Suicide Postvention: Reminders and Revelations

[Content warning: The following post contains explicit discussions of suicide.]

A few weeks ago, I had the opportunity to attend the London-Middlesex Suicide Prevention Council’s annual professional development day. This year, it was devoted to the topic of suicide postvention and was led by the absolutely outstanding Dena Moitoso, a registered psychotherapist based in the Kitchener-Waterloo area.

One of the things that I love most about professional development days is that no matter how widely and often I read about death, dying, grief, and bereavement, presentation such as this one are a welcome opportunity to remind myself of many of the fundamental principles of approaching the topic of death with compassion and an open mind. To that end, I wanted to talk about my positive experience from this professional development day by sharing these principles and how Dena built on them to discuss the complexities of suicide postvention.

What is suicide postvention?

When I first saw the title of the PD day, I was a bit confused as I’d never heard the word “postvention” before. I reasoned that if “prevention” came before (PRE-vent) and “intervention” came in the middle of something (INTER-vene) then “postvention” must refer to everything that comes afterwards. What I would come to learn, however, is that even though these prefixes refer to times before, during, and after a crisis or event, suicide postvention is also a prevention and an intervention. That’s the thing about a crisis or traumatic event, as anyone who has experienced or studied responses to these phenomena will tell you: crises and trauma have a way of pervading, manipulating, and persisting across our conception of time and space.

Let’s start with a definition, though. The SPRC defines suicide postvention as “an organized response in the aftermath of a suicide to accomplish any one or more of the following:

  • To FACILITATE the healing of individuals from the grief and distress of suicide loss;
  • To MITIGATE other negative effects of exposure to suicide; and
  • To PREVENT suicide among people who are at high risk after exposure to suicide.”

The word “postvention” is primarily used in the context of the suicide prevention field and, as Ken Norton from the National Alliance on Mental Illness reminds us, it is essential that we prepare for postvention before a suicide. This is another reason why the time-based prefixes muddle the issue. Although crises may not be predictable, being able to understand and prepare for these crises can help equip us to know how to respond in a time of heightened and often confusing emotional, physical, and mental reactions, not to mention logistical complications. Norton notes that the following key players and participants are well served by suicide postvention training: first responders, coroners, funeral directors, faith leaders, emergency departments, clinicians, and journalists. I find these last two to be especially interesting because when it comes to crisis and trauma, we often think of clinicians and journalists as secondary players in the grand scheme of things. However, these are also individuals with a wide sphere of influence and often have immediate, long-term access to people and communities who are affected by crises and traumatic events. Being able to communicate thoughtfully to and about the folks involved is a crucial skill that may or may not be a standardized component in clinician and journalism training. And even though first responders are obvious roles that would seem to require specialized training, it is only recently that educators and professionals in those fields have begun to fully understand and implement training that accounts for the effects of trauma.

That said, even if you are not someone who is interested in understanding or likely to be exposed to similar kinds of crises, suicide postvention responses are part of a larger skill set that we might call “grief literacy,” that is, a sense of competence and basic knowledge in how to effectively and compassionately engage with people in a time of grief and bereavement. One of the things I hear most often from friends, family, and storytellers is that they don’t know what to do or say when faced with a person experiencing grief and loss. Specifically, they are afraid of doing and saying the wrong thing, and this fear can sometimes produce a distance between individuals and communities that would otherwise be a part of someone’s support system.

So how do we become “literate” or begin to understand how to be there for someone in the aftermath of a death, especially one as complex as the suicide of a loved one? Thanks to Dena, the structure of the professional development day laid the groundwork for asking this question. Dena’s approach to postvention was to connect grief, trauma, and bereavement in order to understand how the body and mind respond to a crisis. This approach is one that I might call psychosomatic, that is, it looks at how the brain creates affective responses and how our affective responses impact our bodies in a kind of dialogue or mutually determinative relationship. When it comes to crises, a lot of the metaphors that we use to describe our emotional and mental responses reflect the physical phenomena that our nervous, circular, and endocrine systems are experiencing. For example, the experience of feeling like you’re a robot, machine, or automaton in the aftermath of a crisis reflects the fact that the body goes into a kind of “autopilot” in order to keep you safe, upright, and relatively functional even when your brain feels like it is melting or wholly overpowered. If you’re interested in this, I encourage you to look at this resource from Harvard for a nicely articulated summary of the science side of things. Even though the science side of things isn’t my specialty, this reminder of the physical impact of trauma on the body and the psychosomatic roots of grief was a very useful component of the day’s presentation.

With this in mind, then, I’d like to return to the idea that there are a few foundations of grief literacy that we can recognize and build on to better understand strategies for suicide postvention.

1. Where and who we are in life impacts and has a close relationship with how we grieve. I suspect I don’t need to tell anyone that, say, a child of four years will have a different relationship to and understanding of loss than a septuagenarian. But what if we start thinking about how grief might differ between a four-year-old girl from Alberta and a six-year-old boy from West Africa? Or how a forty-year-old mother of two whose household income is quite comfortable would experience the aftermath of loss differently than a sixteen-year-old queer homeless boy? Although you may not feel equipped to fully understand the networks of power, geography, and preconception that affect how we see ourselves and how others see us, it is well worth reminding ourselves that one of the first components of grief literacy and relating to a grieving person is being there with your ears first, listening with compassion and without judgement, and taking your lead from the person to whom you are listening. There may be time for questions that can help you better support this person later. However, in the immediate aftermath of a traumatic event, no matter how well you think you know a person, making space and being with them rather than overpowering them or making assumptions is a great place to start. This leads me to my second point, which is more specific to suicide postvention, and that is:

2. Proximity and identification count for a great deal. Where we are in location and in life in relation to a person has an enormous effect on our response to the loss of that person. I can tell you that since becoming a mother, my affective response to the loss of a child has intensified drastically and changed in a number of different ways. I can also tell you that I respond very differently to the news of the death of a person with whom I share a number of characteristics than one with whom I do not have much in common. In the aftermath of a suicide, this is even more significant. Peers and colleagues might find themselves experiencing additional complications in their grief because of similarities between them and the person who died, and those of us who are already experiencing mental health issues, distress, anxiety, PTSD, or grief will find that this identification can exacerbate existing issues and make us more susceptible to harm or danger as a result of those issues. Furthermore, although suicide can be traumatic for everyone in the sphere of influence of the person who died, the trauma of hearing the news of a suicide is very different from the trauma of being, for example, a loved one who finds the body of a person who died by suicide. Suicide postvention asks us to take proximity and identification into account as a part of the larger work of empathy and holding space for someone’s experiences. And while we are on the topic of “proximity,” it is worth noting that…

3. Attachments and relationships are not the same things. This distinction comes from an understanding that even though we may not choose our relationships, our attachments are more frequently a matter of deliberate choice and outreach on our part. For example, I have many aunts and uncles for whom I care deeply but with whom I am not particularly close. I do, however, have a number of colleagues with whom I have worked for years and to whom I have grown very close. The loss of an aunt or uncle that I’ve known since birth may thus be very sad but a different intensity of loss from what I might feel if I lost a beloved colleague with whom I’ve worked closely, even if only for a few years. Anyone who has experienced estrangement or has a non-traditional family structure will tell you that the folks in we might call our “chosen family” are much closer to us than our blood relatives. In some cases, your chosen family might consist of mostly blood relatives, and that’s important to understand, too.The danger lies in thinking that someone will not be affected by loss just because the title of the relationship is not familial or the relationship has existed for a shorter time than other relationships. The frequency of contact is another aspect of relationships that can have an impact on attachment. A woman whom I consider a dear, trusted friend moved to Toronto to pursue her law education and career while I have been caught up in learning to become a parent and getting back on track with my career. As a result of these efforts, it has been hard to be able to meet in person or find time to stay in touch. That doesn’t change the fact that I love this woman very much and would be devastated if anything ever happens to her. Someone looking at, say, her text message history might not realize this, however, and so if something were to happen to her, I might not come to mind as someone who would be strongly affected. Part of suicide postvention is realizing that we can’t make assumptions about who is and is not affected by the traumatic event of a suicide and that it is not our place to decide who is and is not allowed to be affected by suicide, how they are affected, or for how long. This leads me to another important point that came up again and again in Dena’s presentation, which is:

The danger lies in thinking that someone will not be affected by loss just because the title of the relationship is not familial or the relationship has existed for a shorter time than other relationships. The frequency of contact is another aspect of relationships that can have an impact on attachment. A woman whom I consider a dear, trusted friend moved to Toronto to pursue her law education and career while I have been caught up in learning to become a parent and getting back on track with my career. As a result of these efforts, it has been hard to be able to meet in person or find time to stay in touch. That doesn’t change the fact that I love this woman very much and would be devastated if anything ever happens to her. Someone looking at, say, her text message history might not realize this, however, and so if something were to happen to her, I might not come to mind as someone who would be strongly affected. Part of suicide postvention is realizing that we can’t make assumptions about who is and is not affected by the traumatic event of a suicide and that it is not our place to decide who is and is not allowed to be affected by suicide, how they are affected, or for how long. This leads me to another important point that came up again and again in Dena’s presentation, which is:

4. There are a number of ways in which grief can become directly or indirectly disenfranchised. Let’s think about how disenfranchisement is defined for a moment. The term, which can also be used in a legal context as it applies to civil rights, refers to the revocation of power or control of an individual, community, or being to a natural resource or amenity to which they are entitled. This amenity could be some sort of privilege, right, or immunity, and while it is used primarily in a legal sense it is an important term to think about when we discuss grief and bereavement. Who has the right to grieve? Who is allowed to grieve, in what way, for how long? What is acceptable, appropriate, permitted, or prohibited? The answers to these question aren’t written in stone, of course, or even defined in certain terms, but the answers are informally shaped by cultural, religious, social, and even political and financial factors. Think for a moment about the way we perceive individuals who have lost a partner or spouse. There are several Miss Manners and other advice columns as well as countless long form articles about etiquette, behavior, and approaches regarding the loss of a spouse. Even though we say that everyone grieves differently, there is still an informal Western standard that we inherited from the Victorians that governs our approach to grieving spouses. Conservative clothing, waiting a certain amount of time before pursuing a new romantic or sexual relationship, wearing or taking off a wedding band—these notions of the grieving spouse may be changing but they are nevertheless pervasive.What I want people to get out of this example is the idea that even if we don’t make conscious

What I want people to get out of this example is the idea that even if we don’t make conscious judgments about the way people grieve or express these judgments to a grieving person, there are certain narratives and forces that inform an “appropriate” idea of who grieves, how, and for how long. If someone’s grief takes a form that is unfamiliar to us, if someone grieves in a way that we feel is not commensurate with the relationship to a lost loved one, or if someone grieves for what we feel is an inappropriately long or short amount of time, we run the risk of disenfranchising a person of the right to grieve in the way that they need to. I should note that this does not mean that people should be entitled to grieve in ways that include harm to themselves and others and should be left alone, or that people should not be supported in changing habits or practices as a result of grief that become harmful to themselves and others. What I do want to express is that a grieving person is directly and indirectly inundated with narratives of permission and prohibition, and this can affect their relationship to their grieving process. Furthermore, we can directly or indirectly support or change these narratives with the choices that we make in how we relate to a grieving person.

For example, let’s say that I have a friend who has lost a parent and that this friend returns to work immediately after the funeral. What might have influenced my friend’s choice? Perhaps she feels helpless after this loss and wants to return to the familiar workspace where she can feel useful, valued, and competent. Perhaps she has no other choice because her financial situation does not permit unpaid leave and her workspace does not offer paid leave. Perhaps she feels pressure to “act normal” and “get back in the swing of things.” Perhaps it is a combination of one or more of these factors. What is important to understand is that there are many forces that underly a person’s experience of bereavement and that when the power to determine this experience for oneself is explicitly or implicitly taken away, an individual can experience disenfranchised grief. The first influence, the choice to return to work, is an empowering one. Even if it turns out to not be the best choice for my friend, it is a choice that she made and is a part of her self-determination in a time of grief. It should thus be respected by friends, family, and colleagues. Swooping in and insisting that it’s “too soon” to go back to work and that she needs to take time off might be well-meaning, but it is not supportive of her right to self-determine and it can contribute to disenfranchisement. Similarly, the implicit social pressure or explicit and very real financial pressure to return to work can result in another serious type of disenfranchisement in which my friend does not feel or does not have permission to take time that she might wish as a part of her grieving process.

Disenfranchised grief is a complex issue, which is why I’ve talked at length about what it might look like. Especially in the case of a traumatic death or crisis like a suicide, the “norms” for grieving and everything we think we know about grief tends to go out the window, and even well-meaning individuals can contribute to disenfranchising a person grieving the loss of a loved one by suicide. This is why a key part of suicide postvention is to leave our judgments about appropriateness, propriety, and what is “normal” at the door. This first step can help us stop focusing on what is supposed to be happening and recognize and respond to what is happening to a person or community in the aftermath of a suicide. This is a good foundation for my next point:

5. Grief is not something we “get over.” Grief and its effects are something that we integrate into our lives in different ways over a long period of time. This is a hard one to write about and an even harder one to experience. I suppose the way that I interpret this core tenet of compassion towards people in a time of grief is this: grief is not an event with an end point or set of signposts. It is not a ruler with markings on it and it is not a burden that we pick up and put down. I have come to think of grief as a set of habits, practices, and beliefs that change and fluctuate over time, things that are an integral part of everything from the minutiae of our daily lives to the “big picture” of how we think about our identities and relationships and everything in between. When, from the outside, we observe someone who has “gotten over” the loss of a loved one, what we are really seeing is a person who has integrated their grief and the changed relationship to the person who died into the way they move through the world.

What this looks like in theory and in practice is a topic so immense and complicated that it deserves several web pages worth of writing rather than this small section. But what I think is essential to understand about the myth of “getting over” with regard to suicide postvention is that grief in the aftermath of suicide can also be considered a set of habits, practices, and beliefs that will, to a greater or lesser degree, be a part of a person’s life for the rest of their life. Suicide will have an impact on individuals and communities in ways we can imagine and for stretches of time that go beyond what we can comprehend, and that means that, once again, we have to leave our judgement at the door and let go of our assumptions if we want to learn how to respond to and engage compassionately with people who have experienced the loss of someone by suicide. More importantly, just as a person learns different ways of relating to their grief, so, too, do we have to be open to learning different ways of relating to a person who is grieving. Our habits, practices, and beliefs in relation to this person will change and shift over time, and that means that being there for someone who is affected by suicide is a dynamic process and not a static achievement. One does not suddenly achieve enlightenment and become a superhero of support for a grieving person. One becomes a watchful student at the side of the grieving person and tries to change with them as they observe and learn more about what that person’s life with grief is like.

Being with someone who is grieving is hard. There are no two ways about it. All the training and qualifications and experience in the world does not make it easy even if it helps us to become more competent and confident in our abilities. This brings me to my final point, one that is hopefully familiar to anyone who works in front-line care or as a first responder:

6. You cannot care for others if you are not taking care of yourself. This is not the first time I’ve talked about this on my blog and it won’t be the last. If someone in your life is grieving or experiencing the effects of a death by suicide, grief becomes a part of your life, even if it is indirect or distant part of it. I can’t remember when I first heard the metaphor of the oxygen mask as a way of talking about self-care, but I suspect I was reminded of it by the very wise Cassandra Yonder. When oxygen masks drop from the ceiling of the plan in a time of emergency, flight attendants remind you that you should always put your own mask on before helping others. This is because if you run out of oxygen while struggling to put a mask on someone who needs help, you’re in trouble and neither of you will get the help you need. If you are able to breathe, you are better equipped to help others who may need assistance to do the same. This is another topic that deserves several thousand words, but I will summarize by saying this: part of your suicide postvention “toolkit” is the ability to self-reflect and assess how you are doing before, during, and after your direct or indirect engagement with suicide. Do not underestimate how important this tool is and please do not hesitate to seek help for yourself if you need it.

Final thoughts

By way of closing, I wish to thank Dena and the LMSPC for another incredible training day. I encourage folks in the London community who are interested in learning more about how they can help people struggling with suicidal thoughts or dealing with the effects of suicide in their lives to visit the resources I’ve listed below. Suicide and its effects are a public health issue that impacts all of us, and as I mention at the beginning of this post, suicide postvention strategies are actually prevention and intervention strategies, too.

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