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GROUNDBREAKING GUIDELINES ADDRESS GRIEF, TRAUMA, DISTRESS OF SUICIDE LOSS

4/20/2015

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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.
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WHAT EXISTS IN THE GAP BETWEEN 'FEELING' GUILTY AND 'BEING' GUILTY?

5/14/2014

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In the latest post on her Speaking of Suicide blog, Stacey Freedenthal calls the self-blame experienced by survivors of suicide loss "raw, painful, even toxic" and says "it does not have to be so" -- suggesting that the suicide bereaved "can replace condemnation with compassion."

First of all, I pretty much agree with what she says about compassion. And I recommend Stacey's post to any survivor who has struggled with self-blame, for it offers a number of ideas (I had never heard of "hindsight bias") and practical suggestions (including a list of questions to consider asking yourself) that might be helpful.

But reading it also made me wonder: Is intense guilt (or self-blame) "bad" for a person? Does it need to be "fixed"?

I'm not talking about the toxic version of feeling guilty: If a person experiences such a feeling so intensely or so unendingly that he or she is debilitated by it, then of course, it must be ameliorated even if it requires professional help.

But there is something normal and perhaps even necessary about feeling guilty (I'm not saying normal and necessary for everyone, for some survivors do not struggle with guilt). In many instances, however, I believe feeling guilty provides a starting place for figuring out one's true relationship to what happened. Again, please don't misunderstand: "feeling" guilty and "being" guilty are two different things, and that's really my point.

Perhaps people's struggle to reconcile the difference between what they feel and what they are actually responsible for is an important struggle for them to experience. They certainly need the support of others to help them bear their pain, but I don't think they benefit from people trying to talk them out of feeling guilty or explaining it away (people who are trying to help the bereaved sometimes do the latter because they, the helpers, can't bear to witness such pain, but that's another topic).

Perhaps the question isn't even, "Am I guilty or not?" or "Am I to blame or not?" The question might be more like, "What forces and facts exist in the gap between how I feel and what actually happened?" There are probably a hundred versions of that question -- and as many answers as there are survivors of suicide loss, for each person's experience is unique -- but people must ask their own version of the question and answer it in their own way, so they can discover and give voice to their own reality.
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DEATH MIDWIFE PROBES REGRET, SADNESS IN REFLECTION ON BROTHER'S SUICIDE

3/27/2014

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When I saw the title "A Death Midwife's Perspective on Suicide" I did not suspect the post was by someone whose brother had died by suicide only a month before she wrote it, but so it was:
My brother, my best friend in life ... lost his battle with bipolar on February 25th ... My brother was also my hero, and we loved to rib each other. I miss him so much every day.
I was reminded, as I read, how much we who have lost a loved one to suicide have in common, regardless of who we are (or who we think we are); and I am grateful to the author, Rowan MistWalker --
a professional tarot and oracle diviner ... [who] from time to time, when Spirit wishes ... serve[s] as a medium, helping others connect with their departed loved ones
-- for reminding me of that.

Her post is a painfully candid review of her interactions with her brother during the final weeks of his life, in which she explains her regrets as eloquently as I've ever heard a survivor of suicide loss explain them:
I wish I had the compassion, the strength, the courage to confront him as he was, day by day, losing the will to live.
That comes from the kind of soul-searching not circumscribed by a person's religious preference, and the remorse and sadness in it breaks my heart. Other people may have the cosmos arranged a bit differently than I do, but if you prick them, do they not bleed? Suicide has shown me the truth of that again and again, both in how it claims its victims with indifference toward "who they are" and in how its aftermath serves as a great and awful equalizer among the bereaved.

Her post includes a picture of Ms. MistWalker's brother, and he looks like a person who would "rib" his sister (and take a good ribbing from her). No doubt he will be missed every day ...
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POWERFUL PERSONAL MOURNING RITUALS MAY BE CLOSE AT HAND

3/15/2014

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A story in this month's Atlantic, "In Grief, Try Personal Rituals," persuades me that there is something everyone should consider doing regarding personal mourning rituals. The story is about research that concludes "there is a specific way many people can, no matter what their circumstances may be, transcend despair and distress" over loss. The "way" is through the use of ritual, but "not your typical rituals":
Many of the rituals reported were not ... public ones ... Rather, they were private rituals. Only 15 percent of the described rituals had a social element (and just 5 percent were religious). By far, most of the rituals people did were personal and performed alone.
These are personal rituals, performed alone, rituals that people devise themselves. The examples offered in the article are quite simple:
• One woman plays a Natalie Cole song and thinks of her departed mother.
• A widower keeps his and his wife's formerly joint appointment at the hairdressers the first Saturday of every month.
• Another woman washes her deceased husband's car every week, just as he used to do (although she does not drive it).

Why are these very straightforward practices so powerful? According to the researchers:
[These] rituals help people overcome grief by counteracting the turbulence and chaos that follows loss. Rituals, which are deliberately-controlled gestures, trigger a very specific feeling in mourners -- the feeling of being in control of their lives. After people did a ritual or wrote about doing one, they were ... less likely to feel "helpless," "powerless," and "out of control."
How can the bereaved practice rituals that are simple, straightforward, private, meaningful, and comforting (even if they are also evocative), and how can others help them do so? Perhaps merely by noticing the natural presence of a practice that is already taking place. In other words, by identifying a meaningful activity that is already happening, a bereaved person could explore (or be encouraged to explore) whether it might serve as a healing ritual.
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O'ROURKE ESSAY IS ARTFUL PRIMER ON THE NATURE OF BEREAVEMENT

3/8/2014

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I don't know where, with barely half an hour's reading, a person might be able to delve more deeply into the nature of grief's complexities and challenges than in Meghan O'Rourke's 2010 New Yorker essay "Good Grief: Is There a Better Way to Be Bereaved?"

Using the ideas and life (and death) of Elizabeth Kubler-Ross as a reference point, O'Rourke tells the story of "the privatization of grief," testifying insightfully to the cost of grief's displacement from the public sphere. In one of many trenchant examples, she recounts a TV scene in which a bereaved person steels herself against her grief at a time when mourning would be "a luxury":
This model represents an American fantasy of muscling through pain by throwing ourselves into work; it is akin to the dream that if only we show ourselves to be creatures of will (staying in shape, eating organic) we will stave off illness forever. The avoidance of death, Kubler-Ross was right to note, is at the heart of this ethic.
O'Rourke's engaging narrative takes us from Freud's misguided role in mourning's demise as a powerful public rite --
Only two years after Emile Durkheim wrote about mourning as an essential social process, Freud's "Mourning and Melancholia" defined it as something fundamentally private and individual. In a stroke, the work of mourning had become internalized.
-- through a sampling of observations from some of the most astute thinkers who chronicled the West losing track of bereavement and of the bereaved. Again, to give just one example, O'Rourke acknowledges the value of George Bonanno's ideas about resilience among the bereaved in general, then comments on his own experience in particular:
He thrived after his own father died, but, as he relates in his book's [The Other Side of Sadness] autobiographical passages, he became preoccupied, many years later, with performing an Eastern mourning ritual for him. The apostle of resilience is still in the grip of loss: it's hard to avoid a sense of discordance.
I do hope this overly brief review of "Good Grief" presents it as the artful primer on bereavement that I believe it is. And, if you've got less than half an hour to spare, please go straight to the end of the essay, where O'Rourke has left us with a gem from Emily Dickinson ("the supreme poet of grief"), which captures the essence of the thing in a mere handful of words: "It feels so old a pain." Indeed.
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GIVING YOURSELF PERMISSION CAN REMEDY SUFFERING 'UNREQUITED GRIEF'

3/5/2014

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Paula McCann, an attorney specializing in elder law, gives us a new and useful term in her recent post "Grief Is Not Selfish!":
Unrequited grief is my term for the grief we carry around inside us that is unprocessed, unanalyzed, suppressed and hidden deep inside us, as if we have a subterranean storage compartment for all our sadness from loss.
Regarding unrequited grief, she advises:
Give yourself permission to feel grief, live in it, swim in it if you want to, but acknowledge it and then start the process of healing from it.
And she wisely observes that claiming permission to grieve is not magical but that people let go of grief "when [they] are ready ... little by little" -- and that grieving is often a lifelong journey:
Yes, sometimes grief becomes a companion for life, but it doesn't take over anymore, it has lost its control or intensity because we acknowledge it and keep living. Maybe we don't laugh as loud, act as carefree, or ever give our hearts away again, but we function, we live, we contribute, we find a way to a reconciled life.
I also want to thank Paula for pointing us to a precious one-line story about grief:
"When my husband was dying, I said: 'Moe, how am I supposed to live without you?' He told me: 'Take the love you have for me and spread it around.'"
Paula blogs at On the Way to Dying: Practical Experience and Insight on Dying in America.
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COUNSELOR TURNS GRIEF ON ITS HEAD AND FINDS IT RIGHT-SIDE-UP

2/7/2014

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Megan Devine (whose partner died by accidental drowning in 2009) has written an insightful post that captures something vital about grief, which I've always known but have found difficult to explain. She got to the bottom of it in five words:
Grief is not a problem.
I suppose we mistake grief for a problem because of the "forces" with which it is integral (grief follows a loved one's death, grief is painful and disorienting and messy and can seem interminable) -- but as Devine points out:
Grief isn't something to be gotten rid of so that we can get back to life. It IS life.
Many of us who work with the bereaved try to explain this in our own way (on my website, I attempt it by quoting Rabbi Earl Grollman), but the idea of simply classifying grief as not a problem gets down to it in a way that I find very helpful.

Bereaved people "don't need solutions," Devine says:
They need support. Support to live what is happening. Support to carry what they are required to carry.
Supporting people in carrying the pain of their loss (I call it "holding a space" for them) honors the experience they are having instead of judging it -- or trying to escape from it ourselves. Devine's admonition -- both to the bereaved and to those who would help them -- is spot-on:
We need to practice being in there with grief, rather than getting out of it.
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WISE PRACTITIONER WEIGHS IN ON 'COMPLICATED GRIEF' DEBATE

2/1/2014

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John Wilson's "The Nature of Complicated Grief" is worthy of a careful reading by anyone interested in Complicated Grief or in the debate over whether grief is (or whether some form of it can be) an illness.

He calls his essay an "attempt to take a balanced view of the arguments for and against diagnosing Complicated Grief," and whether one agrees that his view is balanced, he does an excellent job of summarizing his topic, delving into everything from Holly Prigerson's and Kathyrn Shear's point of view to key ideas from authors featured in a recently published book of scholarly essays on Complicated Grief, which Wilson calls "a seminal collection of writing."

He thoughtfully covers the issue of what constitutes normal grief and grief from a traumatic death and identifies the features proposed to distinguish Complicated Grief from both, namely its intensity, duration, and effect on a person's functioning. He elaborates on this latter feature, which is most interesting to me -- for it is a person's ability to function in life that I rely on to determine if someone I am working with might need more assistance than I am able to offer.

The value of Wilson's essay, in part, is that it shows a clinician -- who is not also a researcher -- trying to grapple with the difficult questions of Complicated Grief (or not) and grief as a malady (or not). To his statement (which is, I believe, a paraphrase of Therese Rando's thinking) "it is the idiosyncratic, complex nature of all grief, normal and complicated, that defines the problem," I would add that the problem also lies in trying to answer such questions in a reductive way, which to me is the crux of the matter.

In the end, he emphasizes a caregiver's point of view with which I strongly agree:
For practitioners, this concept reminds us of the importance of a client-centred approach rather than a reliance on textbooks to tell us what to expect, both in healthy and dysfunctional grief ... Clients are not there to fit into neat theories, they are individuals. We can and should learn about grief by listening closely to their human experience.
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SIMPLE LIST OF "64 THINGS" CAPTURES ESSENTIALS OF GRIEF

10/13/2013

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There are times when a short and simple message delivers insight on a subject better than the most detailed and sophisticated explanation does -- and such is the case with a post on the What's Your Grief? blog, titled "64 Things I Wish Someone Had Told Me About Grief." Litsa Williams, who publishes the blog with Eleanor Haley, has not only identified 64 potentially helpful things to know about grief, she also invites readers to comment on or add to the list, and there is an active discussion unfolding at the end of the post.

Not all of the items on the list would be of value to everyone and not everyone would agree that all of them are "truths" about grief. But I think it's likely worth bereaved people's time to go through the list and judge for themselves what applies to them personally, for doing so affirms that people who grieve have a great deal in common.

As a bonus, some of the items listed are actually hyperlinks that point to additional information on the topic addressed. For instance, "when people offer support, take them up on it" is linked to a post describing a journaling exercise that helps you "map" your support system; and "people will say stupid, hurtful things without even realizing it" leads to a post about what not to say to a bereaved person.


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FREE MANUAL GUIDES DESIGN OF COMPREHENSIVE SUICIDE GRIEF SUPPORT

9/30/2013

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The recently published "Pathways to Purpose & Hope" is a comprehensive manual providing expert guidance, pointing to key resources, and sharing practical examples on how to create a community-based organization to support survivors of suicide loss. And the entire manual -- all 100-plus pages of some of the most practical information available on suicide grief support -- is absolutely free to download.

The manual was created by Friends for Survival, one of the oldest survivor-run organizations in the country focused exclusively on suicide grief support (and which publishes the "Comforting Friends" newsletter). Although the manual was designed for a California audience, 95% of it is applicable to any community anywhere in the country, and anyone interested in developing a broad range of survivor services would be wise to add it to their list of prime references.

It begins with this claim:
Survivors need more than a meeting with a couple of sympathetic souls and a box of tissues These guidelines are based on a program designed by 50 survivors over a period of 30 years to provide multiple services to meet the complex needs of survivors in the aftermath of suicide. This guide offers a detailed discussion of the process for creating and sustaining a suicide bereavement support program that is effective, community based and supported by professional resources in the local area.

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