Our understanding of people bereaved by suicide (PBS) in Hong Kong and the way forward

By Dr. Paul WC Wong D.Psyc. (Clinical)

Assistant Professor, Department of Social Work and Social Administration, and

Honorary Fellow of the Center for Suicide Research and Prevention (CSRP),

The University of Hong Kong

Email: paulw@hku.hk

Outline Part one. Suicide problem in HK

Part two Hong Kong PBS’ grief reactions

Part three. What can we do to “help”?

Part four. What can we do to “understand”?

Part five. Reflections

Part two Hong Kong

PBS's Grief Reactions

Empirical study on people bereaved by suicide and services for these individuals are very limited (Farberow & Andriessen, 2001).

Hong Kong is of no exception.

What do we know about the people bereaved by suicide in Hong Kong?

Based on the 150 people bereaved by suicide who participated in a psychological autopsy study (interview timing mean=7.3

months, SD=4.0)……

The majority of the informants were the spouses (n=37, 24.7%), parents (n=31, 20.7%), and siblings (n=44, 29.3%) of the deceased, 21 (14.7%) were children, and 17 (11.3%) were others including friends, relatives, and co-workers (Chen et al., 2006).

Who were they?

Chen, Chan, Wong et al., (2006) Suicide in Hong Kong: a case-control psychological autopsy study. Psychol. Med.,  36  (2006), pp. 815–825

Apart from the typical bereavement reactions such as cognitive disorganized, dysphoric, somatic distress, and social and occupational disruptions, people bereaved by suicide……

Using a self-developed questionnaire. We found….

Wong, Paul W. C.; Chan, Wincy S. C.; Beh, Philip S. L. (2007) . What can we do to help and understand survivors of suicide in Hong Kong? Crisis: The Journal of Crisis Intervention and Suicide Prevention, Vol 28(4), 2007

Items Strongly Disagree

n(%)

Disagree n(%) Neutral n(%) Agree n(%) Strongly Agree n(%)

Perspective on Suicide

Suicide is a kind of relief for the deceased 53(35.3) 13(8.7) 11(7.3) 23(15.6) 48(32.0)

I think that his/her suicide is pre-determined by fate and nobody can prevent it from happening.

49(32.7) 13(8.7) 19(12.7) 23(15.3) 43(28.7)

Stigmatization

I will not tell other the reason for his/her death.

36(24.0) 26(17.3) 24(16.0) 14(9.3) 47(31.3)

I fear that others may think I will follow his/her steps (committing suicide).

70(46.7) 9(6.0) 15(10.0) 10(6.7) 43(28.7)

Psychological

I am lonely. 63(42.0) 16(10.7) 19(12.7) 15(10.0) 32(21.3)

I am anxious. 36(24.0) 13(8.7) 32(21.3) 28(18.7) 36(24.0)

I am miserable. 39(26.0) 14(9.3) 25(16.7) 25(16.7) 42(28.0)

I feel comfortable for there is someone who listens to my sharing.

28(18.7) 13(8.7) 40(26.7) 21(14.0) 44(29.3)

Social adjustment

I visit relatives and friends. 8(5.3) 8(5.3) 15(10.0) 23(15.3) 89(58.7)

I get along with family. 4(2.7) 3(2.0) 15(10.0) 33(22.0) 87(58.0)

I show empathy and support to my family. 56(37.3) 24(16.0) 30(20.0) 30(20.0) 86(57.3)

I cannot cope with daily routines. 87(58.0) 19(12.7) 12(8.0) 15(10.0) 10(6.7)

The information seems to show that….In Hong Kong

About 30% are lonely

About 40% are anxious

About 45% are miserable

About 74% visit relatives and friends

About 80% get along with family

About 16.7% cannot cope with daily routines

-

+

““Postvention practices for people Postvention practices for people bereaved by suicide bereaved by suicide should not be should not be

prescriptiveprescriptive but instead should but instead should empower them empower them to find their own to find their own

paths” paths”

- - a concluding remark from the Australian, Norwegian, Belgian, and a concluding remark from the Australian, Norwegian, Belgian, and

Slovenian workforces (Grad et al., 2003)Slovenian workforces (Grad et al., 2003) - -

Part two What can we do

to “empower empower them to find them to find their own their own paths”paths”?

Since March 2007

Postvention using a public health approachPostvention using a public health approach

http://www.mindmap.hk/survivor/

Part two. What can we do to “help”?

If we use suicide risk levels as an anchor, we can subdivide all existing and potential activities into three types:

Universal – not all suicide survivours develop complicated grief and suicidal risk, and require additional help for their bereavement (Jordan, 2001). We suggest that some informational support and immediate help at the early phase of suicide bereavement may be useful to all people bereaved by suicide as a stress management strategy.

Selective – designed for bereaved persons who are deemed to be likely to experience a complicated form of grief or suicide risk.

Indicated – targeted toward people who are experiencing complications in their grieving process or expressing high suicide risk .

The USI Approach in Helping People Bereaved by Suicide (PBS) based on their suicide risk

Indicated

Selective

Universal

Suicide R

isk

Universal

Manual for survivours: distributed at public mortuaries and downloaded at http://csrp.hku.hk/files/70_1851_335.pdf

Universal: aims to normalize feelings, provide informational support, and to enhance help-seeking

behaviour.

Universal

A website for survivours (csrp.hku.hk/sos)

Universal

“留給最愛的說話 /The Belated Dialogues between the Suicides and Their Families”

– a book on people bereaved by suicide

Selective

Closed, six-session, CBT psychological education group? Or support group?

Selective: aims to identify and help those who might be at risk for complications or some level of

suicide risk.

Things that we had to consider when planning for support groups

Leadership: By who? Survivours? Mental health professionals? Volunteers? “One of the key factors that makes or breaks a support group is the facilitator” (Myers & Fine, 2006)

Membership: Who attends? Children? Elderly? Spouse? Parents? Men only? There is no evidence on whether groups based on relationships are more or less helpful than those for one type of survivor (Cerel et al, manuscript).

Open-Ended or Close-Ended?

Also it is unknown if this type of sharing, hearing, and repeating traumatic stories may actually re-traumatize survivors (Cerel et al. manuscript)

The Effects of a Pilot Psycho-Educational Group based on a Cognitive-Behavioral Therapeutic (CBT) Approach for People

Bereaved by Suicide in Hong Kong (unpublished data)

Objectives of the Group

Conceptual framework:- Cognitive Behavioral Therapy (CBT)

Major aim:

- To help suicide survivors understand their grief and normalize the ways in which it manifests by providing support and education in a safe in a safe environmentenvironment.

Methodology

Participants:Survivors recruited with the help of Eastern District HKP (as part of the initiatives of the community-based suicide prevention programme)

Measures:

1. Stress management (Healthy Living Follow-up Survey questionnaire)

2. CES-D (Center for Epidemiologic Studies Depression Scale)

3. Social Support (US NHANES questionnaire)

4. Inventory of Complicated Grief

5. Suicidal ideation, attempt and behavior

6. Demographic information

Test 1 CBT Group Test 2 6 months Test 3

Group Contents

Theme Contents

1 Introduction Lecture on suicide in Hong Kong

2 Psychological Needs Lecture on stages of suicide bereavement

3 Guilt and self blame

(negative thoughts)

Concept of ABC

4 Letting go Focus on the “present”

5 Goal setting Steps to set goals

6 Closing session Acknowledge the continuous support among the group

Demographic background of the group

Gender: 12 Females 5 MaleAge: 33 to 73 yrs

Family relationship: Parent, Spouses, Children, Sibling or Fiance

“Multiple” survivors

Incident taken place: 1 month to over 2 years ago

Depression (CES-D)

-2.14 (SD=4.45)

-1.91 (SD=5.02)

Mean Difference

192940

13.71 (SD=3.25)

15.31 (SD=5.99)

16.85 (SD=8.68)

Mean

Min. scores 1078

6 months after the group (Test 3) (4 cases)

After the group(Test 2)

Before the group (Test 1)

Max. scores

Social Support (Cont’d)

0

2

4

6

8

10

12

14

Test 1 Test 2 Test 3

InsufficientEmotionalSupport

Number ofpeople theysought helpfrom

Complicated Grief (Prolonged Grief Disorder)

-0.58 (SD=0.76)

-0.20 (SD=0.55)

Mean Difference

2.41 (SD=0.44)

2.69 (SD=0.81)

2.89 (SD=0.91)

Mean

002Number of members with diagnosis of PGD

6 months after the group (Test 3) (group 1 only)

After the group(Test 2)

Before the group (Test 1)

Feedbacks from the Group

Mutual supports and learning among survivors

Normalizing their ways of expressions

Increase of self-awareness

Knowledge gain

When should the survivors join the group? (after 1 month? 2 to 3 months?)

Group and individual counseling

Eagerness to help other survivors

Indicated

We hesitate to recommend any effective indicated individual interventions for suicide survivours in Hong Kong because:

(1) there is still a considerable debate in finding out whether grief is a “disease” and when grief should be treated as a “disorder” (Glass, 2005); and

(2) there is a dearth of empirical treatment studies for complicated grief that have been found to be efficacious (Shear et al., 2005).

Indicated: aims to help those at higher risk of suicide

Despite all that, we suggest that people bereaved by suicide who have persisting symptoms and impairments which may bear some resemblance to MDD, PTSD, Pathological Grief, Adjustment Disorder, or at high risk of dying by suicide should be assessed and treated by psychiatrists or clinical psychologists (Jordan & Neimeyer, 2003).

Part three What can we do

to “understand”?

Part three. What can we do to “understand”? (in an ideal situation)

We need not just to establish answers for “WHAT works for survivours?” but also “What works for WHOM?”

We need to understand:

1. the “course” of suicide bereavement by longitudinal research;

2. need to identify the features which make individuals vulnerable to, or protected from, developing severe psychological distress following bereavement by suicide;

3. need to explore the impact of suicide on family dynamics and family communication among Hong Kong suicide survivours because evidence from the West may not be applicable to Chinese families;

4. how and how much social stigmatization would affect help-seeking behaviour of survivours would be another important topic that would worth studying; and,

5. Most importantly, the suicide risk of people bereaved by suicide.

Efficacy intervention research studies

Should adopt the following research designs (if possible):

(1) comparisons with no treatment groups;

(2) comparisons with other treatment groups; and

(3) randomised assignment of survivours to interventions.

Reflections

There are unique features experienced by people bereaved by suicide;

However, not all people bereaved by suicide develop complications or suicide risk;

Little, if not none, is known if the effects of any interventions reduce the suicide risk of people bereaved by suicide;

Thus, without much empirical evidence, all interventions must be based on a “do-no-harmdo-no-harm” principle (Schut & Stroebe, 2005).

We should acknowledge the importance of including survivors into the work of suicide prevention with stringent ethical considerations.

The End Thank You

http://csrp.hku.hk

paulw@hku.hk