Tony Salvatore, MA, Director of Development/Suicide Prevention, Montgomery County Emergency Service, Norristown, Pennsylvania

Suicide Scene Roles

Going “by the book,” the primary roles of police officers at a suicide are to secure the scene, perform a questionable death investigation, and conclude the investigation if it is determined that a crime has not occurred. The “book” does not say much regarding other people on location who may be informants and, until the investigation indicates no foul play, persons of interest. The scene is taken over by law enforcement personnel, EMTs, and staff from the coroner’s or medical examiner’s office. Outside, emergency vehicles of all types are everywhere. Inside, usually secluded in a room, are those “others” who are the parents, spouse, siblings, partners, children, or friends of the victim. Those relationships terminated abruptly, unexpectedly, and perhaps violently. Now, they are transitioning to a role they never imagined: suicide survivor. They are traumatized, confused, and struggling to regain control as they are handed off to officials to answer various sets of questions. After some time, everyone, including their loved one’s body, leaves. They are on their own at the beginning of a grief journey that may never really end.

CISM and Suicide Survivors

Most emergency responders are familiar with Critical Incident Stress Management (CISM). Suicide is a major critical incident, and exposure to a suicide creates a significant risk of substantial harm to the emotional well-being or mental health of those it touches. A suicide may even lead to post-traumatic stress disorder (PTSD) for survivors. CISM was designed for such events. CISM training addresses suicide survivor grief as part of the suicide prevention course; however, CISM is more applicable to helping police officers and other emergency responders cope with the suicide of one of their own than with suicide survivors in the community.³ A CISM-based debriefing model for family suicide survivors has been proposed, but family members will not be ready for CISM’s structured protocols n the minutes or hours after a suicide.⁴ Nonetheless, CISM training can give emergency responders basic intervention skills and the confidence to reach out to suicide survivors, as well as insight into the nature of major traumatic events with long-term consequences.

Effects of a Sudden Death on Survivors

Most suicides take those close to the victim by complete surprise. Warning signs are not well-known and not always recognized, and this lack of forewarning only adds to the burden of the loss. Family members and friends often say that they never saw it coming, and being blindsided by a suicide generates anxiety, fear, and a sense of vulnerability. One bereavement and grief specialist, William J. Worden, PhD, has identified several effects of sudden deaths, of which the following are most characteristic of suicide survivors:

• Survivors are often unable to comprehend the reality of what has occurred.
• Survivors often feel intense guilt after the loss.
• Survivors often feel compelled to attribute the loss to someone associated with the victim.
• Survivors experience a deep feeling of helplessness.⁵

Survivors feel responsible because they “didn’t do anything.” Parents agonize that they let their child down. Blame for the loss may be put on a third party (e.g., a therapist, counselor, school, friends) or on other family members. Those left to grieve may view the suicide as rejection, abandonment, or betrayal, and, as a result, they may be angry at the victim. Victims’ families may voice such feelings to police officers; they may also fault the police for the death if they had recent contact with the victim. Those who have witnessed a suicide, found the victim, or were notified of a suicide may display behavior resembling an emotionally disturbed person. They may be very disorganized, may be uncomprehending, and may have difficulty staying focused on matters at hand, but these reactions are most likely grief-related. These sentiments are generated by the psychologically debilitating nature of a suicide loss.

Immediate Needs of Suicide Survivors

Suicide survivors are “anyone who is significantly negatively impacted by the suicide of someone in their social network.”⁶ It is a pre-existing personal connection with the victim that makes one a suicide survivor, not just exposure to a suicide.⁷ In the first hours and days, suicide survivors may need the following:

• Understanding that what they are feeling is normal—they may think that they are suffering a severe psychiatric crisis or even a “breakdown,” but what they are enduring is an acute bereavement that is associated with a traumatic loss.
• Support—whatever coping skills they employed with previous losses may fail them now. Suicide loss is best endured with help. Mutual self-help will be beneficial, but that will come later.
• Understanding that they will need time to deal with their loss and grief—most survivors will need to take things slowly, take care of themselves and their families, and not set or accept deadlines for “getting over it.”

Suicide survivors are the secondary victims of the suicide, but they are still victims in their own right. Some survivors may have pre-existing mental illnesses, and the loss may cause symptoms to reoccur. They should be urged to immediately contact their mental health provider or be directed to a crisis center or hospital emergency department.

Why should police officers take on the needs of suicide survivors? They are best positioned and prepared to do so. They are emergency helpers. Many officers may have crisis intervention training that could be useful. Police officers have a holistic overview of the suicide scene and all who are part of it. Others present have much narrower perspectives—coroners or medical examiner staff tend to focus only on the body; EMTs and paramedics will usually depart when they see that their prospective patient is deceased.⁸ In most areas, by default, survivors can look only to police officers for immediate help.

Current Concepts of Suicide

When dealing with those traumatized by suicides, it is helpful for officers to understand how and why suicides happen. Two new models supported by research serve this purpose. The Interpersonal Psychological Theory (IPPT) states that a potentially fatal suicide attempt may occur only when an extremely strong desire to die and the capability for lethal self-harm are both present.⁹ An intense desire for death can come from the belief that one is a burden to others or that one does not belong. The feeling of being a burden can arise from a sense that one is not fulfilling expectations, which may lead to thinking that one’s life has no value. Feeling a failure to belong may flow from a perception that one is not cared for by those that one cares about. More than a desire to die is necessary for a suicide—an individual must also be able to take his or her life. Fear, pain, and the instinct for self-preservation must be overcome. This ability can result from abuse, trauma, and a history of violence, or it may be a byproduct of past attempts or mentally practicing a suicide plan.

Another new theory of suicide is the Integrated Motivational-Volitional Model, which sees a suicide attempt as the outcome of a process with three phases: (1) the pre-motivational, (2) the motivational, and (3) the volitional.¹⁰ An individual may progress from low suicide risk to high risk through the interplay of fixed background factors (e.g., gender or mental illness), triggers (e.g., a recent loss), ideation, forming intent, assembling a plan, and carrying out the plan. At the pre-motivational phase, an individual has serious risk factors, but is not suicidal. These risk factors may include financial problems, legal issues, divorce or other interpersonal conflicts, substance abuse, and mental illness. Strong self-criticism and a sense of failure in meeting expectations may also emerge at this stage. All are pre-conditions for the possible onset of suicidal feelings or intent. The motivational phase opens with the onset of suicidal ideation. Intent to die appears in this phase, which may be voiced, texted, or otherwise communicated. In the last stage, the volitional phase, the individual has formed a suicide plan and set it in motion. There is a resolute commitment to terminating one’s life per a specific plan. Means are being brought to bear, and the capability for lethal self-harm is operational. The individual is at or nearing the point of no return.

These two theories add these points to our understanding of suicide.

• A suicide is the outcome of a plan.
• Suicide requires a capability to engage in lethal self-harm.
• Suicide becomes more likely when a plan is ruminated upon over time.
• A suicide is the result of a process.

Suicides are seldom spontaneous acts, and some suicides are preventable if the victim seeks help or shows signs of distress that can be recognized. In the absence of intervention, victims progressively move to a state where a suicide (or suicide attempt) is all but inevitable.

Some Misconceptions about Suicide

Suicide is often stigmatized and subject to many widely held misconceptions. The negative mythology of suicide is a liability in dealing with persons affected by a suicide who may be struggling with the hurtful aspects of prevalent stereotypes of suicide victims. In Myths about Suicide, psychologist Dr. Thomas Joiner examines common misbeliefs about suicide.¹¹ One such misconception is that, once someone becomes suicidal, it is inevitable that he or she will die by suicide and little can be done to deter this. The reality is that suicide is preventable, and many deaths could have been averted if the victim had received help and was unable to access lethal means such as firearms. Another misconception is that suicide is an act of revenge or anger toward those who were close to the victim. Actually, as the IPPT model discussed above indicates, victims are more likely to believe that their deaths will benefit those they love.¹² An especially stigmatizing incorrect belief is that a person has to be “out of his or her mind” to take his or her life. Joiner notes that, while mental illness may play a role in many suicides, it is not a cause, and few suicides involve individuals who are psychotic or seriously impaired. Joiner also takes issue with the idea that suicide is a purely impulsive act. As the IPPT model demonstrates, suicides do not just happen; they are planned outcomes. Joiner advises that “we need to get it in our heads that suicide is not easy, painless, cowardly, selfish, vengeful … nor rash.”¹³ This advice is just as important to emergency responders as it is to survivors.

Basic Suicide Postvention

Suicide survivors may be difficult to relate to when their loss is fresh, but studies indicate that help would be welcomed if offered.¹⁴ A survey of suicide survivors found that police assistance immediately after the loss was appreciated and viewed positively. This study also found that “[r]eactions by first responders, such as police, EMS, fire, and medical examiner personnel, have a lasting impact and can vastly influence the course of recovery.”¹⁵ This influence could be favorable or unfavorable depending on the manner in which it was provided, and the best way to ensure a positive result is to employ a suicide “postvention” approach.

Suicide postvention is a form of crisis intervention that attempts to reduce the negative consequences that may affect those close to the victim of a suicide or those who have experienced a suicide. It facilitates the recovery from trauma caused by a suicide. Suicide postvention involves (1) providing aid and support with the grieving process and (2) assisting those who may be vulnerable to conditions such as anxiety, depressive disorders, or even suicidal ideation. Suicide postvention should begin as soon as possible after the suicide, which is where police officers, as first responders, come in.

Police officers can perform the following suicide postvention actions:

Try to establish rapport with survivors—Extend offers of help and caring by “being there.” Police officers should introduce themselves. If survivors are not receptive, just back off, otherwise continue to communicate and establish rapport.

Permit initiation of grief normalization—If the survivors are so inclined, let them discuss their feelings and concerns. Be ready for a lot of emotion and conflicting sentiments. Don’t try to sort things out for them; they will get to that later.

Facilitate understanding of critical incident processing—Briefly explain the investigative activities that follow any unnatural death. Tell them why the coroner or medical examiner will take the body and how they can arrange for pickup by the funeral director.

Assist in mobilizing their support system—If necessary, help survivors identify those who may be resources, e.g., family physician, clergyperson, other family members, or trusted friends. Do not say that they have to make these contacts, just note that they may be helpful.

Share information on community services—Provide contact information for local grief support resources like Survivors of Suicide or other services that the survivors may reach out to if necessary. Local resources may be found on the Internet. Many Employee Assistance Programs (EAP) may be able to give referrals to grief support resources, and health insurance plans may be able to direct members to grief counselors.

Encourage their follow-through—Urge them to see their family physician. Grief isn’t a medical problem, but it impacts health and may aggravate existing medical and behavioral health conditions.

These simple actions can get the family and other survivors started toward recovery from their loss. Many departments have already taken steps to meet the immediate needs of suicide survivors, such as introducing specialized suicide postvention programs.¹⁶ There are few training programs on suicide loss specifically designed for police, but local law enforcement leaders can call on crisis centers and suicide prevention groups in their areas or entities such as Survivors of Suicide as possible sources of information and education.¹⁷

Closing Thoughts

Routine death scene activities can cause distress to survivors after a suicide. Consider the following suggestions for handling
suicide scenes:

• Crime scene processing—“Treat all deaths as homicides at first, even suicides.” Many officers have heard this, but have probably never been told how upsetting this can be to those struggling with the loss. Try to respect their feelings. The family may be sure that it is not a suicide—it is not the officer’s job to change their minds.
• Interference with the scene—Sometimes family members will cut down the body, hide the gun, throw away the pill bottle, start to cleanup, or withhold any note. A lecture on death scene procedures will not help; instead, explain that their cooperation is essential and indicate the disposition of items like notes, wallets, and other personal effects.
• Officiousness—Falling back on authority will not help with suicide survivors and will only leave a lasting resentment. Police are trained to use strength to resolve situations, but officers know that this does not apply in all situations. A suicide loss crisis is one of those exceptions.

  Police officers witness the aftermath of many suicides, but it will usually be the first for the survivors. Officers can assist by being sensitive, by listening, and by sharing information. This can have a significant effect on how a family eventually recovers from their loss. It can lessen their risk of grief complications and even suicidal behavior. The victim’s death did not end the suicide emergency; it just enveloped others who now need help.

  Lastly, being involved with a suicide in an official capacity, even after many such experiences, does not in any way shield police officers from the emotional devastation that follows such deaths. After helping the survivors, officers should try to minimize any critical incident stress that they may be feeling. This is particularly true if the officers or someone in their families has been suicidal or if they lost a loved one, friend, or colleague to suicide. CISM, peer counselors, the departmental chaplain, or other trusted resources can help and should be considered. ♦

  
  Notes:
  ¹Centers for Disease Control and Prevention, “FastStats: Suicide and Self-Inflicted Injury,” http://www.cdc.gov/nchs/fastats/suicide.htm (accessed January 9, 2015).
  ²Centers for Disease Control and Prevention, “Injury Prevention & Control: Data & Statistics (WISQARS),” National Violent Death Reporting System, http://www.cdc.gov/injury/wisqars/nvdrs.html (accessed January 9, 2015).
  ³International Critical Incident Stress Foundation, “Suicide Prevention, Intervention, and Postvention,” course description, http://www.icisf.org/suicide-prevention-intervention-and-postvention-2 (accessed January 9, 2015).
  ⁴Gerald A. Juhnke, “The Family Debriefing Model: An Adapted Critical Incident Stress Debriefing for Parents and Older Suicide Survivors,” The Family Journal 7, no. 4 (October 1999): 342–348.
  ⁵J. William Worden, Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner, 4th ed. (New York, NY: Springer Publishing, 2009).
  ⁶John Jordan, “Bereavement after Suicide,” Psychiatric Annals 38, no.10, (2008): 670–685.
  ⁷Karl Andriessen, “Can Postvention BePrevention?” Crisis 30, no. 1 (2009): 43–47.
  ⁸Tony Salvatore “Life after Suicide: How Emergency Responders Can Help Those Left Behind,” EMS World 39, no. 2 (2010): 54–57.
  ⁹Thomas Joiner, Why People Die by Suicide (Cambridge, MA: Harvard University Press, 2005).
  ¹⁰Rory O’Connor, “The Integrated Motivational-Volitional Model of Suicidal Behavior,” Crisis 32, no. 6 (2011): 295–298.
  ¹¹Thomas Joiner, Myths about Suicide (Cambridge, MA: Harvard University Press, 2010).
  ¹²Joiner, Why People Die by Suicide.
  ¹³Ibid.
  ¹⁴Jannet McMenamy, John Jordan, and Ann Mitchell, “What Do Suicide Survivors Tell Us They Need? Results of a Pilot Study,” Suicide and Life-Threatening Behavior 38, no. 4 (2008): 375–389.
  ¹⁵Catherine Davis and Barb Hinger, Assessing the Needs of Survivors of Suicide (Calgary, Alberta: Calgary Health Region, 2005).
  ¹⁶Frank Campbell et al., “An Active Postvention Program,” Crisis 25, no. 1 (2004): 30–32.
  ¹⁷See the American Foundation for Suicide Prevention Directory of Suicide Loss Support Groups by State, http://www.afsp.org/coping-with-suicide-loss/find-support/find-a-support-group (accessed January 9, 2015).

  
  Please cite as

  Tony Salvatore, “Suicide Loss First Aid: How Police Officers Can Assist Suicide Survivors,” The Police Chief 82 (April 2015): 62–65.

  Top