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

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

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 15-24 y.o.

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. - 2010 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 15-24 y.o.

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

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

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

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

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”

HOW IS GRIEF AFTER SUICIDE DIFFERENT?

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

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

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?”

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

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

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

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!

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”

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”

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 – www.samaritanshope.org 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 – www.afsp.org) AAS – Annual Healing After Suicide Conference (www.suicidology.org) Fund-raising walks Activism Peer to peer support Fund-raising Political advocacy

HOW CAN FRIENDS, FAMILIES, AND COMMUNITIES HELP?

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

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

Wrap-Up Questions? Comments?

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