Grief-After-Suicide-Walking-the-Journey-with-Survivors

Grief after Suicide: Walking the Journey with Survivors Webinar Description: The Grief after Suicide: Walking the Journey with Survivors webinar was presented by John Jordan, Ph.D., FT, a licensed psychologist in private practice in Wellesley, MA, and Pawtucket, RI, who specializes in working with loss and bereavement This webinar discussed some of the unique challenges of suicide loss for mourners and for those who would help them In this webinar, Dr Jordan addressed some of the central concerns that most survivors bring to therapy, and the themes that caregivers must help survivors address At the end of this webinar, participants will be able to: Identify at least four themes in bereavement after suicide Describe common psychological recovery tasks for suicide survivors Identify broad clinical guidelines for work with mourners after a suicide Webinar Duration: Approximately 89 minutes Brandy Brooks: Good afternoon and welcome to the Grief after Suicide: Walking the Journey with Survivors webinar My name is Brandy Brooks and, aside from being the moderator this afternoon, I am a Contract Manager for the Massachusetts Department of Public Health Suicide prevention Program, the sponsors of this webinar Before I introduce our presenter, Dr Jack Jordan, I would like to go over a few housekeeping issues First, to view video for this webinar, go to www.readytalk.com and enter access code 6245494 to join this webinar Additionally to listen to the audio portion for this webinar, you need to dial 1-866-7401260 Again, that’s 1-866-740-1260 and you need to enter the access code 6245494 Also, should you experience any technical difficulties with either the audio or video for this webinar, please dial 1-800-843-9166 Again, that’s 1-800-843-9166 and a ReadyTalk representative will be more than happy to help Secondly, all telephones are muted except mine and Dr Jordan’s So, please use the chat function located in the left corner to type any questions you may have Given the number of participants, Dr Jordan will his very best to answer as many questions as possible as we go along and at the end of the webinar during the question and answer period Now that I’ve gotten that out of the way, let me introduce our presenter, Dr Jordan Dr Jack Jordan is a licensed psychologist in private practice in the Wellesley, Massachusetts and Pawtucket, Rhode Island where he specializes in working with loss and bereavement He was also the Founder and Director, until 2007, of the Family Loss Project, a research and clinical practice providing services for bereaved families He has specialized in work with survivors of suicide and other losses for more than 30 years As a Fellow in Thanatology from the Association for Death Education and Counseling, or ADEC, Jack maintains an active practice in grief counseling for individuals and couples He has run support groups for bereaved parent, young widows and widowers, and suicide survivors with the latter running for over 13 years Dr Jordan is the clinical consultant for Grief Support Services of the Samaritans in Boston, where he is helping to develop innovative outreach and support programs for suicide survivors In 2011, Dr Jordan was the co-recipient of the Leaders in Suicide Prevention Award from the Massachusetts Coalition for Suicide Prevention for his work with the Grief Support Services at Samaritans He is also the professional advisor to the Survivor Council of the American Foundation for Suicide Prevention, or AFSP, and a former Board member of AFSP and ADEC In 2006, Dr Jordan was invited to become a member of the international workgroup on death, dying, and bereavement and was the recipient of the ADEC 2006 Research Recognition Award Dr Jordan has been involved in several research projects on the needs of people grieving after suicide and, in 2004, received research funding from AFSP He has also provided training nationally and internationally for therapists, healthcare professionals, and clergy through PESI Healthcare, CMI Education, the American Foundation for Suicide Prevention, and as an independent speaker He has also helped to organize and lead many healing workshops for suicide survivors Dr Jordan has published over 35 clinical and research articles, chapters, and full books in the areas of bereavement after suicide, support group models, the integration of research and practice in thanatology, and loss in family and larger social systems He is published in professional journals, such as Omega, Death Studies, Suicide and Life-Threatening Behavior, Psychiatric Annals, Crisis, Grief Matters, and Family Process He is also the co-author, with Bob Baugher, of After Suicide Loss: Coping with your Grief, a book on suicide bereavement for surviving friends and family He is also the coeditor, with John McIntosh, of the new book, Grief after Suicide: Coping with the Consequences and Caring for the Survivors, a professional book on the impact of suicide and intervention to help suicide survivors So now, without further ado, I will now turn it over to Dr Jordan Dr Jordan, are you there? Jack Jordan: Yes I am Brandy Brooks: Okay Jack Jordan: Thanks very much, Brandy I’d like to extend a warm welcome to all of you for joining us for the webinar today I really appreciate your joining us because talking about suicide is a difficult topic, I know, and doing the work with survivors can be a difficult topic Let me just actually say a word about definition and also a word to survivors who may be listening Sometimes the word ‘suicide survivor’ can be a confusing choice of words or language because logically it could mean, when we say ‘suicide survivor’, it could mean someone who has attempted suicide and survived the attempt But, within suicidology and particularly in North America, a ‘suicide survivor’ has come to mean someone who is grieving intensely after the loss of someone important to them to suicide That’s the way I will be using it today In other words, a survivor is someone who is grieving after a suicide, not somebody who has attempted suicide If I’m talking about someone who has attempted, I’ll use the word ‘attemptor’ I also want to say something to those of you who may be survivors who are listening, whether you’re a survivor or whether you’re a clinician and a survivor also I know it can be difficult sometimes to hear a more academic professional talk about something that is so intensely painful and personal I would ask each of you who are survivors to two things One is to listen to what I have to say and take it with a grain of salt because, of necessity, I will have to make a lot of generalizations about what the experience is for people after suicide or what might be helpful for them You may or may not find that it’s for you or what your experience was The second thing is just to take care of yourself Sometimes listening to ideas or hearing a clinician present about suicide bereavement can be triggering so I want you to whatever you need to to take care of yourself emotionally In terms of my own background, in addition to what Brandy said about being in private practice and doing just a great deal of work over the last 30 years with bereavement in general and with suicide survivors in particular, I think of myself and call myself a distant suicide survivor I did have a great-uncle die in 1987 of suicide I also had one patient take their life, early in my practice This was a situation where I saw a couple in therapy for a while and then they decided to stop the therapy and the marriage A couple of months after that, the husband took his life and the wife came back to see me for a while after that Both of those were sad experiences for me but, honestly, they were not life-transforming experiences for me Many of the people that I work with, many of the people that you may work with in whatever setting you your work will be people whose lives will be profoundly transformed or changed by the loss of their loved one to suicide Really, I feel that most of what I have learned about the experience comes from my having walked the journey that’s why I call the webinar what I call it from having walked the journey, at this point in my life, with hundreds of survivors That’s a little bit of background about myself, both personally and professionally Brandy essentially read my bio to you Let’s talk a little bit about what we’re going to try to cover today and let’s see if I can get the technology right and move us to the second slide There we go I just gave you the introduction I’m going to spend a very short amount of time on what I call Suicide 101, which is just a little bit of background about suicide in America I that because, if you're going to work with survivors, it’s important that you have an understanding of what some of the forces are that lead to suicide One of the tasks that survivors face is to make sense of a death that often doesn’t make any sense One of the things I try to encourage survivors to is to educate themselves about suicide I want to give you just a little bit of background information about suicide We’re going to talk about the experience of losing someone to suicide and what we know about what the impact can be on people I’m going to talk some about recovery tasks for survivors; some of the psychological work that I think survivors need to to heal I’ll conclude with some guidelines, broad guidelines, that really kind of incorporate everything that I’m going to be saying today in the webinar for you to keep in mind when you're doing counseling or clinical work with survivors I can take questions throughout the webinar if, as Brandy said, I’ll my best to try to answer as many as I can I can’t promise that we’ll have time to get to all of the questions but I’ll my best to answer as many as I can Okay, let’s talk a little bit further about the definition of who is a survivor and what I call survivorhood In the past, particularly in terms of research, there hasn’t been a really clear definition of; what we mean by a survivor? Sometimes some studies have referred to a survivor as anybody who’s been exposed to a suicide In other words; have you known somebody who’s died by suicide? We know that over the course of their lifetime about two-thirds to three-quarters of Americans will, at some point in their life, knows somebody who dies by suicide The most common definition is probably the second one here which is a kinship relationship In other words, survivors are typically thought of as the immediate family of the person who died by suicide More recent studies have looked at psychological closeness to the deceased, regardless of whether they were blood kin or not to them; for example, studies that look at the friends of an adolescent who takes their life who may have been close friends of that young person In the book that John McIntosh and I have just published, called Grief after Suicide, it’s on your reading list, we try to offer a definition that we think is both broad and narrow, in a sense The definition is that a suicide survivor is someone who experiences a high level of self-perceived psychological, physical, and/or social distress for a considerable length of time as a result of the suicide of another person That definition is both broad, in that it does not presume that survivors are only the kin, only the immediate family of people It could be anyone in the social network of someone who dies by suicide It could even be someone who was not in that person’s social network Just as a hypothetical example, if someone were to jump in front of a subway train, the driver of that subway train may be deeply impacted by that They may be very traumatized by that experience In that sense, it might meet this definition of being a suicide survivor even though that’s not the kind of person we normally would think of as needing clinical services or that support groups would be designed around helping But, they may be somebody who’s profoundly impacted by the suicide of this person It also does not presume that, because someone is kin or close to the person, that automatically that they're going to have a difficult time so that we’ve included in this definition that a high level of distress that persists for period of time is part of the definition Alright, moving on; a little bit of Suicide 101, of suicide epidemiology I would like everyone listening to this call to please understand that suicide is a public health issue in the United States There has been a real see change going on in the last 20 to 25 years in the United States Traditionally suicide has been understood as a private event that happens in a family that mostly the community doesn’t talk about or they talk about behind closed doors But, it’s seen as sort of something that happens in a family but it doesn’t have anything to with the rest of our communities It’s just sort of a dysfunctional behavior by an individual, maybe from a dysfunctional family, but has nothing to with the rest of us There’s been a very strong and growing effort to understand suicide as a public health issue in the same way that violence or AIDS or other behaviors and illnesses that impact the whole community need to be seen as public health problems and a public health approach can make an impact on that There are, around the world, there are about million people a year who die by suicide and that’s quite probably and underestimate of the true number There are more people who die of suicide around the world than die of war and homicide combined There are about as many people who die of suicide around the world as die of AIDS around the world When you think about the amount of public health attention that has been given to AIDS, and I’m not bemoaning that at all, but when you look at the amount of public health attention that has been given to AIDS versus the amount of public health attention that has been given to suicide, the latter pales in comparison In the United States there are about 36,000 official suicide completions a year I say official because, again, it’s probably an underestimate of the true number We don’t have good data about the number of attempts a year but our best estimates are that for every completion there are probably 20 to 25 attempts so there’s probably 800,000 to 900,000 attempts a year in the United States Suicide is the tenth leading cause of death in the United States It is the third leading cause of death for young people, meaning people in the age range from 15 to 24 Males complete suicide at a rate that’s about four times that of females Females attempt suicide more often than males but males are much more likely to actually complete suicide Very important, about 90% of people who die by suicide, at the time of their death have a diagnosable, unfortunately often undiagnosed and untreated, but they would meet criteria for having a psychiatric disorder, most often mood disorders; clinical depression or bipolar disorder I want to talk a little bit about who is a survivor How many survivors are there? What are some of the common themes that survivors experience in their grief? And what is the impact of suicide on family systems, not just on individuals? A common statistic that has been kind of thrown around for years, it really came from Edwin Shneidman, who is the grandfather of suicidology in America He once said that for every suicide there are at least six survivors The problem is that Ed was simply making a guesstimate He really had no empirical data that he was basing that on It was just his best guess about how many people were likely to be impacted by a suicide If we took that figure alone that would mean that there were about 180,000 maybe 200,000 new survivors a year in the United States We don’t actually have good data on how many survivors there are because, as I said earlier in the presentation, many studies have not clearly defined how they have delimited who is a survivor; how you would count that Before you count something you have to be able to define it What we now have is some data about exposure to suicide Remember that exposure to suicide is different becoming a survivor, at least in the definition that I offered Exposure means that you’ve known somebody who’s died by suicide but that may or may not have a profound impact on you In 2002, Alex Crosby and Sacks did a very well-designed, large telephone survey of households in the U.S and I don’t remember the exact number but I believe there were 7,000 or 8,000 households that they surveyed and extrapolated from that to the general U.S population They found, based on their survey data, that approximately 7% of the U.S population will report that they’ve been exposed to someone in their social network who has died of suicide within the last year So, about 21 million people a year know somebody who dies by suicide in the United States About 1.1% of the U.S population will report that they’ve lost a family member, which would translate to a little over million people a year Of people who have been exposed, about 3.2% report they’ve lost an immediate family member; a brother or a sister, a parent, a spouse, a child Not quite 14% report that they’ve lost an extended family; a cousin, an aunt, an uncle, a grandparent As you would expect, about 80% of people report that they’ve lost a friend or an acquaintance Again, this could be someone that they knew at work, just barely knew just somewhere in their social network But, this begins to give us some idea of the number of people who, at least, are exposed Of that population of people who are exposed, we don’t really have good data about how many of those people will go on to have a very difficult time There has only really been one study that had been done that’s tried to look at that and the methodology was somewhat suspect That study found that if we’re just talking about immediate family, yes, the or figure may be about right; that for every suicide, on average about to immediate family members are significantly impacted If we’re talking about the entire social network, we may be looking at something more like 30 or 40 people are fairly significantly impacted We need a lot more research on that So what are some of the prominent themes for suicide survivors? What’s the impact on families? And are there even some positive effects of losing someone to suicide, psychologically? What the field is calling post-traumatic growth Again, for those of you who are survivors, I want you take what I’m about to say with a grain of salt It may or may not have been what you have experienced The first two items; let me see if I can use the technology here and just mark these There we go The question of “Why did this happen?” and the need to make sense of this and closely correlated with that or related to that is the question of assigning responsibility for the death The issues of guilt and blame about it are very, very powerful for suicide survivors and are usually not nearly as prominent after most other kinds of deaths They can be after other traumatic deaths For example, in a homicide, certainly the issue about responsibility and blame are very prominent themes for survivors of a homicide loss The ‘why’ question is pervasive for most suicide survivors Suicide is inherently a mysterious and frightening and confusing cause of death The general public does not have collectively as a society, we not have a narrative about why suicide happens and why people take their life So, when it happens it’s frightening and confusing for people We’re also not clear about whether suicide is something that people choose out of their own free will In other words, “Is this a voluntary act?” Or is it something that people are driven to, either because of circumstances; they're overwhelmed with stress events in their life, or because of a psychiatric disorder? I would suggest to you that, and I’ve come to think about suicide as the perfect storm It is the coming together of multiple factors in just the wrong way that create the conditions that allow suicide to happen Those factors range from everything from the individual’s neurobiology there’s a growing amount of evidence that psychiatric disorders and suicide itself may have some genetic component to them and involve neurobiological disregulation on the part of individuals and the public generally doesn’t understand that -to certainly stressor event play a role in creating the conditions that allow for suicide Life experience does For example, people who’ve had a history of having been abused, particularly sexually abused, repeatedly as a child have an elevated rate of risk for suicide over their lifetimes so that life traumas and events can contribute to this It really is the coming together of multiple factors In my experience, suicide is never the result of just one thing even though people in social networks, society, want to have a simple explanation “Oh, he killed himself because he lost his job.” “He killed himself because his wife left him” Kind of simple one-sentence explanations of why someone does something But, suicide is a very complex phenomenon and is multi-determined One of the tasks for survivors is come to develop a sort of rich and complex narrative of what happened to their loved one Related to that is the issue about, “What role did I or did other people have in this tragic event?” As I said a minute ago, people tend to be confused about; is this something that people choose or not? I would suggest to you that there’s no simple answer to that either Clearly when people are suffering from severe psychiatric disorders, schizophrenia or a psychotic disorder, people are not regulating their behavior in any way that we would call choosing or free will If someone is hearing command hallucinations and they're hearing voices that say, “You have the Devil in you You need to jump off this bridge.” No one would say that that person is making a choice out of their own free will to end their life On the other hand, someone who has a very severe terminal illness; they're in a great deal of pain, and they say, “I don’t want to go on with this anymore” and they decide to end their life Whether you agree with it morally or not, most people would say that person is making a choice It may be a choice profoundly influenced by the pain or the circumstances they're in but there is some degree of choice in that I would suggest to you that each suicide differs as to how much choice or free will’s involved It’s a very complex phenomenon to just trying to understand what led to a particular suicide The third point would be issues about trauma and helplessness It’s easy to see that people can be traumatized, and I don’t simply mean traumatized in the sense of very emotionally upset, that’s obvious but I mean also traumatized clinically in the sense of post-traumatic stress disorder It’s kind of easy to see that if someone witnesses the suicide or discovers the body that that could lead to post-traumatic stress disorder, a kind of re-living of the horrific experience I want to also advise you that people don’t have to have been an eyewitness to the suicide to be traumatized by it I’ve worked with far too many people who were not an eyewitness to their loved one’s suicide but they certainly have developed traumatic imagery about it They have nightmares about it They're haunted by the manner in which their loved one died If you're working with survivors, it’s very important to not only ask about grief and bereavement but to ask about trauma symptoms The fourth point is anger It is normal to feel anger when you lose someone to any cause of death It can be particularly normal to feel it when you feel like your loved one has made some kind of a choice to either reject you or abandon you This gets into the construction that the survivor makes about, “Did this person choose to this or not?” I’ve worked with many survivors who tell me that they’ve never felt angry about what has happened and I’ve worked with other survivors who are furious with the person who took their life and say, “How could they have done this to me? Didn’t they know how much they would hurt me or hurt their children or hurt their family?” It’s interesting to note that suicide is the Latin root of the word suicide literally means self-murder In some ways, the reactions of some suicide survivors are very akin to the reactions of homicide survivors If you had your loved one murdered by someone you can imagine how you might feel about the perpetrator of that murder but, in suicide, you have a profoundly difficult and confusing conundrum because the, quote-unquote, perpetrator is also the victim That makes for a very confusing, conflicting set of emotions about what has happened “Should I be furious with this person for doing this or should I feel sorry for them?” That adds to the kind of merry-go-round of confusing and conflicting feelings that survivors might experience The last one’s relief I want to, again, be careful about this In my experience, when people are blindsided by the suicide; they had no awareness that their loved one might have been thinking about suicide, you rarely see relief as one of the emotions that people experience In contrast to that, when the suicide is the end point of a long downward spiral, a long struggle with a psychiatric disorder, then you may see relief as one of many emotions that the person experiences I remember working with a couple whose daughter had multiple psychiatric hospitalizations, had made multiple suicide attempts, and finally, after an attempt in hospitalization she was discharged then a couple of days later completed suicide After the couple went through the first set of religious holidays, I’ll never forget the mother coming in and saying to me in a very quiet voice, “Actually, Dr Jordan, it was one of the best holidays we’d had in years.” Because one of the emotions that that mother felt was relief that this ordeal, both for herself and her husband and for her daughter, was over It’s really akin to when someone has died a long difficult painful death of cancer, for example, we give people permission to feel some relief that that ordeal is over Well, in a sense, you can think about people’s dying along painful difficult death from bipolar disorder or depression, but society doesn’t give people permission to have, as one of their emotions, relief This mother felt a lot of other emotions including great sorrow, both about the loss of her daughter and the life that her daughter had led, and she felt a lot of other complex emotions but one of them was relief That can happen sometimes Shame and also social disruption; most of you probably know that there’s a long history of stigmatization both of suicide and a psychiatric disorder In the Middle Ages, the body of someone who died by suicide was not allowed to be buried in church grounds The body was often taken out and mutilated or put in a public place as a warning to other So, there is something about being exposed to suicide that has a kind of role-modeling effect But, the increasing chances of dying by suicide if you’ve been exposed to it are not a huge increase It’s a small increase But, I’ve worked with many survivors who have some suicidal ideation Sometimes people will say to me, “I now feel like I understand what my loved one was going through because this is so painful or difficult for me I can relate to being in a kind of psychological space in which death seems like it would be easier than carrying on.” Suicide can raise, for survivors, the question about, “Why I go on and how can I learn to survive this, to bear this?” Certainly, of course, suicide can produce profound sorrow, as other deaths If you lose someone to suicide, you miss them and grieve for them and want them back in your life in the same way that you would grieve for them if they had died from any other cause Let’s go on to the next slide I see that the volume’s better Good Thanks for bringing that to my attention Let’s talk a little bit about the impact of suicide on family systems, not just on individuals but on the family as a unit First of all, suicide immediately presents for a family a problem about information management “How much are we going to tell other people? and “Are we going to tell people the truth about what was happened here?” This can be a very divisive issue in families There are families in which some members of the family say, “We have to tell people the truth.” Other people say, “We can’t tell people the truth What will people think of us if they know that our husband or our child or our parent died of suicide?” It can split families It can be divisive It’s not only an issue about, “What we tell people outside the family?” It’s an issue about, “What we tell certain members of the family?” For example, I’m working with a woman whose husband died by suicide and they had one child who was three years old at the time When her husband took his life, she simply told her three year old son, “Daddy was sick.” but didn’t explain what that meant or why or the circumstances of his death The child is now about five and half years old and he’s beginning to ask more questions about, “Well, how was Daddy sick? What was he sick from? And why did he die?” She’s struggling with how much and how to tell her child the truth about this It’s a very difficult issue for parents As mental health professionals, we generally want to encourage parents to be truthful with their children, and that’s what I do, but I also have empathy for how difficult a discussion that is and the wish to protect your child and sometimes to want to honor the image of the parent that you want to keep for your child In general, what you want to help children is to develop a relationship with you as their parent that they feel like the information they are getting is the truth, that they can count on you, trust you to tell them truth, and that the information is packaged in ways that’s appropriate for their developmental age A three or four year old doesn’t necessarily need to know all the gruesome details of how the person died but they may need to know that the person acted in a way that ended their own life Then, when they get older if they trust the relationship with their parent, they will ask more questions, typically, and want to know more details about that You can answer those as the child gets older Secondly, these kinds of deaths, both suicides and other traumatic deaths, can really disrupt family routines and rituals Dinner may not get put on the table Holidays may not be celebrated It changes people’s emotional availability to each other A parent who is very depressed and saddened may not be able to function in a parental role very well within a family Husbands and wives may not be able to be emotionally, sexually, available to each other, as supports to each other All of this can be destabilized or disregulated by the powerful grief that can ensue after a suicide It also can change the distance and power configuration within a family system A parent who’s used to being an authority figure within the family, the disciplinarian, etc may now feel immobilized A parent may feel like, “I have misjudged my child and they were suicidal and I didn’t know it How can I trust my judgment, going forward, about my other children?” They feel immobilized about making judgments about their other children or about setting limits with their children It can produce a communication shutdown in families Oftentimes family members are very worried about each other and, because of that, they're worried about what the impact is going to be on other people in the family They will avoid talking about it as a way of trying to protect everybody Everybody in the family is trying to protect everybody else This, then, leads to a kind of conspiracy of silence about it Or, another version of that is that, because there’s a great deal of anger generated by the suicide and a wish to blame somebody, the family avoids talking about it because they know, “If we start talking about it we’re going to start blaming each other We’re going to turn on each other because we’re angry with somebody in the family about not doing what they should have done.” It can be potentially very divisive within the family Lastly, it can produce what I call coping asynchrony, which is just a fancy way of saying people grieve with different styles, at different paces, at different speeds This can be very problematic in a family system Sometimes, I think of a family I worked with in which the adolescent daughter took her life The husband was focused really on, “How I protect the family?” Often a role fathers are in “I want to protect my wife and my children from this I want to protect the family I want to get us back up and functioning again as quickly as possible.” His wife, on the other hand, was really shutting down She literally had trouble coming out of the bedroom for several weeks She couldn’t go by the room in the house, the daughter’s bedroom, where her daughter had taken her life She really shut down and she was just focused on nothing but her daughter and wanting to contact her daughter She wanted to see a medium Nothing else mattered to her but the loss of her daughter This began to produce a great deal of tension between the parents He wanted his wife functioning back as a wife and a mother in the family and she was basically saying, literally and metaphorically, “Why can’t you come to the bedroom with me? Why can’t you join me in my grief? How can you be so focused on functioning when our daughter has done this in our family?” That’s a common pattern in families Families need to give each other, the members, give each other wide berth to grieve in their own way and their own style without becoming judgmental about it Otherwise, it can be very divisive What it can lead to is blame and scapegoating, which can be very divisive When you see a family that is doing cutoffs or people will not talk to each other or blaming each other about the suicide Or, where there’s a lot of overt arguing or fighting about it, that’s a marker of a family that’s having a very difficult time and needs help A suicide can also produce a tremendous amount of anxiety about, “Can this happen again?” both in a specific way, “Could someone else in the family be suicidal?” and in a more generic way We know this about trauma in general, once the trauma has happened to someone, people will become hyper-vigilant about, “Can the trauma happen again?” And, just in general, “Can something else bad happen to me? How I know it won’t happen again?” So that normal developmental processes in families for example if parents have a child die by suicide they're likely to be particularly watchful of and clinging to, in some ways, their other children It may make it difficult for those children, over the coming months and years, to separate from their parents Likewise, children become hyper-vigilant about their parents, even young children, about the well-being of their parents They may have difficulty being able to work on developing a life for themselves because they see how wounded their parents are after this It makes normal family processes of individuating and separating more complicated for family systems The result of all of this can be a loss of family cohesion I would be remiss if, when I talked about all of these things that can go wrong and be problematic in a family system and for individuals after suicide, if I didn’t also talk about what the field is calling post-traumatic growth after suicide What we mean by that is really resilience that people show in healing and even becoming stronger, more compassionate, wiser people after this kind of traumatic experience People’s identity will change after a suicide People will develop a kind of survivor identity People have said to me, “If you would have told me two years ago that my child was going to take their life and that I would still be putting one foot in front of the other, I would have told you that you were crazy I couldn’t survive that but I guess I have I guess, somehow, I’ve found something in myself I didn’t know was there.” So their identity has shifted as a result of that People change their relationships with other people Often times people will put more priority on relationships They realize that life is short and unpredictable and they will express more love and affection for other people When you have suffered greatly it sensitizes you to the suffering of people around you, not just other people who’ve lost someone to suicide, but just that most people experience pain in their life and we’re often not tuned into that or aware of that But, when we have that in our own life, we can become more sensitized to the fact that other people are experiencing that also People also will decide life is too short and, “I have to make up my mind about whether I’m leading my life now the way that I want to.” They will get out of bad relationships; bad jobs, bad friendships, bad marriages that are not helping or are dysfunctional I see a lot of those kinds of changes happen after a suicide Other forms of post-traumatic growth are a changed outlook or world view on life Some people say, “I have a renewed or a changed sense of purpose for my life.” It may involve helping other people It may involve becoming a kind of an activist about, “I’m going to try to prevent suicide so that this doesn’t happen to other people I’m going to reach out to other suicide survivors.” or, it may just be, “I’m going to try to become a better person in my own way.” I’ve seen people who’ve felt that part of what led to the suicide was that they had substance abuse problem and they weren’t paying enough attention to their child so they may decide that they're going to get sober, clean and sober, and to work on that and they're going to it honor of their child So, there are ways in which people decide to become a better human being as a result of this terrible tragedy that has happened in their life They also begin to feel appreciation for the things that they have in their life and sometimes it can deepen their spirituality or faith Now, suicide can also produce a spiritual crisis for people, both because of the theology of religion; if you believe your loved one has gone to Hell as a result of the suicide that can produce a deep crisis for some people, but just more generally like, “How could God let this happen? How could God let this happen to me? I’ve been a good person My child, my husband was a good person How could things like this happen to someone like me?” Having to work through those issues are profound residual issues that people have to work through when they have a traumatic experience such as a suicide All of these are things that can lead to psychological or spiritual growth I don’t really care what language you use about it but they're a form of psychological growth for individuals I see a question here Let’s pause for a second and take a question before we move on I see a question from someone named Peggy Morse and the question is; when others say “If that happened to my child then I just couldn’t live.” that presents a conflict to a parent who finds resilience Peggy, I wonder if you could explain a little bit more what your comment means I’m not sure if I quite understand it I’m going to go on to the next slide but, if you're listening, if you could just clarify a little bit about you mean or what the question is, that would be helpful to me and I’ll try and respond to it So what can we to help survivors as caregivers, as clinicians, as people who may come in contact with survivors and want to be of help? The first thing I want to talk about are what I see as some recovery tasks for survivors By recovery tasks, what I mean is the kind of psychological work that I’ve found that people need to to learn to carry the loss, to integrate the loss in themselves I don’t use the word ‘to resolve’ the loss You sometimes hear the language used that this person has unresolved grief I don’t find that language very helpful because it implies that grief is something that one, quote-unquote, resolves and gets over and then moves on with your life This is kind of the societal expectation and, unfortunately, it’s often the expectation of mental health professionals too, which is that grief is something that is like an unpleasant sort of like having the flu It’s an unpleasant experience that you just sort of get over and then move on with your life I’ll give you a metaphor that a member of one of my support groups once used that I think is just spot on It’s just perfect He said that people think when you're grieving it’s like having a heavy boulder put on to your shoulders and then when you get over your grief, quote-unquote, over it, what you is you take the boulder, you put it down on the road, and then you just go on down the road without the boulder on your shoulders He said, “That isn’t what’s happening to me What’s happening to me is that my back is getting stronger.” I just think that’s a perfect metaphor about what really happens, by and large, for people who are grieving after this kind of traumatic loss What I mean by that is that people learn to integrate the loss and to carry it with them They can that more or less successfully I’m not saying that some people don’t have a great difficulty with that But, this kind of loss changes people It has a permanent impact on people It’s not something that people get over and just put behind them It becomes a part of who they are in the world These are tasks, then, that help people integrate the loss into who they are The first task really is containing the trauma and a restoration of a sense of control This is really true in all traumatology, is that traumatic experiences are very disregulating of our physiology, of our emotional life, of our cognitive functioning The first task is for people to sort of get a handle on and contain the trauma so that it doesn’t leak into every aspect of who you are and become a permanent way of functioning in the world We don’t have time in this seminar to talk about it but there are a number of techniques, such as EMDR and things that are similar to prolonged exposure therapy that can be useful in helping reduce trauma symptoms in suicide survivors and survivors of other types of traumatic death The second task is what I call a creation of a narrative of the suicide What I mean by that is, because suicide is so puzzling and confusing, survivors will spend a great deal of time trying to make sense of what has happened and they have to spend a lot of time, typically, trying to understand the state of mind of the person who died They have to also sort out a sense of realistic responsibility for the death and develop a realistic perspective about the perfect storm, really; about the multiple causes that led to this death Typically, survivors begin by overestimating the role that they had in the death and the things that they could have done to have prevented it and they underestimate or just are unaware of all the other things that may have been contributing to the suicide Over time people have to go think those things through and they may have to some investigation work They may need to talk to other people who had contact with the deceased, who knew them well If you have a child in college who takes their life, you may need to talk to that child’s friends and roommates, their professors, to see what seemed to have been going on with them as you try to develop a picture of what was going on psychologically with this person Sometimes there is a formal procedure called a psychological autopsy that is really a systematic way of doing this that’s used in research and sometimes in forensic medicine by medical examiners In essence, survivors often have to their own personal psychological autopsy to understand the suicide This needs to be supported by clinicians Sometimes clinicians will try to short circuit this or say, “You don’t want to dwell on this It’s not productive to dwell on this.” But, this is a necessary task of healing for survivors The third task is what I call dosing oneself This is basically beginning to gain skill at regulating the pain The psychological pain can be so intense that people need to find ways of cultivating analgesia or relief from the pain, both from traumatic images and memories and from waves of grief that they may be experiencing Some of the first tasks in working with someone may be asking people, “Have you found any way to get relief from this? Any way to distract yourself from it?” We sometimes think, as grief counselors or as therapists, our job is to get people to go towards the pain But, traumatology teaches us that the first order of business for somebody who’s traumatized is not catharsis It is not having them be flooded with what they're already flooded with It is actually learning to gain a measure of control over it and then asking people, in a controlled way, to re-expose themselves to the traumatic stimuli or triggers, if you want to use that language Learn social management skills; because people around the survivor often know how to relate to the survivor, how to provide support, because it creates a kind of social awkwardness, survivors have to learn how to manage other people’s reactions to them They may have to say to people, “You know, it’s okay if I cry It’s okay to ask me about my son or my husband I would like to talk about this.” Or the converse Survivors may need to say to other people, “You know, I mean well when you ask me questions when you ask me what happened but I don’t understand myself yet what happened and I’d actually rather not talk about it right now.” So, survivors have to sometimes learn to be proactive about teaching people in their social network what they need from the social network Survivors often don’t know what they need This is a kind of trial and error learning process about being able to this and figuring out what is going to be helpful for me from other people Another skill that goes along with this is being able to stay away from or manage people who make you feel worse Sometimes people will say incredibly hurtful or ignorant things to survivors People will say, “Well, didn’t you know they were depressed? Didn’t you see this coming?” What may be blurted out as simply wanting to get more information but it can be incredibly hurtful to a survivor Survivors may need to say, “Well, no, I didn’t see it coming and that question is really a hurtful question Please don’t ask me questions like that again.” Or literally to avoid people who make them feel worse Obviously that’s difficult to if that person is in your family or you have to interact with them regularly People may be able to learn how to psychologically put their armor on or distance themselves from certain people There’s now beginning to be research evidence that, not only does good social support help people heal after losses like this but, let’s call it bad social interaction I don’t want to call it social support negative social interactions with people actually prolong people’s grief responses People need to repair and transform their relationship with the deceased I think it’s probably a truism that we never lose anybody in our life to death without there being some kind of unfinished business with them; things that are left unsaid, things that we could have said or done that weren’t done But, this can be particularly true after a suicide in which suicide, almost by definition, tends to rupture the relationship between the deceased and the survivor, the mourner It comes as a revelation to people to realize that even though the person has died, “I’m going to continue to have a kind of psychological relationship with this person They're going to be important to me I’m going to carry them in my heart and I can repair this relationship that has been so severed or that I have been injured by.” A skillful grief counselor can help people that There are lots of ways that people it kind of intuitively; writing letters, going to the grave, talking to the person There are techniques, sort of empty-chair techniques, I use guided-imagery techniques that can be very helpful and therapeutic for people in repairing and transforming the connection with the deceased into one that’s a more positive one and that can also involve forgiveness People also need to be able to develop what I would call a durable biography of the deceased This language is from Tony Walter, who is a British sociologist He says the main task of grieving is to develop what he calls a durable biography of the deceased This is a narrative of the life of the deceased What happens after suicide is that it’s as if the life story of the deceased has only one paragraph and that paragraph is the last paragraph in the book saying, “This person died by suicide.” It’s as if that is the only important thing about them One of the tasks for survivors is to able to say, “No, wait a minute That’s not true This person had a life and I want to remember and honor and take pleasure in the life this person; that suicide is not the only important or even the most important thing about this person’s life.” It takes a while and it takes support for survivors to be able to remember and honor the life of the person who dies, not just the death of the person who died Then, people have to be able to learn to live in the world without this person and to reinvest in a new life for themselves; to rebuild their life without this person Let’s pause for a minute and take a look and see if there are any questions that people have; questions or comments they want to add This would be a good time to it before I move into my summary comments Let’s go back to Peggy’s clarification Peggy had originally said; when others say, “If that happened to my child and I just couldn’t live.” presents a conflict to a parent who finds resilience Then she goes on to clarify; survivor guilt The death is life-changing but you still find a way to carry the loss and function It doesn’t mean that you loved them less I think, perhaps, what Peggy is saying is that, sometimes when people lose someone to suicide, they find that, in addition to the pain and the sorrow, there can also be positive changes that happen inside themselves They can feel guilty about finding the positive changes inside themselves That can be a problem Part of why I mention relief when I a presentation about suicide bereavement is because I want people to understand that relief can be a normal emotion and part of why I talk about post-traumatic growth is because I want people to understand that the human spirit has enormous resilience in it and that people grow after these kinds of experiences They don’t grow because of this, and I’ve never met a survivor who said, “This is the best thing that ever happened to me in my life.” but what you hear is that people say, “I grew in spite of this I would give anything to have this person back but, given that it happened, I found a way to carry this boulder.” if you will, to go back to that metaphor, “and I became a stronger or wiser or better person as a result of this.” Sometimes people can feel conflicted about this, that, “I had to lose my loved one this way for this to happen.” If there are other questions or comments that people have, please feel free to add them I’m going to go on to talk about my concluding comments now These are the kind of summary comments that I would like to make about grief after suicide and about working with someone who is bereaved by suicide The first thing is that, as a caregiver, as a clinician I want you to revise and be open to revising your assumptions about the grieving process and about what role you play as a caregiver or clinician with survivors First of all you have to be open to revising your assumptions about how long the grieving process takes and the intensity of the grief I’ve already shared the metaphor about the people learn to carry the boulder, not set it down and leave it behind them In a very real sense, people will grieve for the rest of their life So, the goal of grief is not to get over their grief, it’s to learn to carry it better and to integrate it for the individual That doesn’t mean that people don’t feel better over time They It doesn’t mean that some of the symptoms of grief; trouble sleeping, trouble concentrating, being able to function in one’s roles as a parent, at work, as a marital partner, etc I’m not saying that that functioning doesn’t return It does If doesn’t return, given a reasonable amount of time, that’s problematic But, we know, from a growing amount of research, that the time trajectory after traumatic losses, not just suicide but after homicides, after sudden unexpected violent death of a loved one, typically is much longer than after more normative deaths Intuitively that makes sense If your great-grandmother dies, at age 97, peacefully in her sleep, it’s probably not going to take you years to get over that, unless she played a very important role in your life and was central to your functioning If your child is murdered or if your child kills themself, it’s going to take you a very long time, much longer period of time, for you to heal or to recover from that The intensity of the grief is not going to be the same as losing your great-grandparent The goal is integration, not resolution I’ve already commented on that The role of the clinician is really not of treatment, the way we think of treating medical conditions or problems I don’t have time to go into this in depth but the psychotherapy that Kassin feels has really been dominated by a medical model It suggests that what we is similar to what doctors when they treat sore throats or when they treat cancer, in which we diagnose people and then we apply treatments to people and the patient’s job is to be a cooperative patient It’s a very hierarchical model In the grief counseling field, people are arguing that what we need to think of this as doing is they’ve invented a new verb called companioning that what we are doing actually is walking with people at a very difficult time in their life and we’re really serving as a kind of attachment figure for people in a very difficult time in their life, in a sense, as kind of equals rather than as being an expert that knows better for people what they need than they know for themselves Second, the goal of counseling in grief support if to provide a safe and sheltered context in which people can their grief work and can learn new coping skills Grieving is a process of skill acquisition That’s not usually how we think of it but people learn new skills about managing their own reactions, about managing the reactions of other people, about reforming their identity These are all skills that people have to learn to cope and to integrate the loss into their life The good news is that skills can be learned and can be taught to people It’s important to attend to traumatization I think grief counselors or people focused on grief sometimes really focus on the sorrow and the sadness aspects and underestimate how important the trauma aspects are It is difficult to work on grief and loss when people are having flashbacks, when they are re-living horrific experiences which tend to interfere with being able to mourn I really think a combined approach, using techniques and interventions from traumatology and from thanatology, the grief counseling field, is really what’s best when we’re thinking about working with suicide survivors It’s important to support the construction of a narrative and support the survivor in the developing and understanding People need to educate themselves about suicide, about grief, about psychiatric disorder as background information as they try to understand, “Why did this person take their life at this point in their life?” Background information, but understanding about what contributes to suicide, what is grief after suicide like, what is psychiatric disorder These are all things that many people maybe have very little familiarity with until they encounter the suicide of someone important to them You can really help facilitate that when you help people educate themselves about these matters You want to help people learn to dose themselves; first of all, just giving people permission to that It is okay to learn skills of distracting yourself from the pain I basically will say to people, “Whatever you that gives yourself some relief from this, as long as it is not self-destructive and not destructive of your relationship with other people, it’s okay to it and you should cultivate it.” So that obviously getting intoxicated every night on alcohol is not a good idea but if going to the movies and losing yourself in a funny movie is helpful for you, then go ahead and that Sometimes families will sort of cancel holidays the first year and they will go if they’re Christian and they're coming up to Christmas, they may say, “We’re not going to Christmas this year We’re going to the Bahamas, someplace where it’s warm and sunny and there’s no snow and there’s no cold weather and there’s well there’s Santa Clauses everywhere in the world now but where there’s not so many reminders because it will be easier for us if we’re not confronted with all of this holiday reminder stuff.” That’s fine What you should is caution people that when you come back you’re going to be hit with it again so it will be difficult coming back But, that’s fine and usually people will tell you, “You know, it was a little easier for us because we gave ourselves permission to put this all at arms-length for a while.” Validate any form of analgesia that is not destructive Address family and social network issues, particularly scapegoating as I mentioned before This will be a good 40% to 50% of what people will talk to you about is the problems they are having dealing with other people in their social network; either their family or in their friendship network in which other people are having trouble understanding, people are saying unhelpful things, or people are avoiding them Coaching them, brainstorming with them about how to deal with those things can be very valuable because this will be a whole new set of problems that people never dreamed of that they would have after they’ve lost someone to suicide Facilitate contact with other survivors There’s a growing amount of evidence that, not for everybody but for many people, being able to have contact with other people who are going through the same experience can be very therapeutic There are a lot of ways to that Face-to-face survivor groups can help Online survivor groups can help Reading the narratives of other people who’ve lost someone to suicide is a way of having an empathic experience with other people who’ve lost someone to suicide In the Boston area, the Samaritans of Boston runs the Grief Support Services, which is an excellent resource for people who are grieving after a suicide Nationally, both the American Foundation for Suicide Prevention and the American Association of Suicidology have online databases of survivors support groups around the country Also the Samaritans in Boston has what we call our Survivor-to-Survivor Network which are trained volunteer survivors who go out and meet with new survivor families in their home so that the survivor doesn’t have to some to a drop-in support group The members of the Survivor-to-Survivor Network will come and visit with the new family All of these resources are on your reading list, the organizations that I just mentioned Go slowly with guilt This is something that I think is very important An instinct we have when we see someone suffering a great deal with a lot of guilt and blaming themselves is we want to take it away We want to make them not be in so much pain I understand that That’s a very compassionate instinct but you can’t it for people People have to work through their guilt and, in essence, put their guilt in perspective themselves rather than you simply absolving them from the guilt I sometimes will say to survivors, “Look, you’ve probably going to have to put yourself on trial I understand that I even will support that My goal is that you and I try and have a fair trial and that we look at all the evidence here rather than having a kind of kangaroo court in which you immediately convict yourself here.” Lastly, follow the principle of don’t waste your grief This is something I heard Terry Maltsberger, who is a psychiatrist who’s worked most of his professional life around suicide prevention, saying that he was talking to a group of survivors and a woman who had lost a child to suicide got up and said, “Dr Maltsberger, I don’t know what to with myself What am I supposed to now with my grief?” Terry said, without a moment’s hesitation “Well, don’t waste your grief.” What he has really saying is, “Try to find some way of making something redemptive or good come out of this.” I’ve found that to be an enormously useful principle in working with survivors, particularly for people who have an enormous amount of guilt and are unable to absolve themselves or to work that through Then, perhaps what they need to is to find a way to, in a sense, atone for that by becoming a better person or being a service to other people in some way but make something redemptive or good come out of this There’s now actually some research evidence that people who are able to this, to find meaning and to find some constructive purposeful meaning and activity that comes out of their grief better than people who simply sit with the pain and the misery that they're experiencing I think there are a couple of other questions Let me try to attend to those and then we’ll wrap up Let me read the questions From Cheryl Poisey (ph), forgive me if I mispronounced that; secondary traumatization issues, for example father of a son who completed suicide wondered if he in his role as a police officer responded in his past with adequate empathy to other families who had experienced suicide How to help deal with this? That goes to the guilt issues What he is doing is he’s had a kind of awakening of his consciousness He now understands what it feels like to lose someone to suicide and I would help him examine that I wouldn’t rush to say, “Oh, I’m sure you’ve been fine.” I wouldn’t try to cut that off prematurely but help an honest and realistic he may be accusing himself too much so you want to try to help him realistically look at how he’s done in the past and, more importantly, how he can it better going forward This is a perfect example of what I was just talking about, about not wasting his grief but becoming a better person as a result of it Suzanne Norton comments; I find it very unfortunate that often times the gatekeeper to people’s suicide-related emotional grief is the doctor whose immediate reaction is to medicate and then refer to a counselor or therapist How can providers allow patients to be more involved treatment and care of what they're dealing with versus creating cocktails of relief? I hear what you’re saying, Suzanne I think this is an unfortunate growing trend which is to immediately medicate We all want to something right away to help relieve the pain and doctors are human beings so when a patient is sitting in front of them and saying, “My son has just killed himself.” And the doctor doesn’t know what to and is feeling helpless they say, “Well, okay, I can write a script for you.” Sometimes they just write a script and that’s all they At least if a doctor is saying “Let me write a script for you and I want to refer you to a counselor.” I think that’s preferable to simply writing a script What I would rather see happen I don’t object to the use of psychotropic medication I think it can have a very useful role in grief counseling but it needs to be part of an overall plan about how to help the person that has to involve human contact not simply a medication Unless the person is refusing to see a counselor they just say “I want a pill” that may a different story Most people are sort of grasping at straws, in that they will try whatever is recommended to them, and I don’t think medication is sufficient in those cases That’s my belief or bias about this I hear you How to change that is we have to educate physicians and medical professionals about dealing with, not just with suicide, but with traumatic grief From Barbara Nealon; at our facility we had a patient-family peer suicide We enhanced our QPR training which is a training for recognizing and knowing how to respond when someone is suicidal, QPR training We enhanced our QPR for the staff and community We developed our own in-house team to provide support using the CISM principles We had a tough year and found ourselves needing to debrief, diffuse, through being so entrenched ourselves with our grief Positive outcome; we built a stronger relationship with one another and developed the survivor support group We just recognized our one year of this group and it is meeting a huge need in our community Hallelujah It sounds like your organization responded very well to this, Barbara You made a very constructive and adaptive response It sounds like your organization did not waste your grief That sounds very good Let’s a last question here from Melanie Varady; AFSP Boston chapter also has a survivor outreach program Yes I didn’t mention that AFSP also has a survivor outreach program in which trained survivor volunteers will come and meet with new survivors If you contact the local AFSP chapter, and you can get their number by going to the national website and get the local AFSP New England chapter, they have a survivor outreach team as well I guess Melanie is the Chapter Director for the AFSP Boston chapter Cheryl says thank you I would like to thank each of you for joining us for this webinar today I really appreciate the work that you're doing and the one thing ask people at the end of any training that I is that you take whatever you feel you’ve gotten from this seminar and pay it forward to someone else Thanks very much for joining us today Brandy Brooks: Just before we break here, I’d just like to piggyback off of Dr Jordan’s thanks for everyone participating I’d also like to thank Dr Jordan for participating and presenting this webinar I don’t know if it was mentioned earlier but I will be emailing slides, as well as a link to the podcast for this webinar, and a survey that I’d like all participants to complete, if you would be so kind In addition, be on the lookout for any emails about upcoming webinars and trainings being sponsored by the Department of Public Health I hope today you’ve gained more knowledge about the common themes in bereavement after suicide, some of the psychological recovery tasks for survivors and, as well, some broad clinical guidelines for working with survivors of suicide Again, thank you all for participating Have a wonderful day Dr Jordan, I don’t know if you have any concluding comments you’d like to share Jack Jordan: Just to thank people Brandy Brooks: Okay Alright, well thank you all for participating Have a great day