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Systems Must Include Three Levels of Care for Aftermath of Suicide


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A summary of how care-delivery systems, individual organizations and agencies, and service providers can address responding to a suicide in a way that meets the needs of everyone exposed to the fatality, both immediately and over the long-term. This is essential reading for leadership, strategic planning, and program development. The blog post on "Grief After Suicide" about this report is at

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Systems Must Include Three Levels of Care for Aftermath of Suicide

  1. 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 ( Download the original document at
  2. 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 "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 ( Download the original document at 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. 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 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 ( and the National Center for PTSD (  
  4. 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. 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. 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 ( taskforce) of the National Action Alliance for Suicide Prevention. The original document is available free for download at] 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]. • 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. 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 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. 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 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