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PARADOX REQUIRES CAREFUL SCRUTINY OF HELP FOR SUICIDE BEREAVED

5/18/2015

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Illuminated candles in rows
By Franklin Cook

A recent blog post on Grief After Suicide argues (convincingly, I hope) that suicide bereavement is unique because suicide itself is a unique way to die. Yet, at the same time, an abundance of research -- not to mention the universality of the human experience of grief -- points to a paradox, namely, that all bereavement over the death of a loved one shares a great deal in common. In other words, grief after suicide is, simultaneously, both different than and similar to bereavement following other means of death.

Understanding and accounting for this paradox is important because, as is stated in recently released national guidelines on responding to suicide, created by the Survivors of Suicide Loss Task Force of the National Action Alliance for Suicide Prevention:*
Suicide grief support is an emerging field of practice poised to gain strength from newer understandings of bereavement adaptation in thanatology [the study of death and bereavement].
This emerging field would benefit tremendously from looking more closely at -- and acting more collaboratively with -- the field of grief counseling (as well as other fields, such as traumatology, mental health crisis response, and disaster response). Doing so would enrich and strengthen suicide grief support through the application of evidence-based and promising practices that are already proving to be effective with a variety of bereaved people. Taking this multi-disciplinary approach would prevent responses to suicide grief from evolving based on narrow or monolithic ideas centered primarily around what is unique about suicide bereavement.

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FALLOUT FROM A SUICIDE CAN TOUCH EVERYONE WHO IS EXPOSED

5/12/2015

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By Franklin Cook

The report "Helping All Who Are Exposed: A New View of Suicide Loss"* (available to read or download, below) describes a framework that considers the needs of everyone who might experience negative effects after someone dies by suicide. The framework organizes people that a suicide could have an impact on into four categories:

   • Suicide Exposed: Everyone who has any connection to the deceased or to the death itself, including witnesses
   • Suicide Affected: Those for whom the exposure causes a reaction, which may be mild, moderate or severe, self-limiting or ongoing
   • Suicide Bereaved Short-Term: People who have an attachment bond with the deceased and gradually adapt to the loss over time
   • Suicide Bereaved Long-Term: Those for whom grieving becomes a protracted struggle that includes diminished functioning in important aspects of their life

The graphic above gives a multitude of examples of people who might experience fallout from a suicide, including many whose needs are not accounted for in current outreach efforts. As the report states,
"Determining how a particular individual might be categorized would not be linked to the person's designation, role, or relationship in reference to the deceased. Rather, each person's reaction to the death would determine the category into which he or she would be classified."

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THE VERDICT IS IN: SUICIDE CAUSES COLLATERAL DAMAGE

5/6/2015

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Line Drawing of Jury

By Franklin Cook

A recent summary report,* "Impact of Suicide on People Exposed to a Fatality," raises an alarm about negative effects some people bereaved by suicide suffer from their loss that go beyond their experience of grief. The report is available, below, to read or download. It delineates research evidence that substantiates two troubling facts:

First, that the bereaved are at a higher risk for suicide:
"Clear and overwhelming evidence [shows] that exposure to the suicide of another person, particularly of a close intimate, elevates the risk of ... death by suicide in the population of people exposed."
Second, that the suicide bereaved are at a higher risk for other negative outcomes:
"The elevated risk for suicidality is not the only adverse effect of exposure to suicide. Many studies have also found elevated rates of psychiatric disorders (particularly depression), social difficulties, and continuing grief reactions in the suicide bereaved when compared with other types of loss survivors or population-level norms."
Even though research on the effects of suicide loss is sparse (which will be the subject of a post later in this series), the report concludes that the United States should "move ahead nationally to strengthen programs, services, resources, and systems to help suicide loss survivors and others affected by a fatality."

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SUICIDE GRIEF IS UNIQUE BECAUSE DEATH BY SUICIDE IS UNIQUE

4/26/2015

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By Franklin Cook

Perhaps the word unique is too restrictive in a discussion of universal phenomena such as death or grief, but according to new national guidelines* for responding to suicide, considering such a perspective ...
... opens the door to asking not only "What makes grief after suicide different?" but also "How does the distinctive nature of suicide itself affect the bereavement experience of survivors?"
Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines suggests that death by suicide can raise questions about the deceased's volition and whether the death was preventable as well as about the role of stigma and of trauma in the death. The emotional reactions of loss survivors to a particular suicide, the argument goes, can be shaped by how each person experiences the death along the continua of it being willfull or not, preventable or not, stigmatized or not, and traumatic or not.

This idea is one of several fresh perspectives offered in the guidelines, which were created by the Survivors of Suicide Loss Task Force of the National Action Alliance for Suicide Prevention to advance a vision for reinventing postvention in America and creating ...

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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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STUDY LINKS SUICIDE LOSS TO DEPRESSION, SUICIDE RISK AMONG BEREAVED

5/2/2014

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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.
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SURVEY: SUICIDE BEREAVED MEN NEED HELP -- AND ARE WILLING TO HELP

4/19/2014

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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.
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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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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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FJC ON THE ROAD: PERSONAL STORY SHOWS NEED TO STUDY BEREAVED MEN

11/17/2013

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Until mid-December, I'll be writing "FJC On The Road" posts to keep readers up-to-date on my travels and on my reflections about suicide bereavement. This post -- originally written for the American Association of Suicidology's "Newslink" -- announces this important survey for men who are bereaved by suicide. FJC

What do we know about the needs of men who are bereaved by suicide, and -- if, in fact, male survivors of suicide loss do have unique needs -- what is being done to meet those needs? The answer to the first question is that we know very little specifically about men's needs after they experience a loss to suicide (beyond what we know generally about grief after suicide, about the differences between men's and women's psychological make-up, and about their different styles of communication and help-seeking). The answer to the second question is that almost nothing is being done to meet the special needs of men who have lost a loved one to suicide.

Here is a personal story -- not about grief specifically but about "sharing emotions" -- that illustrates why it is important to find answers to these questions.

The first experience I had that marked me as a man in therapy (as opposed to a woman in therapy) was in early 1982 in an aftercare support group in Twin Falls, Idaho, which was designed to help people who had completed inpatient treatment for addiction make a successful transition back to the community after spending a month in an institution.


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