Coping with Suicide

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Coping with Suicide

• Barbara A. Olesko, NP
• Coordinator, Psychiatric Consultation Liaison
  Service

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• Time does not heal,
• It makes a half-stitched scar
• That can be broken and again you feel
• Grief as total as in its first hour.
• -Elizabeth Jennings

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Suicide Survivors

• There are about 31,000 suicides each year in the
  USA.
• It is the countrys 11th leading cause of death.
• 90 of all people who die by suicide have a
  diagnosable psychiatric disorder at the time of
  their death, but only one in five patients who
  suicide, or 6000 deaths, were in treatment at
  the time of their death (Luoma, Pearson Martin,
  2002).
• It is estimated that for every suicide there are
  at least 6 - 12 survivors (American Association
  of Suicidology, 1999).

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Survivor Research

• Reed and Greenwald (1991) found that the
  attachment and kinship relationship becomes a
  grief response they refer to as survivor-victim
  status. They found that attachment was more
  important than kinship relation in the intensity
  of grief. Higher levels of attachment
  significantly increased guilt, shame and mental
  preoccupation.
• McIntosh and Kelly (1992) report there are more
  similarities than differences in the grief
  response among suicide, accident and natural
  death survivors.
• Van der Wal (1989) concluded the literature
  provides no empirical evidence that suicide
  survivors show a greater incidence of
  complicated, pathological or prolonged
  bereavement compared to survivors of other sudden
  and unnatural deaths.
• Brent (1996) found exposure to suicide does not
  result in an increased risk of suicidal behavior
  among friends and acquaintances, but has
  relatively long impact in terms of increased
  incidence of anxiety and depression and PTSD.
• Jordan (2001) found there are qualitative
  aspects of the mourning process that are more
  intensified and frequently more problematic for
  survivors of suicide loss than for other types of
  mourners.

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Suicide Survivors Common Reactions

• Grief
• Shock and Numbness
• Denial
• Search for a reason for the suicide WHY?
• Shame
• Guilt and Responsibility
• Blaming and Scapegoating
• Anger toward self, others, the deceased
• Sadness
• Bewilderment
• Confusion/Forgetfulness
• Feelings of abandonment and rejection

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Common Reactions - continued

• Loneliness and Social Isolation
• Social Supports Affected
• Difficulty Trusting Others/ Feel Abandoned
• Relationships with others are often affected,
  sometimes negatively
• Depression
• Heightened Suicide Risk and Ideation

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Coping Differences

• Males
• Getting back to work
• Getting back to a routine
• Attending to practical
• matters
• Attending to outside
• interest e.g., sports,
• hobbies

• Females
• Reading / researching about
• suicide
• Talking to friends and family
• Joining support groups
• Seeking professional
• counseling
• Giving back through
• volunteer work

Gender Differences in Coping after Suicide
Davis, C Hinger, B. (2004)
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Impact of Formal Supports

• Police
• EMS
• Fire
• Medical Examiner
• Clergy
• Psychiatric provider
• Family Physicians
• School, Workplace

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Clinicians as Survivors

• Patient suicide is experienced by as many as one
  in three psychiatric residents and by as many as
  half of psychiatrists in practice (Ellis, et al.,
  1998).
• Interns, residents and other novice clinicians
  have been found to experience higher rates of
  suicide among their clients than more seasoned
  clinicians (Bongor, 1991).
• Mental health practitioners, in general, view
  suicide as a leading source of work-related
  stress (Berman Jones, 1991), and it has been
  described as the most traumatic event of their
  professional lives (Hendin, et al., 2000).
• Treating clinicians are also survivors and loss
  of a patient to suicide is a difficult and
  stressful event. Clinicians have high levels of
  self-blame and guilt (Peterson, et al., 2002).

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Suicide Bereavement Commonalities

• There is growing recognition that the suicide of
  a patient triggers the same intense emotions
  among mental health professionals as those
  typically experienced by family and friend
  survivors. These include shock, denial, grief,
  guilt and anger (Ruskin, 2004 Peterson, Luoma,
  Dunne, 2002 Farberow, 2001 Hendin et al., 2000
  Grad, Zavasnik, Groleger, 1997 Litman, 1994
  Jones, 1987).

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Therapists Reactions to Patients Suicides

• Ruskin, et. al., 2004 study examined the effect
  of suicide on psychiatrists and psychiatric
  trainees found feelings of helplessness reported
  71, recurrent feelings of horror 55, and over
  50 reported significant anxiety symptoms
  following the suicide of a patient.

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Therapists Reactions to Patients Suicides

• Tillman , in press
• Frequent Experiences of Clinicians
• After the Suicide of a Patient
• Traumatic Loss and Grief
• 1. Traumatic responses (shock, numbing,
  dissociation, somatic symptoms)
• 2. Immediate affective responses (crying,
  sadness, anger)
• Interpersonal Relationships
• 3. Relationships with the patient and/or the
  patient's family
• 4. Relationships with colleagues (including
  personal analyst, supervisor, peers)
• Professional Identity
• 5. Risk management concerns
• 6. Feelings of inadequacy, shame, humiliation,
  guilt, judgment, self-blame
• 7. A sense of crisis
• 8. Effect on work with other patients

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Therapists Reactions to Patients Suicides

• Hendin, et al., 2000 Interviewed 26 therapists
  whose patients had committed suicide. They
  completed a semi-structured questionnaire about
  their reactions, wrote case narratives, and
  participated in a workshop to discuss their
  cases.

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• Hendin, et al., 2000, Therapists Reactions to
  Patient Suicides

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Therapists Reactions to Patients Suicides

• Pearson, et al., 2002 No real empirical data
  speak to the issue of how clinicians are
  perceived as they deal with family and friends of
  the deceased no systematic description of how
  survivors perceive various types of therapist
  behaviors.

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Helpful experiences after a suicide to promote
coping

• Davis and Hinger (2004) surveyed survivors to
  find out what would be most helpful after a
  suicide occurs
• Immediate support following suicide
• Survivors identified informal supports, such as
  family, friends and neighbors, as providing the
  most comfort in the crisis period after the death
• Practical support that was helpful included food
  preparation, making phone calls, providing
  transportation and assisting with funeral
  arrangements
• Emotional support was identified as being
  important just having someone there to listen
  without blame and providing compassion
• Survivors being open and honest about the suicide
• Attending support groups specific to suicide loss
  were found to be helpful
• Professional therapy
• Supportive school and workplace

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Unhelpful experiences after a suicide that
impeded coping

• Davis and Hinger (2004)
• Issues related to communication lack of
  communication, inappropriate communication and
  failure to communicate honestly by both formal
  and informal support systems
• Failure by others to acknowledge suicide as the
  cause of death
• Lack of compassion and understanding
• Unrecognized survivors
• Unrealistic expectations about the grieving
  process/time
• Lack of communication from the treating clinician
• Lack of services for children

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Recommendations for Family/Friends

• Provide support to informal social support
  networks (family, friends, community) of suicide
  survivors
• Implement a coordinated, active program that will
  enable newly bereaved survivors to connect with
  trained and experienced survivors
• Enhance and coordinate formal supportive services
  to survivors of suicide
• Increase and improve training for professionals
  who encounter survivors of suicide
• Improve education and awareness about suicide and
  its aftermath for both survivors and the general
  public

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Promotion of Grieving in the Workplace and
further Recommendations

• Post-vention or Debriefing
• Individual therapy/supervision after the suicide
• Seek the support from a colleague to process the
  loss and move beyond the grief
• Manage caseload with help from colleagues if
  possible
• Seek supervision and/or consultation when you are
  serving someone known to be at risk for suicide
• Improved training, education and research

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Resources

• www.afsp.org (American Foundation for Suicide
  Prevention)
• www.suicidology.org (American Association of
  Suicidology)
• www.sprc.org (Suicide Prevention Resource
  Center)
• www.rochesterpreventsuicide.org (Center for the
  Study and Prevention of Suicide)
• http//mypage.iusb.edu/jmcintos/therapists_mainpg
  .htm (Therapists as Survivors of Patient Suicide)

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Local Resources

• Out of the Darkness, Rochester NY Walk for
  Suicide Prevention (Oct 7, 2006, Genesee Valley
  Park) organized through AFSP
• Organization for Attempters and Survivors of
  Suicide in Interfaith Services (OASSIS)
• Depression and Bipolar Support Alliance
• DBSA/NAMI RochesterRecovery Awareness Grant
• Rochester Police DepartmentVictim Assistance
  Program
• NAMI Rochester (http//www.namirochester.org)