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)

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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.

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.

A recent survey of men bereaved by suicide suggests that:

• Suicide bereavement is profound and sustained for the majority of men, with 30% reporting that grief remained a constant difficulty in their lives one to three years after their loss and another 30% saying that it was a constant difficulty for longer than three years.
• Men generally believe friends, family, and peers (others who have experienced a loss to suicide) are the most helpful.
• Peer assistance and one-on-one help are especially valued by men, who also say they rely on information from the Internet for assistance.
• Most men believe men and women grieve differently, and plenty of men fit the stereotypes commonly associated with men's handling of emotional matters.
• Many men, on the other hand, believe that stereotypes get in the way of healthy grieving and that societal influences hamper men's grieving.
• Many also see bereavement as very individualistic, reporting that they are as emotionally expressive about their grief as women are.
• Men are interested in being peer helpers for other bereaved men, especially if they are far enough along in their own grief and are trained and supported.

This last finding -- that many men are willing to help each other with grief after suicide -- is of utmost importance, for men themselves likely hold the keys to their own recovery.

Unified Community Solutions (my private consultancy) and the Carson J Spencer Foundation (Sally Spencer-Thomas's nonprofit organization) distributed the survey to help us explore developing more-effective programs and resources for suicide bereaved men. We are hopeful that by this summer, we'll have an idea about how we might begin making new inroads into supporting men bereaved by suicide.

Please see the copy of the slides from the presentation on the survey that Sally and I (and Rick Mogil, who directs suicide grief programs for the Didi Hirsch Community Mental Health Center) delivered at the American Association of Suicidology conference in Los Angeles last Saturday.

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.

I'm not going to be a spoiler for Jennifer White's inspiring closing line in her post about founding the Hope After Project in memory of her mother, who died by suicide in 2011: Please go to her post yourself and read it from top to bottom. Her story is as heartwarming as they come:

I had connected to what was good in [my Mom] and it produced something good in me. I had looked at the chipped paint and dirty walls and dedicated myself to making that school a better place for kids to learn. In that moment I forgot my pain for a minute. I thought about my friend who was with me and realized I had seen a lightness in her, too. By volunteering together we had found hope after our loss. In that moment [the] Hope After Project was born.

When it comes to ideas about grief and healing, the Hope After Project is brilliant. If you've got two minutes, let this creative, innovative young woman tell you about it herself:

I could begin everything I write about grief after suicide with this: "Everybody's journey is different. Each of us is trying to find our own way to carry our grief." (To carry our grief: I'm holding on to that idea.)

A post from Anne Thorn of Cornwall, England -- "Will I Ever Get Over the Guilt?" -- reminded me of the singular path that each of us follows, and I am thankful to her for describing a part of her journey. In brief, three things helped her reconcile her feelings of guilt after her son, Toby, died by suicide: (1) something the author of this little booklet wrote on the topic (see pp. 16-20), (2) this handout from LaRita Archibald, and (3) this advice from her physician:

When I went to my GP and I told him that I would have found it easier to cope with losing Toby if he had died of an illness ... he said to me "Your son did die of an illness, it was called depression."

Now, I might have thought (and you might think, as well), "if those three things helped her deal with her feelings of guilt, maybe they'll help me," which is an altogether reasonable -- and very hopeful -- assumption. In fact, for me, the awareness that my father died from the disease of depression was extraordinarily helpful in coping with my feelings of guilt.

However, when I go to the contents of the booklet and the handout, I find some ideas that do not line up -- for me -- with what is helpful regarding guilt. The booklet gives a prescription (tells me what to do, exactly) that I dont agree with, and the handout makes a bold statement about personal responsibility that I half agree with but half don't.

Even so, those items were obviously helpful to Anne (for she is recommending them to others). Would I recommend them to others? Absolutely, yes I would.

Why? Because if one survivor found them helpful, another might also find them helpful. The booklet was was written for the American Association of Suicidology by Jeffrey Jackson, who is a survivor of suicide loss, and the handout's author, LaRita Archibald, is a survivor and a leading expert in the field. Most of all, I would recommend them because, to come full circle, "Everybody's journey is different."

Nobody's way of grieving is right or wrong. Survivors who share what has been helpful to them, like Anne and Jeffrey and LaRita, are offering an invitation, as 12-Step groups say, to "take what you want and leave the rest." We are strengthened by our diversity -- by our sharing and our conversations about our differences -- as well as by our awareness of all that we have in common.

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.

Debra Leibowitz has been writing her Miami Herald "Beach Buzz" column for 15 years, keeping folks up-to-date on community miscellany, everything from new stores in town to good deeds done by the citizenry. It's not front-page news, but it's the first thing people read to find out what's going on in the neighborhood.

Leibowitz's perennially upbeat column this week took a tragic turn:

As many of you know, on Dec. 10, my boyfriend, Richard Sharpstein, a well-respected criminal attorney -- and longtime Miami Beach resident -- died as the result of suicide. He was 63.

It is remarkable to me that, even as condolences are finding their way to her -- at a time when, in her words, she has "been paralyzed from grief" -- Leibowitz found the strength to deliver her column and to share her private sorrow with the world. She tells their story ("as fate would have it, we fell in love, almost immediately") and describes her pain ("I am angry he is not here and that he took away a big part of my life -- and future -- without asking"). Then she says something that, to me, is pretty amazing -- and which serves as a wonderful example of a bereaved person saying what she needs.

Here are a few highlights:

• Take a walk with me or invite me to play tennis or attend an event.
• Accept the fact that I cry a lot. I can't help it. I am sad and so many things remind me of Richard.
• Allow me to feel sorry for myself, but not too sorry.
• Don't ask me if I "feel better." I don't have the flu that runs its course in two weeks.
• Be patient with me and keep reaching out, even if I don't reply right away.

I have told many a survivor that it is not our job to "train" people how to be helpful to us, but maybe I should rethink that, for Leibowitz's advice from the heart is a powerful reply to the request the newly bereaved so often hear: "Let me know what I can do ..."

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.

The following is from a transcript of the Open to Hope Radio program on Aug. 22, 2013, featuring an interview by OTH hosts Dr. Gloria Horsley and Dr. Heidi Horsley with Franklin Cook, publisher of the Grief after Suicide blog (you can listen to the interview here):

Heidi Horsely: Franklin is our friend. He's also somebody that we work with, and our worlds just keep crossing, and we keep connecting. His father died by suicide in 1978. Franklin is a consultant, speaker, and trainer in peer grief support. After volunteering as a support group facilitator, he became an advisor to the Suicide Prevention Action Network and National Suicide Prevention Lifeline, and he is now developing suicide survivor services based on life coaching principles. He is also one of our Open to Hope authors. Welcome to the show Franklin.

Franklin Cook: Thanks so much for having me. It's so good to be with you both.

Gloria Horsely: Franklin, tell us about your journey. Tell us about your dad dying and how old you were, and that kind of thing, to start.

FC: My dad died a long time ago now, in 1978. He was 49 years old, and I was 24 years old. Unfortunately, he suffered a very, very severe depressive episode, which included psychotic features and suicidality, and he wound up finally being hospitalized. In fact, my dad died in a psychiatric hospital. So that's how our journey began. My mom, and I have three brothers, and it truly changed our lives -- shattered our lives at first -- and we can take that anywhere you'd like to go with it.