Clinical work with suicide loss survivors: Implications

Death Studies

ISSN: 0748-1187 (Print) 1091-7683 (Online) Journal homepage: http://www.tandfonline.com/loi/udst20

Clinical work with suicide loss survivors: Implications of the U.S. postvention guidelines John R. Jordan & Vanessa McGann To cite this article: John R. Jordan & Vanessa McGann (2017): Clinical work with suicide loss survivors: Implications of the U.S. postvention guidelines, Death Studies, DOI: 10.1080/07481187.2017.1335553 To link to this article: http://dx.doi.org/10.1080/07481187.2017.1335553

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Date: 12 July 2017, At: 13:10

DEATH STUDIES https://doi.org/10.1080/07481187.2017.1335553

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Clinical work with suicide loss survivors: Implications of the U.S. postvention guidelines John R. Jordana and Vanessa McGannb a

Private Practice, Pawtucket, Rhode Island, USA; bPrivate Practice, New York City, New York, USA ABSTRACT

The loss of a loved one to suicide can present difficult challenges for suicide loss survivors (people bereaved by suicide) as well as for clinicians who would seek to help them. Building on the recommendations in the new document Responding to Grief, Trauma, and Distress after a Suicide: U.S. National Guidelines, this article provides an overview of clinical work with suicide loss survivors. It includes discussions of the common themes of suicide bereavement, the psychological tasks for integration of a suicide loss, and the options for providing grief therapy after a suicide. The article will be of value to caregivers who work with suicide loss survivors in counseling or therapeutic context.

Whether it involves short-term crisis-oriented interventions, or longer term grief therapy, work with suicide loss survivors presents many challenges for mental health professionals. The majority of therapists receive very little training in how to work with grief of any kind, let alone traumatic bereavement such as suicide. Without a full knowledge of suicide and its aftermath, it is very possible to make clinical errors which can hamper treatment. Indeed, the guidelines that are the subject of this special issue explicitly call for the improved training of mental health professionals to deliver interventions to survivors as well as for solid research on those interventions (Survivors of Suicide Loss Task Force, 2015). In this article, we will provide guidance for mental health professionals and other caregivers that is based on recommendations from the guidelines (Survivors of Suicide Loss Task Force, 2015, pp. 31–34), from our own read of the clinical literature, and on our own extensive clinical experience in providing grief therapy for suicide loss survivors.

Background issues about suicide that therapists should understand Is grief after suicide different, and if so, in what ways? While a full discussion of this issue is not possible here (see Jordan, 2001; Jordan and McIntosh, 2011b, 2011c for a detailed discussion), we believe that there are some aspects of suicide as well as the grief that follows it of which mental health professionals must be aware if they wish to help suicide loss survivors. The guidelines specifically discuss some of the factors that differentiate CONTACT John R. Jordan © 2017 Taylor & Francis

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suicide from most other modes of death (Survivors of Suicide Loss Task Force, 2015, pp. 1–15). These factors include the perceived intentionality of the death, perceived preventability of suicide, and stigmatized and traumatizing nature of suicide. There are two additional aspects of suicide that therapists should understand if they are to be of help. First, the duration and intensity of grief after suicide is often longer and stronger than after many other types of loss. The effects of elevated rates of suicide bereavement-related problems, such as psychiatric disorders, social isolation, and suicidal ideation, attempts, and even completions have been described elsewhere in this issue (see Postvention is Prevention – The Case for Suicide Postvention, by Jordan) and in several recent literature reviews (Erlangsen & Pitman, 2017; Pittman, Osborn, King, & Erlangsen, 2014). These effects have been documented as far out as 10 years after the death (Feigelman, Jordan, McIntosh, & Feigelman, 2012; Saarinen, Hintikka, Viinamäki, Lehtonen, & Lönnqvist, 2000). Thus, clinicians should understand that for many of their clients, the intensity and duration of their distress is likely to be greater than for most other bereaved clients. Clinicians should be cautious about simply assuming that “grief is grief,” and recognize that the criteria for the duration and intensity of more normative losses (e.g., death of an elderly parent) are not likely to apply to many of their suicide loss survivor clients. For example, if a client is expressing great amounts of anger or guilt in the first months or year after a suicide, this is not necessarily evidence that he or she is “stuck” in their grief.

Private Practice, 10 Exchange Court - Unit 401 Pawtucket, RI 02860, USA.

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J. R. JORDAN AND V. MCGANN

Second, mental health clinicians should specifically be aware of the now well-established linkage between exposure to the suicide of someone to whom one is psychologically close and elevated rates of suicidal thinking in those who have been exposed (see Postvention is Prevention – The Case for Suicide Postvention, by Jordan, this issue, for further discussion). Indeed, it is vital that clinicians be prepared to assess for and work with this not uncommon problem in their clients who are bereaved by a suicide. While we believe that every client who seeks mental health treatment for any presenting problem should be screened for suicide risk, this should be considered mandatory for those who seek treatment for suicide bereavement. Space does not permit us to cover all the elements of an appropriate suicide risk assessment here, but clinicians should seek education about suicide risk assessment if they plan to work with loss survivors (Jobes, 2016; Joiner, Walker, Rudd, & Jobes, 1999). In addition, we believe that an important distinction for the clinician to make is between passive and active suicidal ideation in suicide loss survivors (Szanto, Prigerson, Houck, Ehrenpreis, & Reynolds, 1997). Passive suicidal ideation is reflected in a diminution of the wish to live and/or in the psychological investment in staying alive. For example, survivors may express an indifference to developing a life-threatening illness or to being involved in a fatal automobile accident (“I would not care if I got hit by a bus tonight”). This is definitely worthy of clinical attention, but it is not necessarily a marker of imminent risk for a suicide attempt by the client. Of course, passive suicidal ideation can also become active ideation, sometimes in short order. Active ideation is present when clients have not only lost their wish to live but are actively contemplating and feeling impulses to do something to end their life. This “something” can range from cognitions (e.g., making a plan or rationalizing why others would be better off if they were dead), to affective components (e.g., increasing despair and hopelessness), to engaging in prodromal suicidal behaviors (e.g., acquiring access to means, such as purchasing a fire-arm or saving up pills). Active suicidal responses such as these should always be considered a “red flag” by the therapist and should warrant a careful assessment of the level of risk in the client. As Sands has pointed out in her elegant metaphor to describe suicide bereavement, in their quest to make sense of the mental state of the deceased, many survivors will have to “try on the shoes, walk in the shoes, and then take off the shoes of the deceased” (Sands, 2009; Sands, Jordan, & Neimeyer, 2011). That is, many survivors have to conduct their own personal

psychological autopsy of the state of mind of the deceased that involves a certain amount of identification with the deceased to understand their suicide. In our experience, this particular form of suicidal ideation is not uncommon in suicide loss survivors, particularly bereaved parents who have lost a child to suicide. At times, the line between passive and active suicidal ideation can be difficult to distinguish. Thus it is vital that the clinician be alert to and knowledgeable of suicidal themes, so that he or she neither overreacts nor underreacts to the client’s material.

Prominent themes of suicide bereavement The guidelines identify several common reactions to suicide loss that Jordan has characterized as the prominent themes of grief after suicide (Jordan, 2008, 2009; Jordan & McIntosh, 2011a). While these emotional and cognitive reactions are not unique to suicide (e.g., many of them are also reported by homicide loss survivors), they are likely to be much more conspicuous and common in suicide loss survivors than in bereavement after most other types of death. A brief listing of these reactions as well as their clinical implications is as follows. The reader is referred to the guidelines (Survivors of Suicide Loss Task Force, 2015, pp. 13–18) for more detail 1. Shock and disbelief. Not all suicides are unexpected. This is often true, for example, when an individual dies by suicide after a long history of psychiatric illness and previous suicide attempts. In these cases, the element of psychological shock and disbelief may be considerably lessened. Nonetheless, in our experience, most suicide loss survivors do not see the suicide coming or else they did not believe that the individual would actually carry out previous threats to end their life. As such, many survivors report an initial response of shock and disbelief at the news of the death. This appears to be particularly likely when the suicide seems “out of character” with the individual the mourner thought they knew, that is, someone who was seen as incapable of killing themselves. Clinically, initial sessions are often taken up with the retelling of the death narrative, and little meaning-making can be accomplished at this stage, since processing the shock of the event overtakes most other aspects of the clinical presentation. In addition, problems with dysregulation of sleep, appetite, and concentration may be the focus of much of the early clinical work. In short, when survivors have been blindsided by the death, there are often a host of trauma symptoms which may require early attention by the clinician.

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2. Why? Suicide violates a belief that almost everyone holds: that everyone wants to live. This assault on the assumptive world of the survivor often produces an intense need to make sense of something that, in the beginning, may not make any sense at all: Why did they do this? The need to answer this central question after suicide is very characteristic of survivors, and the process of sense-making after a suicide often takes longer and requires more psychological effort than after almost any other modes of death (Neimeyer & Sands, 2017). Addressing the “why” issue takes patience, including on the part of the practitioner. Explorations may be repeated and dissected in a fact-finding manner while the answers to the question are often ultimately opaque and elusive. However, in our experience, having support to ask the questions, more so than the act of finding clear and specific answers, is what is therapeutically useful for the suicide loss survivor. Indeed, a client may need to ask the questions until they do not need to ask them anymore, whether or not they feel they have satisfied their search for answers. One caveat: some survivors report that their therapist seems much more interested in discovering the answer to the “why question” than they are—they feel that the therapist focuses more on the psychology of the deceased than the survivor. They also feel that the therapist can focus on the “pathological dynamics” of a family or individual in a way that feels stigmatizing or blaming. Thus, it is very important for clinicians to stay close to the material the survivor brings to the session and to be more of a witness to the explorations rather than a driver of them. One useful frame for this intense need for meaningmaking after a suicide is to compare it to a trial or investigation. We often have said to new survivors something to the effect of “I understand that you need to put yourself (and sometimes others) on trial here. I will even support that investigation. My only request is that you and I work to be sure that we look at all of the evidence, and that we have a fair trial.” This frame validates the need for the client to struggle to make sense of the death, while also conveying the idea that suicide is a complex phenomenon and rarely the result of just one thing or person. One of the tasks for clinician and client together is to learn to understand and hold the complexity about what happened to the client’s loved one, and how to think about the issue of responsibility for the death. 3. Shame. Suicide and psychiatric disorders have a long history of fear, punishment, and stigmatization associated with them (Colt, 2006; Cvinar, 2005;

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Feigelman, Gorman, & Jordan, 2009). This helps to explain the feelings of shame that many loss suicide bereaved feel. Survivors often internalize the larger cultural attitudes toward individuals and families who experience mental health problems. Some refuse to publically acknowledge the cause of death or to tell only a selected few the truth. This can exacerbate the recovery process because it intensifies the feelings of humiliation and unworthiness that accompany suicide as well as the social isolation that can follow a death by suicide. It is important when working with survivors to acknowledge the real stigma that exists in society around suicide and to refrain from implying to the survivor that this is just “all in their head.” One of the positive aspects of having survivors share their stories, whether at support groups or advocacy events, is that they come in contact with other “normal” people—people just like them who have been touched by this tragedy as well. Any and all interventions that help survivors feel less ashamed can have powerful effects on the grief course of the survivor. 4. Responsibility, guilt, and blame. Since suicide is frequently perceived as an inexplicable and frightening cause of death, it usually elicits in the bereaved a need to not only understand why the person took their life but also to assign responsibility for the death. In our clinical experience, many survivors begin by blaming themselves, often focusing on perceived “sins of omission and commission”—things they failed to do (but should have) and things they did do (but should not have). They often suffer from what one client of the first author called the “tyranny of hindsight”—that is, the compulsion to look back at circumstances that led up to the death and to identify real or imagined mistakes they have made. Of course, some survivors also direct this need to blame outward toward another person(s) such as a family member, a person in the community, a mental health professional, etc. And sometimes, survivors also direct blame for the death toward the deceased. As with the search for answers to the “Why?” question, exploring culpability can be a long and arduous process. When they are grappling with a felt sense of responsibility, it is usually not helpful for a survivor to hear a simplistic insistence (from their therapist or elsewhere) that “it was no one’s fault” or “it was not your fault.” Instead, they frequently need to go through a process of intense examination and, as previously noted, it is more helpful if their therapist can act as a benign magistrate who makes sure that the “accused” has a fair-minded trial. Often, survivors ultimately feel that they may have done something

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which added to their loved one’s pain. However, over time they might see this as only one of the many factors leading to their loved one’s death. As one survivor so aptly stated to the second author, her feelings changed from remorse to regret. Over time, she went from feeling overwhelmingly responsible for the death to feeling sadness that she did not have the benefit of hindsight to see the errors in her actions. 5. Anger. The Latin root of the word suicide literally means “self-murder.” Thus, the reactions of suicide loss survivors can sometimes resemble those of homicide loss survivors, which are usually dominated by rage at the perpetrator. In suicide, however, the “perpetrator” of the “murder” is also the “victim”— which can make for a very confusing and conflicting set of emotions in the survivor. Learning to hold these contradictions can be a major challenge for survivors, who find themselves simultaneously feeling angry with the deceased, and yet sorry for them. Of course, survivors can also harbor feelings of anger and rage at others who they hold blameworthy or support networks who they feel are letting them down in their grief. In terms of countertransference, clinicians can struggle with the challenge of witnessing and working with the extent of the anger coming from some survivors. There is a temptation to try to get the client to “calm down” or “move past it” before he or she is ready. In our experience, only a full exploration and understanding of the hurt and rage can free a client enough to feel understood and thus be more tempered in their feelings. 6. Rejection and abandonment. It is also common for a survivor to view the suicide as an interpersonal statement by the deceased about the relationship with the mourner. For example, a wife whose husband has taken his life may feel deeply abandoned by him, left to cope on her own with their children and the financial challenges of the family. Or, she may feel that the suicide is a rejection of her affection, and proof that she failed to love her husband enough to make him want to stay with her. Obviously, these perceptions regarding the meaning of the suicide can add to the emotional pain suffered by the survivor. They can also add to the difficulties survivors face in trying to restore a sense of self-esteem and well-being after the death. Psychoeducation about the nature of suicidal thinking can be helpful with these concerns. The concept that their loved one wanted to end their psychological suffering rather than end a specific relationship can be comforting to many. Of course, there are circumstances when a loved one choses a specific date to die (such as a

birthdate or anniversary), or when they leave an accusatory note, that issues of rejection become more central for the survivor and more challenging for the clinician to manage therapeutically. However, the concept that a loved one was in an altered and dysregulated state of consciousness is often a helpful concept to have in mind when exploring these themes with survivors. As one survivor of a suicide attempt stated “I wasn’t trying to kill myself—I was trying to kill the pain.” 7. Fear For most of the public, suicide is a mysterious and frightening cause of death. Although it is rarely a completely impulsive act, to the friends and family of the deceased, suicide can seem to be a terrifying “bolt from the blue.” Thus, common sequelae of suicide include hypervigilance, a heightened and anxious watchfulness about whether the traumatic event will be repeated as well as a strenuous mental effort to figure out how a reoccurrence can be prevented. This hypervigilance can cause strain in family relationships, as when a surviving teen from a family where the suicide of one child has occurred comes home late—only to find a terrified parent who fears that another child has taken their life. In such cases, it is helpful for the clinician to communicate that these are common reactions in parents after a traumatic event such as suicide, and that that they usually dissipate over time. The clinician can also play an important role as an independent “sounding board” for the parent about what concerns about their surviving child may be realistic, and which are driven by the trauma-based anxiety of the parent. 8. Relief. As mentioned, suicide is not always a surprise (Wojtkowiak, Wild, & Egger, 2012). When it comes at the end of a long, usually downward struggle with psychiatric disorder, family and friends can find themselves feeling relieved that the ordeal of worrying about and caring for the person is finally over. This bears much similarity to the feelings that many caregivers have experienced when a loved one has suffered from, and then died of cancer or dementia. The caregiver may feel a sense of relief that their loved one is no longer suffering, and that they themselves no longer need to keep watch over them. In our clinical experience, this feeling of relief is also usually accompanied by feelings of shame and guilt for having such thoughts and emotions. Clinically, it is beneficial for the survivor to understand that it is entirely human to feel relief when suffering ends, and that it is acceptable to feel that one’s life might change for the better in some ways after a suicide has happened.

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Tasks of loss integration Historically, grief has been seen by the mental health profession as something to be “resolved,” that is, to be worked through and then finished. This also accords with the more general societal notion of losses as something that one “gets over.” A different, and more relevant, concept for thinking about traumatic losses is the idea of integration. This is illustrated beautifully by a member of a support group that was run by the first author. This person stated that “People think that when you are grieving, it’s like having a heavy boulder put on your shoulders. And at some point, I’m supposed to just put that boulder down, and go on down the road. But that isn’t what is happening to me. What is happening is that my back is getting stronger!”

This profoundly insightful observation conveys the realization that the loss of someone to suicide produces a grief that can be thought of as transformational rather than homeostatic in nature. That is, it changes the person who goes through the process. The idea that people simply “get back to their old self” is at best, inaccurate, and in some instances, directly harmful to survivors. Thus, rather than referring to the goal of resolving a loss, we strongly prefer the language of integrating a loss. Or to use the words of this group member, the goal is to learn to carry the grief with a stronger back. This crucial difference is a concept that we encourage clinicians to hold in mind when they consider the goals of grief therapy with survivors. We believe that the work of therapy is to learn to carry the loss with strength and serenity, not to get over it. Along these lines, we would like to outline the psychological tasks that we believe most survivors must accomplish if they are to effectively integrate their loss. These will be briefly summarized below, and the reader is also referred to additional resources for a more in-depth discussion of these ideas (Jordan, 2008, 2009, 2015). 1. Containment of trauma. Many loss survivors experience not only an intense grief response but also trauma symptoms—and some survivors develop full blown posttraumatic stress disorder (De Leo, Cimitan, Dyregrov, Grad, & Andriessen, 2014; Pearlman, Wortman, Feuer, Farber, & Rando, 2014). We believe that clinicians make a significant error if they do not assess for and intervene with the trauma responses that may include extremely disturbing visual, auditory, and other sensory memories of the death. The guidelines also note that while survivors who either witnessed the suicide or found the body are probably more likely to develop post traumatic stress disorder (PTSD), a survivor does not have to have been an

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eyewitness to the suicide to develop a traumatic picture in their mind of the death scene. When appropriate, treatments for trauma symptoms need to always be included in the treatment planning for people who are bereaved by suicide. 2. Creation of a narrative of the suicide and meaningmaking about the death. For almost everyone (including mental health professionals), suicide can be a mysterious cause of death. Moreover, since a suicidal person can hide their intentions, many survivors are blindsided by the death. For these reasons, most survivors need to spend considerable mental time and energy answering the “Why did they do this” and “What were they thinking/feeling?” questions. Some become veritable detectives, investigating every moment, movement, and communication of their loved one’s last days to understand their thoughts and feelings. As Sands notes, survivors must “try on the shoes” of the deceased—this “personal psychological autopsy” is a part of the deeply felt need to make sense of a death that often makes no sense at all (Neimeyer, 2015; Neimeyer & Sands, 2017; Sands, 2009; Sands et al., 2011). 3. Learning to dose exposure and cultivate psychological sanctuary. The core of trauma is helplessness (Van der Kolk, 2014). Something horrific has happened, and the individual cannot dominate it (Fight), run away from it (Flight), or hide from it (Freeze). Grief after suicide is usually a combination of the grief response and trauma response. It can cause intense psychic pain that is experienced as intrusive, involuntary, and frequently overwhelming. Since it is very difficult to live with such continuous and intense pain, one of the most important tasks for survivors is to find “islands of respite” from their pain. These can include any place, person, or activity that provides relief from the continuous preoccupation with the death, and help in downregulating the powerful emotional arousal following the death. The only caveat to this principle is that the source of respite must not be self-destructive (e.g., drinking heavily) or destructive to other people (e.g., raging at another family member). Examples might include “losing oneself” in one’s work, engaging in new recreational activities, partaking in intense physical exercise, and self-soothing with activities such as walks in the woods, meditation, yoga, or listening to comforting music. Of course, initially survivors may have a great deal of difficulty with these tasks, but encouraging and “allowing” respite from grief can be very therapeutically beneficial. 4. Managing changed social connections. As the guidelines note, suicide is a highly stigmatized mode of death, and the stigma often carries over to survivors

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of a suicide loss. Many survivors find that a portion of their relationships are altered or even permanently lost after the death of their loved one. Many also report avoidance behaviors from their friends and family members, coupled with occasional bursts of outright condemnation of the deceased or scapegoating of the survivor (Feigelman, Gorman, et al., 2009). Moreover, survivors themselves may “self-stigmatize” and withdraw from previously close connections out of a sense of shame and estrangement (Dunn & Morrish-Vidners, 1987). All of this may contribute to what has been called “social ambiguity” after the death (Jordan, 2008, 2009), where the implicit rules of social interaction around bereavement support are unclear. The result can be awkwardness and avoidance on the part of the social network around the survivor, which can make suicide a very isolating experience. The repair and rebuilding of connections with family members and peers as well as the forging of new connections can be a major challenge for survivors. 5. Repair and transformation of the relationship with the deceased. The field of thanatology has been challenged by the introduction of the concept of continuing bonds with the deceased (Klass, 1999; Klass, Silverman, & Nickman, 1996). The idea that the death of a loved one may end a life, but does not need to end a psychological/spiritual relationship with the deceased, has thus received considerable attention in the last 20 years (Field, 2006a; Root & Exline, 2013; Stroebe, Schut, & Boerner, 2010). This literature suggests that while continuing bonds may be helpful in the healing process for many bereaved persons, they also may be a hindrance for a subset of mourners (Field, 2006b; Field et al., 2013; Stroebe, Abakoumkin, Stroebe, & Schut, 2011). From a continuing bonds perspective, the psychological task in mourning a more normative death is one of transforming the nature of the relationship with the deceased, not ending it. The suicide of a loved one, however, can make this task much more difficult to accomplish. Suicide is almost always experienced as a rupturing of the relationship with the deceased; often it is also experienced as an abandonment or rejection of the survivor by the deceased. As such, an important focus of grief therapy with suicide loss survivors must often be an exploration of the considerable “unfinished business” suicide can leave behind. 6. Memorialization of the deceased. After death, nearly every society encourages some form of remembering of the deceased, particularly the good and honorable things about their life and the validation of their positive impact on the living. After suicide, however,

this may be a much more difficult process. The stigmatized nature of suicide, along with its often times sudden and unexpected manner, may leave the bereaved preoccupied with only the very end of their loved one’s life—as if the fact that they died by suicide was the only important thing about the deceased, and a dishonorable one at that. Survivors often need emotional permission to review, remember, and honor the entire life of the departed, not simply the last minutes or days of their life that resulted in suicide. With this support, and over time, the balance of what a survivor can focus on contains more memories of the positive aspects of their loved one’s life rather than the negative aspects of their loved one’s death. 7. Resumption of and reinvestment in living. Virtually all losses require the mourner to adapt to a changed world as well as a changed identity and sense of self (Neimeyer, 2001, 2016). They also require that the mourner eventually, as Sanders notes, makes a decision to go on with their own life (Sanders, 1999). For most mourners, this means both a resumption of old patterns and a discovery of new activities, relationships, and pursuits that bring pleasure and meaning to the individual. For some suicide loss survivors, it can literally mean a struggle for the survivor to go on living rather than following the path of the deceased. This can be a long and emotionally painful effort—one that will require considerable social and sometimes professional, support to be accomplished. In our next section, we address some of things that professional caregivers who work with survivors should know in providing this support.

Intervention options for survivors In this section, we will provide a brief review of the limited research literature on interventions for suicide bereavement. We will also describe the range of intervention options for survivors. The research literature on interventions designed specifically to help suicide loss survivors is sparse, to say the least. A qualitative review by Jordan and McMenamy (2004) reviewed existing interventions for suicide loss survivors as well as general interventions for bereavement that would likely be helpful to suicide loss survivors. They noted the small number of studies and widespread lack of methodological rigor among that studies that had been done. Although there were some group interventions that showed some promise, their general conclusion was that “ … while there is anecdotal evidence and a general clinical impression that services are helpful, we must conclude that the efficacy of formal interventions for survivors

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has yet to be scientifically established” (Jordan & McMenamy, 2004, p. 345). Likewise, a more recent literature review by McDaid and colleagues reached similar conclusions, indicating that “ … Although there is evidence of some benefit from interventions for people bereaved by suicide, this is not robust. Further methodologically sound evidence is required to confirm whether interventions are helpful, and if so, for whom” (McDaid, Trowman, Golder, Hawton, & Sowden, 2008, p. 438). Finally, a recent review by Szumilas and Kutcher (2011) found no evidence of effectiveness at reducing suicide attempts or completions in survivors, and no evidence of cost-effectiveness of the programs. However, there was a marginal support for the effectiveness of school-based gatekeeper programs at reducing depression and suicide attempts, of family-based postvention programs at reducing distress, and of survivor outreach programs at increasing participation in follow-up support services, and for bereavement support group programs at producing short-term reductions in emotional distress. It should also be noted that an evaluation of a pioneering postvention program in Australia, the Standby Service, has demonstrated several positive effects of participation in the service, ranging from reduced suicidal ideation to improved reports of wellbeing and social connectedness (UnitedSynergies, 2009). A separate study also found a significant economic offset in terms of medical costs for recipients of the service (UnitedSynergies, 2011). One recent clinical development from thanatology that does merit attention is the protocol developed by Shear and her colleagues for the treatment of complicated grief (CG). The treatment is known as complicated grief therapy (CGT) (Shear, Boelen, & Neimeyer, 2011; Shear, Frank, Houck, & Reynolds, 2005; Shear et al., 2014; Shear et al., 2016). In a recent, well-designed randomized controlled trial of people who suffered from complicated grief, some of whom were suicide loss survivors, the efficacy of CGT versus “complicated grief-informed management,” with and without an antidepressant medication, was studied (Shear et al., 2016; Zisook, 2016). CGT was found to be the more effective form of therapy for CG. It is also important to note that for suicide loss survivors, who had elevated rates of suicidal ideation at the start of treatment, the CGT was effective at reducing suicidal thinking. Perhaps surprisingly, however, the addition of an antidepressant did not improve the outcomes for CG over a placebo, although it did improve the treatment of depressive symptoms. With regard to clinical options for loss survivors, the choices mostly come down to the choices available for any bereaved person. That is, bereaved persons are

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generally offered individual, family, and occasionally, group treatment (see Jordan and McIntosh (2011a) for a full description). While not a formal clinical intervention, for many survivors, peer-to-peer contact with other fellow survivors also appears to serve a very important function in their recovery process (Feigelman et al., 2012; Jordan & McIntosh, 2011a; McMenamy, Jordan, & Mitchell, 2008). Three primary forms of peer-to-peer contact can be identified. The most common is participation in a face-to-face bereavement support group with other suicide loss survivors (Jordan, 2011a). While these groups may be facilitated by professionals, lay persons, or a combination of both, the core of what appears to be helpful is the opportunity to interact with other people facing the same challenge of integrating the suicide loss of a loved one and rebuilding one’s life after such a catastrophe. The second form of peer-to-peer contact is through online support groups. The article in this issue by Walker offers one excellent illustration of such a group (“After Suicide: Coming Together in Kindness and Support”), and a chapter by Chastin-Beal offers another such example (Beal, 2011; Feigelman, Gorman, Beal, & Jordan, 2008). Finally, the so-called survivor-to-survivor outreach teams form a third setting for peer-to-peer interaction. In these teams, trained survivor volunteers (sometimes accompanied by a mental health professional) meet with new survivors shortly after the death and provide information, suggestions, and above all, emotional support for the newly bereaved family (Campbell, 2011; Campbell, Cataldie, McIntosh, & Millet, 2004; Hurtig, Bullitt, & Kates, 2011; UnitedSynergies, 2009). For more information about all of these forms of intervention, please see the numerous descriptions of model programs presented by Jordan and McIntosh (2011a).

Grief therapy with suicide loss survivors In this section, we will discuss what we believe are the fundamental roles or functions of individual grief therapy in helping clients bereaved by suicide to integrate their loss and to rebuild a life without the deceased. We draw on the several recent, clinically focused books and articles that address work with survivors of suicide and other traumatic losses (De Leo et al., 2014; Dyregrov, Plyhn, Dieserud, & Oatley, 2012; Feigelman et al., 2012; Jordan, 2011b, 2015; Jordan & McIntosh, 2011a; Kosminsky & Jordan, 2016; Neimeyer, 2012b; Neimeyer, 2015; Neimeyer, Harris, Winokuer, & Thornton, 2011; Neimeyer & Sands, 2011; Pearlman et al., 2014; Rando, 2015; Rubin, Malkinson, & Witztum, 2012; Sanford, Cerel, McGann, & Maple, 2016).

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Therapeutic relationship and bearing witness to the story The process of having one’s story witnessed by the community after a loss has been a part of the communal response to bereavement in every human culture from the beginning of recorded history (Stillion & Attig, 2015). Moreover, the role of interaction with supportive others in integrating a loss is well established by the many research studies that demonstrate the value of social support in helping to mourners to heal after a loss (Dyregrov & Dyregrov, 2008; Hass & Walter, 2007; Silverman, 2004). Within the context of grief therapy, this support/witnessing function has been referred to as “companioning,” or “expert companioning” (Tedeschi & Calhoun, 2003). And in a recently published book on grief therapy, Kosminsky and Jordan present an approach to grief therapy that is reflected in their definition of grief therapy: Grief therapy is a concentrated form of empathically attuned and skillfully applied social support, in which the therapist helps the bereaved person reregulate after a significant loss by serving as a transitional attachment figure. (Kosminsky & Jordan, 2016, p. 100)

Rooted in contemporary attachment theory, interpersonal neuroscience, and broadly defined psychodynamic approaches to psychotherapy, their approach emphasizes that the work of facilitating and bearing witness to the narrative of the mourner should be at the very foundation of all grief therapy, regardless of the theoretical orientation or types of techniques used by the clinician. The experience of being empathically listened to by another person(s) serves multiple functions for a bereaved individual. These include a subjective experience of “feeling felt” or understood by a confidant, a reduction of the profound feelings of isolation that may accompany mourning, an opportunity for teller of the story to reflect on the meaning of their loss from a wider perspective as they listen to themselves relate the narrative, and an opportunity to receive affirmation of the mourner’s continuing worth and “belongingness” to community (particularly important after stigmatized and isolating deaths such as suicide). All of these findings suggest that the establishment of an emotionally attuned and empathically responsive therapeutic relationship is crucial to the success of grief therapy—perhaps particularly with individuals who have been traumatized by the suicide of a loved one (Kosminsky & Jordan, 2016; Neimeyer, 2012a). Expert guidance and psychoeducation For most people, bereavement after suicide is a very alien experience—one for which they have almost no

“road map” about what to expect of or how to survive the journey. In addition, because of its relatively rare occurrence and stigmatized nature, survivors may not know anyone else who has lived through this experience. The guidelines make clear that new survivors have several needs with which clinicians may be able to help (Jordan, Feigelman, McMenamy, & Mitchell, 2011; McMenamy et al., 2008; Survivors of Suicide Loss Task Force, 2015). One of these essential needs is for accurate and useful information about suicide, trauma, grief, and resources that may be of help to them, such as bereavement support groups. Other needs can include practical support around the aftermath of the death (e.g., finding an attorney), family support in dealing with the concerns of particularly vulnerable members (e.g., parents helping their children after a suicide), and help in finding venues for contact with other survivors (e.g., online survivor support groups). And of course, survivors may also want and need the help provided by formal grief therapy with a welltrained and compassionate mental health clinician (Jordan, 2011b). Accordingly, there is a very important role for the clinician to play as a “grief expert”— someone who is more familiar with what the immediate and longer term normative response after suicide looks like as well as information about how to find and access resources needed by the survivor and family. For example, the heightened intensity of their grief and trauma responses may frighten the bereaved survivor as well as those around them in their family and social network. Likewise, the stigmatized nature of suicide, and the social avoidance that results, may compound the feelings of isolation and abandonment with which survivors must contend. In addition, the intense need to address the “Why” and “Responsibility” questions that often follow suicide can make mourning a suicide death unlike anything the mourner (or their social network) has ever experienced. Given all of this, a considerable portion of the clinical work with suicide survivors will entail helping the client to educate themselves about suicide and grief after suicide. It can also involve proactive teaching about many of the factors that contribute to suicide as well as the confusing “roller-coaster” of thoughts and emotions that the suicide bereaved may experience in their mourning process. Finally, the role of grief expert may entail the use of specialized clinical techniques that facilitate work on any of the “Tasks of Integration” described previously. For example, specialized techniques (such as EMDR) may be required to resolve trauma symptoms. Or the task of repairing the relationship with the deceased can be a particularly challenging undertaking after a suicide and may necessitate the use

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of bereavement-focused techniques such as guided imagery conversations or letter writing with the deceased (Jordan, 2012; Neimeyer, 2012b). To summarize, a major function of the grief therapist after suicide involves a kind of “expert coaching,” a combination of support, gentle encouragement about self-care, active teaching of information and skills, and the use of specialized clinical techniques. Other therapeutic issues likely to affect grief Bereavement never happens in a vacuum. That is, mourners always have a personal history, personality structure, and coping style that will influence the way they cope with the suicide of a loved one. While it is beyond the scope of this article to review all of the “pre-existing” variables that may influence a given individual’s response to loss (see Burke and Neimeyer (2013) for more on this), it is worth briefly mentioning four factors which are likely to be an issue in bereavement in general, and suicide bereavement in particular: the mourner’s trauma history, their loss history, their attachment orientation, and any pre-existing psychiatric disorders. Any and all of these may require focused attention from the clinician. It is well established that a history of trauma, particularly traumatizing abuse and neglect as a child or adolescent, is likely to influence an individual’s reaction to additional traumatic events in one’s life (Anders, Shallcross, & Frazier, 2011; Litz, SaltersPedneault, Hofmann, & Weinberger, 2007; Pearlman et al., 2014; Van der Kolk, 2014). Likewise, an individual’s history of losses, again particularly during childhood and young adulthood, is a predictive variable in terms of bereavement outcome (Kosminsky & Jordan, 2016). Previous traumas/losses that include the suicide of an important attachment figure appear to be a particularly salient risk factor for adverse outcomes and the development of complicated grief reactions in mourners. As mentioned in a previous article in this issue (“The Impact of Suicide – The Case for Suicide Postvention” by Jordan), there is now compelling evidence that children who have been exposed to suicidal behavior and/or completion of a family member are at elevated risk for suicide themselves, later in life (Kuramoto, Runeson, Stuart, Lichtenstein, & Wilcox 2013; Song, Kwan, & Kim, 2015; Spiwak et al., 2011). This may be an especially potent factor when the subsequent trauma is the suicide of a loved one. In addition to a person’s loss/trauma history, their attachment orientation and their history of previous psychiatric disorder(s) have been shown to be associated

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with their response to a loss. In general, people with an insecure attachment style (particularly anxious attachment styles) have been linked to the development of complicated grief responses in mourners (Meij et al., 2007; Stroebe, Schut, & Stroebe, 2005; Thomson, 2010; Zech & Arnold, 2011). Likewise, people with a previous history of psychiatric disorders, particularly mood disorders, are more likely to develop those disorders again after a major loss (Auster, Moutier, Lanouette, & Zisook, 2008; Kendler, Myers, & Zisook, 2008; Sidney Zisook & Lyons, 1989; Sidney Zisook & Shuchter, 2001). It is important to note that most of these findings about variables that may influence the grief trajectory have mostly been established in samples with older people who have lost a spouse/partner to natural causes—not with regard to the loss of a loved one to suicide. Still, it seems quite likely that these factors will play an equal, if not greater role in the response of suicide loss survivors to the death of their loved one. It will be important for all clinicians to do a thorough assessment of survivors who present for grief therapy, including history gathering with respect to the individual’s past experience with other losses, other traumatic events in their life, their history of psychiatric disorders, and their general attachment style. It will also be important for clinicians to be prepared to treat these additional factors, when the clinician and client agree that they are playing a role in restraining the healing process for the bereaved survivor. Fostering posttraumatic growth in survivors The vast majority of the clinical and research literature on clinical work with suicide loss survivors focuses on the ways in which survivors can be psychologically wounded by the suicide of a loved one. Nonetheless, survivors can also demonstrate what has been called posttraumatic growth (PTG) (Calhoun & Tedeschi, 2014; Feigelman, Jordan, & Gorman, 2009; Genest, Moore, & Nowicke, 2017; Moore, Cerel, & Jobes, 2015). PTG refers to the ways in which people who have survived a highly challenging and stressful experience— such a life-threatening illness, a violent assault, or in this case, the suicide of a loved one—show evidence of becoming wiser, more resilient, and more compassionate individuals. This growth may be manifested in a variety of domains. For example, people may report a deepened appreciation for interpersonal relationships or a heightened gratitude for certain “blessings” in their life. They may describe a greater sense of spirituality or an altered and more meaningful sense of purpose in one’s life. And they may find that their outlook on life has been changed for the better, with a broader and

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wiser perspective on the purpose of their life, or that their priorities in life have been shifted since their loved one has died. We mention the possibility of PTG because it is easy for clinicians to become focused on the damage that suicide can leave in its wake, and the particular psychopathologies that their clients are showing as a result of their loss. We believe that this more narrow perspective misses a crucial opportunity for positive change after a traumatic loss such as suicide. In our own practice, we have known many suicide loss survivors who have become stronger and more mature people as a result of their loss. These transformations are truly hardwon—but they are also authentic and profound. We encourage all mental health professionals who work with suicide loss survivors to collaborate wholeheartedly with their clients to look for this opportunity for positive psychological and spiritual growth, even in the face of an event that is likely one of the postwounding experiences of their life. Only when we recognize the potential for this growth in each survivor with whom we work can we truly be of service to them on this difficult journey.

Conclusion – the therapist’s experiences with and attitudes about suicide Clinical work with suicide loss survivors can be challenging but ultimately very rewarding work. Suicide is a complex phenomenon and so is the bereavement that follows it. It involves multifaceted elements of trauma, grief, and some unique attributes of suicide as a cause of death (such as the perceived intentionality of the death) that must be understood by the clinician to be truly effective. We believe that there is also one additional issue about which conscientious clinicians should be mindful—their own experiences with, attitudes about, and reactions to the act of suicide. We would like to conclude this article with some observations about this important issue. As members of a given society, therapists inevitably internalize many of the beliefs and attitudes about suicide that are present in that society. At least in USA, suicide has historically been seen as a taboo and shameful act that reflects either characterological weakness and/or sinful and illegal behavior. Indeed, it was not until the late 20th century that attempting suicide was decriminalized. This historical legacy is changing, but it is changing slowly. And, we believe that it is being replaced by a potentially more compassionate and benign narrative: that suicide is primarily the result of psychological disorder. Nonetheless, even this new understanding of suicide can contain negative components. In particular,

even when it is not stigmatized as “bad,” suicide is usually perceived as some kind of a failure. That failure may be viewed as the result of the suicidal person, who “failed” to try hard enough to stay alive. Or, it may be viewed as the failure of some other person in the deceased’s network, including but not limited to their family (e.g., spouse, parents, etc.), their community (their church group or work colleagues), or, importantly, their professional caregiver(s). And of course, if the clinician was involved with the deceased in some way, then that sense of failure can experienced as a professional and/or personal failure on the part of the clinician. It is beyond the scope of this article to discuss in depth the sometimes devastating impact that the suicide of a client may have on mental health professionals, but it is important to recognize that therapists can experience all of the reactions to the suicide of a client, a family member, or a friend/colleague in exactly the same ways that have been described above for other suicide loss survivors. Clinicians are by no means immune or invulnerable to the same distress as anyone else involved with a suicide. For a more in-depth discussion of these issues, the reader is referred to several excellent articles on this subject (Alexander, 2007; Dransart, Treven, Grad, & Andriessen, 2017; Grad & Michel, 2005; Grad, Michel, & Weiner, 2005; Grad, Zavasnik, & Groleger, 1997; Gutin, McGann, & Jordan, 2011; Knox, Burkard, Jackson, Schaack, & Hess, 2006; Rycroft & Weiner, 2005; Schultz & Weiner, 2005; Spiegelman, Werth Jr, & Weiner, 2005; Ward-Ciesielski, McIntosh, & Rompogren, 2013; Weiner, 2005). Suffice it to say that clinicians, like every other human being, can have strong feelings about suicide, and by extension, about those who have been associated with a suicide, the survivors. Our point is that this sense of failure associated with suicide can produce countertransferential feelings, thoughts, and behaviors in therapists who are working with survivors. For example, clinicians may find themselves angry with the person who took their life, and the “damage” the death has caused. Or, they may find themselves wanting to blame the family or others (including other mental health professionals) for the death through their negligence in caring adequately for the deceased person. And perhaps most commonly, clinicians can experience a suicide as a failure on their own part if they were involved with the deceased as a client. Beyond the sense of failure, suicide may also invoke other reactions, such as fear of the resulting suicidality in the loss survivor, or impatience with the survivor for not “getting better” faster. They may feel shame with their colleagues if they felt that the suicide was a failure on their part, or if they are unable to help the survivors

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“get better.” And of course, if the clinician has been impacted by suicide elsewhere in their own personal or professional life, then some of the residual thoughts and feelings from that previous experience are likely to be evoked in the therapist who works with a survivor. Whether they have had firsthand experience of a suicide or not, it is essential that clinicians be aware of their own biases and beliefs about suicide—their own countertransference. These personal reactions to suicide are not intrinsically a problem if handled well—indeed, they can be a rich source of insight and compassion for the challenges that their survivor client must face. But to make use of one’s personal experience, the clinician must also engage in a careful examination of their beliefs, feelings, and thoughts about suicide in general, and about the particular suicide with which they have become involved. Questions such as what caused it, who is responsible for it, and what should have or could have been done to prevent it all need to be reviewed not only by the client(s), but by the clinician themselves? Mindfulness about one’s own “assumptive world” about the phenomenon of suicide will allow the clinician to be fully present to the experience of their client and selfaware when their own beliefs and feelings begin to intrude on the therapeutic process. As therapists ourselves, the authors have witnessed the power of offering a knowledgeable, patient, open, and optimistic stance toward the journey that loss survivors take (Jordan, 2011b; Kosminsky & Jordan, 2016). As the guidelines state, mental health workers need improved training to deliver effective interventions to suicide loss survivors. It is our hope that the concepts described in this article will lay the groundwork for that training and also lead to more robust research in the field about effective ways to be of help to suicide loss survivors.

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