Life After Suicide

      Every year in the United States, there are 30,000-32,000 suicides, roughly one every 18 minutes. Most of these deaths bring together two groups of people under very unpleasant circumstances: emergency responders and family members or others close to the victim, known as "suicide survivors."

   Suicides do not occur every day in any community, but emergency responders will be involved when one happens. It may be treating and transporting someone who made a suicide attempt and succumbs to his injuries. It may occur on site when a suicide attempt results in death, or it may be notifying the family of a suicide. Emergency responders are trained to deal with suicide attempts, but few are prepared for aiding after a completed suicide, when the survivors become the "patients."

   In 2001, the U.S. Department of Health and Human Services (DHHS) called for training paramedics and EMTs to better help those they encounter after a suicide. The National Strategy for Suicide Prevention: Goals and Objectives for Action (see www.mentalhealth.org/suicideprevention) notes that emergency personnel can "set the tone for being respectful and sensitive to the needs of survivors and need to be prepared themselves for the impact such events may have on their own thoughts and emotions." A few communities offer such training, but most often it is learned on the job.

   DHHS called for an increase in "the proportion of those who provide key services to suicide survivors (i.e., emergency medical technicians) who have training that addresses their own exposure to suicide and the unique need of suicide survivors." This article details an effort to meet this goal in southeastern Pennsylvania by Montgomery County Emergency Service, Inc., a nonprofit psychiatric crisis facility in Norristown, PA, the home of Pennyslvania EMS Station 305, a BLS service that responds only to psychiatric emergencies (see www.mces.org).

WHAT IS SUICIDE POSTVENTION?

   Suicide postvention attempts to reduce the negative consequences that may affect those close to the victim of a suicide or those who have experienced a suicide. Its purpose is to facilitate recovery from traumatic loss caused by a suicide.

   Suicide postvention involves (1) providing aid and support with the grieving process and (2) assisting those who may be vulnerable to conditions such as anxiety and depressive disorders, suicidal ideation, self-medicating and other harmful outcomes of severe grief reactions.

   Suicide postvention should begin as soon as possible after the suicide. That's where emergency responders come in.

WHY DO SUICIDES HAPPEN?

   Every suicide is different, and the circumstances are unique to the individual involved. However, two common underlying factors are intense psychological pain and extreme hopelessness.

   Psychological pain arises when there is some seemingly unsolvable and totally frustrating situation in an individual's life, such as a compelling personal, interpersonal or financial problem, or something else.

   Whatever the problem, it is something the person finds devastating and believes cannot be "fixed." Coping and problem-solving skills fail; self-esteem and sense of control over one's life diminish. This brings on hopelessness, which may lead to suicidal thinking. In the absence of strong protective factors (e.g., social supports) and with high risk factors (e.g., drinking, access to a gun), a suicide attempt may occur.

   Suicide risk is increased by drinking or drugs, which lessen inhibitions and increase impulsiveness. This heightens vulnerability to thoughts of suicide and makes depression and anxiety much worse.

   Some suicides may be sudden and impulsive, but most are the result of a process over time. As it unfolds, it offers many points for getting help. While not all can be prevented, suicides are preventable.

WHO'S DYING AND HOW?

   In the U.S., 80% of all suicides involve adult males from their early 20s to their late 80s. Suicide risk among men rises with age, and those age 65 and older account for about 20% of all suicides. Men ages 80-84 have the highest suicide rate.

   Women complete suicide less often than men because they tend to be less involved with alcohol, they use different means and they seek help. Older women rarely complete suicide; however, females attempt suicide more than males. Many of these attempts require emergency medical care.

   In regard to race and ethnicity, the overwhelming majority of suicide victims are white, although suicides in the African-American community are increasing. Suicide rates are low among Asians and most Latinos (except teen girls). Suicides among non-white women are uncommon.

   Firearms are used in most suicides. Guns are involved in 65%-70% of male suicides and in 40%-45% of adult female suicides. They are part of the reason more males die by suicide than females.

   Veterans account for 20% of U.S. suicides. All have some familiarity with firearms, many have experienced trauma, and alcohol misuse may be a problem. The risk for suicide is highest in younger, white, male veterans ages 18-44. Physically and emotionally disabled veterans are also at high risk.

   Most suicides involve an adult white male who dies violently in a location where he will most likely be found by someone who is very close to him in life. He will leave 6-8 folks behind who will have a very hard time dealing with the loss. These are the people who will need postvention and your help.

MISCONCEPTIONS ABOUT SUICIDE

   Attitudes about suicide affect how emergency responders behave toward those close to the victim. They may share many popular myths about suicide or be influenced by beliefs about suicide that are part of professional cultures. Attitudes may also be shaped by encounters with individuals who repeatedly threaten suicide or make low-lethality attempts. (Such behavior is usually indicative of a serious personality disorder and can lead to more dangerous suicidal acts.)

   When emergency responders believe suicide is the result of personal weakness, it may lead to judging the victim and marginalizing him as a "loser." This attitude may come across even if nothing is said.

   Emergency responders may also see suicide as "normal" in cases of devastating illness, disability, legal or financial problems. Suicide is never rational. Saying someone "committed suicide" conveys the notion that he was in control. Acutely suicidal people are driven by a desire to die that is beyond their control, which is why they may be involuntarily hospitalized, if they are so fortunate.

   Mental illness, drugs and alcohol are often seen as causes of suicide. These factors increase the risk of suicide but do not cause it. People with mental illness do take their lives, but their deaths are the result of a combination of factors.

   Another myth is that suicide attempters "really want to die" and will "do it" sooner or later. Those who are suicidal do not necessarily want to die; they just want to end unbearable emotional pain. Being acutely suicidal is not a permanent condition. Crisis intervention often works with suicidal people.

WHAT IS DIFFERENT ABOUT SUICIDE LOSS?

   One way to understand suicide loss is to think of it in terms of the layers of grief it involves. The baseline is the same grief we all feel when we lose somebody we love or care for a lot.

   The first layer relates to suicide being avoidable. Survivors feel responsible and guilty because they "didn't do anything." Parents agonize that they let their child down. Blame for the loss may be put on third party (e.g., a therapist, counselor, school, friends, etc.) who knew of the risk, but didn't act.

   The second layer relates to the seemingly intentional nature of suicide. Those left to grieve may feel the victim chose to leave them. This can generate anger and a sense of abandonment, betrayal or rejection. Emergency responders may hear these feelings expressed.

   The third layer relates to the unanticipated nature of most suicides, which leads to an obsessive search for the "why." Family members and friends are literally shocked because they never saw it coming. Being blindsided by suicide generates anxiety, fear and a sense of vulnerability.

   The fourth layer relates to the stigma and shame attached to suicide. Even when outsiders do not express such feelings (and they often do), the family may hold deep-seated values that conflict with suicide. Those close to the victim may even be blamed for the death.

   Last are helplessness and worthlessness, which open the door for hopelessness, the potentially deadly mindset behind the emotional pain that may have precipitated the victim's suicide. Suicide survivors are at high risk of suicidality. Many victims had family histories of suicidal behavior.

IMMEDIATE NEEDS OF SUICIDE SURVIVORS

   In the first hours and days, suicide survivors may need:

• To see that what they are feeling is normal. Those bereaved by suicide may think they are suffering a severe psychiatric crisis. Losing someone to suicide is like a personal "9/11."
• To get support. A suicide is a sudden, unexpected and often violent death. Whatever got them through any previous deaths will fail them now. Suicide loss is best endured with help. Most suicide survivors find that the best source of help is contact with others who have lost loved ones to suicide. This is available through suicide loss support groups.
• To understand they will need time to deal with their loss and grief. A three-day funeral leave does not suffice with a suicide. Most survivors will need to take things slowly and take care of themselves and their families.

   Suicide survivors are the secondary victims of the suicide who manifest many of the physical and behavioral signs of victims of disasters or other trauma.

POSTVENTION "FIRST AID"

   As an emergency responder, you can:

   Establish rapport with survivors

   Extend an offer of help and caring by "being there." Introduce yourself and other responders on the scene. If there is a feeling that things are being forced, just back off. If not, continue.

   Initiate grief normalization

   Let them discuss their feelings and concerns. Be ready for a lot of emotion and conflicting sentiments. Don't try to sort things out for them. They'll get to that later. Let them know that their emotional turmoil is understandable given the abnormal nature of their loss.

   Facilitate understanding of critical incident processing

   Explain the investigative activities that occur with any unnatural death. Tell them why the coroner or medical examiner will take the body and how they can arrange pick-up by the funeral director.

   Assist in mobilizing the support system

   Help survivors identify those who may be resources, e.g., a family physician, clergyperson, other family members or trusted friends. Don't say they have to make these contacts; just note that they may be helpful.

   Share information on community services

   Provide contact information for local grief support resources like Survivors of Suicide or other services they may reach out to if necessary. Local resources may be found on the Internet or in the phonebook.

   Encourage follow-through

   Urge them to see their family physician. Grief isn't a medical problem, but it impacts health and may aggravate existing conditions.

   These simple actions can get the family started toward recovery from their loss.

   Being involved with a suicide will not be easy for you either. After you have helped the family, take care to minimize your own critical incident stress. Aiding the survivors is a form of mutual self-help that may ease a suicide's impact on you. Special care should be taken if you have personally experienced suicidality or lost someone close to suicide.

BEHAVIORS TO AVOID

   Routine death scene activities can cause distress after a suicide. Here are some suggestions for handling them:

•    Crime scene processing

     "Treat all deaths as homicides at first, even suicides." Have you heard this? If so, you were probably never told how upsetting this can be to those struggling with the loss. Try to respect their feelings. Consider having one of the emergency responders not engaged in the investigation attend to the family's postvention needs.

•    Information gathering

     There are a lot of questions at a death scene, most related to determining the cause. The family may feel sure it is not a suicide. It is not your job to change their minds. The best course is to get "just the facts" in a way that is as minimally disturbing as possible to the bereaved (and to you).

•    Interference with the scene

     Sometimes the family will cut down the body, move the gun, throw away the pill bottle, start to clean up or hide any note. A lecture on death scene procedures won't help. You can say that you understand what's been done, but their cooperation is essential. Tell them things need to be left as they were for a bit and any note or personal effects will be returned.

•    Officiousness

     Suicide scenes may involve a struggle between a family that has lost control and emergency responders who are trying to take control. Falling back on authority will not help and will only leave a lasting resentment. Policies need to be applied with a little flexibility in some cases, and suicides are one of them.

SUPPORT SOURCES

   Mutual self-help groups are a common means of support for suicide survivors. Groups provide belonging, acceptance and normalization. They are empowering and enhance coping ability. Groups are "safe places" where survivors can be with others who understand their feelings.

   At group sessions, participants introduce themselves, say what they are comfortable in saying about their loss, and share thoughts and feelings. Facilitators may share materials for discussion or reference.

   Some groups are "open-ended." There is no fixed agenda, and they can be joined at any time. Other groups cover a preset agenda over a set period, usually a few weeks. Group leaders act as facilitators and try to assure that each meeting is meaningful for all in attendance.

   Sponsors of such groups include Survivors of Suicide (SOS) for suicide survivors and The Compassionate Friends for those who have lost a child of any age. To Live Again provides support to those who have lost spouses. Grief counselors, hospitals and hospices may also have groups.

   There are limited suicide loss support resources for children. Older teens may benefit from groups involving adults, but young children may need professional attention.

QUESTIONS YOU MAY BE ASKED

   Typically, you may only be involved with those dealing with the suicide loss for a very short period. However, even in passing, you may hear some of the following questions:

   What happens to the victim's personal effects removed by the police or the medical examiner?

   What happens to the gun (if one was involved)? Can disposal of the gun be arranged?

   Will an autopsy be performed on the victim? Who has access to the results of the autopsy?

   Is it possible to see the body at the coroner's/ME's office? Where is the morgue located?

   How is transport of the body from the ME's or coroner's office set up?

   How can the scene be cleaned up?

   Such questions can be referred to the coroner or medical examiner, a funeral director or the police (who may know of crime scene cleanup services and be able to help with unwanted firearms).

THINGS NOT TO SAY

   The following comments don't help, regardless of the speaker's intentions:

   "It was his/her time." (A suicide is always a premature death.)

   "There was nothing anyone could have done." (This is not convincing or comforting.)

   "Did you know that he/she was mentally ill?" (As if suicide wasn't stigmatizing enough.)

   "I know exactly how you feel." (Even if you have had such a loss, this is best not said.)

   "You know, you have to let her/him go." (Now is not the time to even think about this.)

   "All that anger will keep you from healing." (Anger is a normal reaction. Healing equates suicide to a cut or fracture.)

   "Don't blame yourself; it was his free choice." (Suicide is more an outcome than a decision.)

TOWARD A PROACTIVE POSTVENTION MODEL

   Emergency responders can offer initial "point of contact" suicide postvention, but most survivors will need further support for at least a short while. Some communities have specialized suicide postvention services, and a few have trained survivor volunteers who can visit the family on request. Post-suicide support resources remain few. Here are some strategies for meeting this need:

Victim Services Model

   This approach extends the mission of a victim services agency. Such entities serve those affected by very traumatic events. With additional training they could readily assist those traumatized by suicide.

Medical Examiner's Office Model

   Postvention services can be added to the medical examiner's office. ME staff are involved with every suicide and are in contact with the next of kin or others close to the victim.

Crisis Center Model

   These services are a natural fit with crisis intervention, linkages to mobile crisis services, and working relationships with police and EMTs.

Agency/Church Model

   Social service and mental health agencies or religious groups can develop postvention capabilities. Such entities could offer support on a long- term basis, if necessary. They would need 24/7 access and linkages to the emergency response system.

   Each approach has advantages and disadvantages, but each could fill a critical unmet need in the community. You can contact local health departments, mental health agencies or grief support groups to urge that such resources be established.

CONCLUSION

Emergency responders may witness the aftermaths of many suicides, but it will usually be the first for the survivors. Suicide loss is a severe emotional trauma that no one is prepared for. Suicide loss has features that make it uniquely painful. Emergency responders are in a position to immediately help by being sensitive, by listening and by sharing some simple information. Such basic caring may have a significant effect on how a family eventually recovers from its loss. It may help lessen their risk of grief complications and even additional suicides. Lastly, keep in mind that the suicide victim's death did not end the suicide emergency. It just changed in nature and impacted others, who need your help.

Tony Salvatore, MA, coordinates suicide prevention for Montgomery County Emergency Service, Inc., Norristown, PA. He is a member of the Pennsylvania Adult/Elder Suicide Prevention Task Force and is on the board of Survivors of Suicide, Inc. He may be reached at tsalvatore@mces.org.