorized as Suicide Bereaved Long- Term. In our case example, the man’s wife—a year and a half after his death❊ —continued to have trouble sleeping and often took sick leave because she felt exhausted. She feared that her job was at risk even though ✜  It is at this level of categorization that standards are needed to describe a typical course of grief after suicide and to establish the duration that separates Suicide Beraved Short-Term from Suicide Beraved Long-Term.   ❊  The question of duration in diagnosing clinical conditions related to bereavement has long been problematic—and a subject of considerable debate. For example, the proposed diagnosis of Persistent Complex Bereavement Disorder included in Section III of the recently released DSM 5 under the category “Conditions for Further Study” designates one year as its benchmark for duration (American Psychiatric Association, 2013).  
  4. 4. 4 her employer had been very sympathetic toward her. She still frequently and unpredictably became uncontrollably angry or unconsolably distraught about her husband’s death, and she was becoming increasingly isolated from her friends and from her children—who said they were very worried but didn’t know how to help her. She had made half a dozen attempts to get help—from a psychiatrist, a grief counselor, a support group, a clergyperson—but each attempt was cut short by her frustration over her feeling that people were not able to understand her. She would fit into the Suicide Bereaved Long-Term category. Anyone in a close relationship might be among the Suicide Bereaved Long- Term—the deceased’s spouse, partner, child, sibling, parent, longtime best friend, etc. They would experience a high level of distress for a considerable period of time (at least a year and up to a lifetime). They might exhibit diagnostic levels of complicated grief, depression, or posttraumatic stress that would require professional treatment (American Psychiatric Association, 2013; Stroebe, Schut, & Van den Bout, 2013). They might try various kinds of assistance or repeatedly seek help without noting any improvement in the severity of their grief. Most would experience the loss as a seminal event in their own life narrative and report that they have been substantially changed by the suicide (Andriessen, 2009; Andriessen, Beautrais, Grad, Brockmann, & Simkin, 2007). Many feel that they have been permanently depleted or damaged. Most people in the Suicide Bereaved Long-Term category would benefit from assessment and treatment by a clinician competent in psychotherapeutic interventions that are effective in helping someone whose grief is being exacerbated by depression; by prolonged, unresolved deleterious aftereffects of a death; or by other complications. It is also possible that appropriate pharmocological therapy could be helpful to some people. REFERENCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disor-ders (5th ed.). Arlington, VA: American Psychiatric Publishing. Andriessen, K. (2009). Can postvention be prevention? Crisis: The Journal of Crisis Intervention and Suicide Prevention, 30(1), 43-47. doi: 10.1027/0227- 5910.30.1.43 Andriessen, K., Beautrais, A., Grad, O. T., Brockmann, E., & Simkin, S. (2007). Current understandings of suicide survivor issues: Research, practice, and plans: Report of the 1st International Suicide Postvention Seminar, September 8, 2006, Portoroz, Slovenia. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 28(4), 211-213. doi: 10.1027/0227- 5910.28.4.211 Cerel, J., McIntosh, J. L., Neimeyer, R. A., Maple, M., & Marshall, D. (2014). The continuum of survivorship: Definitional issues in the aftermath of suicide. Suicide and Life-Threatening Behavior, 44, 591-600. doi: 10.1111/sltb.12093 Stroebe, M., Schut, H., & Van den Bout, J. (Eds.). (2013). Complicated grief: Scientific foundations for health care professionals. New York: Routledge.

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