1. The Role of Religiosity and Spirituality in Responding to Survivors of Suicide Bonnie M. Benson, MEd Bong Joo Hwang, PhD Robert M. Bennett, MSW Todd Gibbs, BA Danielle Finch, BA The Ohio State University Counseling and Consultation Service Big 10 Counseling Centers Conference February 10, 2011 Minneapolis, MN

2. Overview Our own reactions to suicide Rationale for applying religiosity and spirituality to treatment of suicide survivors Religious and spiritual perspectives on suicide Bereavement in suicide survivors Assessment and intervention with survivors Case example Discussion and questions

3. Introduction A note about language Introduction of presenters Our own reactions ▫How do I feel when I learn that someone died by suicide? ▫How do I make sense of death by suicide? ▫How comfortable do I feel helping a client explore religious or spiritual beliefs related to suicide or another means of death?

4. Rationale: College Student Mental Health Suicide 2nd leading cause of death on college campuses High documented rates of suicidal thoughts and attempts on college campus Developmental risk of mental illness Increased number of students on campus with previously diagnosed mental disorders (Suicide Prevention Resource Center, 2004)

5. Rationale: The Big 10 Study: “The Gold Standard” Most comprehensive study of suicide among college students Initiated by University of Illinois in 1983, transferred to University of Chicago in 1986 Recorded deaths of 261 students who completed suicide, 1980-1990, among 12 Big Ten schools Rate of suicide among college students half the rate of general population (7.5/100,000 vs. 15/100,000) (Silverman, Meyer, Sloane, Raffel, & Pratt, 1997)

6. Rationale: Statistics for OSU 2009 ACHA survey of 10,000 randomly selected OSU students; 21.2% response rate ▫19.6% diagnosed with depression ▫4.6% intentionally injured themselves ▫ 6.8% seriously considered suicide ▫1.5% attempted suicide (American College Health Association, 2009)

7. Rationale: OSU Suicide Cases from 9/1/00 to 8/31/10* 1 st year 2 nd year 3 rd year 4 th year Grad /prof Total Male56812536 Female000022 Total56812738 * Provided by the OSU Student Advocacy Center compiled by: Ellen S Grudowski

8. Rationale: Survivors Each suicide leaves at least six, and possibly hundreds of, survivors On college campus, survivors are many, including friends, faculty, and staff of different cultural/religious backgrounds May experience particularly difficult grief process related to religiosity/spirituality Understudied area of suicide research (American Association of Suicidology, 2011)

9. Religious and Spiritual Perspectives on Suicide Buddhism Hinduism Agnosticism Atheism Islam Judaism Christianity

10. Four Noble Truths ▫Suffering ▫Origins of suffering ▫Cessation of suffering ▫The way leading to cessation of suffering Suffering is the result of craving ▫Craving for sensual pleasure ▫Craving for existence ▫Craving for non-existence Religious and Spiritual Perspectives on Suicide: Buddhism (Disayavanish & Disayavanish, 2007)

11. Religious and Spiritual Perspectives on Suicide: Buddhism Skillful vs. Unskillful Acts ▫Suicide as unskillful act ▫Results in rebirth to a lower plane of existence with increased suffering (Disayavanish & Disayavanish, 2007)

12. Religious and Spiritual Perspectives on Suicide: Hinduism Precepts prohibit violence and murder Suicide for selfish reasons ▫“Bad death” ▫Results in karmic debt that negatively affects rebirth (Lakhan, 2008)

13. Religious and Spiritual Perspectives on Suicide Agnosticism ▫Belief that a deity may or may not exist Atheism ▫Complete disbelief in all deities past, present, or future  Higher power is not required to behave ethically and morally  Afterlife is not required to enjoy living or avoid an early death ▫Fundamentalist atheist may identify as a ‘strong atheist’ (Morton, 2011; Lizardi & Gearing, 2010; Robinson, 2010)

14. Religious and Spiritual Perspectives on Suicide: Islam Only one phrase in Qur’an about suicide: “…do not kill yourselves. Surely God is merciful toward you” (Surah 4: 29-30) Prophetic tradition clearly prohibits suicide Those who complete suicide ▫Spend eternity in hell reenacting their death ▫Still regarded as believers but survivors may be stigmatized ▫May be refused burial by cemeteries (Clarke, Oxford Islamic Studies Online, accessed 2011)

15. Religious and Spiritual Perspectives on Suicide: Islam Self-sacrifice for a religious cause is restrained by ethic of caution “Suicidal” military missions perceived as martyrdom rather than suicide (Clarke, 2011; Sarfraz & Castle, 2002)

16. Religious and Spiritual Perspectives on Suicide: Judaism Preservation of human life valued above all else ▫Suicide and non-suicidal self-injury regarded as criminal acts akin to murder ▫Soul of one who completes suicide in state of limbo – soul cannot return to the body nor be let into any soul world Strict believers do not permit post-death rituals or burial (Gearing & Lizardi, 2009; Jacobs, 1995)

17. Religious and Spiritual Perspectives on Suicide: Christianity Bible ▫The word “suicide” does not appear ▫Judas and Saul neither condemned nor praised St. Augustine, 5 th Century CE - suicide a violation of the sixth Commandment St. Thomas Aquinas - suicide one of most dire sins because individual cannot confess or repent the act (Gearing & Lizardi, 2009; Phipps, 1985; Kennedy, 2000)

18. Religious and Spiritual Perspectives on Suicide: Christianity Catechism of the Catholic Church ▫Mental competence is a prerequisite to sin ▫If suicide is a result of mental illness, it cannot be considered a sin ▫Historically refused burial in Catholic cemeteries but rarely practiced currently ▫Funeral rites include prayers for forgiveness and comfort for survivors (Phipps, 1985; Gearing & Lizardi, 2009; Catholic Church, 1994)

19. Bereavement in Suicide Survivors: Unique concerns Guilt, responsibility ▫Foundational beliefs about world ▫Connection to the suicide ▫“Personal psychological autopsy” Shame, stigma, social isolation, family relational disturbance ▫Blaming ▫Secret-keeping, silence ▫Self-stigma (Jordan, 2008)

20. Bereavement in Suicide Survivors: Unique concerns Perceived rejection/abandonment by deceased ▫Causality multiply-determined  Choice  Life situation  Mental illness ▫Anger toward deceased Trauma symptoms ▫Horror, intrusive reliving, avoidance, insomnia, numbing, loss of meaning ▫Normal for all survivors, intensified if witnessed event or found body (Jordan, 2008)

21. Bereavement in Suicide Survivors: Unique concerns Complicated grief ▫Intense, unremitting yearning for deceased + trauma-like symptoms ▫Increased risk of suicidality ▫More likely to experience complicated grief than survivors of natural death (Jordan, 2008)

22. Fielden’s Model of Grief for Survivors of Suicide: Research Methods Semi-structured interviews N = 6 ▫Four mothers ▫One father ▫One sister New Zealand

23. Fielden’s Model of Grief for Survivors of Suicide: Thrown-ness Thrown-ness into the lifeworld of surviving the suicide of a loved one ▫Discovery ▫Turmoil Experiencing chaos ▫Shock, disbelief, numbness, paralysis Dreaming as a way of saying “goodbye” ▫Finishing unfinished business

24. Fielden’s Model of Grief for Survivors of Suicide: Survival Mode Fear of not coming through ▫Disbelief: Difficulty accepting & confusion Living in the world of stigma and shame ▫Embarrassment & avoidance Moving through the lifeworld of blame ▫Family, friends, & acquaintances

25. Fielden’s Model of Grief for Survivors of Suicide: Searching Mode The “why” questions Clues: Suicide notes and written passages Reflecting on their relationship with their loved one Living in the lifeworld of guilt ▫Recovery guilt Living in the lifeworld of anger ▫Directed toward mental health providers Searching for reminders of their loved one ▫Places & activities

26. Fielden’s Model of Grief for Survivors of Suicide: Moving On Mode Creating a different lifeworld ▫Acceptance ▫Outward focus ▫Future orientation ▫Not forgetting but forgiving

27. Fielden’s Model of Grief for Survivors of Suicide: Implications for Treatment Non-linear process Inward & outward focus Calmness & turmoil

28. Assessment and Intervention Engage students in discussion about their religious/spiritual beliefs ▫Importance of belief system  Attendance at services, observation of practices  Importance of religious community relationships  Strength of identification with religious tenets  Recent changes in degree of religious commitment ▫How client conceptualizes, perceives relationship between suicide and spirituality  Sanctions against suicide  Interpretation(s) of suicide within spiritual community  Conflicts between personal and community beliefs (Gearing & Lizardi, 2009)

29. Assessment and Intervention Engage students in discussion about their religious/spiritual beliefs ▫Role of beliefs in previous coping  Source of comfort or contribution to distress  Impact involvement with services, leaders  Lead to avoidance of using spirituality as resource ▫Value of strengthening beliefs and practices  Identify protective elements of belief system  Identify distressing elements (Gearing & Lizardi, 2009)

30. Assessment and Intervention Consider student development level ▫Coping skills – emotions, boundaries ▫Autonomy, interdependence, identity, values ▫Level of tolerance for divergent views Provide psychoeducation about grief process Use expressive arts in therapy ▫Destruction Creation ▫Receptive vs. Expressive - letter-writing, journaling, poetry, visual arts, music (Chickering & Reisser, 1993; Stepakoff, 2009)

31. Assessment and Intervention Outreach to the bereaved Resources ▫Support Groups ▫Self-help/bibliotherapy ▫Online memorials  Increase connection with others  Enhance relationship with deceased  May decrease ability to let go of loss ▫Websites  Few encourage seeking mental health services  No way to assess trustworthiness, helpfulness  Nothing offensive, harmful found (Krysinska & Andriessen, 2010)

32. Case Example Nancy is a 20 year-old White female sophomore at a Midwestern university who came in for therapy because of her best friend’s suicide. During the first session, Nancy talked about how close she was to her friend while growing up and going to school together. She said the suicide was shocking because her friend was always positive about life and did not tell her about any serious issues. Nancy felt sad and betrayed by her friend. She also reported feeling responsible for her friend’s suicide because as a best friend she did not do anything to prevent it. Nancy identified as Christian in her intake paperwork and is struggling with the idea that her kind friend may spend eternity in Hell.

33. Group Discussion Questions 1.Think about your personal beliefs about death, afterlife, and the consequence of suicide. How would you approach the session with Nancy if your personal beliefs are different from hers? 2.How would you respond if Nancy asked about your beliefs? 3.How would you go about helping Nancy work on her issues?

34. Discussion and Questions

35. References American Association of Suicidology (2011). Survivors of Suicide Fact Sheet. Retrieved February 7, 2011, from http://www.suicidology.org/c/document_library/get_file?folderId=232&n ame=DLFE-160.pdf American College Health Association (2009). Ohio State University Executive Summary Spring 2009: American College Health Association National College Health Assessment II. Retrieved February 7, 2011, from http://slra.osu.edu/posts/documents/exec-summary.pdf Chickering, A. W. and Reisser, L. (1993). Education and identity. 2nd Ed. San Francisco: Jossey-Bass. Clarke, L. (2011). Suicide. The Oxford encyclopedia of the Islamic world. Oxford Islamic Studies Online. Retrieved January 25, 2011, from http://www.oxfordislamicstudies.com/article/opr/t236/e0761 Disayavanish, C., & Disayavanish, P. (2007). A Buddhist approach to suicide prevention. Journal of the Medical Association of Thailand, 98(8), 1680- 1688. Fielden, J. M. (2003). Grief as a transformative experience: Weaving through different lifeworlds after a loved one has completed suicide. International Journal of Mental Health Nursing, 12, 74-85.

36. References Gearing, R. E., & Lizardi, D. (2009). Religion and Suicide. Journal of Religion & Health, 48(3), 332-341. Jacobs, L. (1995). The Jewish religion: A companion. Oxford: Oxford University Press. Jordan, J. R. (2008). Bereavement after suicide. Psychiatric Annals, 38, 679- 685. Kennedy, T. D. (2000). Suicide and the silence of scripture. Christianity Today. Retrieved January 25, 2011, from http://www.christianitytoday.com/ct/2000/julyweb-only/42.0.html Krysinska, K. & Andriessen, K. (2010). On-line support and resources for people bereaved through suicide: What is available? Suicide and Life- Threatening Behavior, 40, 640-650. Lakhan, S. E. (2008). Hinduism life and death. Student BMJ, 16, 310-311. Lizardi, D., & Gearing, R. E. (2010). Religion and suicide: Buddhism, Native American and African religions, Atheism, and Agnosticism. Journal of Religion and Health, 49, 377-384.

37. References Morton, C. (2011). Funerals—dying an atheist. American Atheists. Retrieved January 25, 2011, from http://www.atheists.org/Funerals_- _Dying_an_Atheist Phipps, W. (1985). Christian perspectives on suicide. Christian Century (Chicago, Ill.: 1902), 970–972. Robinson, B. A. (2010). Agnostics and agnosticism: Uncertainty about whether God exists. Retrieved January 20, 2011, from http://www.religioustolerance.org/agnostic.htm Sarfraz, M., & Castle, D. (2002). A Muslim suicide. Australasian Psychiatry, 10(1), 48-50. Silverman, M. M., Meyer, P. M., Sloane, F., Raffel, M., & Pratt, D. M. (1997). The Big Ten Student Suicide Study: A 10-year study of suicides on Midwestern university campuses. Suicide Life-Threatening Behavior, 27 (3):285-303. Stepakoff, S. (2009). From destruction to creation, from silence to speech: Poetry therapy principles and practices for working with suicide grief. The Arts in Psychotherapy, 36, 105-113.

38. References Suicide Prevention Resource Center. (2004). Promoting Mental Health and Preventing Suicide in College and University Settings. Prepared for Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services Supported by Grant No. 1 U79 SM55029-01 October 21, 2004. Accessed on February 7, 2011 at http://www.sprc.org/library/college_sp_whitepaper.pdf

39. The Role of Religiosity and Spirituality in Responding to Survivors of Suicide Bonnie M. Benson, MEd Bong Joo Hwang, PhD Robert M. Bennett, MSW Todd Gibbs, BA Danielle Finch, BA The Ohio State University Counseling and Consultation Service Big 10 Counseling Centers Conference February 10, 2011 Minneapolis, MN