An article in a recent issue of the University of Portland campus newspaper,The Beacon, introduced me to a story about a death by suicide that was stigmatized and how the effects of stigma are unfolding in real time -- and hopefully about how stigma is being overcome.

The article, by UP student Logan Crabtree, caught my eye because he tells of founding, with fellow student Jesse Dunn, an Active Minds chapter at UP "following the suicide of our friend Mike" -- and I am always moved when, in the aftermath of suicide, survivors like Crabtee and Dunn take action to improve mental health resources and services in their community.

I was also touched by Crabtree's frankness about the struggles of the new chapter, including the impact that another student's suicide had on him, only nine months after the death of Michael Eberitzsch II:

We were devastated by the news of Conner Hall’s suicide ... For me his death felt like a personal failure. I spent weeks questioning and reviewing every event, article and Facebook post we had made [during the start-up of Active Minds]. What else could we have done? Why did this happen? What else can we do?

I sympathized with Crabtree regarding his feeling of personal failure, which I believe everyone involved in suicide prevention has grappled with, each of us in our own way -- and I was curious about what was happening at UP. An Internet search led me to the backstory, which is, at turns, both troubling and hopeful -- just as facing the harsh reality of suicide often is.

I hardly know where to begin in heartily recommending the "Silent Suffering" series published today by the Columbus Dispatch. Each of its half dozen in-depth feature stories and handful of engaging videos is in itself worth experiencing. Taken all together, the series offers an extraordinary opportunity to see suicide from the perspectives of those who struggle with thoughts of killing themselves, of caregivers who are devoted to preventing suicide, of family members who are left behind to ask "Why?" and truly of everyone in a community who is affected by suicide.

Click on the picture above to go to a video that sets the scene for the entire series (the video features several moving stories from people's personal experience). My introduction to the series came when a colleague sent me the article "Some Survivors Cope with Loss by Helping Others Affected by Suicide," which tells the stories of people bereaved by suicide who now volunteer in a variety of ways that change -- and literally save -- the lives of others struggling with suicide and its aftermath.

I hope the following quote from the "Helping Others" story persuades folks to explore whatever might interest them in this superb series. These are the words of Mary Ann Ward of Columbus, Ohio, who lost her son Murray to suicide in 2009 -- and who now facilitates a support group for people bereaved by suicide.

“All we can do is accept this loss without ever understanding it, and lean on one another to move forward ... I can give hope to those who are newer than I. From the pain, we can grow in knowledge and wisdom, and experience joy again.”

By Franklin Cook

The special report "Systems Must Include Three Levels of Care for Aftermath of Suicide" (available to read or download below) is essential reading for anyone involved in developing, implementing, or assessing services designed to help people who have been affected by a suicide fatality, such as first responders, mental health practitioners, and the suicide bereaved.

Based on recently released national guidelines,* the report delineates three levels of care:
   • Immediate response: crisis assistance, triage and referral, follow-up
   • Support: assistance with grief and loss, self-help
   • Treatment: interventions for potentially debilitating conditions

Quoting Goal 6 of the guidelines -- which is to "ensure that people exposed to a suicide receive essential and appropriate information" -- the report explains that providing such information is a goal that applies across all three levels of care. It also features an addendum, "Information for People Exposed to a Suicide" that outlines the kinds of information that are valuable to people exposed to a suicide and points to the online resource directory available at bit.ly/afterasuicide.

By Franklin Cook

A historic document, Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines, was announced earlier this month at the Association for Death Education and Counseling conference in San Antonio and at the American Association of Suicidology conference in Atlanta. The Grief After Suicide blog -- in an upcoming series of posts -- will cover a number of ways that this groundbreaking document is paving the way for reinventing postvention in America. For instance, the guidelines:

• Summarize research evidence showing that exposure to suicide unquestionably increases the chances that those exposed -- perhaps especially the bereaved -- are at higher risk for suicide as well as for numerous, sometimes debilitating mental health conditions
• Highlight the effects of a fatality on people beyond family members of the deceased, including friends, first responders, clinicians, colleagues, and others (even entire communities) who may require support in the wake of a suicide
• Describe a new framework for classifying people who experience a suicide (Exposed, Affected, Short-Term Bereaved, and Long-Term Bereaved) that will help focus research and guide the development of programs and services to meet the unique needs of specific populations (see the graphic at bit.ly/continuummodel)
• Advocate for a systems approach, through organizing interventions into three separate, overlapping categories:
    • Immediate Response: Based on mental-health crisis and disaster response principles
    • Support: From the familial, peer, faith-based, and community resources that help the bereaved cope with a death
    • Treatment: By licensed clinicians for conditions such as PTSD, Depression, and Complicated Grief
• Argue that suicide bereavement is unique because death by suicide is unique (i.e., it involves questions about the deceased's volition, the effects of trauma, the degree that suicide is preventable, and the role of stigma in people's treatment of the deceased and the bereaved)
• Present an outline of the research needed to expand and enrich what is known about suicide bereavement and other effects of suicide (which will lead to the development of evidence-based practices in suicide postvention)
• Assert that suicide grief support efforts ought to be informed by research and clinical advances over the past 20 years in the fields of bereavement support, traumatology, and crisis and disaster preparedness
• Include an appendix outlining numerous, practical resources for the suicide bereaved and those who care for them (please link to the expanded, online version of the resource clearinghouse)

---

An excerpt of the guidelines (Table of Contents, Executive Summary, Acknowledgements, Preface) is available at bit.ly/excerptsosl, and the complete document is available at bit.ly/respondingsuicide. The guidelines were created by the Survivors of Suicide Loss Task Force of the National Action Alliance for Suicide Prevention.

A new study of the effects of suicide bereavement on mortality, mental health, and social functioning indicates "that exposure to suicide of a close contact is associated with several negative health and social outcomes, depending on an individual's relationship to the deceased." For example:

• People who lose a spouse or partner to suicide and mothers who lose an adult child are at increased risk of suicide.
• Parents who lose a child to suicide are at increased risk for needing psychiatric care.
• Offspring who lose a parent to suicide are at increased risk for depression.
• Across a range of kinships groups, people bereaved by suicide experience more shame and rejection than do people bereaved by other violent deaths.

The findings are especially valuable because comparisons were made between people bereaved by suicide and other bereaved people (instead of to non-bereaved people), which pinpoints "the specific effects of suicide."

The study observes that "at present, support services after suicide bereavement are concentrated in the voluntary sector" even as suicide risk, depression, and other negative effects of suicide loss might be relieved by professional services:

Policy makers will need to strengthen the responses of health and social care services to [the suicide bereaved] if they are to mitigate the clear risks of suicide and depression. Such efforts can minimise distress, improve productivity, and contain costs of health-care treatment.

In today's society, "the clear risks" of significant distress and even debilitation or death from losing a significant person in one's life to suicide are largely overlooked. This study supports the need for community caregiving systems to respond effectively to the damage done by suicide to those left behind to mourn the dead.

MARCH NEWSLETTER FEATURE

People involved in suicide prevention and suicide grief support hear a lot about "reducing stigma." In an online course I just finished creating for the National Center for Death Education, I write:

Suicide stigma continues to be a powerful and active force that is woven into the fabric of our communal interactions. Stigma affects people who think about suicide, who attempt it, who die from it, and who are left behind to mourn the dead ... Research shows that stigma negatively affects [survivors of suicide loss's] tendency to seek help, their social connections, and their sense of isolation ... SOSLs consistently report that people often do not know what to do or say to acknowledge or support their mourning, which suggests that suicide stigma continues to influence people's beliefs and behavior.

We also know from research that direct contact with people who are stigmatized reduces negative stereotypes. This indicates how powerful Mike Purcell's "Putting a Face on Suicide" project might be, for PAFOS provides the next closest experience to "direct contact" with people affected by suicide stigma. The project shares thousands of pictures in a simple format that is breathtaking in how it captures the beauty and diversity of people who die by suicide and heartbreaking in how starkly it portrays the tragedy of suicide.

The simple format is a plain frame containing each person's picture, name, and age. The pictures are broadcast one suicide victim after another in a seemingly unending stream on the PAFOS Facebook page. The pictures of each unique -- and very alive -- human being connect us all to one another, hopefully in a way that weakens the influence of suicide stigma.

Here are instructions for submitting information about a loved one for inclusion in "Putting a Face on Suicide."

Subscribe to the Grief After Suicide Newsletter.

When I summarized a handful of reflections various representatives of the Christian faith offered about suicide in the wake of the suicide of the son of mega-church pastor Rick Warren, I found great hope in the compassion and understanding that was universally expressed by the commentators I quoted.

So I noted with interest an op-ed in the Houston Chronicle by a leading suicide researcher, Thomas Ellis, who commented on Warren's first sermon after his son's death four months ago. Ellis writes,

[Warren] resisted the urge to explain the unexplainable and instead delivered a sermon with a passionate call to action. His emphatic message was that neither suicide nor mental illness should be cause for shame; and he committed to his global audience to use his public ministry to eradicate the stigma associated with mental illness.

As I wrote in my last post regarding the recently released DSM-V revision eliminating the bereavement exclusion for depression, "this dialogue and debate will be ongoing." Hopefully, the discussion will be constructive and solution-oriented, and I'd like to contribute to it -- in that spirit -- whenever possible, so I am responding to the invitation of Donna Schuurman, Executive Director of the Dougy Center, to share "When Does a Broken Heart Become a Mental Disorder?" with readers of the Grief after Suicide blog.

The document, created only a week ago by an ad hoc group at a meeting of the International Work Group on Death, Dying and Bereavement, protests what Schuurman calls (in her comments to the American Association of Suicidology listserv, where she posted it) "the trend to pathologize grief" by outlining the three main points in the argument against eliminating the bereavement exclusion (namely, grief is not depression; antidepressants are already overprescribed; and most antidepressants are prescribed by primary care practitioners who, it is feared, will misprescribe them to bereaved people).

Below is an excerpt from my response to Donna on the AAS listserv, which summarizes both the argument in favor of the exclusion and my point of view about the matter, lists a couple of resources I have found to be helpful, and takes a run at framing the debate in the larger context of what I allude to as problems related to the "DSM 'industry'":

A recent study published in the British Journal of Psychiatry on the views of people bereaved by suicide regarding news coverage of a suicide fatality found that currently available media guidelines for appropriate coverage of a suicide may not adequately take into account the needs of survivors of suicide loss.

[There is] a tension, and a difference of emphasis, between guidance for the press based on strategies to prevent copycat suicides (especially avoidance of certain details) and the perspectives of bereaved people (who feel they have a right to expect sympathetic and accurate reporting). There is a tension between a guideline that suggests that certain information should be withheld/not disclosed and a perspective that favours (in reports of an individual case) an accurate account, which may include such information (such as an image of the person who died).

At issue is the fact that ...

... systematic reviews of the literature have concluded that suicide rates may rise after media reports of suicide, especially if the dead person was a celebrity, if the report glamorises the suicide, if reporting is prominent, or if the method of suicide is discussed in detail.

Of course, those findings have influenced the media guidelines issued by suicide prevention proponents (see the U.S. guidelines), and the importance of preventing copycat suicide is paramount; but the bereaved's concerns about news reports of suicide also ought to be taken into account. The study of survivors showed that some want to share their story through news reports but others do not, so it would be helpful to have information and assistance readily available to the newly bereaved -- including how to take care of their own needs and what impact news coverage has on suicidal behavior -- so they can make make informed decisions about talking with the media.

Frank Dumont is a type of survivor of suicide loss that people who work in suicide bereavement call a clinician survivor,* which is a caregiver who has been affected by the death of a patient's suicide. Dumont is an internal medicine specialist in Colorado, and according to a recent NPR story, the suicide of a patient he had been treating left Dumont "stunned, and guilt-ridden."

On what turned out to be the patient's last visit to the doctor's office, the man gave Dumont a gift:

"What in hindsight struck me about that visit is that he brought me a gift, which was a geological survey marker from the top of Longs Peak ... And what I didn't realize at the time was that that was, I think, a farewell gift, or a bit of a parting gift, from him. Because I did not see him again. And the next that I had heard of him was from an emergency phone call from his wife about a month later, and she called needing to be seen. ... She had to come in and talk to me [about] how to deal with the fact that her husband had committed suicide."

Dumont's patient was being treated for depression, and he shot himself with a rifle; and the doctor regrets not asking the man if he had guns in his home:

Dumont says he thinks more physicians would talk with their patients about guns if they got information about health risks associated with them.

BJ Ayers has lost two sons to firearm suicide, yet she knows that -- living in Cheyenne, Wyo., famous for its frontier culture -- addressing the role of guns in suicide can be challenging. In another NPR story, Ayers said,

"It's not that we want to take the gun away from the gun owner. We know that we have responsible gun owners in Wyoming. It's, you know, Wyoming is a gun state. We're rich in that history."