- 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
2. 3. Terms
- 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)
- 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).
4. Family Systems Nurse
- 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)
5. Description of Population
- 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
6. Description of Population
- 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)
7. Incidence
- 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).
8. Incidence Massachusetts Department of Public Health, Injury
Surveillance Program (Sept. 2008). Suicides & Self-Inflicted
Injuries in Massachusetts: Data Summary In 2006, there were 437
suicides among Massachusetts residents; a rate of 6.8 per 100,000
residents. The number of suicides was 2.4 times higher than
homicides (N=437 and N=183 respectively) in 2006. The total number
of suicides among MA residents increased from 429 in 2004 to 469 in
2005, then decreased to 437 in 2006. The suicide rate among MA
residents is lower than that of the U.S.In 2005 (the latest
statistics available nationally) the suicide rate for the U.S. was
11.0 per 100,000 residents compared to 7.3 per 100,000 for
Massachusetts. Source: Registry of Vital Records and Statistics, MA
Department of Public Health *Rates presented in this bulletin
cannot be compared to bulletins published prior to 2008. Methods
were changed to calculate rates based on all ages rather than only
persons ages 10 and older which was the method previously used.
Rates overall are only slightly lower due to this change.Figure 1.
Suicide and Homicide Rates,* MA Residents, 1996-2006 9. Incidence
Figure 2. Magnitude of Suicides and Self-Inflicted Injuries
resulting in Acute Care Hospital Stays or Emergency Department
Visits, MA Residents, 2006 118,000* In 2005, Samaritans
organizations in Massachusetts responded to over 118,000 crisis
calls. *this number includes repeat callers; individuals who
contact the Samaritan hotlines more than once. 4,454 Hospital Stays
for Self-Inflicted Injuries (FY2006) 437 Completed Suicides (2006)
6,969 Emergency Department Visits for Self-Inflicted Injuries
(FY2006) Sources: see Methods section Massachusetts Department of
Public Health, Injury Surveillance Program (Sept. 2008). Suicides
& Self-Inflicted Injuries in Massachusetts: Data Summary 10.
Review of the Literature
- 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
11. Theoretical Discussion
- 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.
ROLE OF STIGMA 12. Theoretical Discussion
- Cohesive family units with good support mechanisms experienced
less stigmatization.
- Development of programs for change
- Authors references from mid 1990s
- Important to address stigma in postvention.
ROLE OF STIGMA 13. Descriptive Research
- 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
-
- psychoeducational approaches
- Recommend taking to account family factors including individual
families traditions and approaches to grieving
FAMILY INTERVENTIONS 14. Exploratory Research
- 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
MENTAL HEALTH & GRIEF REACTIONS 15. Exploratory Research
- 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.
MENTAL HEALTH & GRIEF REACTIONS 16. Exploratory Research
- 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
MENTAL HEALTH & GRIEF REACTIONS 17. Exploratory Research
- 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
MENTAL HEALTH & GRIEF REACTIONS 18. Clinical discussion
- 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.
SOLUTION-FOCUSED THERAPY 19. Explanatory Research
- 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
NARRATIVE THERAPY 20. Explanatory Research
- 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).
NARRATIVE THERAPY 21. Explanatory Research
- 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
- Rolling versus closed admission practices, setting and
context
- The theoretical orientations, e.g. family systems.
NARRATIVE THERAPY 22. Predictive Research
- 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
SEEKING MENTAL HEALTH SERVICES 23. Predictive Research
- 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.
SEEKING MENTAL HEALTH SERVICES 24. Predictive Research
- 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
SEEKING MENTAL HEALTH SERVICES 25. Assessment
- 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.
26. Assessment
- In addition, the following is included in the family assessment
to better capture the qualities of their system:(Constance &
Morrison, 2002)
-
- level of autonomy of individuals and subsystems
-
- openness and clarity of boundaries between family members
-
- religious orientation and spirituality of the family
27. Assessment
- 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.
28. Counseling
- 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
29. Counseling
- 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
30. Teaching
- 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
31. Leadership
- 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
32. Leadership
- 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
33. Case Study
- 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
34. 35. Suicide Survivors Story
- http://www.youtube.com/watch?v=MvjEmRBuKiU
- Lidia Bernik is the Director of Network Development for the
National Suicide Prevention Lifeline
36. References
- 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.
37. References
- 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 .
38. References
- 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.