Guest Blog Post by Marlene Kenney, LICSW
Tell us a little about you, your experience becoming an EMDR therapist, and how you became interested in suicide postvention.
My career has been centered on healing and understanding trauma and traumatic grief, beginning with my anthropological research on my Blackfeet mother’s Tribal experience in reservation boarding schools through a career in critical incident response, psychotherapy, and community mental health. I was introduced to EMDR Therapy in my treatment following a traumatic event. I became trained in EMDR while working as a trauma-focused therapist and critical incident responder. EMDR changed my practice completely by providing me with a way to conceptualize the roots of overwhelming life experiences AND a route to improving current life conditions through trait change from the inside out. As a member of a critical incident response team in Massachusetts, EMDR is helpful in all critical incidents and disasters, from the Boston Marathon bombing to responding to suicide deaths. The Commonwealth of Massachusetts Department of Public Health partially funds the CIT team for suicide prevention and postvention, so effective service to people and communities bereaved by suicide is an aspect of my work. Suicide loss is often traumatic for loved ones and families, and EMDR therapy from the acute stage through years of integrating the loss has offered hope and recovery. Like all potentially traumatizing experiences, early intervention with EMDR after a death by suicide for individuals, families, and communities can impact long-term mental health outcomes by decreasing the stress response. I am particularly hopeful that EMDR can also decrease the suicide risk of bereaved people, a known outcome of exposure to suicide loss. In this way, postvention with EMDR is suicide prevention. In 2018, I was trained in Group Traumatic Episode Protocols (Shapiro & Laub, 2008), and in 2019, Integrative Group Trauma Protocols (Jarero & Artigas, 2012) and began using EMDR with groups and families bereaved by suicide.
Can you please help define suicide postvention and what settings can use this intervention?
Suicide postvention is the coordinated action(s) taken following a suicide death that reduce community and individual risk of suicide contagion, decrease overall stress activation, and bolster ongoing suicide prevention. Postvention providers include individuals, organizations, families, and communities. Use of EMDR in response to a suicide death can take place in community centers, schools, workplaces, and private practice offices, and in best practice, there is collaboration among providers. Riverside Trauma Center in Dedham, Mass., has identified twelve best practices in suicide postvention with a public mental health framework. EMDR practitioners can enhance our practice by seeing our work in this larger system light. Among these provider guidelines: stabilize the environment (which includes people experiencing an acute stress response), promote healthy grieving, and reduce community contagion. EMDR can play a vital role in postvention when conceptualized with multiple points of entry for loss survivors and communities. In their 2022 EMDRIA conference talk, Morrow and Kaptan identified low, medium, and high-intensity EMD and the 3 levels of EMDR laid out in the Council of Scholars 2021 article What is EMDR therapy? (Laliotis et al., 2021) offers the perspective of EMDR belonging wherever we access loss survivors. Because loss survivor’s care is often episodic over a period of time, EMDR therapists and critical incident responders need to be prepared with a spectrum of EMDR-related interventions to meet the survivor where they are in their healing from traumatic grief. Low-intensity and EMDR-derived techniques, like Acute Stress Syndrome Stabilization (Jarero and Artigas), the 4 elements, and some group protocols can be used immediately in community settings. I have utilized EMDR early intervention, in conjunction with psychoeducation about suicide, trauma, and grief in all of these settings when invited in after a suicide death. Clients seeking EMDR in private practice can get immediate relief from derived techniques like Flash (also low intensity) as preparation for longer-term healing work on trauma symptoms like sleep disturbance and intrusive thoughts. EMDR for suicide loss can take place right after the death or over the course of months or years, and postvention is always prevention because addressing trauma with EMDR reduces the client’s risk of suicide.
Talk to us briefly about the incidence and prevalence of suicide and what kind of support is needed for those impacted by suicide.
Suicide is the 11th leading cause of death in the United States, and in 2021 48,183 Americans died by suicide, according to the American Foundation for Suicide Prevention (AFSP.org). Middle-aged, white men are the highest-risk group according to the CDC’s most recent statistics in 2021. Suicide is the second leading cause of death for people 0-18; in 2021, the 25-34 age category had the highest rate of increase. Suicide is the second leading cause of death for people 0-18 and in 2021 the 25-34 age category had the highest rate of increase. Suicide attempts are much more prevalent, with 1.70 million attempts reported in the United States in 2021. It is estimated that one suicide death exposes 28 people directly, and this exposure is considered a significant risk factor for suicide. So, how we treat and care for individuals, families, and communities after a loss can impact later suicide death. The impacts of suicide loss can show up many years and sometimes generations later. Caring for people acutely bereaved involves EMDR early intervention, safety planning, and other suicide prevention applications, as well as trauma-informed care from providers and community members. Loss survivors report that in addition to a skilled trauma provider, loss survivor groups, working with a compassionate faith leader, and also with a spiritual intuitive help on the road to recovery. EMDR G-TEP groups are effective in the EMDR early intervention when we want to reach as many people as possible using the safest methods. Cultivating social connection through peers in these groups reduces isolation and burdensomeness, increasing protective factors of hope, belonging, calm, and self-efficacy. Postvention highlights that people bereaved by suicide require multiple pathways to healing and touchpoints for recovery and centers trauma and risk in the grieving process.
What successes have you experienced when using EMDR therapy with loved ones of people who die by suicide?
In the acute reaction days, weeks, and months following her teen brother’s death by suicide, my young adult client became suicidal. After a brief stay in a psychiatric hospital where she was “diagnosed” with bipolar disorder, she cobbled together a young adult career until a traumatic incident occurred while traveling for work when she was referred to me for EMDR. During EMDR treatment, we worked on targets around the death (getting the news, the funeral, returning home to his room and anniversaries, etc.) that left her feeling emotionally overwhelmed and responsible for his death. Over time, she began to have more capacity to regulate her stress response and thrive in the next chapter of her life. Juanita, a Latinx woman, witnessed the death of her adult brother in her home. Our therapeutic collaboration began one month after his death with EMDR EEI, and therapy ended, after which she returned to EMDR with me four years later to address the roots and underlying vulnerabilities that complicated her grieving for her brother and relationships in her life. Seven years after his death, our work has allowed her to integrate their childhoods of poverty and violence and to see that she could honor him and have a new relationship with him after death. After seven years of touching in and out of EMDR work, she reports feeling more organized, joyful, and able to manage her nervous system. These successes reflect how EMDR therapy can assist in adaptation, healthy grieving, and identity reconsolidation. I have used Jarero’s Acute Stress Syndrome Stabilization to assist caregivers so they can help others and employees they can return to work. GTEP groups with families and close friends (including teens and adult colleagues) reduce the disturbance of the worst parts and allow groups to witness resourced recovery and resilience, which is a huge success in postvention work. Individual follow-up for people still having reactions and concerns following a group is enhanced because the individual has the experience of cultivating hope in the group setting. Care for loss survivors is often intensive in the first three months and then sporadic with EMDR over several years. It’s a tender journey that can take a long time of patient EMDR therapy to deeply repair the injury to identity that comes with traumatic grief. EMDR helps address intrusive thoughts about hopelessness and the client’s wish to die, which is common and risky for loss survivors.
What issues/difficulties would you say are common in this population, and how does that impact EMDR therapy?
People bereaved by suicide are often focused on what I call the BIG WHY. In therapy, they are in agony, repeatedly going through what they should have done or would have done differently to save the life of their loved one. This speaks to the loss survivor’s high need to make meaning of what happened. Helping them “tolerate the blind spots” (Jordan, 2020) is one crucial aspect of the therapeutic work that challenges the EMDR therapist. AIP theory helps with this work, but allowing the person’s system to do the work of finding more adaptive ways to connect with a livable narrative of the death. We will never make the suicide death feel better, but with EMDR we can assist in integrating the trauma and loss and cultivating a less overwhelming experience of grief. Sometimes there is responsibility for not having seen the risk factors and warning signs which is especially excruciating for loss survivors and EMDR therapy is helpful to allow survivors to work through their unique associations and pain of the “tyranny of hindsight” (Jordan, 2020). New or increased suicidal ideation is not unusual for suicide loss survivors. The often vivid horror, images, and detailed information that is shared encourages the brain to rehearse and learn about suicide and this social learning theory is thought to be the core of risk. EMDR therapists will encounter SI while working with people bereaved by suicide and should take it seriously, while also helping to work it through as part of what is maladaptively stored from the death by suicide.
What ethical considerations are there to consider when working with suicide postvention?
When the ripple effect of a death by suicide happens in a community, there is often information that emerges in different groups, myths about suicide, and misinformation as part of the collective meaning-making. Providers often hear many aspects of the person’s story that add up to the lethal risk and this is especially true in the early response period. The family’s permission to share the cause of death and any details is helpful for practitioners. Privacy for family, friends, and the deceased is an important ethical consideration in this case. Even when our knowledge could assist in explaining what happened, providers are urged to keep confidentiality. There are situations in which the person who died by suicide’s family doesn’t want the death called a suicide and providers are asked to follow that guideline as a right to self-determination. Another conundrum is around talking about the means of death. It is strongly advised to avoid sharing the details, because they may overwhelm the nervous system of the listener. EMDR practitioners are in a position to help reprocess any overwhelming material that is already held by the client, but we don’t want to add to the distress or risk. It is recommended that providers still talk about suicide in general terms, with statements like “If it was a suicide what would it mean to you,” or identifying that “what’s sad is that person didn’t know that help could help.”
Are there any myths you’d like to bust about using EMDR therapy with suicide postvention?
Even with so much effort around suicide assessment and prevention, myths abound that create barriers to using EMDR therapy in postvention. One myth is that EMDR therapy “causes” someone to re-experience the horror of the loss. I tell clients and consultees that EMDR therapy in this context helps the client remember their loved one without the horror by addressing the components of a disturbing memory. A persistent myth in suicide prevention/postvention is that “talking about suicide will put the idea in someone’s mind.” Loss survivors, attempt survivors, and people with suicidal intrusions report that it is actually the opposite experience. Talking about suicide and working with it using EMDR helps reduce the disturbance, promote adaptive information processing, and reduce despair. Basic EMDR training often leaves clinicians with the idea that a client is not ready for EMDR if they have suicidality. During the course of EMDR therapy for suicide loss survivors (whether as EMDR EEI or longer-term psychotherapy), a therapist will likely need to address the client’s suicidality due to the trauma exposure. And in fact, trauma itself is a risk factor for suicide. EMDR is safe and supportive for loss survivors from the early stages of acute bereavement through paced recovery over time.
What multicultural considerations might EMDR therapists need to consider regarding EMDR therapy and suicide postvention?
Grieving in general can be culturally specific and death by suicide in particular can be heavily inflected with cultural meaning. We want to respect the religious and cultural significance of suicide and the timing for treatment around rituals while at the same time helping clients integrate the trauma. Some cultures and religions believe that death by suicide is a sin with eternal consequences, and families are often deeply disturbed by that previous meaning. Being culturally informed about suicide allows clients to work through what is difficult and use the culturally based assets that generate connection, meaning, and belonging. The stigma around suicide complicates grieving, and it is often necessary to target stigma as a possible EMDR target in and of itself. Perhaps, working on the target of cultural shame first would allow the person to address a piece of the experience that may build capacity for additional trauma work.
Do you have any favorite free EMDR-related resource you would suggest to therapists working with this population?
I use the Four Elements with loss survivors because it gives them multiple techniques to manage dysregulation and track and reflect on their level of disturbance. Elan Shapiro (2007) published the Four Elements exercise in a Journal of EMDR Practice and Research “Clinical Q & A” and I find my adaptation helpful for work in the field.
Marlene Kenney is a Licensed Clinical Social Worker whose community response and EMDR psychotherapy practice is based in Arlington, MA. Her interest in collective traumatic grief began with her anthropology master’s thesis about the legacy of the Catholic boarding school on her mother’s Blackfeet reservation. She is active in Ukrainian humanitarian mental health recovery with First Aid of the Soul as a trainer, group leader, and consultant, and is on the advisory board. Marlene is part of the G-TEP global network and uses group EMDR for critical incident response. Marlene enjoys collaborating with clinicians as an EMDR Basic Training facilitator, and EMDRIA approved consultant. She was a member of the Council of Scholars Future of EMDR project, Clinical Practice group. She was a panelist at the EMDRIA 2022 conference and presented her work on trauma response in 2020 on a global panel about the impact of violence in society. She is a National Psychological First Aid and Post Traumatic Stress Management trainer for the National Child Traumatic Stress Network and is a sought-after clinician and trainer in topics related to suicide loss and prevention. She has worked with the Massachusetts Department of Public Health, Boston Resilience Center, Federal Emergency Management (FEMA/Mass Support), and is a member of the Riverside Trauma Center Critical Incident Team, as well as the EMDR Humanitarian Assistance Program. She provides clinical and crisis management consultation and support to municipalities and organizations nationally and internationally.
Resources
American Foundation for Suicide Prevention. https://afsp.org/
Becker, Y., Estevez, M. E., Perez, M. C., Osorio, A., Jarero, I., & Givaudan, M. (2021). Longitudinal multisite randomized controlled trial on the provision of the acute stress syndrome stabilization remote for groups to general population in lockdown during the COVID-19 pandemic. Psychology and Behavioral Science International Journal, 16(2). DOI:10.19080/PBSIJ.2021.16.555931. Open access retrieval: https://juniperpublishers.com/pbsij/articleinpress-pbsij.php
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EMDR Research Foundation. Suicide Prevention & Survivor Support Fund. https://emdrfoundation.org/donate/marcia-murray-memorial-fund/
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Jarero, I., Roque-Lopez, S., & Gomez, J. (2013). The provision of an EMDR-based multicomponent trauma treatment with child victims of severe interpersonal trauma. Journal of EMDR Practice and Research, 7(1), 17-28. Open access: https://doi.org/10.1891/1933-3196.7.1.17
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Jacob, R., Li, T. Y., Martin, Z., Burren, A., Watson, P., Kant, R., Davies, R., & Wood, D. F. (2020). Taking care of our future doctors: A service evaluation of a medical student mental health service. BMC Medical Education, 20(1), 172. Open access: https://doi.org/10.1186/s12909-020-02075-8
Jamshidi, F., Rajabi, S., & Dehghani, Y. (2020). How to heal their psychological wounds? Effectiveness of EMDR therapy on post-traumatic stress symptoms, mind-wandering and suicidal ideation in Iranian child abuse victims. Counselling and Psychotherapy Research, 21(2), 412-421. https://doi.org/10.1002/capr.12339
Jordan, J. (2020). Lessons learned: Forty years of clinical work with suicide loss survivors. Frontiers in Psychology, 11:766. Open access: https://doi.org/10.3389/fpsyg.2020.00766
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Laliotis, D., Luber, M., Oren, U., Shapiro, E., Ichii, M., Hase, M., LaRosa Salvi, L., Alter-Reid, K., & Tortes St. Jammes, J. (2021). What is EMDR therapy: Past present and future directions. Journal of EMDR Practice and Research, 15(4). Open access: http://dx.doi.org/10.1891/EMDR-D-21-00029
Lehnung, M., Shapiro, E., Schreiber, M., & Hofmann, A. (2017). Evaluating the EMDR group treatment episode protocol with refugees: A field study. Journal of EMDR Practice and Research, 11(3), 129-138. Open access: https://doi.org/10.1891/1933-3196.11.3.129
Manfield, P. E., Engel, L., Greenwald, R., & Bullard, D. G. (2021). Flash technique in a scalable low-intensity group intervention for COVID-19-related stress in healthcare providers. Journal of EMDR Practice and Research, 15(2). Open access: http://dx.doi.org/10.1891/EMDR-D-20-00053
Maxfield, L. (2021). Low-intensity interventions and EMDR therapy. Journal of EMDR Practice and Research, 15(2), 86-98. Open access: http://dx.doi.org/10.1891/EMDR-D-21-00009
Morrow, R., & Kaptan, S. (2022). From 1:1 to 1:more than one (Group EMDR). EMDRIA Virtual Conference.
Mainthow, N., Perez, M. C., Osorio, A., Givaudan, M., & Jarero, I. (2022). Multisite Clinical trial on the ASSYST individual treatment intervention provided to general population with non-recent pathogenic memories. Psychology and Behavioral Science International Journal, 19(5), 1-9. Open access: https://juniperpublishers.com/pbsij/pdf/PBSIJ.MS.ID.556024.pdf Retrieved from: https://juniperpublishers.com/pbsij/volume19-issue5-pbsij.php
Ostacoli, L., Carletto, S., Marco, C., Baldomir-Gago, P., Di Lorenzo, G., Fernandez, I., Hase, M., Justo-Alonso, A., Lehnung, M., Migliaretti, G., Oliva, F., Pagani, M., Recarey-Eiris, S. Torta, R., Tumani, V., Gonzalez-Vazquez, A. I., & Hofmann, A. (2018). Comparison of eye movement desensitization reprocessing and cognitive behavioral therapy as adjunctive treatments for recurrent depression: The European Depression EMDR Network (EDEN) randomized controlled trial. Frontiers in Psychology, 9(74), 1-12. Open access: https://doi.org/10.3389/fpsyg.2018.00074
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Date
July 5, 2023
Contributor(s)
Marlene Kenney
Topics
Self-Harm/Suicidality