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    What is postvention?

    Postvention refers to the work that is done after a person has attempted suicide, or after a person has died by suicide.

    The two different groups affected by postvention efforts include:

    • People who have experienced a suicide loss
    • People who have experienced a suicide attempt, as well as their close family and friends

    Postvention activities work to support these two different groups in an effort to prevent further suicides or attempts from happening. Activities include things like grief counselling and support groups.

    Why postvention?

    People who have been exposed to suicide are at greater risk of suicide themselves – this is why ensuring they receive the proper care after a suicide death or attempt is critical.

    People who have been affected by a suicide loss need help to work through their grief, while those who have attempted suicide need to be supported in working through the thoughts and circumstances that lead them to consider suicide.

    Warning signs and acute warning signs

    People who have been exposed to suicide are at greater risk of suicide themselves – this is why ensuring they receive the proper care after a suicide death or attempt is critical.

    People who think about suicide typically exhibit warning signs.

    Any significant change in behaviour can be a warning sign for suicide. We can be more alert to warning signs when we are sensitive to those around us, and when we appreciate that anyone can have thoughts of suicide. Active listening can help us tune in to comments they make that may indicate they’re struggling.

    Some warning signs include:

    • Statements that indicate hopelessness or being a burden
    • Threatening suicide or talking about wanting to die*
    • Looking for ways to die*
    • Suicide attempt
    • Increased substance use
    • No sense of purpose in life or evident reason for living
    • Withdrawal from friends and family
    • Rage, anger, irritability
    • Recklessness
    • Dramatic mood changes

    *These warning signs indicate immediate suicide risk. Stay with the person who is exhibiting these signs and connect them to help. In Canada, call the crisis line at 1-833-456-4566.

    (American Association of Suicidology, n.d.)

    Care for the caregiver

    People who have been exposed to suicide are at greater risk of suicide themselves – this is why ensuring they receive the proper care after a suicide death or attempt is critical.

    Regardless of whether you’ve experienced a suicide loss or know someone who has attempted suicide, you’re likely carrying a lot of weight on your shoulders. Responding to both a death and a person who has attempted is difficult work; it can be hard on everyone involved.

    It’s important to prioritize self-care everyday to ensure we can stay healthy for ourselves and for others. After intervening with someone considering suicide, take time for your own processing and recovery. Knowing ourselves, what helps us recharge and taking time to do it is critical for caregivers.

    Who is most at risk following a suicide?

    People who have been exposed to suicide are at greater risk of suicide themselves – this is why ensuring they receive the proper care after a suicide death or attempt is critical.

    Following a suicide death, the people who are most likely to consider suicide themselves are those who were closest to the person who died. This includes friends, family members, and colleagues.

    Research indicates that up to 135 people are impacted by one suicide, ranging from the more seriously affected to those more simply exposed (they knew the person) (Cerel et al., 2018).

    Being exposed to a suicide, and especially multiple suicides, can increase the likelihood of people considering suicide themselves, if they:

    • see suicide as an option or a ‘normal’ or ‘common’ reaction to life circumstances following the death of someone close to them
    • are still severely grieving one suicide when another happens; this may lead to feelings of hopelessness and reinforce the idea that suicide is an option
    • are already struggling with mental illness or thoughts of suicide, or have a past suicide attempt

    Therefore, it is critical to make counselling opportunities available for those affected (Erbacher et al., 2015; Carson J. Spencer Foundation et al., 2013).

    About suicide grief

    People who have been exposed to suicide are at greater risk of suicide themselves – this is why ensuring they receive the proper care after a suicide death or attempt is critical.

    It’s normal for us to grieve the death of someone we know. Suicide grief is unique. It can be a far more intense and complicated experience compared to other types of loss.

    People impacted by suicide loss may ask themselves, ‘What could I have done  to prevent their death?’ and ‘Why didn’t I see the warning signs?’ ‘Why did they do this to me?’ ‘How could they not have told me things were this bad?’

    Some may remain stuck in their grief journey, held hostage by these questions for years.

    Suicide is no one’s fault. It is the result of deep, psychological pain brought on by a constellation of factors.

    When people who have lost someone to suicide understand that it’s not their fault and that they carry grief that needs to be worked through, they can begin their grief journey.

    Typical suicide grief responses include:

    • Shock and numbness
    • Profound sadness
    • Anger and blame
    • Guilt
    • Shame
    • Relief
    • Denial

    (Canadian Association for Suicide Prevention, 2018)

    Best practices for after a suicide

    People may spend time in hospital or respite care following an attempt, both very structured and supportive environments. They may also spend time away from their workplace, school, or other familiar environments. Supports should be put in place to ensure they continue to be supported when they re-enter their community.

    Specialized supports

    Specialized supports, in the context of postvention and after a suicide attempt, are activities that directly assist a person after a suicide attempt. They can be provided by a variety of caregivers including professionals, skilled volunteers, and trained peers and in a variety of settings, such as emergency departments, inpatient and outpatient care, and community agencies. Support groups, and self-help practices also play key roles, particularly through the grieving process. Coordinated systems and access to services is key. Here are some examples of specialized supports for after a suicide death:

    After a death by suicide, postvention is most effective when different groups work together to provide a multi-pronged approach. Here are some actions that should be taken following a death:

    • Verify death and cause
    Information should not be released until a) authorities have released the official cause of death and b) the family has agreed to have these details released. Families are encouraged to release the cause of death (suicide), as oftentimes people will know that the death was a suicide. Being open and honest about this fact helps people process the death and opens up a dialogue for others who are struggling to seek help. The method of suicide should not be released.

    • Mobilize a crisis response team and coordinate resources
    Ahead of a crisis it is useful to:
    – Gather a crisis response team, ideally with members and experts inside and outside of the community. (Outside members and experts will be able to identify areas where support is needed, perhaps more readily than those within the community).
    – Coordinate resources such as identifying grief support professionals, who can come into the community when a crisis happens.

    • Disseminate information
    After a death by suicide has been confirmed and the family has agreed to release this information, compile a statement to your community and its stakeholders including:
    – Condolences to the family
    – Language appropriate to the audience
    – Factual information only, including the acknowledgment that the death was by suicide
    – No mention of method of suicide

    • Make grief counselling available
    Make grief counselling available to anyone who requests it. In addition to grief counselling, if the community has other supports, such as counselling, available to them, link people to those supports and make them widely known.

    • Identify those most impacted
    People closest to the deceased should be identified and offered additional support; additional support should be offered to anyone who requests it in the broader community, too.

    • Provide suicide awareness education
    Discuss with the community: mental illness and its connection to suicide; outline warning signs of suicide and let people know how they can help someone who may be struggling; and use non-judgmental, non-sensational language that is appropriate and sensitive.

    Recovery from an attempt

    People may spend time in hospital or respite care following an attempt, both very structured and supportive environments. They may also spend time away from their workplace, school, or other familiar environments. Supports should be put in place to ensure they continue to be supported when they re-enter their community.

    After a person has attempted suicide, they may be supported in their physical recovery and spend time in hospital. Following that, connecting them with mental health supports that are appropriate for them is key. Ideally, people who have attempted suicide and whose crisis point has passed are able to leave the hospital and live in a supportive environment, either with others who have had the same experience where psychological supports are available 24/7 (respite centre), or at home, supported by their loved ones and connected to psychological supports on a regular basis.

    What is recovery?

    People may spend time in hospital or respite care following an attempt, both very structured and supportive environments. They may also spend time away from their workplace, school, or other familiar environments. Supports should be put in place to ensure they continue to be supported when they re-enter their community.

    Suicide is complex because people are complex and everyone will have different factors leading up to their suicide, therefore, recovery can be complex, too.

    Those in recovery should define what recovery means to them. Traditionally, recovery has been seen as a return to ‘normal,’ or a return to the way things were before. This may not ever be possible and especially in the context of recovery from suicidality. People may live their whole lives with thoughts of suicide, while others may experience one attempt and never attempt again. If people are empowered to define what recovery means to them, they are empowered to set goals for themselves that are attainable and ultimately, keep them motivated through their journey (Amering & Schmolke, 2009; Bergmans et al., 2017).

    Learn more about recovery

    How does recovery happen?

    People may spend time in hospital or respite care following an attempt, both very structured and supportive environments. They may also spend time away from their workplace, school, or other familiar environments. Supports should be put in place to ensure they continue to be supported when they re-enter their community.

    When possible, recovery needs to suit the needs of each individual and their complexities. Ideally, the individual will have a say in who their mental health professionals are and what type of treatment they will receive, according to what they believe will work best for them, informed by input from professionals.

    Recovery needs to be culturally appropriate, trauma-informed, strengths-based and holistic, that is, it needs to treat the whole individual and not just their symptoms.

    Working towards mental wellness is a long journey and every one of us faces setbacks sometimes.  Recovery is most effective when the person in recovery has control over their journey: when they’re supported appropriately, they can choose their own path and learn how to better cope with their thoughts of suicide.

    Best practices for after a suicide attempt

    People may spend time in hospital or respite care following an attempt, both very structured and supportive environments. They may also spend time away from their workplace, school, or other familiar environments. Supports should be put in place to ensure they continue to be supported when they re-enter their community.

    Specialized supports

    Specialized supports, in the context of postvention and after a suicide attempt, are activities that directly assist a person in recovery. They can be provided by a variety of caregivers including professionals, skilled volunteers, and trained peers and in a variety of settings such as emergency departments, inpatient and outpatient care, and community agencies. Support groups and self-help practices also play roles. Coordinated systems and access to services is key. Here are some examples of specialized supports:

    Psychological treatment (or psychotherapy) is the treatment of mental unwellness including suicidality. This treatment does not involve medication, though the two can be paired together. When psychological treatment is trauma-informed and culturally appropriate, it can help people learn healthy and effective ways of coping with challenges.

    Health care professionals are more aware than ever of the effects of trauma. This has led to the creation of Trauma-Informed Care (TIC) — an approach that specifically considers the impact of previous traumatic experiences. TIC represents a significant paradigm shift from what has been called a “deficit perspective” to one that is strengths-based (British Columbia Ministry of Health, 2013).

    Cultural safety and competence are key components in providing services to Indigenous people, newcomers, and racialized populations. Without them there are greater chances of inaccurate or inappropriate assessments, inadequate treatment, and risk of re-traumatization in the treatment of trauma (Twigg & Hengen, 2009).

    For example, to effectively treat traumatized people who are Indigenous, caregivers:

    • need to be trained to deliver a trauma-informed approach in an Indigenous context
    • must be aware of the interplay of traumatic historical events and social conditions that impact both the community and the individual

    (Haskell & Randell, 2009; Linklater, 2014)

    People who have attempted suicide may find positive support among others who have had the same experience. Many people who have attempted suicide experience ambivalence – the dual experience of wanting to live and wanting to die – an experience that may be addressed among peers in a support group.

    Respite centres are an under-utilized but promising alternative to hospital settings for those who attempt suicide. Some people who have attempted suicide have had negative experiences in hospitals – respite centres can be a welcoming environment where the mental health of the patient or “guest” is the primary focus (Croft et al., 2016).

    A safety plan is a document that supports and guides someone when they are experiencing thoughts of suicide, to help them avoid a state of intense suicidal crisis. Anyone in a trusting relationship with the person in crisis can help draft the plan; they do not need to be a professional.
    When developing the plan, the person experiencing thoughts of suicide identifies:
    • their personal warning signs
    • coping strategies that have worked for them in the past, and/or strategies they think may work in the future
    • people who are sources of support in their lives (friends, family, professionals, crisis supports)
    • how means of suicide can be removed from their environment
    • their personal reasons for living, or what has helped them stay alive

    A safety plan is written when a person is not experiencing intense suicidal thoughts. It may be written after a suicidal crisis, but not during.

    A person’s unique strengths, abilities, and support people are identified in the plan so that they can draw on them when they experience intense thoughts of suicide.

    Public awareness campaigns

    Campaigns or news stories that emphasize recovery after a suicide attempt can send powerful messages of hope to those recovering from a suicide attempt.

    Mainstream media plays a significant role in suicide. Reporting on suicide in a thoughtful manner that considers its complexities while promoting recovery helps prevent suicide. Positive stories of recovery can be especially powerful. Responsible media reporting can go a long way in demonstrating that people with thoughts of suicide can recover and go on to live meaningful lives (Niederkrotenthaler & Till, 2019).

    Means safety

    Means safety refers to the identification of methods that are used to die by suicide and making those methods more difficult to access. After a suicide attempt, suicide risk can be reduced by removing means of suicide from their home, or limiting their access in a way that prompts reflection, for example, by locking means away in hard to reach places. Why does it work? As people’s thoughts of suicide intensify, their perspective narrows until it tunnels. If their method of suicide is blocked, their constricted thinking at the moment leaves them unable to come up with a new plan. Instead, they do not attempt suicide at this time. Means safety creates a pause for someone thinking about suicide to reconsider their plan, and gives further opportunity to seek help.

    References

    American Association of Suicidology. (n.d.). Warning signs. https://suicidology.org/resources/warning-signs/

    Amering, M. and Schmolke, M. (2009). Recovery in mental health: Reshaping scientific and clinical responsibilities. Chicester, UK.: Wiley-Blackwell

    Bergmans, Y., Gordon, E. Eynan, R. (2017).  Surviving moment to moment: The experience of living in a state of ambivalence for those with recurrent suicide attempts. Psychology and Psychotherapy: Theory, Research and Practice,90(4), 633-648.

    British Columbia Ministry of Health. (2013). Trauma-Informed Practice Guide. Retrieved from http://bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf

    Canadian Association for Suicide Prevention. (2018). Suicide grief: Normal reactions to suicide loss. Retrieved from https://suicideprevention.ca/coping-with-suicide-loss/suicide-grief/

    Carson J. Spencer Foundation, Crisis Care Network, American Association of Suicidology (2013). A manager’s guide to suicide postvention in the workplace: 10 action steps for dealing with the aftermath of suicide. Denver, CO: Carson J. Spencer Foundation.

    Cerel, J., Brown, M., Maple, M., Singleton, M., van deVenne, J., Moore, M., & Flaherty, C. (2018). How many people are exposed to suicide? Not six. Suicide and Life-Threatening Behavior. DOI: 10.1111/sltb.12450

    Croft, B., Ostrow, L., Italia, L., Camp-Bernard, A. & Jacobs, Y. (2016). Peer interviewers in mental health services research. The Joural of Mental Health Training, Research and Practice, 11(4), 234-243.

    Erbacher, T., Singer, J. & Poland, S. (2015). Suicide in schools: A practitioner’s guide to multi-level prevention, assessment, intervention and postvention. New York: Routledge.

    Haskell, L. & Randall, M. (2009). Disrupted attachments: A social context complex trauma framework and the lives of Aboriginal peoples in Canada. Journal of Aboriginal Health, 5(3), 48-99.

    Linklater, R. (2014). Decolonising trauma work: Indigenous practitioners share stories and strategies. Toronto, ON.: Fernwood Books Ltd.

    Niederkrotenthaler, T. & Till, B. (2019). Suicide and the media: From Werther to Papageno effects – A selective literature review. Suicidologi. DOI: https://doi.org/10.5617/suicidologi.7398

    Twigg, R. & Hengen, T. (2009). Going back to the roots: Using the medicine wheel in the healing process. First Peoples Child & Family Review, 4(1), 10-19.