These Guidelines will help your service develop and implement a bereavement policy that will lead to improved support for family and friends when someone with a mental illness dies by suicide.

Research tells us that people bereaved by suicide may be at higher risk of taking their own lives, so intervention at this stage is an important, and often overlooked, suicide prevention strategy.

Information and support are essential in helping family and friends cope after someone takes their own life. Bereaved family and friends can feel confused, guilty and angry, but having their grief acknowledged, and where possible questions answered, can aid the process of understanding and living with the death of someone close.

Clinical and community support services both play an important role. Empathic listening and offers of condolence can be helpful, and mental health services that were in contact with the person who died are often well placed to offer support and referrals to family members. They can also offer additional support directly to any bereaved friends being treated for their mental illness by that service. This kind of help need not require additional resources. Making links with other services and using the skills of your staff can be all that is required.

These Guidelines can also be used to support family and friends when a person with mental illness is reported missing. Bereavement associated with missing persons can be extremely distressing and confusing, and support and acknowledgement of this grief by mental health services is also very important.

Not all Guideline suggestions will be relevant to your service, but by considering the issues discussed, you can develop appropriate and compassionate policies to support bereaved families and friends.

When a person with a mental illness dies by suicide, offering support and acknowledging the grief that family and friends experience can help them cope, and so reduce the risk that they may also die by suicide.

Facts and figures :

• Suicide is one of the main causes of premature death among people with a mental illness, and 10-15% of those affected die by suicide.
• People bereaved by suicide may be at higher risk of dying by suicide themselves.
• Bereaved family and friends who have a mental illness themselves are even more vulnerable and may need additional support.
• Bereaved family and friends often experience long-lasting and complex grief reactions.
• When services acknowledge the bereavement of families and friends, they are recognising the burden of care that families and friends carry to support people with mental illness.
• Australian Mental Health Acts state that, where possible, working with families is integral to the provision of good mental health care.

If a client of your service dies by suicide, arrange a meeting as soon as possible with relevant staff (management and those who had contact with the person) to discuss the issues covered in these Guidelines.

Discussion at this meeting aims to:

• Determine the most appropriate way to support bereaved family and friends.
• Establish the most appropriate person to contact the bereaved.
• Ensure a plan is in place to support staff.

If family or friends make contact before the service is aware of the suicide, establish if they would like further contact and support, and if so, arrange a meeting with them.

If the death occurs within the service, the SANE Bereavement Guidelines should be followed in line with your organisation’s critical incident reporting and medico-legal policy.

Who are the family and friends of the person who has died by suicide, and is it appropriate to make contact?

What do we know about the family and friends of the person?

• Have they made contact with our service before?
• Have they been involved in the care of the person?
• Do we have their contact details?

Even if the service has not had contact with family or friends before, this should not prevent a call to acknowledge the death and offer support. It may be necessary to make contact with more than one family member to ensure that everyone receives support, especially where family members may not be on speaking terms.

Have any family or friends of the person who has died, previously or currently, used our service?

If someone close to the person who died is a client of your service, they may be particularly vulnerable and in need of additional support.

How long has it been since the person had contact with our service?

Even if the person who died had not accessed your service for some time, it may still be appropriate to contact bereaved family or friends. Issues to consider include how long the person was involved with your service, whether your service was central to their care, if the family would benefit from contact and referrals that you can offer, and was the person accessing any other mental health services besides yours?

It is recommended that you contact other services the person may have accessed, to establish how they plan to respond. Determine whether it is appropriate for all services to be in contact with the family, and if not, identify the lead service and ensure this is communicated with all services who treated the person.

How can our service support family and friends?

• Talking to family and friends gives the opportunity to establish realistic boundaries about the help that your service can offer and the questions that can be answered. Making contact will acknowledge their grief, help ensure they have appropriate supports available, and help them prepare for other issues that may arise. This contact may include:
• A letter or phone call of acknowledgement and support.
• A meeting between the family and the service.
• Follow-up phone calls over the next few months.
• Counselling from your service, or an external bereavement service.
• Information and referrals
• Support groups
• Home visits
• Specialist support for any children in the family.

What support can we offer family and friends who are also clients?

• Acknowledgement and increased support from case-worker
• Additional counselling
• Bereavement peer support.

What may prevent family or friends from accessing support?

• Non-English speaking
• Disillusionment with mental health services
• Distance or isolation
• Cost of services such as counselling
• Cultural appropriateness, with indigenous Australians for example.

How can we help family and friends overcome these barriers?

• Use interpreting services.
• Be compassionate and willing to engage with family and friends to answer questions about the person who has died.
• Be willing to visit family and friends at home, or help them find local support services.
• Investigate low-cost services such as treatments for depression via a GP Mental Health Plan if approriate.
• Help them identify community-based bereavement support .
• Offer an indigenous worker as a liaison person if needed.

When is the best time to make contact?

It is important to offer support and referral soon after the suicide, but the most appropriate time will vary between individuals. Initial contact 1-2 weeks after the death is usually recommended, but be prepared to re-schedule if the person doesn’t feel ready to access your help. If this is the case, a second contact at 6 weeks following the death is advised. This is a time when initial support from friends and family starts to reduce and can create a sense of isolation.

What issues may arise during contact with bereaved family and friends, and how should we respond?

A range of emotions will naturally arise, including anger, guilt, anxiety and sadness. The death of someone close can leave people feeling shocked and bewildered. Friends and family can feel a range of emotions including anger, frustration and fear that they may unintentionally direct towards others. It is important to be mindful of this, listen and let people sit with their grief and emotions. This can be difficult if you feel that negative emotions are being directed at you personally and it is natural to feel some anxiety. Discuss how you can manage your own emotions as well as how you can be comfortable with expressions of emotion by the bereaved family and friends. Staff in contact with bereaved family and friends, especially, may need supervision or psychological support.

Concerns about the mental health of bereaved friends or family

It is normal for grieving friends and family to feel depressed for a time. However, be on the alert for signs that the person is not coping or may be feeling suicidal, particularly with those who have a mental illness and may be more vulnerable.

Medico-legal issues
Issues of liability can be a real concern and it is essential to operate in conjunction with your organisation’s medico-legal policy. However, this should not prevent contact and support being offered. If unsure of the legal implications, seek legal advice. Remember there is nothing wrong with a phone call to offer condolence and referrals.

Confidentiality
Confidentiality rules can be confusing. Health workers are sometimes unsure what they can say to families and close friends. It is important to check the confidentiality laws for your State or Territory, and be clear about what you can discuss. If the family were already involved in the treatment, there is no reason why the client’s treatment cannot still be discussed. They are also entitled to access medical records of their deceased relative under the Freedom of Information Act.

The coronial process
Following a suicide, families will usually have contact with the coroner’s court. Every state and territory has coronial services that offer some form of support to people who have experienced the traumatic death of someone close. Make contact with the coronial service in your area to learn more about their processes and what they provide.

Who is the most appropriate person within your service to make contact with family or friends?

• Who in your service had the most engaged relationship with the person who died, their family or friends?
• Who has the necessary counselling skills to make contact with the family?
• Who may have had experience previously in supporting people bereaved by suicide?
• Who will be able to answer questions about the client’s treatment? There may be more than one person who could speak with the family.

The most appropriate may not be the most senior person on the team, but they should feel supported and confident in their ability to make what could be an emotionally difficult call.

How will you support your staff during this time?

If you have an existing debriefing policy, use this to make sure all staff have the opportunity to talk about the suicide. Finding out about the death of someone who used your service can be very confronting, even if some staff didn’t have direct contact with the person who died. It is particularly important for the person who has contact with the bereaved family or friends to have the opportunity to debrief about any difficult issues that were discussed. If you do not have an existing debriefing or staff counselling policy, establish a person within your service, or someone external to your service, who can offer psychological support.

It is also important to run any investigations or meetings about the suicide in an atmosphere of understanding so that staff do not feel judged or criticised.

Action Plan
The SANE Bereavement Guidelines explain the important issues to consider when responding to bereaved family and friends. To implement these Guidelines, we encourage your organisation to adopt them as policy, and to communicate this to staff. Use this Action Plan or adapt it to better suit your service.

• Inform staff about the Guidelines and ensure that everyone understands the need for them and how they are to be used.
• Address obstacles by discussing with staff any challenges they perceive in supporting bereaved families and friends.
• Agree to implement the SANE Bereavement Guidelines as organisational policy and set a timeline to achieve this. Review the policy regularly (at least once every two years).
• Link with existing policies and procedures on critical incidents, medico-legal issues, and staff support after a suicide.
• Incorporate referral information in policy and procedure documentation and databases. Contact bereavement services in your area: building stronger links between mental health and bereavement services will ensure that people have better access to services when they need it most.
• Consider ongoing training needs for staff, such as a bereavement support skills or a suicide for staff, such as a bereavement support skills or a suicide prevention workshop (for example, the ASIST program). A staff member could also attend one of SANE Australia’s train-the-trainer workshops on this issue.

The SANE Bereavement Guidelines are endorsed by the Royal Australian and New Zealand College of Psychiatrists.

For more information:

• www.grief.org.au
• www.compassionatefriendsvictoria.org.au
• www.lifeline.org.au
• www.missingpersons.org.au
• www.sane.org

Where to call for help :

• 24-hour crisis telephone counselling Lifeline: 13 11 14
• National Missing Persons Coordination Centre: 1800 000 634
• Australian Centre for Grief and Bereavement: 1300 664 786
• Salvation Army Hope Line: 1300 467 354
• SANE Helpline: 1800 18 sane (7263) helpline@sane.org
• Suicide Call-Back Service 1300 659 467

Provided by SANE Australia, a national charity working for a better life for people affected by mental illness i through campaigning, education and research.