Postvention: �An introduction to grief after suicide

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EMILY DUVAL, PSY. D., M.A., PSYCHOLOGY, LPCC, CA

MBACP (ACCRED.)., UK

© 2008-2022

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Attendees

• Practitioners, clinicians
• interns
• helpline volunteers
• mandated reporters who have essential risk assessment training
• roles supporting those who have experienced suicide loss
• Each slide has audio! Press the Play button on the speaker icon for the full material

What is covered

Higher level overview, introduce subject of postvention and the experience of working with survivors

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Initial reactions to suicide: �what are yours?

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A Survivor �of Suicide…

• Is someone who has lost a loved one to suicide
• Survivors are those whose lives are significantly impacted by the suicide, including relatives, close friends, or healthcare providers who regularly interacted with the deceased.
• At least six survivors are intimately affected for every death
• Considered at increased risk for suicide

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The impact is far reaching

DATA

San Diego Suicide Deaths 2022

• Estimated 390

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California 2021

• Reported 4,148

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United States 2021

• reported 48,183
• Males rate of suicide four times higher than female
• Aged 85 + have the highest rate
• American Indian, Alaska Native, and Caucasian had highest rates

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Globally

• 700,000+ a year

��Data: Methods��

1. FIREARMS

2.SUFFOCATION

3. POISONING

4. FALLS

5. PIERCING OR CUTTING

6. DROWNING

7. FIRE

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LANGUAGE GRID FOR�SENSITIVE PHRASING

���Edwin S. Shneidman founded the American Association of Suicidology (1968) and pioneered the postvention movement�

What is Postvention?

Aims of Postvention efforts

• Reduce negative consequences for Survivors
• Starts with immediate needs, crisis response, stabilize community
• Prevent contagion effect
• Provisions for ongoing and longer-term support in the grieving process

“TRADITIONAL” GRIEF CYCLE

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• Shock, denial
• Depression, guilt
• Anger
• Bargaining
• Acceptance

Complicated Grief�may occur when….

Possible Survivor Reactions

• Feeling abandoned and rejected, Disenfranchised
• Loss of faith in mental health providers
• Loss of faith in belief system
• Feelings of guilt, “if only I had….”
• Rage
• Post-trauma symptoms

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• Feeling the need to ‘fill their shoes’, pressure to perform
• Repeating the story
• Fixating on ‘why’
• Shame, mixed emotion, confusion, being deceptive about the cause of death
• Removing all traces of the lost person
• Idealizing the lost person, romanticizing suicide

�����������Survivor Encounters: �Disenfranchised Grief�

• Rejected by usual support network
• Community culture and attitudes
• Suicide is subject to rumors and gossip
• “Tell us why”
• People expecting you to be “over it”
• Avoidance, lack of acknowledgement

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• Sometimes, unlikely friends appear - meeting other survivors of suicide loss

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Photo: scienceabc.com

The Effect of Suicide on Families

• Occurs in both functional and dysfunctional families
• Divisive grief
• Raises concern about a perceived ‘suicide gene’ or contagion effect
• Feeling as though suicide will be a legacy or curse
• Family secrets revealed
• Roles changing
• Comparing loss based on relationships
• Family of origin cultural influence

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Children as Survivors

Impact on communities

• Collective mourning
• Philosophical / moral questions
• Staffing volunteer helplines/ surge in callers
• Safety discussions with children, vulnerable citizens
• Increase efforts to engage in conversations and reduce stigma
• Pervasive cultural and subcultural attitudes about suicide are ever present

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International Workplace Response to Suicide

VANDEPOL, B. (2003)

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�Postvention Phases of Care�

DUVAL 2023

Workplace Considerations�After a suicide

• Safe messaging
• Remind staff of support resources/Employee Assistance Program (EAP services)
• Identify vulnerable staff
• Understand high risk factors
• Fitness-to-practice
• Healthcare settings
• High risk industries
• Negatively impact productivity
• Absenteeism, presenteeism

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• Some staff may blame or resent the organization
• Avoid sudden attempts for morale boosts
• Focus on stress reduction
• Leadership to de-stigmatize mental health issues
• Promote worker empowerment and mental well-being, long-term
• Honor or acknowledge anniversaries/dates

Vignette Practice: Melanie

• Age 26
• Nurse trainee, full time
• Melanie learned through friends that her fiancé, Paul, was found by his parents in their garage. The death was determined to be suicide. Melanie had already felt rejected by Paul’s family who were of a different race and religion to hers. A week after the death, Melanie informed her counselor that Paul’s mother excluded her from the planning of the upcoming memorial service, and also blamed her, “You’re practically a nurse, how could you not see the signs?”
• Melanie’s supervisor allowed her 3 days off from work.
• How would you support Melanie, and what factors would you consider?

Possible Responses to Vignette

MELANIE

• -Personal loss of intimate partner
• Excluded from planning memorial
• Cultural exclusion from family
• -Disenfranchised grief
• -Fitness to practice in her nursing position
• -Support Group, reduce isolation
• -Melanie may be vulnerable and at-risk for suicide, herself

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It will be prudent to fully explore risk and potential vulnerabilities, provide psychoeducation as needed, inquire about workplace support from her employers, in addition to social support networks. Consider timing and accessibility of Survivor support group options.

The Healing Odyssey

• Support groups, sharing and bonding with other survivors
• Ongoing individual therapy
• Reading to gain an intellectual / philosophical understanding of suicide
• Creative projects - writing, painting, music, bodywork, athletic goals
• Establishing a dedicated memorials - tree, park bench, scholarship
• In grief, healing is not a linear process and may involve some setbacks

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Potential Barriers to Healing

• External vs. Internal
• Social Stigma
• Method of death, traumatic memory
• Inquest or investigation
• Legal and financial obstacles
• Unsatisfactory therapy interventions
• Disenfranchised grief

Normalizing Setbacks �in the healing process

Post traumatic growth

Quotes from survivors �

“Suicide is frowned upon in my culture and religion. When I found a counselor, drawing out a timeline and writing in the losses I’d experienced throughout life helped me to gain context of my son’s suicide… as part of my whole life story, and see the event through a non-judgmental lens”

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• “when I returned to work after my wife’s suicide, everyone ignored the issue…I felt invisible”

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• “My generation doesn’t handle grief well, let alone suicide. My boss has been the most supportive listener, of all people. I can’t be honest with my immediate family.”

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• “My husband’s suicide was so traumatic……at some point over the years, I realized [he] had actually given me a gift… I learned so much about myself, how to empathize and show compassion…”

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In review…

• Awareness for the complexities of loss by suicide
• Including disenfranchised grief
• Postvention and Survivors
• The importance of reducing stigma
• Using sensitive language
• Individual, Family, Organizational and Community responses
• Healing and post-traumatic growth

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References & Resources�

Other resources :

Survivor or Suicide Loss Resources - Survivors of Suicide Loss San Diego Survivors of Suicide Loss San Diego (soslsd.org

988 Lifeline 988lifeline.org/

Crisis Text Line www.crisistextline.org/

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About me: �Emily Duval, Psy.D., LPCC

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• Certified in Suicide Intervention in 1994
• Became a Certified Grief Counselor in 1998
• Obtained Master's of Psychology degree in 2004 from Golden Gate University, San Francisco, CA
• Doctoral degree (Psy.D.) completed in 2020 from California School of Professional Psychology 
• Licensed Professional Clinical Counselor in California (LPCC683)
• Accredited psychotherapist in the UK (MBACP, Accred.)
• Practitioner, writer, supervisor, trainer, presenter in the United Kingdom (Cardiff, Bristol, London) 2004-2013
• Subject Matter Expert in suicide postvention
• Keynote speaker on suicide postvention
• Contributing, published author on suicide postvention
• Survivor of Suicide (SOS) loss support group facilitator 
• Co-chair of the postvention subcommittee for the San Diego Suicide Prevention Council
• Dissertation subject: Postvention in Organizations: Preparing Leaders for the Aftermath of Suicide

This presentation of suicide postvention fundamentals is a modified, updated version of a 6-hour training course I first developed in 2008 and delivered to practitioners and helpline volunteers in the United Kingdom. Slides may be used with written permission only. Contact emd@exapattherapy.com

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