Prevention is Postvention

Professional Resource Article

Abstract

Postvention is major part of prevention. The plan that organizations and practitioners have in place after a crisis is critical. For mental health clinicians in private practice, a comprehensive crisis management plan to reduce risks of suicide for students and families in postvention crisis of a school shooting requires many levels of systemic support and change. This includes increasing the awareness of suicide prevention, joining with communities in times of a school shooting to provide therapeutic support. Overall, with the flexibility of private practice, therapists can readily partner and provide access to resources in the aftermath of a school related shooting or suicide pact crisis. Suicide prevention in crisis management is the topic area that ignited this researcher’s interest, a passion for postvention, and concrete answers. For the purpose of this article, the researcher focuses on the positive ripple effects of crisis management on the private practice mental health care system in the area of suicide prevention. Keywords: Postvention, Crisis Management, Suicide

Postvention

Columbine. Sandy Hook. Majorie Stoneman Douglas. The three names listed above are schools that endured lifeshattering crisis. The Columbine massacre was a school shooting that occurred on April 20, 1999 at Columbine High School in Columbine, Colorado where fifteen youth were killed (including both perpetrators). The Sandy Hook shooting occurred on December 14, 2012 at Sandy Hook Elementary School in Newtown, Connecticut leaving 26 lives lost (20 children and 6 adult staff members). On February 14, 2018, a gunman opened fire at Marjory Stoneman Douglas High School in Parkland, Florida (17 students and staff members were murdered while many others were injured and survived). It has been 3 years since the Parkland community made national news, sharing an outcry of pain from the lives lost, and sparking a movement on gun violence prevention with the “March for Our Lives”. Recently, the Parkland Survivors returned to the headlines as the families of the 52 people killed, injured or traumatized in the shooting at Stoneman Douglas High School reached a $25 million settlement with the Broward County school district (Allen, 2021).

Still, the chaos that endured at each school and the constant media reports thereafter disgorges remnants of trauma and emotional instability for students, staff, and parents. Moreover, secondary and vicarious trauma was evident as millions across the nation watched on social media, news outlets, or volunteered on site and entered the narrative of “Parkland Strong”. The narratives overtime, revealed severe pre and post crisis miscommunication seemed to play a catastrophic role in recovery and postvention services. There were also gaps in bureaucratic responsiveness at the level of school security and communication. Additionally, social service systems were overwhelmed with referrals and requests for mental health care and support. Determining the path forward for prevention brings to light an opportunity for mental health providers to explore adaptive approaches to lead crisis management consultation in postvention.

Survivors Remorse

Considering the traumatic aftereffects of a school shooting, schools and communities need a space where trained and licensed therapists are integral to the journey ahead. The path forward must include a systemic outlook that focuses on mental health services at an organizational, communal, individual, and family level. The messaging and care shown in the postvention period is critical for repair and resiliency.

Therapists helped thousands of students, educators, and community residents process post-traumatic stress disorder, feeling of survivor’s remorse, vicarious trauma, and thoughts of death by suicide. Unfortunately, three survivors of the Marjory Stoneman Douglas High School shooting massacre chose death by suicide. For a community that was trying to heal from the paralyzing pain of the initial occurrence, more unexpected loss and grief continued to reopen the wound for those left behind. Postvention begins here, assessing survivors, sharing common mental health concerns or signs for parents and community to be aware of, consulting on systemic crisis management steps, and putting policies in place for suicide prevention.

Mental health professionals may be able to be influential in the trajectory of choices post crisis, especially regarding suicide prevention. The survivors of suicide are unique to each death narrative, but they can include the parent, siblings, extended family, teachers, friends, and clinicians who have worked with the deceased. All of these people may be affected by the person who died by suicide (and their level of closeness may not be a factor). While it is a volatile subjective matter, those who consider themselves survivors of the deceased are dealing with great wounds and bereavement almost simultaneously due to the stigma of a student who dies by suicide. Many see students as having so much possibility and potential, yet they may not know what immense mental or physical pain they are concealing within.

Additionally, a common assumption about survivors of suicide is that they are somehow explicitly or implicitly to blame for the death. The survivor is often perceived to have either directly caused the person to kill him- or herself or alternatively as having done nothing to prevent the death (Jobes, D. A., Luoma, J. B., Hustead, L. A., & Mann, R. E., 2000). Moreover, traditional support groups for parents who have lost a child are not as empathetic to a family who has lost a child to suicide in comparison to a child who has died from cancer or another terminally ill disease. Socially, suicide is viewed as a choice that one made instead of a complex and personal matter that leaves many unknowns. This is quite a social burden to bare especially if the family of the deceased remains in the same community or has other children within that particular school or educational system. The family continues to grieve while being shamed or seen as guilty. Survivors experience a great deal of pain in the recovery process from anger to disbelief (Jobes, D. A., Luoma, J. B., Hustead, L. A., & Mann, R. E., 2000).

Recognizing this, our field needs to be aware that survivors of a shared trauma like a school shooting may consider suicide as a means to cope with the anger, confusion, and unbearable pain. As providers of clinical care, we can provide a positive, sacred, and confidential space to help survivors grieve and gain support in their journey. Wraparound services that include clinical counseling services, suicide-specific family support groups, education to communities, and consultation to schools regarding survivor’s remorse are unique parts of our practice. Concerning suicide prevention, attention to these areas can help mental health care practitioners in private practice or community agencies create effective crisis management plans for postvention. By having holistic wraparound services to consider survivors remorse, clinicians are preparing a plan to prevent future personal or physical crisis.

Mental Health Crisis Management Plan: Suicide Postvention Recommendation

Postvention is major part of prevention. As clinicians, we need to be aware of clients who may have been experiencing immense pain and feelings of burdensomeness, and what is our plan of support if the client dies by suicide? How do we support survivors? What recommendations can we make to support parents, schools, students and the community? How do we care for ourselves as survivors? These important questions can serve as reflective practice and cyclical support by contributing to an adaptive crisis management plan.

For mental health providers in private practice, a comprehensive crisis management plan to reduce risks of suicide for students and families in postvention crisis is necessary. Action plan efforts include increasing the awareness of suicide prevention pre-crisis, joining with communities in times of a school shooting to reflect on what has occurred and providing supports to empower away from a suicide crisis, and most importantly, providing access to resources for care such an individual or family therapy. Overall, following the crisis of a suicide of a student, the following lists encompass relational and reflective recommendations to help build a mental health crisis management plan:

School Systems Level Consultation

Crisis Detection

Listen to students.

Have school personnel monitor what’s going on in social media and outside of school- Did anyone back out of a suicide pact? Anyone feeling guilty?

Don't be afraid to ask if someone is going to commit suicide. If you ask- you will not plant the idea in their head. You may save their life.

Prevention

Evaluate what process or supports the school presently has in place.

Secure an internal and external team of stakeholders.

Suicide should not be dramatized or glamourized.

It’s an intentional and authentic balance, doing nothing can be just as dangerous as doing too much.

Containment

Identify the role, scope, and responsibilities of each person during the crisis to maintain damage control.

Involve parents, community leaders, mental health professionals, medical professionals, clergy, and police officials.

Strive to treat all deaths the same- whether cancer or suicide.

Always tell the truth and share developmentally correct information.

Use a single spokesperson to speak to media to provide a written, factual, nonsensational statement pertaining to the death and the schools response to the crisis.

Recovery

Have a multidisciplinary team in place for consultation or ongoing support is also advantageous when planning to prevent or resourcing after a crisis.

Identify a list of students who were close to the deceased so that they can meet with a mental health professional at a selected time.

Meet with student body in small groups, not an assembly.

Allow students to leave class as needed or regularly regarding the suicide.

Consider a living memorial- give credit and space for survivors to cope.

Learning Process

Utilize the National Center for Suicide or American Suicide Foundation “After a Suicide: Toolkit for Schools”.

Students cannot be adequately supported until faculty are empowered, must train teachers and staff in suicide prevention and postvention.

Offer training & support on Survivors Remorse.

Parental Systems Level Consultation

Listen to your children and friends of the deceased.

Inform nuclear and extended family members of facts.

Start or join a suicide survivors group.

See a mental health professional as needed.

Monitor what’s going on in social media and outside of school.

Take time to grieve.

Seek spiritual support or guidance according to their faith.

Reflect on being prepared to answer the why (even if there is a suicide note), “We’re never truly going to know why, but we want to support each other” – Dr. Scott Poland (2016)

Read “Suicide Myths” by T. Joiner (2011)

When ready, complete an onsite or online course on suicide prevention and survivors remorse

Participate in a “Out of the Darkness” Walk for Suicide Prevention and Survivors

Don't be afraid to ask if someone is going to commit suicide. If you ask- you will not plant the idea in their head. You may save their life.

Community Systems Level Consultation

Listen to the citizens.

Ensure media does not sensationalize suicides at schools.

Involve mental health, public health, and education in a community suicide prevention plan.

Create a community committee focused on suicide prevention. and postvention with a local community agency serving as a host agency to facilitate and organize.

Provide and fund ongoing, “What is suicide, prevention, myths, & resources” course specific to that city available online and/or through local libraries

Host out of the darkness walk for families affect by suicide

Provide and fund ongoing training & support on Survivors Remorse

Master/Doctoral Students, Marriage & Family Therapists, Mental Health Professionals Workplace Level Consultation

Complete training or educational course on Crisis Management in Private Practice

Screen potential clients

Remove potential weapons

Lock doors

Avoid working late at night alone

Set & practice office wide evacuation drill

Designate a panic room for safe retreat

Have client safety lockers for personal items

Call for help (colleges, first responders, police)

Have code words for emergencies to alert coworkers

Learn CPR

Learn self-defense techniques

Complete training or educational course on Suicide Prevention, Suicide Myths, & Survivors Remorse.

Create opportunities for experiential or relevant practice, not just a training video or didactic lecture.

Review current research on best practices or crisis prevention.

Have a team in place whose responsibility it is to conduct continuous quality improvement concerning crisis management.

Read Flemons, D. & Gralnik, L. (2013). Relational suicide assessment. New York: W. W. Norton

Read “Suicide Myths” by T. Joiner (2011)

Conclusion

It is an inside job. Start with the students, then the staff members, families, and community. All members of the school system and community need proper information and training in crisis and suicide prevention. This includes sharing warning signs to establishing an adaptive process of what to do in a crisis. Postvention should be very transparent and practiced frequently. Additionally, building relationships is critical. Having students feel safe to confide in adults and gain the tools of compassion and empathy to treat each other with respect is putting relational scaffolds in place for students to be able to be autonomous within school boundaries. Ultimately, prevention saves lives as it is better to be prepared than reactionary to something that could have been averted with strategic plans in place.

Trauma, like that of a disastrous school shooting, leaves many open wounds. Survivor’s guilt and remorse may bring up immeasurable grief, disbelief, and suicidal ideations. Moreover, thoughts of survivor’s remorse may arise and feelings of being a burden or no self-worth can be isolating. Both are not a healthy lens through which to view the present moment or experience bereavement. This is where therapists serve best. In understanding suicide myths, risk factors, preventative measures, and having a crisis management plan with a relational suicide assessment approach, we create and provide consultation on systemic supports that can help students, families, schools, and communities. In response to community trauma or school crisis like student suicide, private practice clinicians and mental health providers cannot work in silos- it is essential to be prepared, connect, and collaborate. This preparation and postvention is about saving lives and scaffolding survivor’s journey forward.

Written By: Debbie Manigat, DMFT, LMFT Debbie is a mental health advocate and suicide prevention educator. She helps students, families, churches and communities heal from a state of crisis, especially those who may be struggling with the impact of suicide. She wrote “THRIVE: Body, Mind, & Soul”, an inspirational guide on suicide and substance abuse prevention which can be found for free download here: www.dmempowers.com/media

References

Allen, G. (2021, October 19). A florida school district will pay $25 million to the families of parkland victims. NPR. https://www.npr.org/2021/10/18/1047153012/parkland-families-lawsuit-25-million-settlement-broward-county

Dr. Pei-Fen Li. Lecture on Crisis Management (2019).

Dr. Poland and Dr. Flemons talk about postvention. 54:30 (2016).

Flemons, D. & Gralnik, L. (2013). Relational suicide assessment. New York: W. W. Norton.

Hellwig-Olsen, B., Jacobsen, M., & Mian, A. (2007). Contemporary issues in campus crisis management. In E. L. Zdziarksi, N. W. Dunkel, & J. M. Rollo (Eds.), Campus crisis management (pp. 285-328). San Francisco, CA: Jossey-Bass.

Jobes, D. A., Luoma, J. B., Hustead, L. A., & Mann, R. E. (2000). In the wake of suicide: Survivorship and postvention. In R. W. Maris, A. L. Berman, & M. M. Silverman (Eds.), Comprehensive textbook of suicidology (pp. 536-561). New York: The GuilfordPress.

Joiner, T. (2011). Myths about suicide. Boston: Harvard University Press.

Jordan, T.A., Upright, P., Tice-Owens, K. (2016). Crisis management in nonprofit organizations. Journal of Nonprofit Educational and Leadership, Vol. 6, No. 2, pp. 159-177

Klebold, S. (2009, Nov.). I will never know why. O, The Oprah Magazine: http://www.oprah.com/world/Susan-Klebolds-O- Magazine-Essay-I-Will-Never-Know-Why/1

Poland, S. (2008, Winter). Sarpy County Nebraska knows it takes the community to stop a youth suicidecluster. AAS Newslink, 25-27. Access here: AASSarpyCountyfinal.doc

Poland, S. (2013). Answering students’ questions after a suicide. Unpublished manuscript. Access here: After aSuicide Answering Questions From Students2013(1).doc

Poland, S. (2009): Congressional Testimony on School Safety and Bullying, Prevention Joint Committee, Early Childhood, Elementary and Secondary Education and Healthy Families and Communities Subcommittees, United States House of Representatives: http://www.youtube.com/watch?v=QRGhGbMA2F4

Sapriel, C. (2003). Effective crisis management: tools and best practice for the new millennium. Journal of Communication Management, 7, 4, pg.348