Best Practices in Suicide Postvention

Introduction

Suicide postvention might look like an odd word. We often use the word “prevention” to refer to things that are designed to stop (prevent) other negative situation or states from occurring. Postvention, then, refers to the things we do after a suicide has occurred. In this context, it often refers to the actions that a school should take in the aftermath of a suicide death but can be used in any context (workplace, family, etc.) where individuals are left grieving a suicide death.

Development of a protocol to respond to suicides will ensure the process is handled consistently and reduce anxiety for all involved. (Carter & Brooks, 1990; King, 1999)

General Best Practices

• Provide immediate debriefing and information to survivors to reduce the impact of the loss (Cox et. al., 2012; Parsons, 1996; Celotta, 1995; King, 1999)
• Identify individuals at high risk and reach out to them (Celotta, 1995; Carter & Brooks, 1990)
• Ensure the media provides a respectful response to the suicide that acknowledges its impact without glorifying it (Bohanna & Wang, 2012; MediaWise, 2003)

Types of Post Loss Support

Forde & Devaney (2006) identify three types of post-loss support. The first is an “expert”, a clinician or professional grief support worker. This does not require someone to be a counsellor but they must have education and training in grief work. The second expert is a “veteran”, someone with lived experience like a suicide survivor. The third kind of support is a “fellow participant”, someone else who is going through the same loss as you at the same time.

Suicide Contagion

Suicide contagion or “cluster suicides” are a phenomenon where a number of suicides occur close in time (days, weeks, or months) after each other, often because of people identifying with the deceased. (Cheng, Silenzio & Caine, 2014) This can occur both as the result of someone they know (like a classmate or colleague) dying, or someone famous.

Two examples of celebrity suicides that increased suicide behaviour were Marilyn Monroe (Goleman, 1987) and Robin Williams (Schonfield, 2015). In Monroe’s case, a spike of actual suicides were documented while in Williams’ case, suicide hotlines saw their usage increase dramatically in the days and weeks of his death.

A number of strategies identified by Cox et. al. (2012), some of which are detailed below, have shown support for limiting contagion:

• Development of a community response plan
• Educational/psychological debriefings
• Counseling for high-risk individuals
• Screening of high-risk individuals
• Promotion of health recovery and prevention
• Responsible media reporting

Media Guidelines

There are a number of media guidelines around how to report that someone has died by suicide. One example include the UK standards created by the MediaWise Trust involving consultation with journalists, suicidologists and survivors. Examples of items in the MediaWise standards (2003):

• Avoid sensational headlines, images and language
• Publicising details of suicide methods can encourage imitation
• Avoid speculation, especially about ‘celebrity’ suicides
• Consider context – suicides in institutions deserve investigation
• Challenge ‘myths’ about suicide

A review by Bohanna & Wang (2012) documented a number of countries where successful implementation of media reporting standards had reduced cases of imitative suicide standards, suggesting they had been effective.

School and Higher Education

Elementary and secondary are the sources of most of the existing research on postvention, and for good reason. Adolescent suicides are the second cause of death for Canadian teens behind car crashes (Statistics Canada, 2011).

It’s important to explain to students there is no right or wrong way to feel, and to emphasize that suicide is most commonly the result of treatable mental illnesses. (Parsons, 1996) This reduces the likelihood of contagion and may improve the number of students who reach out for help.

Examples of interventions after a suicide after provided by Carter & Brooks (1990) and similar to those recommended by King (1999):

• Evaluation and therapy for survivors
• In-service training for school staff members
• Support Groups
• Community Resources
• Media management

Short (8-12 session) group counselling is the format recommended by Carter & Brooks for evaluation and therapy of survivors. Often these groups focus first on the survivors closest to the deceased and then “fan out” to wider parts of the school community that are affected.

Celotta (1995) makes a number of recommendations for the few days after a school suicide:

• Provide debriefing to students in the immediate aftermath of the suicide, for an extended period on the first day and then shorter but regular periods in the later days
• Provide teachers with information about the plans for the next couple days and information on how to identify risk factors in youth
• Provide information to students in small groups and ensure they are able to ventilate their feelings
• Do not provide students information on why the student died or the exact method, to protect the privacy of the family
• Confirm that while many people think about suicide and death, that suicide is not a normal reaction to stress suicidal behaviour is not the most effective way of handling stressful situations (Oct 11, 2016 – See the comments section for a discussion of this point.)

Secondary Gain

It’s also important for staff to identify and eliminate opportunities for “secondary gain”, these are opportunities for students to receive attention and extra motivation for them to enact suicidal behaviours. (Callahan, 1996)

Examples of secondary gains can include students being allowed time off during class, being given special privileges by staff or counsellors and being given a “cachet” or status by anyone involved in the school.

Memorials

One of the most misunderstood (and possibly researched elements) of suicide postvention is the idea of memorials for the deceased. Memorials must balance two competing factors: the need to prevent contagion and the need to allow survivors the opportunity to appropriately grieve and remember the deceased.

Physical memorials such as plaques or special trees should be avoided. (Fineran, 2012; Callahan, 1996) As well, do not hold additional events (assemblies, etc.) for students that would not be held for a student dying of an accident or other sudden death. Fineran notes that there is no empirical support for or against different types of memorials, but that they may contribute to contagion if not closely monitored.

Veterans / Police

While military veterans have, for many years, had suicide rates lower than the general population (Jones, 1994), this trend has begun to reverse. Veterans, both police and military often face unique challenges that may make them more likely to attempt and die by suicide.

Veterans often present with higher rates of mental health issues than the general population because of deployment (Pare & Radford, 2013), and use firearms in suicide attempts more frequently (Kaplan, McFarland & Huguet, 2009).

Although research on postvention specifically related to veterans is limited, there have been some reviews.

Carr (2011) reviewed a suicide in Iraq and what actions were taken. In that case, standard traumatic incident guidelines in use by the US Army were followed, with the needs of the Company affected prioritized.

Soldiers were told about the suicide in small groups, while leaders were told to keep watch on high-risk soldiers. Referrals were given to soldiers experiencing acute stress responses (including the soldier who found the suicided soldier), while other soldiers with existing mental health problems found them exacerbated by the suicide.

These responses are all consistent with the existing postvention protocols, with the added concern that counselling on lethal means may become more important because of possession of firearms.

Ghahramanlou-Holloway (2011), responding to Carr’s paper noted that, especially in military circles the number of survivors may be underestimated, while Pearson (2011) expanded on the idea of suicide bereavement being a mix of grief and trauma, and the utility of employing normal military combat stress control techniques to manage it.

There is no research that I am aware of that explores police postvention as of yet, and only limited research regarding police suicide prevention programs, such as the kind explored by Mishara & Martin (2012).

Conclusion

Suicide postvention is a developing field but there is significant evidence that activities to prevent contagion and further trauma work. Additional research should be undertaken to explore specifc populations, such as police, and to evaluate the effectiveness of postvention activities like memorials and debriefing sessions.

Bibliography

Fineran, K. (2012) Suicide Postvention in Schools: The Role of the School Counselor. Journal of Professional Counseling. 39(2)