Matthew Erlich MD FAPA Garra LloydLester Suicide Prevention Conference NY 09132016 Disclosures and acknowledgments None of the authors of this paper has any potential conflicts of interest or is receiving any financial support to disclose ID: 694234
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ADDRESSING Postvention: what to do after the tragedy to prevent further tragedy?Matthew Erlich, MD, FAPAGarra Lloyd-Lester
Suicide Prevention Conference NY
, 09.13.2016Slide2
Disclosures and acknowledgmentsNone of the authors of this paper has any potential conflicts of interest or is receiving any financial support to disclose. Slide3
PresentersMatthew Erlich, MD, FAPA; Assistant Professor of Clinical Psychiatry, Columbia U College of P&S / NYSPI; Director, OMH Consult Service, NYS Office of Mental Health; Co-Director, OMH Cognitive Health Services
Garra Lloyd-Lester
;
Associate Director, Suicide Prevention Center New York, NYS Office of Mental HealthSlide4
Learning ObjectivesDescribe the principles of postvention in the outpatient and community context.Understand the current research and literature for postvention in the outpatient and community setting.
Identify ways in which communities can engage in meaningful postvention activities.
Use the Agency Template for PostventionSlide5
One suicide, 11 victims…Thomas Insel, formerly of the NIMH, noted that with every suicide, there are eleven victims
– the person who suicide and the ten caregivers devastated by the loss, coping with the stigma, and at risk themselves
.
This
may be an underestimate.
Insel
T: Director’s Blog: A New Research Agenda for Suicide Prevention, Feb 5, 2014. Available at
http://www.nimh.nih.gov/about/director/2014/a-new-research-agenda-for-suicide-prevention.shtmlSlide6
What is Postvention?By show of hands, how many of you are familiar with postvention?Slide7
What is Postvention?Intervention after suicide is called “postvention”Originated by Edwin Shneidman
in 1968 at
first
conference of the American Association of
Suicodology
Postvention addresses
the care of bereaved survivors and
caregivers
Acknowledges the importance of preventive and intervention efforts in the period “after”
Commonly confused with “counseling”, preventing grief reactions, and stopping contagionSlide8
Shneidman’s Principles of PostventionPostvene with the survivor(s) early, ideally within the
first 72-hours
.
Survivor(s
), contrary to popular thought, are
often willing and eager to talk
to a professional.
Negative
emotions regarding the suicide (i.e., shame, anger, guilt, among others)
should be explored, but not initially
.
The
postvener
is a ‘reality-tester’
, reasoning with the survivors to explore the tragedy within the context of the event.
Source:
Shniedman
E. Postvention: The Care of the Bereaved (from Consultation-Liaison Psychiatry), Suicide and Life-Threatening Behavior, Winter 1981; 11 (4), 349-359.Slide9
Shneidman’s Principles (cont’d)Medical
evaluation of the survivors is critical
with consistent monitoring of physical and behavioral
health.
Avoid
banal optimism or platitudes
that undermine the hard work of addressing the reality of a suicide.
Postvention
bereavement treatment
may take several months to a year
– and certainly more than a few months or sessions.
A
comprehensive best practice postvention program
should include preventive, interventive
, and
postventive
efforts.
Source:
Shniedman
E. Postvention: The Care of the Bereaved (from Consultation-Liaison Psychiatry), Suicide and Life-Threatening Behavior, Winter 1981; 11 (4), 349-359.Slide10
Implicit to Postvention:Suicide, sadly, is not 100% preventable and as such survivors need immediate care and are often eager for the opportunity to share their feelings
Suicide is stigmatized and postvention may mitigate shame from the important interventions needed
Postvention can function as prevention and further prevent a suicide of a survivor
Erlich MD, GAP Committee on Psychopathology. Envisioning Zero Suicide.
Psychiatr
Serv. 2016 Mar
; 67(3
):
255Slide11
PREVENTION vs. postventionRobust literature and many operationalized tools regarding suicide prevention, there is a dearth of postvention resources
What
is out there is sparse and variable with the possible exception of resource guides regarding the risk of suicide ‘contagion’ among adolescents
.
Ramchand
et al. Suicide
Postvention in the Department of Defense: Evidence, Policies and Procedures, and Perspectives of Loss Survivors. Santa Monica, CA: RAND
Corp, 2015. http
://www.rand.org/pubs/research_reports/RR586.html.Slide12
Postvention as PreventionSuicide of a close family-member, friend, etc., is a risk factor for suicidePostvention efforts strengthen prevention thru behavioral health, psychosocial, spiritual, and public health services to the survivors.
Proactive approach by addressing bereavement and shame
Postvention is destigmatizing and promotes
recovery for survivors.
Aguirre RTP, Slater H: Suicide postvention as suicide prevention: Improvement and expansion in the United States. Death Studies 34 (6): 529-540,
2010Slide13
Not there, yet.Trauma-informed therapies, psychological first-aid, and bereavement counseling are effective treatments, but lack an operationalized treatment for postvention episodes. A gold standard postvention treatment does not exist yet
Post-discharge
structured follow-up to survivors and their families which actively engages them during periods of care transition has the best evidence.
Luxton
DD, June JD,
Comtois
KA: Can
postdischarge
follow-up contacts prevent suicide and suicidal behavior? A review of the evidence. Crisis: The Journal of Crisis Intervention and Suicide Prevention 34(1): 32-41, 2013Slide14
Example: NYC Subway’s “12-9”“
‘
The
look on their faces -- it was like looking into a mask of horror
,’
he
said…That
time, his blood pressure went sky high. His nerves were shot, and he needed nearly a year and a half to pull himself together.
‘I
felt all kinds of guilt
,’ he recalled...”
(
Clyde
Haberman
, “The
Numbers Motormen Dread:
12-9”, NYT, 6/13/2000)
Protocol: 3-days off + counseling. Could be months. May never return.
Protocol
: 3-days off + counseling. Could be months. May never return.Slide15
If “an ounce of prevention is better than a pound of cure,”Then, what is the correct dose of postvention?Slide16
A pilot surveySurvey of psychiatrists at think-tank, Group for the Advancement of PsychiatryAims: What do you do post-suicide? Do you know of postvention protocols? If so, are they used?
Challenges / barriers post-suicide
Intent:
Inform a larger survey (to come in Psych Times in Fall, 2016)
Recommendations to enhance postvention resourcesSlide17
Demographics and BackgroundSurvey given to190 individuals, response rate of approximately 47.4% (n=90)
Gender: The
majority of respondents were male (71.6%) with a mean age of 56.8 years (SD 15.9 years).
Experienced: Clinicians
had an average of 24.6 years of experience (SD 16.7 years).
Incidence: Approximately
one-third of the sample had experienced no patient suicides (34%) or 1 patient suicide (37.8%). A quarter had experienced 2-3 patient suicides (24.4%). A small percentage of the sample had experienced 4-5 patient suicides (1.1%) or more than 5 patient suicides (2.2
%)Slide18
Some findings…As expected, psychiatrists with greater experience (more years in practice) were more likely to have more patient suicides (p=0.027)Approx. 80% called family or friends of the
victim; ~70% offered condolences; and ~20% apologized.
>10% of those experienced 1 or more suicides used a suicide postvention procedure or toolkit.
But, significantly, MD’s
with more patient
suicides were
more likely to
call (p=0.036), and use
postvention procedure or toolkit
(p=0.002)Slide19
Additional findings:Most MD’s post-suicide of their patient review their notes, obtain informal supervision, discuss with a colleague. Less than 1/3rd contact risk-assessment, lawyers, or litigation specialists.
~10% stopped accepting new patients deemed at risk for suicide (F > M, p=0.032)
Most not aware of postvention, and likely that the link between postvention to prevention is vagueSlide20
What’s the state of community postvention?What is the need for a comprehensive and coordinated postvention response at the community level-and what is being doneEnsuring a community response is coordinated with individual agency/systems responses that may already be in place e.g. schoolsDevelopment of a an electronic resource kit that can be used by community stakeholders to provide guidance on critical elements of postvention, independent of a formalized responseSlide21
ResourcesGeneral ResourcesAmerican Foundation for Suicide Prevention (AFSP):
https
://www.afsp.org/coping-with-suicide-loss/resources.
Suicide
Prevention Resource Center (SPRC):
http://www.sprc.org/programmatic-issues/prevention-strategies/postvention-and-crisis-response
Action
Alliance Postvention Toolkit:
http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/Managers-Guidebook-To-Suicide-Postvention-Web.pdf
Suicide Prevention Center of NYS
http://preventsuicideny.orgSlide22
Resources, cont’dSurvivor Programs / ResourcesThe Connect Program: http://
www.theconnectprogram.org/training/reduce-suicide-risk-and-promote-healing-suicide-postvention-training
Loving Outreach to Suicide Survivors (LOSS):
http://
www.lossteam.com/PDFs/LOSSTeamChapterRTP.pdf
HEARTBEAT, a peer support
resource:
http
://
heartbeatsurvivorsaftersuicide.org/index.shtml
Suicide: Finding Hope, resource from a clinical psychologist who is also a suicide
survivor:
http
://www.suicidefindinghope.com/content/contacting_the_clinician
Slide23
Thank youAcknowledgements to Group for the Advancement of Psychopathology’s Committee on Psychophathology and Stephanie Rolin, MD MPH (Columbia / NYSPI)