Wednesday, December 21, 2011

Tensions in Postvention: An International Dialogue Part I

By Sally Spencer-Thomas

In the aftermath of a suicide, several needs are evident —psychological first aid for those most directly affected, help for communities as they return to a level of functioning, and surveillance for vulnerable individuals who might be harmed by contagion. The strategies to achieve meeting these needs sometimes come into conflict with one another and create tension in our postvention efforts. Well-meaning and well-informed people can find themselves firmly standing on one side or another of these points of potential disagreement, complicating an already difficult process.

In September this year, I had the honor of facilitating an international discussion on the “Tensions in Postvention” at the International Association of Suicide Prevention’s (IASP) World Congress in Beijing. About two dozen people gathered to join some of the top suicidologists from around the globe as we explored the challenges of supporting individuals, families and communities in the aftermath of a suicide. Among the invited participants were:

· Karl Andriessen, M.Suicidology, (BELGIUM), Coordinator of the Suicide Prevention Program of the Flemish Mental Health Centres, and Co-Chair of the IASP Taskforce on Suicide Bereavement and Postvention. He is a tireless advocate for the needs of people bereaved by suicide.
· Prof. Onja Grad, PhD, (SLOVENIA), clinical psychologist who has worked with survivors on a daily basis for the past 22 years — with individuals, families, groups. She is also a teacher at the University of Ljubljana School of Medicine.
· Myfanwy Maple, PhD, BSW (Honours Degree), (AUSTRALIA), senior Lecturer, Social Work Course Coordinator, School of Health. He is a social work academic and researcher in suicide bereavement over the past decade, particularly examining the experiences of individual family members experience of loss.
· Sandra Palmer, Ph.D. (NEW ZEALAND), a registered psychologist and Clinical Manager Community Postvention Response Service, and provides support to communities experiencing suicide clusters or contagion. She continually faces the challenge of balancing the need for communities and families to honor the loss of loved ones with safe postvention practices to manage contagion to prevent further losses in the community.
· John Peters, M.Suicidology (UNITED KINGDOM), lost his son to suicide 19 years ago and has for many years been a volunteer with Survivors of Bereavement by Suicide including staffing their Helpline each week and running peer-led support groups and an annual support day.
· Diana Sands, PhD, (AUSTRALIA), Director, Bereaved by Suicide Service; has worked with families bereaved by suicide for over twenty years, produced a film and wrote a book for children bereaved by suicide. She will speak to the complex and sensitive issues regarding how to talk with children bereaved by suicide.

During this session we discussed the following questions:

1) How can we balance the need to prevent contagion with the need to honor loss?
2) How do we balance getting a familiar sense of normalcy with the acknowledgement of significance to a community that has been deeply affected by a suicide loss?
3) Do we tell children about suicide or not? When do we tell them? How much information?
4) What services do we provide – lay led, professionally facilitated or some combination? Knowing that the research indicates the benefits of peer led efforts, how do we manage quality control and sustainability?
5) How do we safely involve survivors or suicide loss and attempts in research? What are the best protocols for this?

In this column, I will review the discussion of the first two questions, and in the next issue of Newslink I will review the discussion of the last three questions.

How can we balance the need to prevent contagion with the need to honor loss? 

As we opened the discussion many participants shared examples of how communities have navigated the balance between what family and close friends want and what is safe for the community. Sandra Palmer talked about how t-shirts printed with pictures of lost loved ones are commonly seen at funerals and memorialization events. She went on to describe how families when told about the potential risk will also print a hotline number or other resource on the t-shirt. I talked about how candle lighting ceremonies are common and how we can help communities make these events safer by coaching the event planners on safe messaging and surrounding the attendees with helpful resources. Jill Fisher of Australia talked about framing a memorial event as a remembrance event celebrating life rather than over-emphasizing the circumstances of a death.

Sandra Palmer: “What we are getting to is about balance.”

Jill Fisher: “We try to do a number of activities to meet a number of needs of the bereaved.”

Onja Grad: “[The response] has to be right away.”

Diane Sands: “Schools are much more careful. Families are more thoughtful and respectful to the community. We can rely on folk to be more thoughtful.”

As in many provocative discussions attendees raised additional questions:

· How can we be proactive in our efforts with families and communities so they understand the risks?
· Knowing that it is never anyone’s intention to cause additional harm, how do we explain to families that there is a risk in doing things the way they planned?
· Many families, including my own, have a huge desire to do prevention work right away, and yet without proper time to grieve and heal sometimes these efforts crash and burn, causing additional hardship. How can we counsel people to heal first and engage in prevention activities later?
· How do we support people in bereavement when we are not of the grieving family’s culture?
· How do we promote young people’s safety while giving them the space to grieve in their own way, which often includes very public expressions through social media? For instance, youth sometimes post on their deceased friend’s Facebook page. Sometimes the outpouring reflects their grief at the loss like a public shrine of flowers and stuffed animials might. Others post comments like “you are now in a better place,” thereby romanticizing the death and minimizing the tragedy.

The general consensus of the group was that both honoring loss and preventing contagion are possible. With outreach to new survivors and supportive instruction about preventing contagion, we can allow a safe space for the bereaved to mourn and direct the grief energy so that risk factors for contagion are minimized.

[To watch this Part I of the discussion: ]

How do we balance getting a familiar sense of normalcy with the acknowledgement of significance to a community that has been deeply affected by a suicide loss? 
This question revolves around a community response to suicide. We noted that returning to a previous routine can be grounding for many after a trauma; it offers structure and a sense of familiarity. Nevertheless, moving too quickly or too completely to “business as usual” can make those closest to the loss feel discounted.

We also acknowledged that in larger systems and communities there will often be many people who are not affected at all by the death, and if we go in “all guns blazing” we can do harm.

Many cited George Bonanno’s work (Bonanno, 2004) on resiliency after trauma and emphasized the potential strength of the human spirit and the power of communities pulling together after a loss like suicide. The key to finding the right balance revolved around framing the interventions as choices with the understanding that different survivors need different things at different points in their grief journey. Jill Fisher called her approach an invitation of the “lightest touch” so that what we offer won’t interfere with the natural resilience that exists.

As Jill noted, “After a suicide you find police, criminal investigators, medical rescue professionals, coroners — up to 10 people in your home — that you have no right to say ‘no’ to. You are invaded. We want to make sure that the bereavement support is a choice you’ve made.”

The group also explored the reality that not all suicide deaths impact communities in the same way. For instance a school that has been rocked by multiple deaths usually experiences heightened anxiety and fear as rumors escalate. For these communities, “returning to normal” might require more conversations of assurance.

One participant described this particular tension in postvention: “Grief is a natural process, and when you put shutters around it, damage can be done. The bereaved will let you know what they need; our role is to support them.”

While the cultures and languages of this diverse group of experts varied, the themes of the challenges were similar. By sharing lessons learned and stories of success, we forged a solidarity in our efforts to support people bereaved by suicide.

Bonanno, G. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59(1), 20-28.

Sally Spencer-Thomas is CEO and co-founder, Carson J Spencer Foundation, founded after the suicide of her brother. The foundation is known for preventing suicide in the workplace, coaching youth social entrepreneurs to be the next generation of suicide prevention advocates, and supporting the bereaved. She is AAS Survivor Division Chair.

"Reposted with permission from the American Association for Suicidology" follow
this link to see the article in Newslink.


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