ADDRESSING Postvention: what to do after the tragedy to prevent further tragedy? - PowerPoint Presentation

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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

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Thank youAcknowledgements to Group for the Advancement of Psychopathology’s Committee on Psychophathology and Stephanie Rolin, MD MPH (Columbia / NYSPI)