families experiencing loss due to death by suicide

1. Families Experiencing Loss due to Death by Suicide: FamilySystems Nursing Perspective Johana Seminiano, RN, BSN NU669-01- Family Nursing Theory Fall 2009 Professor Tucker

Suicide - a conscious act of self-induced annihilation, best understood as a multidimensional malaise in needful individual who defines an issue for which the suicide is perceived as the best solution(Schneidman, 1985, as cited in Pompili, Lester, De Pisa, Del Casale, Tatarelli, & Girardi, 2009).

Suicide survivor - a family member or friend of a person who died by suicide(American Association of Suicidology. 2007)

debateable

Postvention - those activities developed by, with, or for suicide survivors, in order to facilitate recovery after suicide, and to prevent adverse outcomes including suicidal behavior(A ndriessen, 2009).

The family systems nurse play an important role in postvention.

Individuals grieving a suicide death experience an elevated level of family dysfunction(Mitchell, Gale, Garand, & Wesner, 2003).

Suicide rates are twice as high in families of suicide decedents compared to families who has never experienced suicide(Mitchell, Gale, Garand, & Wesner, 2003)

Suicide survivors are those who have been directly affected by a suicide loss

High risk for unresolved & complicated grief that if left untreated can traumatize the family system and potentially lead to generations of dysfunction

90% of people who take their lives have a diagnosable and treatable psychiatric illness (AFSP, 2009)

In one study, 18% to 34% of suicide survivors reported maladjustment between 1 and 4 years after their loss with 2% of survivors experiencing psychiatric progression a year after the loss ( Cleiren & Diekstra 1995 as cited in Andriessen, 2009)

Suicide is the fourth leading cause of death for adults between age 18 and 65 years old and is the eleventh leading cause of death in the United States(National Center for Health Statistics, 2006 as cited in American Foundation for Suicide Prevention, 2009).

There are over 32,000 suicides annually in the US, with an estimated 6 survivors for every suicide(American Association of Suicidology, 2008).

Theoretical discussion on the role ofsocial stigma

Discussion of a descriptive research on recommendedfamily interventions

Discussion of an exploratory research onsuicide survivors mental health and grief reactions

Clinical discussion onsolution-focused therapy

Discussion of an explanatory research onnarrative therapy

Discussion on a predictive research onsuicide survivors seeking mental health services

Suicide taboos and historical stigma.

Surgeon Generals definition of stigma(U.S. Department of Health & Human Services, 1999 as cited in Cvinar, 2005).

Suicide survivors felt blamed and avoided.

Survivors perceived themselves to be stigmatized or they were the objects of stigma.

Anger and family disintegration were found in bereaving suicide survivors.

Some cases saw survivors disconnecting themselves from their homes and moved to new environments.

Cohesive family units with good support mechanisms experienced less stigmatization.

The family unit

Development of programs for change

Authors references from mid 1990s

Important to address stigma in postvention.

Family therapy is seen as the treatment of choice for suicide survivors used solely or with other adjunctive interventions

Five guiding approaches are used as a framework for therapists

integrative model

systems theory

psychoeducational approaches

attachment theory

narrative models

postvention approaches

Recommend taking to account family factors including individual families traditions and approaches to grieving

Systematic review of studies by searching the PsychINFO and MEDLINE databases

Studies have to meet seven criteria

Only studies that utilized subscales on depression and anxiety were reported

Qualitative analysis of the data was conducted and results were categorized under concepts of mental health variables and grief variables

Results show 41 out of 69 studies met the inclusion criteria

Studies show that suicide survivor groups are a heterogeneous group in that some experience a profound sense of grief and others experience relief

Few significant differences were found among mental health variables between survivor groups and other bereaved groups.

Significant differences found in studies where instruments used targeted specific grief reactions & sensitive to variables important for suicide survivors

Results using specific instruments show that survivors experienced an increased level of rejection compared to other bereaved groups

Shame and stigma were found to be strong for suicide survivors

Survivors experience a low level of shock/unexpectedness, which is stated to prolong their grief experience

No evidence support different reactions between suicide survivors and other bereaved groups

Limited data is available on the increased risk of suicide attempt by suicide survivors

There is an increased risk among family members of suicide completers in twin, adoption, and family studies

Limitation- no mention of how effective each recommendation is

Solution-focused therapyis defined as a strength-based model that helps clients resolve present problems by building on their existing resources and previously applied effective solutions (p. 93).

Applicable to families coping with suicide in that it strengthens their internal coping mechanisms and past successful abilities in solving problems

It recognizes the notion that families know what is best for them and therefore addresses their unique grief reactions (p. 93) of coping with suicide.

Study depicts the usefulness of narrative therapy on a psychotherapeutic group made up of suicide survivors

8 weeks, 2-hour sessions, 7 members in total attended all sessions, an advanced practice psychiatric-mental health nurse & social worker facilitated the sessions

(1) introduction, (2) weeks 2-4 provided each participant the time to discuss their loss, (3) presentations about Suicidology with updates on the most recent research, (4) adaptive coping skills and strategies, (5) termination of the group and discussing resources for ongoing support

Two types of narratives were discussed:

Agentic narratives are described as depicting events in such a way as to suggest the narrator is in control, despite disruption by traumatic life events (p. 96).

Victimic narratives are described as events affecting the narrators life and as being controlled by outside forces (p. 6).

Limitation on the use of narrative therapy onsupport groups composed of suicide survivors:

Type of facilitator needed to provide the best structure in support groups

Grouping of survivor groups meaning do survivors maximize its potential if its members are all suicide survivors

Re-narration of events supported to be beneficial or can they re-traumatize survivors

Duration of attendance

Rolling versus closed admission practices, setting and context

The theoretical orientations, e.g. family systems.

Determine if suicide survivors would seek help faster if an active postvention model (APM) were used compared to the traditional passive postvention model (PP) of referral

Determine if differences are present between individuals who receive APM compared to those who did not in terms of characteristics of suicide and decedent, clinical problems since the death, and engagement in group treatment

Dataset from 356 suicide survivors presented at the Baton Rouge Crisis Intervention Center from 1999 to 2005 were analyzed

Participants in the APM and PP group were fairly homogenous- most were female, only 2 to 2.4% were Black, age range 18 to 80 years old

Results show APM participants attended more support groups and were more likely to attend support group meetings

Decedents of APM recipients were more likely to have died a violent suicide method than nonviolent ones compared to PP recipients.

Decedents of APM recipients had a history of receiving mental health treatment and suicide attempts.

APM recipients also were less likely to receive suicide notes and were more likely to have discovered the decedent

Both groups experienced a previous history of suicide in their family alike.

Results regarding clinical problems since the death show that APM and PP recipients showed no differences in clinical presentation( problems with appetite, exercise, sleep, and concentration since the death)

APM recipients were no more likely than PP recipients to report current suicidal ideation at the time of their intake

Family problem of incomplete grief, unresolved grief, or stuckness.

Relational issues: dissatisfaction from renegotiating of relationships and reassignment of family tasks and roles, unnegotiated relationship issues, and stressed interpersonal relationships

Members of the family may experience problems such as behavioral disorders, compulsive disorders, anxiety attacks, suicidal ideation, sleeplessness, and decreased appetite, to name a few.

Family mappingco-constructed by the family and the therapistmay be conducted to help locate trauma and loss and tracks responses of family members.

In addition, the following is included in the family assessment to better capture the qualities of their system:(Constance & Morrison, 2002)

alliances and conflicts

level of autonomy of individuals and subsystems

openness and clarity of boundaries between family members

gender roles

ethnic considerations

religious orientation and spirituality of the family

Assess the impact of the suicide, the family members relationship to the deceased, and perception of the deceased prior to death (Constance & Morrison, 2002)

An identified goal may be for the family to undergo the grief process while maintaining the integrity of the family system. Later goals may include forgiveness, restructuring of relationships, reassignment of tasks and roles, and participate in suicide prevention advocacy.

Response to suicide are varied and include powerful and painful emotions including stigma, blame, anger, guilt, shame, and searching for why?

Framework used has to be meaningful to the family

Dependent upon the familys past experience with grief and learned coping mechanisms, counseling should begin to where the family is

Culturally and developmentally appropriate counseling approach needs to be conducted

Family members may fear the realities of death and may undergo a cycle of pain and symptomatology.

Counseling should address ways in healthy or helpful grieving

Help family members anticipate and manage emotive-promoting events to help them normalize their extreme emotions and decrease anxiety so they may undertake their day-to- day activities

Provide tools that are fitting to each participant including relaxation techniques

Refer suicide survivors to sources that have the potential to satisfy their search for meaning of the loss such as support groups, family psychotherapeutic groups, psychoeducation sessions on suicide, and religious or spiritual groups

Need to advocate the strength of the family as a vehicle for moving its members to becoming unstuck from their grief

Need to take leadership in the search for intervening effectively

Ensure adequate funding, gain social support, and shift social thinking surrounding suicide

Speak at a legislative hearing to gain legislative support on acquiring funds for further research

Gain public attention on the importance of addressing factors and issues surrounding suicide

Shift social thinking on suicide by helping the media portray suicide away from the stigma suicide receives and in turn, the suicide survivors suffer

Help the profession of family systems nursing gain an awareness of their own attitudes and beliefs about survivors of suicide and gap in the body of knowledge surrounding the care of suicide survivors

Pompili, M., Lester, D., De Pisa, E., Del Casale, A., Tatarelli, R., and Girardi, P. (2008). Surviving the Suicides of Significant Others: A Case Study.Crisis, 29(1), pp 45-58

Reports the case of a family which lost a member from suicide, depicts the deep psychache of survivors

Psychache- coined by Edwin Shneidman as the cause for suicide and described as the hurt, anguish, soreness, aching, and psychological pain in the psyche (the mind)

Suicide occurs when psychache is unbearable

Survivors experience profound grief that is often underestimated

http://www.youtube.com/watch?v=MvjEmRBuKiU

Lidia Bernik is the Director of Network Development for the National Suicide Prevention Lifeline

American Foundation for Suicide (2009).Facts & Figures.Retrieved from www.afsp.org on November 11, 2009.

Andriessen, Karl. (2009). Can postvention be prevention?Crisis, 30(1), 43-47.

Centers for Disease Control and Prevention (2001).State Suicide Prevention Planning: A CDC Research Brief . Retrieved from http://www.cdc.gov/ncipc/dvp/Suicide/state_suicide_prevention_planning.htm

Cerel, J., Padgett, J.H., Conwell, Y., & Reed, G.A. (2009). A call for research: The need to better understand the impact of support groups for suicide survivors.Suicide and Life-Threatening Behavior, 39(3), 269-281.

Cerel, Julie & Cambell, F.R. (2008). Suicide Survivors Seeking Mental Health Services: A Preliminary Examination of the Role of an Active Postvention Model.Suicide and Life-Threatening Behavior, 38(1), 30-34.

Constance, B. & Morrison, H. (2002). Survivors of Suicide: Emerging Counseling Strategies.Journal of Psychosocial Nursing and Mental Health Services, 40(1), 28-39.

Cvinar, Jacqueline G. (2005). Do Suicide Survivors Suffer Social Stigma: A Review of the Literature.Perspectives in Psychiatric Care, 41(1), 14-21.

American Association of Suicidology (Jan. 2008).Survivors of Suicide Fact Sheet. Retrieved from http://www.suicidology.org/web/guest/stats-and-tools/fact-sheets

Pompili, M., Lester, D., De Pisa, E., Del Casale, A., Tatarelli, R., and Girardi, P. (2008). Surviving the Suicides of Significant Others: A Case Study.Crisis, 29(1), pp 45-58.

Schneidman, E. S., Farberow, N. L. & Litman, R. E. (1970).The Psychology of Suicide . New York, N.Y.: Jason Aronson, Inc.

Sveen, C.A. & Walby, F.A. (2008). Suicide survivors mental health and grief Reactions: A systematic review of controlled Studies.Suicide and Life-Threatening Behavior, 38(1), 13-29.

World Health Organization, Department of Mental Health (2005).Preventing Suicide: A Resource for Primary Health Care Workers(WHO/MNH/MBD Publication No. 00.4). Retrieved fromwww.who.int/mental_health/media/en/59.pdf .

De Castro, Sahily & Guterman, J.T. (2008). Solution-focused therapy for families coping with suicide.Journal of Marital & Family Therapy, 34(1), 93-106.

Horwitz, Susan H. (1997). Treating families with traumatic loss; Transitional family therapy. In Figley, C.R., Bride, B.E., and Mazza, N. (Ed.),Death and trauma; the traumatology of grieving(pp. 211-230).Washington, D.C. Taylor & Francis.

Kaslow, N.J. & Aronson, S.G. (2004). Recommendations for family interventions following a suicide.Professional Psychology: Research & Practice, 35(3), 240-247.

National Institute of Mental Health (July 2009).Evidence-Based Prevention is Goal of Largest Ever Study on Suicide in the Military.Retrieved from http://www.nimh.nih.gov/science-news/2009/evidence-based-prevention-is-goal-of-largest-ever-study-of-suicide-in-the-military.shtml

National Institute of Mental Health (2001).Summary of National Strategy for Suicide Prevention: Goals and Objectives for Action . Retrieved from http://mentalhealth.samhsa.gov/suicideprevention/strategy.asp

Mitchell, A.M., Gale, D.D., Garand, L., and Wesner, S. (2003). The use of narrative data to inform the psychotherapeutic group process with survivors.Issues in Mental Health Nursing, 24,pp 91-106.

Murphy, S.A., Tapper, V.J., Johnson, L.C., Lohan, J. (2003). Suicide ideation among parents bereaved by the violent deaths of their children.Issues in Mental Health Nursing, 24(5), 5-25.

families experiencing loss due to death by suicide

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