1.
"Systems Must Include Three Levels of Care for Aftermath of
Suicide" is based on Responding to Grief, Trauma, and Distress
After a Suicide: U.S. National Guidelines (2015), by the National
Action Alliance for Suicide Prevention’s Survivors of Suicide
Loss Task Force (bit.ly/sosl-taskforce). Download the original
document at bit.ly/respondingsuicide.

2. 1
Providing Information After a Suicide
Goal 6 of the guidelines is to “ensure that people exposed to a suicide
receive essential and appropriate information”—which is a goal that applies
across all three of the levels of care, above. The Addendum to this document,
“Information for People Exposed to a Suicide” (pp. 5-6), enumerates Goal 6
and its objectives and outlines in general the kinds of information that is
valuable to people exposed to a suicide. An online directory, After a Suicide:
Coping with Grief, Trauma, and Distress, is available at bit.ly/afterasuicide.
"Systems Must Include Three Levels of Care for Aftermath of
Suicide" is based on Responding to Grief, Trauma, and Distress
After a Suicide: U.S. National Guidelines (2015), by the National
Action Alliance for Suicide Prevention’s Survivors of Suicide
Loss Task Force (bit.ly/sosl-taskforce). Download the original
document at bit.ly/respondingsuicide.
Systems Must Include Three Levels of Care for Aftermath of Suicide
Special report❋
Responding to Grief, Trauma, and Distress After a Suicide: U.S. National
Guidelines views the aftermath of suicide from a long-term, systems
perspective and outlines three levels of care to address the needs of
everyone who is exposed to a fatality:
1. An immediate response, which has three essential components:
crisis
response, triage (primarily, identification of high-risk individuals),
and follow-up across systems
2. Support focused on helping people cope with grief and heal from loss,
including delivering emotional assistance and personal guidance as
well as psychoeducation about suicide, grief, trauma, and self-care
3. Treatment provided by licensed mental health or medical providers
and focused on acute or chronic mental health issues, trauma, and
other debilitating conditions related to exposure to suicide
Immediate Response After a Suicide
Developing and maintaining programs, services, resources, and systems for
responding immediately after a suicide could be informed, according to the
guidelines, by principles from fields such as disaster response and mental
health crisis response that are based on best practices, research evidence,
and/or consensus among practitioners and experts.
❋
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 28, 2015

3. 2
Here are two examples of principles from the fields of disaster and crisis
response that broadly apply to suicide postvention, which might provide a
starting place for strategic planning related to responding to suicide:
• Hobfoll and colleagues (2007) assembled a worldwide panel of experts
to consider what is known about responding to disasters and mass
violence and “identified five empirically supported intervention
principles that should be used to guide and inform intervention and
prevention efforts at the early to mid-term stages.” As is noted in the
guidelines, these include promoting safety, calm, hope,
connectedness, and self-efficacy (as well as community-efficacy).
• The Center for Mental Health Services has put forward its own practice
guidelines, based on expert consensus, for responding to mental
health crises, (see the blog post “Mental Health Crisis Response
Principles Apply to Aftermath of Suicide” at bit.ly/mhcrisisresponse).
Principles such as these have influenced the implementation of a number of
response models—including, for example, Psychological First Aid (Brymer et
al., 2006) and Skills for Psychological Recovery (Berkowitz et al., 2010).
Approaches such as these likely merit consideration as sources for guiding
suicide postvention program development. Here, for instance, are the "Core
Actions" of PFA, along with their respective goals (Brymer et al., 2006, p.19):✜
1. Contact and Engagement ... To respond to contacts initiated by
survivors, or to initiate contacts in a non-intrusive, compassionate,
and helpful manner.
2. Safety and Comfort ... To enhance immediate and ongoing safety, and
provide physical and emotional comfort.
3. Stabilization (if needed) ... To calm and orient emotionally
overwhelmed or disoriented survivors.
4. Information Gathering: Current Needs and Concerns ... To identify
immediate needs and concerns, gather additional information, and
tailor Psychological First Aid interventions.
5. Practical Assistance ... To offer practical help to survivors in
addressing immediate needs and concerns.
6. Connection with Social Supports ... To help establish brief or ongoing
contacts with primary support persons and other sources of support,
including family members, friends, and community helping resources.
7. Information on Coping ... To provide information about stress
reactions and coping to reduce distress and promote adaptive
functioning.
8. Linkage with Collaborative Services ... To link survivors with available
services needed at the time or in the future.
Overlapping Levels of Care
All three levels of care include, to some extent, overlapping approaches to
caring for people who have experienced a negative impact from being
✜
It should be noted that PFA is widely implemented and is supported with technical
assistance and training by its developers, National Child Traumatic Stress Network
(bit.ly/pfaonline) and the National Center for PTSD (bit.ly/psych1staid).

4. 3
exposed to a suicide, and it is especially important to distinguish the next
two levels—support and treatment—from one another. They are
distinguished primarily by whether there are clearly circumscribed clinical
interventions being applied to deal with a diagnosed mental health condition.
Generally, if the intervention is not being applied in response to a formal
diagnoses, then it constitutes support; and if the response is related to a
diagnosis, then it is treatment). On one hand, support can be delivered either
by almost any kind of grief support practitioner or by a practitioner who is
licensed as a mental health (or medical) clinician while, on the other hand,
treatment can be delivered only by a clinician licensed to treat a diagnosis.
As the guidelines state in the introduction to Strategic Direction 3 state:
Most people who experience the death of someone close to them, includ-
ing people bereaved by suicide, more or less successfully navigate the
course of their grief without specialized or professional assistance. But
suicide loss commonly affects people in especially deleterious or long-
lasting ways. The goals and objectives in this strategic direction address
the roles of all kinds of service providers in assisting the bereaved, taking
into account the impact of suicide and loss survivors’ need for compas-
sionate understanding and support from all quarters—as well as the
possibility that they may require professional assistance [i.e., treatment]
in their healing. (Emphasis added.)
The first set of objectives in Strategic Direction 3 (Treatment and Support
Services) identify characteristics that approaches to treatment and support
share in common, namely, that they are “accessible, adequate, consistent,
and coordinated across systems of care." This also includes that they:
• Are based on evidence of effectiveness and/or are congruent with
widely accepted principles being applied in practice in the field
• Take into account the diverse needs and socio-cultural perspectives of
various individuals, families, and communities
• Include provisions for identifying acute or debilitating conditions that
might require additional resources and/or a higher level of care
• Promote communication and collaboration between and among
support services and clinical services
Support After a Suicide
Support services focused on suicide grief, according to Goal 9 of the
guidelines, ought to “provide an array of assistance, programs, and
resources that help bereaved individuals and families cope with and recover
from the effects of their loss to suicide.” The Goal 9 objectives focus on
developing and maintaining the infrastructure for three broad categories of
caregivers to deliver “information, emotional support, and guidance … and
psychoeducation about suicide, grief, trauma, and effective self-care.”
The categories:
• Professional caregivers, such as grief counselors, mental health and
social work practitioners, physicians, and nurses, etc. (these are the
same kinds of licensed caregivers who deliver treatment for a
diagnosed condition and are discussed under “Treatment,” below)

5. 4
• Community caregivers, such as funeral directors, faith leaders, and
chaplains, volunteer grief support helpers, hospice staff, school
counselors, social services workers
• Peer-to-peer helpers, suchas those working face-to-face in mutual-help
groups and one-on-one, through the telephone and Internet, and at
activities such as healing conferences, retreats, and memorial services
Treatment After a Suicide
Professional clinical services, according to the guidelines, must provide an
array of treatment, programs, and resources that help people affected by
unremitting or complicated grief, PTSD, depression, suicidality, and other
acute or potentially debilitating conditions. As is noted above, these services
are delivered by licensed practitioners who are treating a diagnosis.
The guidelines recommend the following:
• That licensed practitioners possess broad competencies in a discipline
such as psychiatry, psychology, counseling, social work, etc., and
specialized knowledge of and experience with people exposed to
suicide
• That medical interventions, such as pharmacotherapy, be part of the
continuum of services available, but not be used as a substitute for
therapy or other psychosocial treatments
• That services be provided at appropriate times across the lifespan of
the suicide bereaved, using approaches relevant to the needs,
strengths, and preferences of the client and including access to
various modalities, such as individual, couple, family, and group
therapy
Conclusion: The levels of care for support and treatment are covered
briefly, above, primarily to share how the guidelines describe these broad
concepts. It is very important to note that the guidelines characterize caring
for the suicide bereaved as “an emerging field of practice” and call in Goal 4
for the nation to “create the infrastructure and delivery systems for training
a wide array of service providers in suicide bereavement support and
treatment and in minimizing the adverse effects of exposure to suicide.”
In order for that to happen, as the objectives for Goal 4 point out, grief
support practitioners of every kind and in every setting and system must be
trained in and supported to fully implement as part of their work in
postvention:
• The principles and practices that apply to effectively responding to
the aftermath of suicide as a mental health crisis
• A variety of approaches to support the suicide bereaved effectively by
helping them cope with their grief and heal from their loss
• Treatment services that effectively remedy or ameliorate acute or
chronic mental health issues, trauma, and other debilitating condi-
tions related to exposure to suicide

6. 5
ADDENDUM: INFORMATION FOR PEOPLE EXPOSED TO A SUICIDE
[Excerpted from 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.]
Goal 6: Ensure that people exposed to a suicide receive essential and
appropriate information.
• Objective 6.1: Enable all service providers who are likely to encounter
people exposed to suicide to distribute accurate and helpful
information to them.
• Objective 6.2: Make information about support and professional
resources available through a centralized source that people exposed
to suicide can readily access in local communities and nationally [e.g.,
see After a Suicide: Coping with Grief, Trauma, and Distress, a free
online clearinghous, available at bit.ly/afterasuicide].
• Objective 6.3: Provide the deceased’s next of kin ready access to
information regarding:
• The fatality, such as the location, manner, and time of the death
• Legal matters, such as police investigations, death notification,
autopsy, suicide note, and the rights of people bereaved by
suicide
• Practical matters, such as regarding the deceased’s personal
effects, making funeral arrangements, and financial and estate
issues
• Objective 6.4: Ensure that people exposed to a suicide have access to
information that is applicable to their age and circumstances
(including children and adolescents). This should include information
regarding suicide bereavement, suicide risk, and mental illness; how
to cope with grief, loss, and trauma; contacts for grief support and
professional assistance; recommendations for reading materials and
other resources; and guidance on handling interactions with the
media. Systematically provide concise, essential information to the
newly bereaved.
• Objective 6.5: Develop and/or disseminate guidelines for people
bereaved by suicide to help them interact with the media and
entertainment industry, on the Internet, and in other public settings
in ways that promote healing and recovery from their grief and are in
keeping with guidelines for safe and helpful messages about suicide
prevention. (See Goal 3 of the guidelines.)

7. 6
From APPENDIX C (“Resources: Supporting the Suicide Bereaved”), which includes a
directory of resources from the online clearinghouse After a Suicide: Coping with
Grief, Trauma, and Distress at bit.ly/afterasuicide.
People bereaved by suicide are likely to find the following types of
information helpful:
• Information about caring for themselves:
• How to cope with grief, loss, and trauma and how other loss
survivors have coped
• Conditions or developments related to the loss that might
require additional or more intensive assistance
• How and what to tell children about the suicide death of
someone with whom they have a close relationship
• Impact of suicide on families and strategies for enhancing
family communication and functioning after suicide
• Information about the nature of suicide bereavement:
• Grief in general and what the experience and evolution of
mourning is like
• Common reactions to suicide loss, such as intense grief, trauma
symptoms, guilt, and preoccupation with why the suicide
occurred
• Physiological responses, such as sleep disruption, appetite loss,
and difficulty concentrating or making decisions
• Severe or long-term reactions, such as depression, increased
anxiety or hypervigilance, a changed view of the world, strain in
interpersonal relationships, and the possibility of posttraumatic
growth
• Contact information for programs, services, and treatment:
• Medical, mental health, and other specialized
professional assistance
• Local, state, tribal, and national organizations focused on
grief support, trauma and crisis response, or suicide
prevention
• Peer-led and community-based programs, spiritual
assistance, and natural helpers (everyday individuals
who have a knack for helping others)
• Information about suicide risk and mental illnesses associated with
exposure to suicide:
• Depression, posttraumatic stress disorder (PTSD) or other
anxiety disorders, and complicated or prolonged grief
• Warning signs of suicide and how to respond safely and
effectively to suicide risk in oneself or others

8. 7
REFERENCES
Berkowitz, S., Bryant, R., Brymer, M., Hamblen, J., Jacobs, A., Layne, . . .
Watson, P. (2010). Skills for Psychological Recovery: Field operations guide.
Los Angeles, CA & Durham, NC: National Child Traumatic Stress Network;
White River Junction, VT: National Center for PTSD.
Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J., Steinberg, A.,
Vernberg, E., & Watson, P., (2006). Psychological First Aid: Field operations
guide (2nd ed.). Los Angeles & Durham, N.C.: National Child Traumatic Stress
Network; White River Junction, Vermont: National Center for PTSD.
Center for Mental Health Services. (2009). Practice guidelines: Core elements
for responding to mental health crises. Rockville, MD: Substance Abuse and
Mental Health Services Administration. [HHS Pub. No. SMA-09-4427]. See also
bit.ly/mhcrisisresponse.
Hobfoll, S.E., Watson, P., Bell, C.C., Bryant, R.A., Brymer, M.J., Friedman, M.J.,
… Ursano. (2007). Five essential elements of immediate and mid-term mass
trauma intervention: Empirical evidence. Psychiatry 70(4), 283–315. Abstract
retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18181708.