Suicide

1.    THE MOBILISATION PHASE

Objectives: Getting an overview and establish contact with all the close relatives who need psychosocial follow up after a suicide and starting adequate aid as soon as possible. Bring in and coordinate the persons who will be responsible for the aid given.

Measures: The objectives are achieved through written procedures that are clear with regard to notification and referral, as well as a target group for aid measures and criteria for the follow up of the relatives in cases of suicide.

Notification procedures starts by updating the names and phone numbers of the individuals responsible for the starting point of the notification procedures:    

• The police is informed about the suicide (through relatives, doctor, priest, etc.)    
• The police notifies the crisis team and informs about the suicide.    
• The leader of the crisis team informs the rest of the team about the situation to ensure a coordinated follow up.    
• The relatives are contacted by the crisis team.

The Target group and criteria for the follow up are the relatives in cases of an actual suicide, not attempted suicide (in cases of attempted suicide there are separate procedures connected with hospitals – for instance Molde Sykehus and Haukeland Sykehus, and National Centre for Suicide Research and Prevention (NSSF). See also: The Directorate of Health: National professional guidelines: Guidelines for suicide prevention in psychological health care, report. IS-1511, 2008).    

• The procedures begin when a suicide is reported to the crisis team.    
• The procedures come into effect regardless of the age of the deceased.    
• Relatives are defined as the closest individuals affected (parents, siblings, partner, boyfriend, girlfriend, etc.).    
• In addition to (closest family), the people close to the deceased will be listed. Pay special attention to younger individuals that are not part of the close family that might have been close to the deceased, and who can be very vulnerable.    
• Work place, class at school, and other “small societies” are assured care through separate crisis plans.

2.    THE EMERGENCY PHASE

Objectives: To decrease the emergency reaction and limit the experience of loss of control by reducing stress, making emergency reactions easy to control, and re-establish a certain amount of order and structure, so that the closest relatives and any other people affected can regain and resume prior functions in the long run.

Measures: The objectives are reached through clear written procedures for emotional first aid and care giving, information and guidance, rituals, mobilising the support of social networks, and potentially organising practical and legal help.

Coordination and responsibilities:    

• The leader of the crisis team will lead/coordinate the follow up.    
• The priest and/or police will notify the relatives by personally going at the home in cases where someone other than the relatives finds the deceased.    
• The police, priest, doctor and possibly psychologist/psychiatric nurse visit the home of the closest relatives immediately after notification.    
• Please note! Professionals who get in touch have to feel that they are competent to work through the individual situations (meaning that they need to feel they are able to handle especially traumatic experiences).

Work form:    

• Direct, through conversation to map the needs for aid measures, going through the chain of events and support conversations (see Measures).    
• Indirect, through advice and guidance to the aid services involved (police, doctor, etc.), and schools, work places considering adapting for the close relative.    
• Help to mobilise close social networks to come and stay with the relatives (see Resources/Cooperation).

Measures (suggestions):    

• Ensure emotional first aid through care, shielding and information. Emotional support and reduction for stress will be crucial before the relatives can be reached with other information (see Measures/emotional first aid). It is important not to encourage a conversation about the emotional aspects of the suicide on the day it happened, as this can reinforce the memories of the occurrence. Sleep within the first six hours after the event should be avoided for the same reason.    
• A person in the crisis team (for instance doctor, priest, psychologist, psychiatric nurse) will systematically go through the event with the closest affected. Please note! It is important that the information come from aid workers with first-hand knowledge of what has happened (possibly also offer for the police to come and inform). This can be done using a model of debriefing or defusing and can be done with individuals or in groups, for example a family (see Measures/debriefing)    
• The conversation should include the relatives’ description of the chain of events, impressions, thoughts and reactions, as well as informing those affected with facts around the cause of death and circumstances surrounding the incident. Please note! If one or more members of the family (or friends) were part of finding or seeing the deceased, conversations about these impressions should be had away from those who have not seen it, so as to avoid unnecessary exposure to details.    
• Inform about common reactions to traumatic events and advice on how these can be lessened. (www.krisepsyk.no / Theme pages – Self-help methods) (see Reactions).    
• Youth and adults are given psychological, educational information and advice that are critical to contribute to make it easier to gradually get back to a normal life while living on with the grief and trauma. Depending on the individual affected family’s situation and the individual age, condition, questions and initiative, what can be brought up and informed about at what time will vary. During the emergency phase and the further follow up, there are a number of topics that the relatives can be prepared for, given understanding for, learn, or informed about (see Measures/support conversations).    
• The professionals that will deal with the relatives and affected should be given all the relevant information in advance. It is necessary to specify that both timing and amount of information have to be adjusted according to the individual needs. Some people can be informed immediately, while others cannot, and information given early should usually be repeated later.    
• Information should be given both in spoken and written form.    
• Information on common reactions in cases of “abnormal events” and “caring for children as relatives” should be printed and handed out to the closest affected as written material.    
• Offer to accompany to the identification of the deceased and information at the hospital.    
• Advice about carrying out viewing, memorial service and funeral (see Rituals).

In cases where children are the closest relatives:    

• Advice about children as relatives, and children and rituals, (www.krisepsyk.no / Theme pages – Grieving children), and (see Rituals).    
• Inform parents of children’s reactions and need for support after traumatic deaths (www.krisepsyk.no  / Theme pages – Grieving children and Siblings after suicide).    
• Help to inform the child about what has happened (www.krisepsyk.no / Theme pages – How to talk to children about suicide?).    
• Investigate whether close family/social networks are called in to help the family/closest affected through the first days. In situations of suicide, many relatives may need daily continuous presence from close friends/family who attend to simple, physical needs, for instance that they get something to eat and drink, and lie down to have some rest.    
• Evaluate the need for practical help with demanding caring tasks.    
• Medical consultation/treatment might be necessary. Hyperventilation, acute anxiety, passing out or similar can occur. Sedative treatment might be necessary, but it is important that people are not unnecessarily medicated.    
• If the deceased committed suicide using a firearm at home, it will be important that the crisis team, correspondent with the relatives, take responsibility for cleaning and tidying the furnishings. If the closest affected are left to do this themselves, cleaning up can be very traumatising in the short and the long term.    
• Evaluate the need for referral to special health services, and evaluate the need for further follow up (see Mapping).    
• If the deceased was employed, make sure that the workplace of the deceased, as well as the relatives’ workplaces, are informed, so as to begin their work plans in cases of suicide. This must be done in cooperation with the relatives. If handled correctly, colleagues can be an important support for the closest affected (see Resources/cooperation/the work place).

Measures for the network of friends (suggestions):    

• It is important to have measures for the friends when young people have taken their lives, because there is a higher risk of a “contagious effect” for new suicides. Apart from the family, many more individuals are usually affected by a young person’s suicide. Youth groups don’t usually seek help for themselves and can suffer from painful reactions to what has happened (see Children/Youth, Social network support, and www.krisepsyk.no / Theme pages – Young people’s situation after suicide). When working with groups of friends, it is important to gather and work with them, if possible. It is also important to remember that the participation of friends after a suicide can be a valuable support for the family of the deceased. Possible measures to take care of the youth could be:    
• Going through the chain of events, normalising the reactions, and information on self-help methods.    
• dentify younger individuals in need of closer follow up (see Mapping).    
• Give information about the suicide and how it happened (if the family agrees to it). Many younger individuals would like to support the family of their deceased friend, but might be uncertain of how to do it, and helping to cross the first barrier can be important. In this area, there are differences between different crowds of youth.    
• Offer information to schools and potential work placed (in cooperation with the relatives), to reduce the spread of rumours and anxiety.

Possible measures:    

• Advice about going through rituals. For instance, organising visits to the place of death (if the younger individuals have not already done this) (see Rituals/“Spontaneous altar”).    
• Preparation of memorial service and funeral, and possibly be part of planning (if the closest relatives wish for them to do so).    Inform about literature suited for the age group (for instance  Ranheim, U. (2002) – ”Vær der for meg”, Bugge, K. (1997) – Også unge trenger støtte i sorgen. Or : Ungdom og sorg. Pamphlet from LUB, LEVE, Kreftforeningen and Vi som har et barn for lite).    
• Stimulate the youth to find their own outlets for their feelings, for instance through music (www.krisepsyk.no / Theme pages – Young people’s situation after suicide/Strategies for coping) or through setting up a website for condolences.    
• Seeing as close friends of young individuals who commit suicide are at a higher risk (for new suicides, among other things), health personnel and others should pay special attention as to they are having problems coping with the situation. Young individuals who are having a very difficult time should be screened for depression and PTSD, potentially with clinical interviews (see Mapping) and possibly be referred to the special health services, based on screening results.

Measures for schools/nurseries (suggestions):The measures should interconnect with the school or nursery’s own plans for crises and deaths. Depending on the closeness and relation the child had with the deceased, different measures must be evaluated:    

• Inform the class of nursery groups (in agreement with the relatives and parents), to start processing, making it easier to approach the individuals and help to reduce the spreading of rumours.    
• Go through rituals to remember the deceased (see Rituals and Resources/collaboration/the school) (www.krisepsyk.no / Theme pages – Grieving children).    
• Preparation to attend the funeral, possibly also a memorial service.    
• Activities in the classrooms and nurseries to let the children express thoughts and that they miss them, for instance through drawing, talking about what has happened in groups, communal attention to the family of the deceased.    
• Evaluate the need for adapted teaching and exempting from exams for children who are relatives.

Measures for contributing personnel/helpers:In single cases, follow up of contributing personnel is not necessary when there has been a suicide, but it is important to regularly go through how the help measures work. (In cases where the crisis team is particularly affected – see “Measures for helpers” in “Transport accidents”.) It is also important to discuss emergency measures if many suicides occur at the same time in a limited area, so as to, among other things, discuss whether the high frequency can attributed to a “contagion effect”.

Time frames and transfer to further follow-up:    

• The emergency phase, when the crisis team begins a number of measures frequently ends after one week (after the funeral).    
• If the municipality has a small population and a small area, the crisis team’s professionals will often be the ones to do the further follow-up, as the municipality often does not have other professionals. The team will come up with a plan for further follow-up of the family or different individuals or groups affected. If the municipality has a small population in a wide area (for instance rural municipalities) it could be useful to do as in the bullet below, provided there are professionals in the municipality.    
• If the municipality has a large population and they live close together (for instance cities), the crisis team will contact the professionals responsible for the area in the municipality where the affected live. The crisis team can give recommendations and some advice for extent and further follow-up based on what has been done up until that point or what measures have been started for the affected.    
• Some central guidance criteria for who should especially receive further follow-up:    
• Adults who are the closest relatives.    
• Children and young individuals who are the closest relatives.    
• People who found the deceased.    
• Some central criteria that increases the need for further and more intense follow-up:    
• High sensorial exposure or a high degree of traumatic delayed reactions.    
• Individuals/families/groups (for instance young individuals) with psychosocial difficulties prior to the suicide.    
• Parents who have lost their only child.    
• When it is clear that adults are not able to fulfil their caring roles for instance to underage children or old and sick.    
• Relatives with a bad/little social network.    
• People who have previously struggled with mental problems or suffered painful losses.    
• The last person to talk to the deceased.    
• To ensure as much stability as possible for the affected, the person from the crisis team who had the most contact with the affected, should preferably be the contact person for the individual/family in the further follow-up. This person should be in close communication with the general practitioner who will be central in the further follow-up of the individual.    
• The leader of the crisis team (or possibly another responsible person in the crisis team) should be responsible for making sure that further follow-up is started and for any referral to other services.

3.    THE FURTHER FOLLOW-UP

Objectives: To give the relatives the psychosocial help and support that they need over time, so they can gradually resume a normal everyday life. Contribute to normalising the thoughts, emotions and reactions as an important part of working through the loss for the relatives. Seek to prevent the traumatic event from becoming a physical or psychological disorder or provoking unnecessary suffering that makes work, school or social life difficult.

Measures: The objectives are reached through clear written procedures to regular contact with the relatives and through continuously evaluating the need for measures, further examinations with them, as well as helping and supporting. Contact and offers of help should be there the first year after the suicide and for some, maybe even longer.

Coordination and responsibilities (suggestion):    

• The procedure for telephone contact should be secured for all affected families in cases of suicide through a clearly defined contact in the crisis team or the general practitioner. This person coordinates further follow-up.    
• School and work place follow their own procedures onwards in the capacity of each plan. (Schools are responsible for taking care of affected students, while the work place looks after the worker as relatives.)

Work form:Direct or indirect through support conversations, advice and guidance, and evaluation of the need for further follow-up:    

• Crisis team meeting for the relatives one month after the death.    
• Crisis team meeting for the relatives three months after the death.    
• Routine for telephone contact for instance 2-4-8-12 months after the death.    
• If the closest relatives show different needs of help (medical, trauma therapeutic intervention, family counselling, specific child professional help, spiritual guidance, support conversations, or practical, economic or legal help) during the routine call from the crisis team contact, the crisis team contact should get in touch with the relevant help services in the municipality and procure such help.

Measures (suggestions):    

• Continue conversations that have been started with the priest, psychologist, psychiatric nurse, etc. Likewise continue medical treatment/consultation, practical assistance etc. that has been started in the emergency phase.    
• Continue to prevent psychosocial difficulties through repetition of/addition to information from the emergency phase (see Measures/support conversations) at the crisis team meeting for those left behind a month after the death. The support conversations in the long-term follow-up will somewhat depend on what has been talked about in the emergency phase, and what has naturally, and rightly, been postponed. The following topics will nonetheless be central to the long-term follow-up:    
• The social cost and the feeling of being alone in the grief.    
• Other people’s expectations about how a person should react to the loss/trauma.   
• Realistic time frames for grief, reactions and difficulties.    
• The wear on couple’s relationships.    
• How the suicide can affect further life together (in cases where the partner is not the deceased)    
• Anxiety about the development and reaction of affected minors.    
• The deceased, missing them, and the emptiness.    
• How to cope with everyday life.    
• Further need for practical help/assistance with young children in the family.    
• The family’s function in the new situation.    
• Questions about the report from the autopsy.    
• How to handle special days and reminders.    
• Trauma specific mapping/screening of PTSD, anxiety, depression, and complicated grief  begin at the crisis team meeting with the relatives three months after the death in cases where no one appears to be having particular difficulties (see Mapping)    
• Evaluating the need for prolonged sick leave.    
• Counselling/guidance: Handling reactions to grief and crisis, handling difficulties living together, handling children’s grief.  
• Information about the importance of getting help from friends, family, and other social networks.    
• Legal and economic guidance (Landsforeningen for etterlatte ved selvmord).    
• Establishing contact with other affected people, for instance through support groups/organisations:    
• LEVE – Landsforeningen for etterlatte ved selvmord    
• Vi som har et barn for lite    
• Kirkens SOS    
• Humanetisk Forbund    
• Fransiscus-hjelpen

When young people have committed suicide:    

• Follow-up gathering for friends (for instance by youth leader, teacher, priest) focusing on the continuing life, how to handle personal reactions, criteria for seeking more help, and trying to identify any young individuals who need further referral.    
• Encourage the network of friends to stay in touch with the young siblings left behind and the parents.

Time frames:    

• The contact with the relatives should last at least until the one-year after the suicide.    
• An important criterion for ending the contact is that the relatives feel they can take part in daily life and hobbies without the reactions from the suicide stopping their participation and self-expression.    
• Ideal frequency: Crisis team meeting for the relatives one and three months after the death, supplemented by routine phone calls for instance 2-4-8-12 months after the death. This can possibly be done by the general practitioner in cooperation with the crisis team.    
• If the affected express a lack of interest in being contacted for instance from the start, or at one of the suggested points of contact, one should respectfully withdraw after asking permission to contact the person at a later (given) time. The affected should be informed about the knowledge possessed about the variation in experiencing being in need of help over time, and the varying stages of grief that can be experienced after a suicide. It is also important to inform them that some people manage very well without help and that they must not make themselves sick. If the affected does not wish any further contact at all, they should be informed of people and phone number to contact if they need the need for help later.   
• After one year, the crisis team/general practitioner should usually be able to be less extensive and active with the psychosocial follow-up of the relatives and continue the client contact/doctor patient relationship as before. If there are signs of isolation or other forms of passivity, the actively outreaching phase should last longer than the first year.

Comments:The further follow-up consists, among other things, of follow-up conversations that are gradually spread out over time. These must, among other things, bring up the family communication about the death, sibling reactions, family dynamics, aspects of opinions, and methods of self-help. Because a suicide involves a trauma in addition to the grief, it is important to evaluate whether family members need follow-up from a psychiatrist to receive help with more specific issues. The same should happen if the grief is persistent, or extended, or for any other reason has become complicated (see Reactions). After the first months, it is important that the relatives are offered to participate in grief groups. This includes siblings, of course. Other offers should be given if there is a need for it, by the professional/crisis team who is responsible for the follow-up, following the municipality’s procedures, and decide in cooperation with the relatives, what psychosocial help is needed.The frequency of the contact must be evaluated individually, but aim for contact close to memorable days and red-letter days. The task for professionals is to be realistic when thinking about the duration of the grief process and be active in offering support and help. From research, we know that relatives need to:    

• Try to understand the motive and the reason behind the suicide (Please Note! Children and young individuals need to receive age appropriate explanations/conversations)    
• Talk about the death and experiences surrounding it.    
• Sort though and put to words feelings and thoughts, especially blame and shame.    
• Discuss and receive advice on how to handle children’s reactions and difficulties.    
• Receive advice about practical issues.

Note! Sometime in 2009, a guide on “Measures for relatives after suicide” will be released. The guile is made by a work group (G. Dieserud, K. Dyregrov & M. Rasmussen) at the Norwegian Institute of Public Health in cooperation with a resource group (among others A. Dyregrov & L. Mehlum) working for the Directory of Health.