The World Health Organisation (WHO) estimates that more than 800,000 people die every year by suicide,1 the leading cause of death globally for males and females aged between 15 and 44 years. In the UK, statistics for 20122 show a total of 5,981 deaths where, at inquest, it was determined either that the deceased took their own life, or an ‘open’ or ‘narrative’ outcome was reached. Under current legislation, coroners have to be clear beyond reasonable doubt that the deceased intended to take their own life before making the decision that the death was suicide.3
Of 5,981 deaths by suicide recorded in 2012, 4,590 were males and 1,391 females, with the highest number of deaths taking place in the 45 to 49-year-old age group.2 By comparison, according to the Royal Society for the Prevention of Accidents, there were 1,754 fatalities on Britain’s roads in 2012.4 If this statistic more than trebled, with the same number of fatal road traffic accidents as deaths that are recorded as unexplained (likely to be suicide), there would surely be a vigorous public debate regarding the safety of our roads. Where is the national outrage in response to the suicide statistics?
In Cornwall and the Isles of Scilly, with a permanent resident population of 532,300 (2011 Census), there are between 60 and 80 deaths by suicide each year, with a higher rate of unexplained deaths in the over-75 age group than the national average.5 The latter is partly due to Cornwall’s popularity as a retirement destination, which has resulted in a disproportionate number of elderly residents. Despite the county’s deserved reputation as an area of great natural beauty, Cornwall has some of the highest levels of social exclusionin the UK5 which can include rural isolation, poor transport links, debt, homelessness, alcohol and substance misuse, and mental health difficulties, all of which can be contributory factors in suicide risk.
Research published in a recent issue of The Lancet Psychiatry6 compared the effect of suicide bereavement with other bereavements. The study highlighted an increase in risk of suicide by partners of the deceased; an increased level of admission to psychiatric care for parents who have lost a child to suicide; an increased risk of suicide in mothers who have lost an adult child to suicide; and an increase in depression in people who have lost a parent to suicide. The estimated increase in risk of suicide in those bereaved by suicide is between 80 per cent and 300 per cent greater than for someone not bereaved by suicide, and the financial impact of one suicide has been estimated to be £1,450,000 per case in England7 (calculating direct costs, for example GP visits, prescribed medication, counselling, funeral costs, use of emergency services, insurance claims etc, and indirect costs which can include lost working hours and loss of productivity in those who are affected by the death). This does not take into account the human cost of grief – and what other type of bereavement carries with it the weight of stigma, as well as shame, anger and rejection?
The creation of a ‘postvention service’
An identified aim of Cornwall and the Isles of Scilly’s suicide prevention strategy7 was to appoint a suicide liaison worker to develop a ‘postvention’ service and thereby reduce risk to people bereaved by suicide. Postvention refers to appropriate and timely interventions delivered to people bereaved by suicide which are believed to be preventative. In the words of Edwin Schneidman, Professor of Thanatology (the scientific study of death) at the University of California, Los Angeles, and founder of the American Association of Suicidology: ‘Postvention is prevention for the next generation.’8
In 2010, Cornwall’s Primary Care Trust (now replaced by Cornwall’s GP commissioning group, NHS Kernow) awarded the contract for developing this service to Outlook South West, a local provider of IAPT services to the NHS. With no job description, we were advised to visit the only other NHS-funded postvention service in the UK and observe good practice. A colleague and I travelled to Northern Ireland to meet Barry McGale, a mental health nurse working in Derry who delivers a service for the Western Health and Social Care Trust, and who is a knowledgeable and passionate advocate for postvention.
Returning to Cornwall, we worked towards developing a service that was sensitive to the cultural and demographic differences between our county and Northern Ireland, and tailored to the limitations of delivering a service which is only funded for one full-time post. This post is currently divided between three BACP accredited counsellors: a service lead (myself), employed for three days a week and covering Mid and West Cornwall and the Isles of Scilly, and two counsellors, one covering the more sparsely populated North and East Cornwall and one who helps to co- facilitate groupwork.
Our initial directive was to support all adults (18 years upwards) bereaved by suicide but, as the service has developed, not only do we have insufficient capacity to achieve this, but it is clear that the people who need our service most acutely are those experiencing the immediate aftermath of the trauma of the death of a loved one by suicide and who are at the greatest risk of self-harm. The advantage of being linked to an IAPT service is that all referrals (whether from the police, GPs, other health professionals, or self-referrals which are usually by telephone) are received by our organisation’s Clinical Administration Team, some of whom have undertaken Applied Suicide Intervention Skills Training (ASIST)9 themselves and have experience of talking to someone recently bereaved by suicide. Appropriate referrals are passed to our team and we make an initial telephone contact within 72 hours of referral. All data and contacts are stored on a non-IAPT pathway on IAPTus, Mayden’s psychological therapy patient management system, which is secure and confidential, and complies with clinical governance.
Following the initial contact, we offer a home visit (occasionally meeting at the bereaved’s GP surgery if preferred) within two weeks. The home visit entails an assessment of need which is specific to each family or individual. The model that informs our initial visit is the six-step model for crisis intervention10 which incorporates counselling skills into the model of systematic helping. Crucially, we are ASIST trained, experienced in carrying out risk assessments when working as psychological therapists within an IAPT service, and able to recognise symptoms of post-traumatic stress disorder (PTSD). Where the bereaved has/have found the body, PTSD can develop11 and part of our role is to explain to the bereaved that we will monitor symptoms for up to three months and then, should symptoms persist or increase, we can refer to our colleagues working within the IAPT service for an assessment for EMDR or trauma-focused CBT. The evidence12 suggests that initially a psychoeducational approach is one of the most effective ways of responding to those in the early stages of suicide bereavement, helping them to understand their responses to the trauma and normalise their emotions; this is our main focus at home visits. However, an assessment of need can also entail accessing practical help for the bereaved who may, for example, have lost the family’s source of income with the death of the main provider, and could need help to access support from the local foodbank or with housing, or help applying for benefits.
The essential skills and training required for a suicide postvention worker are the ability to assess for risk of self-harm and symptoms of PTSD; as well as a sound knowledge of mental health issues and local services, and confidence in liaising, where appropriate, with GPs and mental health teams. Working alongside an IAPT service, not only do we have those skills and experience but as counsellors and/or psychotherapists, we have extensive training in ethics and boundaries. Boundaries can become blurred when working within the home of the bereaved and, in some situations, being involved with up to three generations of the same family. Although not delivering structured psychological therapy, we are utilising counselling skills and need to be mindful of the principles and core values of the BACP Ethical Framework at all times. Increasingly, we are developing knowledge about the inquest process and we liaise with the police and the coroner’s office on behalf of our clients. Dependent upon need, we maintain monthly contact with the bereaved (which will usually be a home visit but sometimes is by telephone or email) up until the time of the inquest. Although the Chief Coroner for England and Wales has, since his appointment in 2012, recommended that inquests in both countries should take place within six months of the death, this is unlikely to be achieved in more complex cases where, for example, the deceased has been receiving treatment from a statutory service at the time of death or may have been detained under the Mental Health Act. This can be particularly complex when the death of a minor occurs and there may be safeguarding issues; inquests of this nature can take up to two or three years in some cases.
We make it clear that we will provide support up to and including the inquest, and will attend the inquest with the bereaved. At the initial visit, we will have given the bereaved a copy of the NHS publication Help is at Hand13 (which contains useful information about the inquest process). However, we may contact the charity, Inquest,14 for more specific advice in complex cases. There is no legal aid for representation at inquests, but there are times when it is clear that our clients do need representation and we can be signposted by Inquest to appropriate legal support which may be prepared to act on a pro bono basis. The inquest process itself can raise a great deal of anxiety in the bereaved, and support through this process is essential. We usually provide one post-inquest follow-up visit which brings a type of closure to our relationship with the bereaved. Our clients sometimes comment, ‘… you are there from beginning to end.’ And we do indeed walk alongside the bereaved for part of the painful journey they have to take.
Bereavement by suicide groups
As the service developed, we became aware that signposting for adults bereaved by suicide (other than suggesting some of the excellent national websites for charities that provide support) was problematic in Cornwall because of inadequate transport links to isolated rural areas. There is one well established monthly support group for people bereaved by suicide in Truro, the centrally located county town, but no other suicide bereavement provision is available to people living in more remote parts of the county. In response to a perceived need for continuing support, we have developed eight-week bereavement by suicide groups, which we deliver three times a year in different localities across the county to ensure they are accessible. These groups are psychoeducational (information-giving) in nature, provide a therapeutic environment for participants, and are facilitated by two members of the team. Throughout the course, where each session has a specific focus, we facilitate participants’ move from emotions to thoughts. The structured nature of the group avoids the risk of the bereaved being retraumatised, which can occur in ‘open’ support groups where the format is one in which participants share their stories. In line with guidance on delivery of groupwork to people bereaved by suicide from the World Health Organisation15 and Lifeline Australia,16 the groups are suitable for a maximum of eight participants who are at least six months, and not more than four or five years, post bereavement. These are what is known as ‘closed’ groups, in that all participants must attend the first session, and no one can come in part-way through the eight-week course. Using a qualitative feedback form with participants at the final session, we have identified an overall improvement in coping skills and functioning in the majority of people who complete the group sessions. Responses to the question, ‘Since attending the group have you noticed any changes in yourself?’ have been overwhelmingly positive, with participants noting that they have been helped to talk about their grief outside of the group and feel more confident in expressing emotions associated with their traumatic loss.
Group members are encouraged to share contact details, and many remain in contact with one another once the eight weeks are over, creating a mutual network of peer support within their own communities.
The underlying theory that informs our groups, and our work generally, is Stroebe and Schut’s dual process model.17 Their research into bereavement at the University of Utrecht has, to a great extent, superseded the earlier staged models of grief where the bereaved could be left with a sense of failure if they had not progressed from one stage to the next. The dual process model allows the bereaved to move backwards and forwards between loss orientation and restoration orientation and acknowledges that grief responses can vary from individual to individual, dependent on a number of factors, including gender as well as cultural responses to grief.
The delivery of our groups has now become the major focus of therapeutic work with our clients. Surprisingly, we were unable to source details about any similar groups being delivered in the UK utilising evidence- based research, and where participants are prescreened in a face-to-face meeting prior to attendance. As a result, we looked further afield and have found information about Waves’ ‘closed’ psychoeducation courses18 developed by Chris Bawden, a lecturer in social work at the University of Victoria in Wellington, New Zealand, which are delivered by Skylight, a not-for-profit company in New Zealand.
I was encouraged by Dr Sharon McDonnell, a researcher in suicide bereavement at the Centre for Mental Health and Risk at the University of Manchester, and the driving force behind the annual national Suicide Bereavement Conference.19 Dr McDonnell has recently returned from Australia and New Zealand where she researched postvention services funded by a Fellowship awarded by the Winston Churchill Memorial Trust (WCMT)29. I applied, and was fortunate and privileged to be awarded a WCMT Fellowship to visit Australia and New Zealand, primarily to look at the delivery of evidence-based suicide bereavement groupwork in both countries. I have been able to visit Wellington and meet with Chris Bawden and the team at Skylight myself, and to make a comparison between their psychoeducation courses and similar initiatives in Australia, where I have visited Louise Flynn, manager of Support after Suicide, a department of Jesuit Social Services in Melbourne, which also delivers psychoeducational courses for people bereaved by suicide; the courses are facilitated by trained counsellors and psychologists.
Closer to home, I have recently delivered talks on our service provision to all CID officers working in Cornwall. CID officers investigate all unexplained deaths (including suicide) and prepare documentation for the coroner. Another aspect of my research overseas has allowed me to meet with Dr Jane Mowll, a social worker and forensic counsellor who is the manager of Support After Suicide in Sydney, working closely with coronial services in New South Wales, Australia.
A recent report by the Government’s All Party Parliamentary Group on Suicide and Self Harm Prevention21 has stated that families should be at the centre of the inquest process.
The report refers specifically to the experience of people bereaved by suicide of the system of coroners’ inquests and their interactions with coroners’ offices. ‘This includes,’ says the report, ‘not only the way that bereaved relatives are supported as they go through the inquest process and the sensitive handling of inquest procedures, but also what advice is provided to bereaved relatives about external sources of support that they could usefully be signposted to.’
The report also points out that bereaved families have previously reported cases where the inquest process failed to put families at the centre and where certain personal information was heard in the coroner’s court without their prior knowledge and without being properly consulted. Concerns have also been expressed, says the report, that bereaved families are not being appropriately supported during their contact with the inquest system.
All too often, families have not been placed at the centre of the inquest. The bereaved, who are frequently traumatised and subjected to stigma and shame surrounding the death, can feel marginalised by the process. Providing well-informed and compassionate support, and liaising with the police to ensure families are continually kept advised of the process, is a goal for suicide postvention, not just in Cornwall but throughout England and Wales where (unlike Northern Ireland and Scotland) public inquests are always held in the case of unexplained deaths.
Hopes for the future
Cornwall’s Suicide Liaison Service is privileged to be invited into the lives of individuals and families at a time of acute distress and trauma. As counsellors and/ or psychotherapists working in healthcare, I believe we are uniquely qualified to carry out this role. I would like to see this model of postvention support adapted to take into account regional and cultural differences, funded by NHS commissioners and public health departments across England and Wales. However, to obtain funding, service providers need to work collaboratively with academics researching postvention to provide NHS commissioners with research-based evidence to support service delivery.
Another hope for the future is that our service will be able to utilise our experience to develop training for mental health workers and voluntary agency staff who deliver services to people bereaved by suicide so that we can work towards achieving a National Framework of skills for people working with this vulnerable and potentially high-risk group. We need to not only break down the taboo surrounding this subject, but improve the knowledge and skills of those who come into contact with the suicide bereaved, thereby reducing stigma, and saving lives.
Anne Embury is Suicide Liaison Service Lead with Outlook South West (a private provider of IAPT services). The Suicide Liaison Service is a public health initiative funded by NHS Kernow to provide support to people bereaved by suicide in Cornwall and the Isles of Scilly.
6 Pitman A, Osborn D, King M, Erlangsen A. Effects of suicide bereavement on mental health and suicide risk. The Lancet Psychiatry 2014; 1(1): 86–94.
7 Knapp M, McDaid M, Parsonage M. Mental heath promotion and mental illness prevention: the economic case. London: Department of Health; 2011.
8 Schneidman ES. Suicide thoughts and reflections, 1960-1980. Special issue of Suicide 1981: 11(4).
10 James RK, Gilliland BE. Crisis intervention strategies. 7th edition. California, US: Brooks Cole/Cengage Learning; 2013.
11 Barlow C, Morrison H. Survivors of suicide: emerging counseling strategies. Journal of Psychosocial Nursing and Mental Health Services 2002; 40(1): 28–40.
12 Dunne E. Psychoeducation intervention strategies for survivors of suicide. Crisis: the Journal of Crisis Intervention and Suicide Prevention 1991; 13(1): 35–40.
13 Hawton K, Simkin S. Help is at hand: a resource for people bereaved by suicide and other sudden traumatic death. London: Department of Health; 2010.
15 World Health Organisation. Preventing suicide: how to start a survivors’ group. World Health Organisation; 2008
17 Stroebe M, Schut H. The dual process model of coping with bereavement: rationale and description. Death Studies 1999; 23(3): 197–224.
18 Bowden C. Waves course outline. Cruse Bereavement Care 2011; 30(3): 25–31.
21 HM Government. Preventing suicide in England: one year on. First annual report on the cross-government outcomes strategy to save lives. London: HM Government; 2014.