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."

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."

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 ...

By Franklin Cook

In introducing "Suicide Loss First Aid: How Police Officers Can Assist Suicide Survivors" in The Police Chief magazine, Tony Salvatore of Montgomery County Emergency Service in Norristown, Penn., points out that more than three-fourths of suicides documented in a 2011 report "occurred in or near the victim's residence." He concludes:

This means that most suicide victims are found by family members or may have had family members who witnessed the death. Relating to those who were close to the victim of a suicide may be one of the most challenging duties that any officer faces, yet few officers receive any training for this task.

The article focuses on the knowledge and skills necessary for law enforcement officers to respond effectively to a scene, covering topics such as the immediate needs of suicide loss survivors, principles of basic suicide postvention (support in the aftermath of a suicide), and a number of other vital considerations.

Salvatore has been writing about the role of first responders in supporting the suicide bereaved for some time (see my 2010 blog post highlighting his work, bit.ly/suicideems), and I hope that the recent publication of national guidelines for effective response to a suicide fatality sparks interest in formal efforts to further develop protocols for first responders. Salvatore has documented the dire need for such protocols, and there are models available that may provide a starting place, such as a guide developed in Canada and guidelines from a police department in England.

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 five-minute video below, Ken Norton goes a long way toward de-mystifying a difficult term, postvention, that is used exclusively in the suicide prevention world: It is a term that is somewhat confusing to everyone. Ken is one of the founders of the Connect program (see Connect's Postvention Training), and he is now the Executive Director of NAMI New Hampshire.

Another helpful explanation of postvention is included in "Responding to Grief, Trauma, and Distress After a Suicide: National Guidelines." The guidelines will be released in mid-April by the Survivors of Suicide Loss Task Force of the National Action Alliance for Suicide Prevention, and there will be a number of future blog posts about them. Here is a draft version of the explanation being developed for the guidelines:

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• "Like" the Grief After Suicide Facebook page .
• Sign up for the Grief After Suicide newsletter.

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.

How do we piece together the next thing and the next thing after that? The only answer that makes sense to me is, one thing leads to another -- and becomes purposeful if we pay attention.

Yesterday, I encountered an announcement for the Seattle premiere of a documentary, Four Sisters. The four sisters featured in the film are all survivors of the suicide of their brothers. The sisters are pictured above in photographs by filmmaker Caley Cook, from left, Lauren Greenberg, Maria Rivera, Laurie Cook-Heffron, and Laura Habedank. (Each sister introduces herself in a clip from the film, available on the Four Sisters home page.)

I highly recommend the film, for it is a beautiful example of how one survivor's loss (Caley Cook's brother died of suicide) reverberates outward and helps other survivors grapple with the broken pieces of meaning we are all trying to fit together. But this blog post is not about the film: It is about going where you're led -- and paying attention.

In the announcement for the film premiere, Forefront Cares is listed as the host of the event. Forefront Cares is the bereavement support program of Forefront, a statewide initiative at the University of Washington whose "goal is to lead other states in innovative approaches to suicide prevention." Forefront is, in part, the brainchild of a colleague and friend of mine, Sue Eastgard.

One thing leads to another.

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.

"Survivor Outlook" shares the words of survivors of suicide loss whose experiences with grief and recovery have been reported in the news. To learn more about the survivors quoted, follow the links to the complete stories. Also, learn how to suggest a story.

"I have to believe the state of depression ... is so dark and gloomy and like a tunnel vision that they really don't think or see beyond that. They don't see the pain they'll be inflicting." Janine Harris, Sioux Falls, SD, lost her 20-year-old daughter, Nicole, to suicide in 2005.

"That's the terrible thing about suicide, is there's no closure." Marie Osmond, Provo, UT, lost her 18-year-old son, Michael, to suicide in 2010.

"All I remember of her is in a soft blue dress, sealed away in a stiff coffin. Her absence has marked my life ever since -- from the comforting of my cousin in the missingness of her mother to the haunting images of her death." Leslie Lamb, who blogs at lesliealamb.com, lost her aunt (who was pregnant when she died) to suicide when Leslie was four years old.

"There was nothing I wouldn't have done or given to see you happy and at peace ... Your presence is very, very missed. Every day something happens where you should be there, and you're not." Cherrie Cran, at a support group meeting in Brisbane, Australia, speaking as if to her son Bede, who died by suicide at age 19.

"You're left with so many questions, the whys and the hows, and why didn't he call me?" Danna McGill, Washington state, lost her best friend to suicide in 2008.