Describe suicide assessment and intervention techniques

1
Providing Quality Bereavement Care

• Objectives
• Define bereavement terms
• Identify myths associated with grief
• Identify five theories related to grief
• Describe normal grief reactions
• Discuss typical grief stages
• Identify specific types of losses
• Discuss effective listening skills- including
  phone support

2
Providing Quality Bereavement Care

• Objectives
• Describe techniques to assist the bereaved
• Discuss the use of bereavement support groups
• List complicated grief factors
• Discuss interventions for complicated grief
• Differentiate between depression and grief
• Describe interventions for depression
• Describe suicide assessment and intervention
  techniques

3
Personal Exploration

• Describe the very first loss you experienced.
• Were you able to share your concerns about your
  loss?
• What is your greatest fear concerning loss?
• How do you respond to others who are experiencing
  loss?
• What is a good helping relationship?
• What is your greatest asset that you bring into a
  helping relationship?

4
Definitions

• Bereavement- objective event of loss
• Grief- physical, emotional and social response to
  loss
• Secondary Loss- losses that are consequences of
  the initial loss
• Mourning- outward acknowledgement of the loss
• Grief Work- process of confronting the reality of
  the death

5
Common Myths about Grief

• All bereaved grieve in the same way
• It takes a year to get over a significant loss
• Its better to not think or talk about the pain
• The intensity and length of your grief reflects
  how much you loved the deceased

6

• When you are sorrowful, look again in your heart,
  and you shall see that in truth you are weeping
  for that which has been your delight.
  -Kahill Gibran,
• The Prophet

7
Grief Theorists

• John Bowlby
• Human beings are hard wired to attach, to love,
  and therefore to grieve
• The stronger OR more ambivalent the attachment,
  the stronger the grief reaction

8
Grief Theorists

• William Worden- Four Tasks of Mourning
• Accept the reality of the loss
• Work through the pain of grief
• Adjust to an environment in which the deceased is
  missing
• Emotionally relocate the deceased and move on
  with life

9
Grief Theorists

• Therese Rando
• Avoidance
• Confrontation
• Reestablishment

• Judy Tatelbaum
• Shock
• Suffering/ Disorganization
• Aftershock/ Reorganization

10
Grief Theorists

• Monica McGoldrick -Family Grief Response
• Developmental differences
• Family reorganization
• Reassignment of roles

11
Contemporary Thoughts on Grief

• No endpoint to mourning
• Dwelling on what has been lost is not
  productive
• The relationship does not end but instead
  reincorporated in new ways
• Remembering is comforting and life-enhancing

12

• If life is a journey, then dealing with the
  death of a loved one is one of those steep rocky
  mountain roads that you dont know if you have
  the strength to climb up and over. The only way
  is one step at a time, moment by moment, and
  eventually you are on top of the mountain with an
  easier path to follow.
• - Patricia Rose Upczak

13
The Physical and Cognitive Experience of Grief

• Confusion, Dizziness, Irritability
• Anxiety, Shortness of Breath
• Tightening of the Chest and Throat
• Sleep and Eating Disturbances

14
The Physical and Cognitive Experience of Grief

• Depression, Paranoia
• Memory gaps
• Auditory and visual hallucinations
• Frightening Dreams
• Inactivity/ Hyperactivity
• Searching Behavior

15
Stage One Shock and Disbelief

• When Dr. Redding told me my mother was dead I
  remember thinking he must be speaking about
  someone elses mother.
• I remember almost nothing in the week following
  the death of my son. That week seems like a
  blur.

16
Stage One Shock and Disbelief

• Adaptive response
• Able to cope with final arrangements
• Funerals/memorials assist transition to reality
• Feelings of disbelief return during the grief
  process

17
Stage Two Suffering and Disorganization

• When the reality of the loss sinks in, the
  bereaved may
• Feel profound sadness, loneliness
• Feel despair over lost dreams
• Loose confidence in themselves
• Be forced to establish identity as single person

18
Stage Two Suffering and Disorganization

• When the reality of the loss sinks in, the
  bereaved may
• Have to take on roles and tasks of deceased
  spouse
• Express difficulty being with others
• Cope with changing relationships with others
• Feel embarrassed about emotional outbursts
• Re-experience prior losses

19
Additional Stage Two Emotions

• Guilt
• I could have done more to prevent her suffering
• I didnt get to see him before he died.
• I was supposed to die first, not him.
• I shouldnt feel relieved, but I do.
• I didnt tell her I loved her before she died.
• Anger
• How dare you die and leave me with all this.
• I blame the doctor. He missed finding the lump.
• If God loved me, he wouldnt have taken her from
  me.

20
Additional Stage Two Emotions

• Jealousy
• Why didnt it happen to someone else?
• I cant stand to see them so happy together.
• Idealization of the deceased
• My father never once got angry in his whole
  life.
• My wife was perfect in every way.

21
Stage Three Aftershock and Reorganization

• As the bereaved reconstruct their life without
  their loved one they may...
• Define what is meaningful to them
• Report confidence in acquiring new skills
• Rekindling of old relationships- start new ones
• Take on new hobbies and interests

22
Stage Three Aftershock and Reorganization

• As the bereaved reconstruct their life without
  their loved one they may...
• Enjoy reminiscing about life with their loved one
• Accept the reality and finality of death
• Return to stable eating and sleeping patterns
• Experience release and relief from their loved
  one
• Adjust to new role changes

23
Specific Types of Losses

• Loss of a Spouse
• Men are more instrumental grievers
• Women are more expressive grievers
• Length of relationship does not predict grief
  response
• Adult Loss of a Parent
• Most common form of bereavement
• Adult child left feeling orphaned
• Cushion of mortality gone

24
Specific Types of Losses

• Adult Loss of a Sibling
• Most neglected loss
• Loss of connection to past
• Guilt about any unresolved issues
• Loss of a Child
• Anger, guilt, separation, search for meaning
• May be the hardest loss
• May have negative effects on couples
  relationship
• Miscarriage, stillborn and newborn death must be
  acknowledged

25
Listening Skills

• Strong emotion, even months after the loss, is
  not abnormal
• Listening to someone crying is difficult, but
  important
• Calm down someone who is hysterical
• Dont change the subject or distract the griever
• Dont give advice or quiz for details

26
Listening Skills

• Empathy is helpful-dont over-do sympathy
• Realistic reassurance is OK
• Dont interrupt- speak when they are done
• Be nonjudgmental- what the survivor feels is
  important (even anger)
• Allow silence

27
Listening Skills

• Listen for content AND the feelings underneath
  the content
• Look for the main idea of the speaker
• Pay attention to non-verbal communication
• Relax, be yourself
• Secure a quiet place to talk

28
Listening Responses

• Nod, smile, intermittent eye contact
• Pause
• Casual Remark -I see Uh huh
• Echo- repeating back the last few words

29
Listening Responses

• Clarify- asking for more information
• Paraphrase- summarizing what you heard
• Interpret the speakers ideas within context

30
Phone Support

• Use words and tone of voice that convey concern
• Enunciate and speak slowly
• Convey understanding even if the response is
  superficial
• Visualize the speaker in a positive way

31
Phone Support

• Respect a desire not to engage in conversation
• Reinforce that they are not alone
• Schedule a visit
• Review VITAS bereavement services

32
Reflective Listening Exercise
33
Techniques to Assist the Bereaved

• Encourage the survivor to grieve in their own way
• Find a quiet, private place to talk
• Use the deceased name in the past tense
• Use the words died, death, dead
• Have them describe the death and any memorial
  events

34
Techniques to Assist the Bereaved

• Ask how theyve been coping since the death
• Ask how they coped with prior losses/ crises
• Acknowledge their strengths and past
  accomplishments
• Affirm their surviving the current loss

35
Techniques to Assist the Bereaved

• Ask them about their relationship with deceased
• Help them examine their special qualities/talents
  
• Advise against any drastic changes
• Reassure them its normal to feel overwhelmed

36
Techniques to Assist the Bereaved

• Help them identify feelings, including relief
• Warn them that emotional ups and downs are normal
• Remind them to take care of themselves
  physically- eat well, rest, exercise
• Suggest they limit alcohol and mind altering
  medications

37
Techniques to Assist the Bereaved

• Suggest that the bereaved.
• Be patient with themselves and others
• Set realistic expectations-small goals
• Take one day at a time
• Start slowly with customary chores
• Do small things for other people
• Set limits and say no when appropriate

38
Techniques to Assist the Bereaved

• You can also
• Validate the survivor for developing new skills,
  roles
• Affirm their right to feel joy and to develop new
  relationships

39
Specific Aids

• Validate the bereaved desire to review medical
  records
• Encourage the use of symbols and transitional
  objects-photos, clothing, jewelry

40
Specific Aids

• Suggest that the bereaved
• Journal to express their grief
• Write a letter to the deceased, to God
• Read about grief- library, bookstore, internet
• Make a family memory book or box
• Do art work to express their grief
• Play out unfinished business
• Role play to increase coping skills

41
Support From Others

• Dont tell me that you understand
• Dont tell me that you know
• Dont tell me that I will survive
• How I will surely grow
• Dont come at me with answers
• That can only come from me
• Dont tell me how my grief will pass
• That I will soon be free
• Accept me in my ups and downs
• I need someone to share
• Just hold my hand and let me cry
• And say, My friend, I care.
• -Anonymous

42
Support From Others

• Support system important in adjustment to loss
• Encourage bereaved to
• Reach out for help-talk with people who listen
  well and reminisce about the deceased
• Reach out for professional help if needed
• Take people up on their offers to help-and be
  specific with requests

43
Support From Others

• Educate bereaved that
• Friends may call less- fear of intruding or dont
  know what to say
• Its not their role to protect or provide support
  to others
• Its OK to set limits with someone who gives
  advice

44
Bereavement Support Group

• Benefits of Support Groups
• Talk with others who understand
• Learn ways to cope
• Average time is 3 months after loss
• Assess that survivor is appropriate for group
  experience

45
Bereavement Support Group

• Groups should be organized by
• similar losses (i.e., death, suicide)
• similar ages (i.e., teens, adults)
• Suggest the survivor try the group at least twice
  before dropping out

46
Complicated Grief Reactions

• Grief is generally complicated when it is
  extremely intense and consuming for more than six
  months
• What is Complicated Grief?
• High risk factors that lead to maladaptive
  adjustment, or.
• Normal symptoms with abnormal intensity and
  duration

47
Complicated Grief Reactions

• In Assessment, we look for
• Risk factors
• Bio-psycho-social-spiritual factors
• Naturally resilient?
• Physically healthy?
• Positive or negative outlook?
• Adequate support system?
• Concurrent life stressors?
• Strength from spiritual faith?
• Normal grievers are generally more in touch with
  reality

48
Complicated Grief Reactions

• Suicidal ideation
• Alcohol or prescription and non-prescription drug
  abuse
• Self destructive behaviors
• Lack of self care
• Radical lifestyle changes
• Ongoing numbness
• Isolation from self or others

49
Complicated Grief Reactions

• Highly anxious and restless
• Depression with sleep and eating disturbances
• False euphoria
• Persistent guilt and/or lowered self esteem
• Irritable and angry continually
• Paranoia

50
Complicated Grief Reactions

• Preoccupation with loved one or with their death
• Themes of loss come up in other areas
• Inability to speak about the deceased without
  experiencing intense and fresh grief
• Inability to change or move possessions of the
  deceased

51
Complicated Grief Reactions

• Having chronic physical symptoms- especially if
  the symptoms resemble those of the deceased
• Extreme fear about their own illness and death
• Extreme idealization of the deceased
• Compulsion to take on mannerisms of the deceased
• Inability to function and feeling out of control.

52
Patterns of Complicated Grief Responses

• Chronic Grief- excessive in duration
• Coincides with ambivalent/dependent relationship
• May include obsessive trips to grave, constant
  conversations about the deceased, etc.
• Delayed Grief- inability to deal with loss
• Grief from original loss may be experienced with
  future loss
• Sometimes denies remembering the deceased
• Happens when mourner is unable to grieve original
  loss due to other responsibilities

53
Patterns of Complicated Grief Responses

• Disenfranchised Grief- inability to publicly
  acknowledge loss
• If loss was related to AIDS, stillborn,
  infertility, abortion, loss of personality from
  Alzheimers
• If deceased was a pet, a friend, gay partner,
  lover, ex-spouse
• If mourner is a child, elderly person or person
  with developmental disabilities
• Exaggerated Grief- intensification of normal
  grief reaction
• Nightmares, extreme anxiety, anger, guilt and
  depression common

54
Patterns of Complicated Grief Responses

• Masked Grief- inability to associate poor coping
  with loss
• May develop psychosomatic symptoms, psychiatric
  symptoms- depression, paranoia, or delinquent
  behaviors
• Sudden Grief- results from an unexpected loss
• Can increase denial and numbness
• May feel regret for things not said or done
• May experience increased anger at others
• Search for meaning of death may prolong grief
  process

55
Interventions for Complicated Grief

• Requires intervention from a trained mental
  health professional
• VITAS bereavement team should
• Make an assessment of the nature of the
  complication
• Make an appropriate referral
• Follow-up on referral

56
Interventions for Complicated Grief

• VITAS bereavement team should
• Educate about normal grief process
• Instill hope- pain will subside with time
• Validate their requesting help
• Provide support to mourner and family
• Suggest a thorough medical and psychiatric
  evaluation

57
Interventions for Complicated Grief

• For disenfranchised survivors
• Validate significance of loss
• Assist them in accessing appropriate support
• For sudden loss survivors
• Provide stability, control
• Help them recognize loss and changes to
  assumptive world

58
Differential DiagnosisGrief vs. Depression

• Grief
• Sudden decline in self esteem-related to loss
• Support from others reassuring
• May have vague thoughts of suicide

• Depression
• Self esteem gradually decreases over time
• Isolation from self and others the norm
• May have active suicide plan

59
Differential DiagnosisGrief vs. Depression

• Depression
• Consistent depressed mood
• Pain is chronic-hard to identify origin
• Little decrease in somatic symptoms

• Grief
• Mood fluctuates
• Pain directly related to loss
• Decrease in somatic symptoms with time

60
Treatment of Depression

• Combination of drug and talk therapy most
  effective
• Refer to MD and mental health professional
• You can intervene by
• Establishing rapport
• Providing psycho education
• Affirming their strengths and accomplishments

61
Treatment of Depression

• You can intervene.
• Teach them to substitute negative thoughts with
  positive affirmations
• Encourage them to discuss negative emotions
• Instill hope- remind them they dont have to
  suffer

62
Treatment of Depression

• You can intervene.
• Help them set a reasonable goal around a fixable
  problem
• Encourage them to do things for themselves, take
  risks, find solutions to their problems
• Encourage distractions- pets, children, TV
• Suggest pastoral counseling, art, music, and pet
  therapy

63
Suicide Assessment

• Not uncommon for bereaved to have suicidal
  thoughts
• Reunite with loved one
• Relief from the pain of grief
• Indications of Suicidal Ideation
• Affairs put in order- personal items given away
• Delegating responsibility for pets, other people
• Ask questions about death
• Sudden change in attitude (happier)
• Statements of hopelessness, helplessness

64
Suicide Assessment

• Low risk- vague thoughts
• Moderate risk- ideation but vague plan
• High risk- lethal plan and means

• Motivation
• Plan
• Means
• Risk Factors
• White Protestant male
• 45 and older
• Lives alone
• Financial worries
• Health problems

65
Suicide Interventions

• Use least restrictive method possible
• - verbal/written contract
• - 24-hour suicide watch
• - voluntary hospitalization
• - involuntary hospitalization
• Involve the VITAS senior management team
• Always give them the suicide or crisis hotline
  number in your area
• Do not leave until you feel they are safe

66
Suicide Interventions

• Reinforce their confiding in you
• Be nonjudgmental and warm
• Use both open and close-ended questions
• Use direct terms (kill yourself, die)
• Get identifying info on the phone

67
Suicide Interventions

• If they are not at imminent risk
• Explore ambivalence, alternative options
• Partialize problems-focus on strengths
• Encourage them to remove any means of harming
  themselves
• Encourage support for others
• Help them focus on meaning in their life

68
In closing

• It is one of the most beautiful compensations
  of life that no man can sincerely try to help
  another without helping himself
• -Ralph Waldo Emerson