1. GRIEF AFTER SUICIDE: The Journey of Survivors
John R. Jordan, Ph.D.
Pawtucket, RI

2. Overview Introduction Suicide “101” Common Myths About Grief
How Is Grief After Suicide Different?
How Can I Survive?
Wrap-up

3. John R. Jordan, Ph.D. - The Family Loss Project
Suicide Epidemiology
Males Complete Suicide at a Rate 4 Times That Of Females
Highest Suicide Rates Are Generally for Elderly, Isolated Males
Highest # Suicide Completions Are for Middle-aged Males
Ethnicity
In both U.S. & Canada, highest rates by far are for Indigenous Peoples
90% Have Diagnosable Psychiatric Disorder - Most Often Mood Disorders
Suicide as a public health problem
Traditionally, suicide seen as a deranged act by a distraught or deviant individual, possibly from a dysfunctional family
1999 – Satcher declared suicide a public health issue, issued a call to action
2001 – National plan for suicide prevention
WHO Report
30-31K a year
Underestimate – at least 20%, perhaps by 100%
18-19K homicides
More people die of suicide worldwide than die of war, & homicide combined, and about the same number as die of AIDS
Until recently, the 8th or 9th leading cause of death (now 11th)
Third leading cause of death of y.o.

4. John R. Jordan, Ph.D. - The Family Loss Project
Suicide Epidemiology
Suicide Is A Public Health Problem
About 38,000 Completions/ Year in U.S
700,000 – 1,000,000 Attempts/ Year in U.S.
20-25 attempts for every completion
Worldwide - Nearly 1 Million Completions/ Year, 20 Million Attempts/ Year
10th Leading Cause Of Death in U.S., 3rd For Young People (15-24)
Suicide as a public health problem
Traditionally, suicide seen as a deranged act by a distraught or deviant individual, possibly from a dysfunctional family
1999 – Satcher declared suicide a public health issue, issued a call to action
2001 – National plan for suicide prevention
WHO Report
30-31K a year
Underestimate – at least 20%, perhaps by 100%
18-19K homicides
More people die of suicide worldwide than die of war, & homicide combined, and about the same number as die of AIDS
Until recently, the 8th or 9th leading cause of death (now 11th)
Third leading cause of death of y.o.

5. Suicide Etiology: Suicide as the “Perfect Storm”
John R. Jordan, Ph.D. - The Family Loss Project
Suicide Etiology: Suicide as the “Perfect Storm”
Genetic Factors
Biological Factors
Low neurotransmitters
Certain medical disorders
Epilepsy
TBI
Personality
Past Experience
Trauma
“Perfect Storm” – the coming together of multiple factors in just the “right” (or wrong”) for suicide to occur
Genetic – impulsivity
Biological – lowered serotonin
Personality – BPD or impulsivity or poor stress tolerance or affect regulation (Linehan’s model)
Past Experience – trauma & abuse, family conflict – PREVIOUS ATTEMPTS
Life Stressors – interpersonal loss, broadly defined & loss of status/failure
Interpersonal connectedness – social isolation
Joiner’s “lack of belongingness”
Social issues – being gay
Opportunity – having a firearm in the house
Practice with overcoming survival instinct – Joiner’s theory

6. Suicide Etiology: Suicide as the “Perfect Storm”
John R. Jordan, Ph.D. - The Family Loss Project
Suicide Etiology: Suicide as the “Perfect Storm”
Life Stressors
Interpersonal loss (particularly suicide)
Role status loss
Interpersonal Connectedness
Social Issues
Opportunity/ Access to Means
“Perfect Storm” – the coming together of multiple factors in just the “right” (or wrong”) for suicide to occur
Genetic – impulsivity
Biological – lowered serotonin
Personality – BPD or impulsivity or poor stress tolerance or affect regulation (Linehan’s model)
Past Experience – trauma & abuse, family conflict – PREVIOUS ATTEMPTS
Life Stressors – interpersonal loss, broadly defined & loss of status/failure
Interpersonal connectedness – social isolation
Joiner’s “lack of belongingness”
Social issues – being gay
Opportunity – having a firearm in the house
Practice with overcoming survival instinct – Joiner’s theory

7. Common Myths About Grief
Myth: Grief Happens In Stages
Instead, grief is cyclical or wave-like
Myth: Grief Is The Same For Everyone (Men, Women, Adults, Children)
Instead, grief is very individual

8. Common Myths About Grief
Myth: Time Heals All Wounds - It Should Take About a Year
Instead, different aspects of grief take different amounts of time
There are significant individual differences
What matters is the direction of the trend, not the time it takes
Myth: Time Heals All Wounds – Just Wait It Out
Instead, grief involves active self-care
Grief involves acquisition of new skills of caring for yourself after emotional injury

9. Common Myths About Grief
Myth: Grief Involves Saying Good-Bye and Achieving “Resolution” of Your Grief
Instead, we keep continuing bonds with our dead
“Your task is not to let go, it is to find a different way to hold on”
Goal = learning to “carry the boulder”, not “put it down”

10. HOW IS GRIEF AFTER SUICIDE DIFFERENT?

11. Prominent Themes For Survivors
John R. Jordan, Ph.D. - The Family Loss Project
Prominent Themes For Survivors
WHY? - Making Sense of the Death
RESPONSIBILITY - Guilt & Blame
SOCIAL DISRUPTION - Isolation
SHAME - Stigma
ANGER - Rejection & Abandonment
In traumatic, “unnatural” death, a need to construct an explanation of:
Causality
Responsibility
Why – making sense
Assumptions violated by suicide
Life wants to live
I know this person
E.g. – Wright – what would it mean if it was suicide “I didn’t know my child”
I can ease their pain
They won’t hurt or leave me
Love is enough to keep them here
Strong need to construct a narrative that makes sense of the death
Is suicide voluntary – how do we assign responsibility?
Sins of commission and omission
Our own motivation towards the deceased
May be anger, a wish to be rid of the person
Why didn’t I prevent it?
Social disruption and Shame
Hx. of stigma associated with psychiatric disorder & suicide
Evidence that survivors are judged more negatively
Range studies of newspaper obituaries, only change is cause of death
Asked to rate the parents – more distressed, guiltier, and more blame-worthy
Self-stigmatization
Social awkwardness – “what is the right thing to say to a survivor”
Anger
Suicide as “self-murder”
Conundrum of perpetrator is the victim
Anger at:
Abandonment
Rejection (suicide as a hostile act, meant to hurt or punish) –
Mary’s patient – their mother called ex-husband on Christmas Day – “This is a gift for all you’ve done to me”, shot herself on the phone
Woman whose husband suicided after affair
Being left with the physical and emotional “mess” 11 11

12. Prominent Themes For Survivors
John R. Jordan, Ph.D. - The Family Loss Project
Prominent Themes For Survivors
TRAUMA - Shock & Horror
RELIEF - The End Of Suffering
SUICIDALITY – Why Go On?
SORROW – Grief & Yearning
Trauma
Witness the suicide or find the body – “What was it like? How did he look?
Imaginal PTSD
Empathic suffering – “what did they suffer?” “did they change their mind? – B. Epstein”
Relief
Woman who daughter suicided
Natural to feel relief at the end of suffering
Suicidality
Will this happen again? – Happens with any trauma
Will it happen to me?
Sorrow 12 12

13. Prominent Themes For Survivors: Family Impact
Information management – who to tell, and what
Communication shut-down
Trying not to upset others
Anger/ conflict management
Disruption of family routines/rituals
Loss of cohesion
Information management – who to tell, and what
Powerful impact of secrets, from certain members of the family, and from the family to the outside world
Communication shut-down
Trying not to upset others, re-open the wound
Anger/ conflict management
Differences in grieving styles
Loss of cohesion
Intense grief is very isolating – each person withdraws into themselves, the other becomes a “stranger”, as everyone tries to deal with this novel experience
Blame/scapegoating
Anxiety about it happening again (esp. for parents) – problems with separations – “Are we cursed?”

14. Prominent Themes For Survivors: Family Impact
Coping Asynchrony - Differences in grieving styles & change in availability
Blame/scapegoating
Anxiety about it happening again (esp. for parents) – problems with separations – “Are we cursed?”
Information management – who to tell, and what
Powerful impact of secrets, from certain members of the family, and from the family to the outside world
Communication shut-down
Trying not to upset others, re-open the wound
Anger/ conflict management
Differences in grieving styles
Loss of cohesion
Intense grief is very isolating – each person withdraws into themselves, the other becomes a “stranger”, as everyone tries to deal with this novel experience
Blame/scapegoating
Anxiety about it happening again (esp. for parents) – problems with separations – “Are we cursed?”
Need to construct a shared narrative

15. Post-Traumatic Growth After Suicide
John R. Jordan, Ph.D. - The Family Loss Project
Post-Traumatic Growth After Suicide
Changed identity
Changed relations with others
Changed outlook on life
Growth 15 15

16. HOW CAN I SURVIVE? Self- Care Educate Yourself Lower Your Expectations
Body
Mind
Spirit
Educate Yourself
About suicide
About grief
About trauma
Lower Your Expectations
“One day at a time”
Be With People Who “Get-It”, Avoid Those Who Don’t
Be wary of “know - it - alls”
Be wary of “know – nothings”
Be with people who walk along with you

17. How Can I Survive? Trial & Error Healing
Expect coping differences - Go outside the family
Multiple pathways towards healing
Learn to “dose” your grief
Try familiarity – re-establish routines
Try novelty – try something new
“Don’t Waste Your Grief” - Engage in activities that:
Honor the life of your loved one
Keep their memory alive
Give a purpose and focus to your grief
Be Patient
Have Faith in Your Resilience!

18. When to Seek Professional Help
The trend of your grief is more important than the speed
Up is “green”
Flat is “yellow”
Down is “red”
When coping methods are self or other-destructive
Particularly, suicidality
PTSD symptoms
Intrusive re-living
Avoidance (getting worse)
Physically “wired” or “emotional numbness”

19. When to Seek Professional Help
Prolonged Grief Disorder
Unending grief/ yearning
Trouble re-investing in life
Loss of meaning/purpose
Prolonged difficulty with acceptance of the reality
Severe depression
Anhedonia (inability to feel pleasure) is getting worse
Sleep, appetite, energy staying dysregulated
Loss of functionality
Active suicidality
Others are consistently saying “Please get some help”

20. Types of Help for Survivors
John R. Jordan, Ph.D. - The Family Loss Project
Types of Help for Survivors
Survivor outreach programs
Survivor to Survivor Network
Samaritans –
Individual therapy
Family/Couples counseling
Support groups
SafePlace groups
Activism
Survivor Outreach Programs
Professional and peer to peer teams
On scene – LOSS Team – Campbell, 2011
Survivor initiated follow-up – AFSP, Samaritans/ Boston
“Survivor buddies” – 1 on 1 (in person or on the internet)
Ombudsman/ advocate – StandBy (Australia) – UnitedSynergies, 2009, 2011
Family/Couples counseling
Psychoeducation about:
Suicide
Trauma
Grief after suicide
Reduce blame, guilt, incidence of CG
Improve communication & information exchange
Foster creation of a shared narrative
Facilitate mutual bereavement support & caretaking
Support Groups
Provide emotional support and normalization, reduce isolation, facilitate exchange of coping strategies
Most are open format, peer led (rather than closed format and professionally led)
Large study of survivor parents, mostly in support groups (Feigelman, Jordan, McIntosh, Feigelman, 2012)
Other forms of survivor contact
AFSP – International Survivors of Suicide Day (Saturday before Thanksgiving –
AAS – Annual Healing After Suicide Conference (
Fund-raising walks
Activism
Peer to peer support
Fund-raising
Political advocacy

21. HOW CAN FRIENDS, FAMILIES, AND COMMUNITIES HELP?

22. How Can Friends, Families, & Communities Help?
When in Doubt, Reach Out!
Offer the “Gift of Presence”
Don’t assume you know what this means
“Don’t say too much”
Offer Assistance
Practical help
Help find resources
Stay in for the long haul
Keep in touch – be available, but not intrusive
Keep asking “How is this for you?
Remember anniversaries

23. How Can Friends, Families, & Communities Help?
Education of first responders
Education of clinicians
Support development of community resources
Information for new survivors
Outreach teams
Linkages between survivors
Eg., AFSP National Survivor Day Conference
Opportunities for activism
Eg., Community Suicide Prevention Council
Support groups

24. Wrap-Up
Questions?
Comments?

25. 3 WISHES – Over Time, That You Will Be Able To:
Make Your Peace With the Suicide
Remember and Honor the Life of Your Loved One
Find Courage, Strength, & Serenity as You Go Forward