Matthew D. Erlich, MD



Matthew D. Erlich, MD, for the GAP Committee on Psychopathology

Suicide is increasingly a part of the national conversation. Deaths from suicide are now at their highest level in 30 years. Suicide is the 10th leading cause of death in the US-well ahead of deaths by homicide, which ranks 17th. In 2014, 43,773 people are known to have killed themselves, and there are likely more suicides that go unrecognized.

 More people die by their own hand than in auto accidents.

Attempted and completed suicides ripple throughout the community, affecting family and friends, community workers (such as police officers and teachers), and clinicians. Former NIMH Director Thomas Insel, MD, noted that with every suicide, there are 11 victims-the person who died and the 10 caregivers devastated by the loss who are themselves at risk.

 For those grieving in the wake of suicide, there are relatively few resources.

Interventions that occur after a suicide are called “postvention”-a term originated by Edwin Shneidman in 1968 at the first conference of the American Association of Suicidology.

Postvention addresses the care of bereaved survivors, caregivers, and health care providers. It aims to destigmatize the tragedy of suicide, promote survivor recovery, and strengthen suicide prevention efforts by providing multiple resources to the survivors-including behavioral health, psychosocial, spiritual, and public health services.

 To many, postvention is a secondary prevention effort, with the goal of assisting in recovery and mitigating trauma.

Here, we briefly review the literature on postvention efforts. We consider the effects on the victim’s caregivers-especially the behavioral health providers who care for a patient who commits suicide. We also provide current resources to help manage survivors’ and caregivers’ emotions and dread.

Postvention efforts have been developed to address a broad array of responses to a suicide. 

 lists selected resources. Most organized efforts focus on the family and friends of the survivor. Fewer efforts address the emotional toll on other caregivers.

A 2015 RAND report for the US Department of Defense highlights the dearth of scientific evidence on how to best respond to a completed suicide, best manage survivors’ grief, and monitor caregivers’ risk for self-harm.

 Despite their heterogeneity, postvention resources can be organized into 3 groups:

These groupings, although not mutually exclusive, reflect the dominant themes of postvention responses and are described briefly below.

 approaches. In the first few days after a suicide, there is immediate need for practical resources by caregivers to guide the survivors with the complicated tasks involved with the end of life after suicide. Active postvention approaches help improve survivor welfare, averting crises and assist with destigmatization.

In a Baton Rouge crisis intervention center, researchers followed 2 cohorts of suicide survivors between 1999 and 2005. One group received an active model of suicide postvention with guidelines and interventions; the other group received “treatment as usual” postvention. An active model of postvention led to earlier treatment for survivors and improved attendance at survivor support group meetings.

 Such early triage efforts function as a form of crisis intervention to manage current grief and to proactively address and anticipate future concerns.

Many organizations and state agencies now recognize that an early postvention response is a critical community responsibility. For example, The Local Outreach to Suicide Survivors (LOSS) is a peer-led program in which a team that includes a caregiver-survivor offers immediate support to survivors, from counseling to helping clean a victim’s home. At national LOSS conferences, members hone their skills and collaborate to improve postvention practices. Several states now incorporate LOSS programs into their postvention practices, and the use of LOSS programs is expected to grow.

) offers both a suicide prevention hotline as well as a confidential hotline in which trained counselors provide ongoing support to survivors. These operationalized, triage, or immediate crisis intervention approaches are increasingly seen as best practices to ensure that survivors are not left alone with the tragic aftermath of suicide, the stigma of having a loved one commit suicide, and the often overwhelming practicalities of managing a traumatic loss.

Grief counseling, narrative approaches, various therapies, and support groups are also available. The management of healing is an essential process both for survivors and professionals who work with them. Beyond concerns regarding professional liability and how this affects mental health workers’ response, there is a lack of expert consensus on managing the loss of a patient. The literature regarding how trainees and their supervisors manage a suicide when it occurs in the educational environment exists, mostly in the form of guidance articles and anecdotal pieces.

Questionnaires in Great Britain and Ireland, for example, showed that among the many trainees who experienced a patient suicide, 51% reported moderate emotional impact, 24% had a severe emotional impact, and 9% considered a change in career.

Such findings have been replicated elsewhere and training programs have responded accordingly with enhanced supervision and modification of their procedures to comfort affected trainees and their colleagues.

For non-clinician caregivers, coping and postvention strategies are more diffuse. There is a dearth of expert consensus, evidence-based guidelines, or rigorous studies. Although a description of the range of therapeutic treatment approaches that constitute survivor therapy is beyond the scope of this article, such therapies range from individual to group support, from passive reading to active role-playing; and from “The Girlfriends’ Guide to What to Expect When Your Girlfriend’s Grieving” to academic guidelines.

 The most standardized and widespread current postvention approaches have been developed to manage adolescent suicides in academic settings. Many of these protocols are rooted in the contagion risk that adolescent survivors may be at some risk of attempting suicide in the aftermath of an adolescent suicide. This phenomenon is well documented and awareness is critical.

 Postvention measures are primarily focused on initial containment of the tragedy and mitigating potential contagion among vulnerable individuals.

Thorough and informative protocols are available. These are intended to help identify at risk adolescents, to provide psychoeducation about warning signs that other adolescents and teachers can learn, and to delineate grief management techniques. One prominent example of this is the Texas Suicide Prevention Toolkit 

) that includes a glossary, FAQs, mnemonics to teach risk assessment, and practical guidelines.

Another containment postvention resource helps manage the aftermath of suicide in the workplace. First-aid interventions in work environments involve training managers and human resource personnel to set a respectful tone, to listen to (and elicit) the emotions of coworkers, and to provide practical resources for both inside and outside the work environment. Some of these protocols provide guidance for managing law enforcement authorities and maintaining a dignified, coordinated message to coworkers.

A variety of community members are affected by suicide. They include first responders, educators, coworkers, public service workers, religious leaders, and law enforcement personnel. The relationship may have been a close one (ie, a teacher/student) or it may not have existed (eg, a dead stranger discovered by a subway worker). Available resources for community workers have focused on delivering postvention to family and friends (eg, suicide in a school or workplace setting). However, few resources focus on community workers themselves, the emotional toll the suicide has exacted, or how to best support survivors.

The behavioral health care provider as a survivor

Roughly half of all individuals who complete suicide saw a health care provider in the month before their death, and a quarter had a behavioral health encounter.

 delineated 8 principles of postvention to guide the clinician in the aftermath of a suicide (

). While his principles were initially developed for behavioral health, they remain relevant and broadly applicable to all clinicians. Other than Shneidman’s principles, there is a dearth of rigorous research and studies on behavioral health professionals who are survivors of suicide (see “

The role of the behavioral health provider in postvention can be critical to other survivors and the community as a whole in reducing morbidity and mortality, increasing suicide prevention and postvention awareness, and destigmatizing the act of “taking one’s life.” Until suicide is no longer a societal issue, postvention efforts are relevant-and a necessity in the aftermath of suicide. All survivors will benefit from continued advocacy for an approach that incorporates postvention into the suicide prevention framework to enhance awareness, continue research in this underfunded area, increase funding for postvention efforts, and increase knowledge of how to implement best practice postvention strategies.

Dr. Erlich is Assistant Professor of Clinical Psychiatry, Columbia University College of Physicians & Surgeons. He reports no conflicts of interest concerning the subject matter of this article.

This article is from the Psychopathology Committee of the Group for the Advancement of Psychiatry (GAP).

 The authors are Matthew D. Erlich, MD, Lisa B. Dixon, MD, MPH, David A. Adler, MD, David W. Oslin, MD, Bruce Levine, MD, Jeffrey L. Berlant, MD, PhD, Beth Goldman, MD, MPH, Steve Koh, MD, MPH, MBA, Michael B. First, MD, Chaitanya Pabbati, MD, and Samuel G. Siris, MD. Dr. Adler is co-owner of Health and Productivity Sciences; Dr. First receives royalties from APPI Press. The GAP, American psychiatry’s think tank, informs and educates mental health professionals, policy makers, and the public at large.

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Articles

Here: a brief review of the literature on postvention efforts; the effects on the victim’s caregivers; and a guide to resources to help manage survivors’ and caregivers’ emotions and dread. 

Addressing the Aftermath of Suicide: Why We Need Postvention

One small sip for “S3” was one miraculous leap for neurotechnology. According to a recent report in Nature, a 58-year-old woman with long-standing tetraplegia (named “S3” in the report) mobilized a free-standing robotic arm to reach out and grasp a cup of coffee-a highly complex fine-motor movement-with merely her thoughts.

Five years before this awe-inspiring moment, a tiny neural implant (called BrainGate) with 96 electrodes was implanted in S3’s motor cortex. BrainGate’s sensor recorded the electrical activity of an array of motor neurons triggered when S3 imagined specific reach and grasp movements; these patterns of motor signals were “translated” (digitalized) into a series of zeros and ones that instructed a computer to operate an independent robotic (mechanical) arm with 3-dimensional movements. With a neural-computer interface, S3 could grasp a cup of cof-fee with brain signals alone. Remarkably, the motor cortex’s firing pattern-the sequence of zeros and ones-that had been recorded 5 years earlier remained essentially unchanged. S3 had a brain-computer interface to thank for restoring volitional movements to her paralyzed limb. Such an achievement is just one of many notable stories unfolding in the emerging field of neurotechnology.

Neurotechnology refers to the science of applying our emerging understanding of the brain, consciousness, thought, and higher-order activities of the mind into developing technologies. The tools of neurotechnology, however, are not new for psychiatrists. For example, in the realm of diagnostic imaging, functional MRI (fMRI) scanning discoveries have linked the brain’s anatomy with localized emotional and cognitive functions and dysfunctions.

One groundbreaking finding was Area 25 that Helen S. Mayberg, MD, identified as a “nerve center” for depression; it may be a reliable barometer for antidepressant treatment as well.

 Moreover, modern electro- and magneto-encephalography can detect tumors, find stroke sites, and specify epilepsy-prone brain areas. Other advances in neuroimaging promise to identify dysfunctional neural circuits associated with human psycho­pathology and suffering.

Beyond diagnostics, neurotechnologies are used in psychiatric treatment. The electromagnetic “wand” used in repetitive transcranial magnetic stimulation (rTMS) is FDA-approved for the treatment of depression, and emerging research indicates that rTMS could help less-en the intrusive thoughts of obsessive-compulsive disorder, improve the painful apathy associated with certain psychotic disorders, and diminish chronic pain caused by migraine headaches and phantom limb syndrome.

Neural implants, including computer chips and optic probes, are already in use to treat epilepsy and Parkinson disease. Similarly, research is under way to use deep brain stimulators to treat obsessive-compulsive disorder, refractory depression, Tourette syndrome, and addictions and to curb appetite and reduce obesity. Advanced drug delivery systems are being designed to zero in on diseased brain sites or turn on genes that could promote cell growth-and to do so without the degree of collateral damage associated with less precise methods.

Smart drugs, “nootropics,” that selectively boost the functioning of neural circuits involved in memory and cognition are another budding frontier. Perhaps the most incredible application is the field of optogenetics, where specially engineered, light-activated (or light-inactivated) ion channels are implanted in the brain to curtain the firing of neurons associated with anxiety or trauma. Native to unicellular algae found in a pond, these implantable ion channels-such as blue-light–activated channelrhodopsin that promotes neuronal firing or yellow-light–activated halorhodopsin that actually silences a neuron-can now assist neuroscientists in disentangling complicated neural circuits and, perhaps, in identifying an anxiety gene that could be targeted with gene therapy. This work is under way with mice, a few cortical steps away from man.

Neurotech’s brainchildren have also attracted considerable non-medical attention. Advancing from science fiction to applied science is a fast-growing, $8 billion business, with investments from commercial, military, and academic interests. While neurotechnologies may be poised to produce magic bullets for clinical medicine, the military hopes they might also fire live ammunition. (Just as S3 can reach for a cup of java with her thoughts, a soldier could similarly operate weaponries with brain-computer interfaces.)

Marketers, too, dream of a neurotechnology that could read minds to then specifically mer-chandize their hosts. And there are many mere human egos eager to have turbocharged brains that function far beyond our all-too-ordinary selves. Yet with every scientific step forward, there is also the prospect of intended and unintended missteps-of applications that are a step in space where no one should go.

The prospect of mismanaging the power of neurotechnology has spawned the field of neuroethics, bringing us face-to-face with questions about who will have access to these culture- (and ethos-) changing technologies, and to what ends they will be utilized. Psychiatrists, neurologists, and neuroscientists, therefore, will have to confront questions of how to best apply novel neurotechnologies in an equitable and ethical way. For example, consider some of the following thornier neuroethical issues.

First, who should benefit? Memory-enhancing treatments, for example, usher in a host of questions about their applications. We may be on firm moral ground when it comes to offering cognitive-enhancing medications or other neurotechnologies to restore lost brain functions to individuals with Alzheimer disease, debilitating cerebro­vascular accidents, multiple sclerosis, and other prevalent and disabling brain diseases. So, too, is the imperative to treat victims of traumatic brain injury who will need medicines or procedures to modulate or erase the traumatic memories that can sear into the brain after a disaster, in combat or from torture or abuse, leaving them “invisibly” yet severely wounded. These inter­ventions make sense.

But should doctors prescribe cognitive enhancers to boost the functioning of a healthy brain or implant artificial neurons or stem cells to fur-ther the mental performance of those healthy from the start? Should recipients be those with debilitating illnesses-or should corporate CEOs and mediocre students (those who can afford it) attain supercharged brains?

What about the use of neurotechnology in homeland security or the corporate marketplace? Will consumers be able to ask their doctor for a nootropic or will it be available on amazon.com? Will (“when” is more likely) a black market emerge? What will be the FDA’s role in dif-ferentiating snake oil from the next truly magic pill or device? Neuroethicists will have plenty to consider.

Moreover, what principles should guide the allocation of precious and powerful resources and services in a society? Should the market forces of supply and demand determine who will get what is needed (or desired) and who will not? Ethicists, policymakers, and clinicians are familiar with these questions of “distributive justice” in which health care resources are meant to be distributed to maximize wellness and minimize misfortune. Meant is a goal, but the question remains as to how.

Second, what should be the psychiatrist’s role in the applications of neurotechnology? Will mental health clinicians have access to fine-tuned diagnostics and new treatments of brain illnesses? Will these new technologies themselves open further windows into heretofore mysteries of the brain? How will our field be changed? How will the profession set its standards and shape its practices?

Beyond everyday clinical practice, neurotechnology may assess a defendant’s veracity or provide forensic evidence for an insanity defense. But while emerging technologies seek to reduce error, applying science in the courtroom is rife with legal ambiguities. Cutting-edge DNA fingerprinting (or DNA typing) provides a contempo-rary example: while scientists and lawyers agree on the uniqueness of an individual’s DNA typing, how the legal system can best apply this datum to assigning innocence or guilt continues to bewilder judges. Debates already rage as to whether fMRI lie-detection scans or EEG-based brain fingerprints are rigorous enough to meet standards of scientific evidence. The jury is still out.

The frontier extends to your mind being read at the local shopping center. Product “neuromarketing” corporate consumer psychoanalysis, if you will, has advertisers using functional brain scanning to assess a buyer’s unconscious reactions to the latest widget that would then allow advertisers to fashion a subliminal pitch that closes the sale by clinching your mind. How will brain research translate into the global marketplace? What about nonmedical institutions, such as government, law enforcement, or academic institutions, using mind-reading devices to make security determinations? The opportunities, and intrusions, are legion.

Third, how will we maintain our medical and mental privacy? If neurotechnologies can figure out how the mind works, read our brain’s thoughts, and even predict our intentions, will privacy be a thing of the past? New standards of medical privacy will need to be written-and regulated. But, by whom?

As of this writing, S3’s sipping coffee remains a remarkable achievement of clinical neurotechnology. Progress is science’s “most important product.” And neurotechnology’s products will yield colossal benefits-making it seductive to dismiss risks for the sake of benefits. There is nothing new here: we have always had to weigh risk against benefit. We want to savor S3’s sip-and the myriad marvels of neurotechnology-but we also need to grasp its risks and carefully govern its advances. There is no technology to guide the way, alas, only our humanity and values.

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 Schoonover CE, Rabinowitz A. Control desk for the neural switchboard. 

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Neurotechnology refers to the science of applying our emerging understanding of the brain, consciousness, thought, and higher-order activities of the mind into developing technologies. The tools of neurotechnology, however, are not new for psychiatrists.

Author | Matthew D. Erlich, MD

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