In working with clients within the realm of the Child Advocacy Law Clinic, I have encountered some previously unforeseen challenges in my capacity as the social worker, given that I am now on a team with law students. As we are working with families who have negative associations with social workers—understandably so, as Child Protective Service workers and Department of Human Service investigators are threatening their family’s integrity by removing their children and often moving for termination of their right to parent—it has been an interesting task to try and work around the wariness these clients have of yet another social worker intruding into their lives. If there is already stigma, misunderstanding and distrust of social workers among working class folks due to the negative associations with treatment for mental illness, for these families who have had their lives invaded, it is all the more understandable that they are reticent to speak with anyone on our legal team. Despite this recognition, it is occasionally frustrating and at times tedious to try and reach out to clients who are disinclined to interact with us already, and ask them to trust me enough to tell me what has been going on in their lives, even if it is to their legal advantage to work with all of us.
It can be very difficult not to automatically default to a sense that I as a worker know better than they do, and that I’m trying to make their lives better; this approach is exactly the same mentality that DHS too frequently takes with families such as our clients’, and in order to truly ally with our clients, it is imperative that the social workers in clinics such as ours not fall into that hubris trap. I, like many others doing social work, am coming from a desire to promote social justice and better working family systems; having client families who are potentially broken enough to have been reported to Child Protective Services offers a significant challenge to my desire to work with families holistically. Our wish is to always have families who are able to be repaired, but the alleged damage we encounter with severe neglect or child abuse cases conflicts with this desire, and we are tempted to choose sides, such that our legal team may be advocating the legal dissolution of the family system. I have needed to approach several of my clients with active humility, recognizing that they know their family situation, their lives, and their stories better than we ever will, in all its complexity. It is our jobs as their advocates to work hard to foster a trusting and working relationship with our clients, such that we may be in the best position to work with and for them, rather than assuming we know what is best for their lives, as too many of our professional colleagues do. This means accepting that it may be in the best interest of the most vulnerable members of the family to be court-removed from their birth families, even though I know from a developmental standpoint that any legal action, including continuing the status quo without intervention, will result in further trauma and pain for the family members.
I have had to set aside some significant initial prejudices in more than one case, because with a mentality that I somehow know “better”, I will never be able to align with a client in a way which is truly respectful or open to understanding the intricacies of their lives. There is always more to a human story than can be captured by a court report or allegations, and my goal as a social worker in a legal team is to look for the complexities in each case which have informed the actors’ decisions for good or ill, that I can work to humanize their story for a harsh system. This has required me, in the instance of one of our lawyers guardian ad litem cases, to set for myself the task of actively trying to find something likeable about a client mother who’s failure to protect, at least superficially, exposed her daughter to sexual abuse at the hands of her partner. Rather than make follow my initial assumptions based upon the court report, however, I have been working to reserve judgment on her inaction and the treatment of her daughter as it is portrayed on paper until I interact with her in person more, and try to better understand the circumstances of her life and the case. Only by doing this am I ever going to be an asset to a legal team working for clients in a family court system; if I allow my prejudices and initial impressions to overwhelm my ability to engage with clients in a way which provides a richer understanding of their world, then I have the potential to be as detrimental to their lives as the DHS workers who give them pause in interacting with social workers in the first place. Recognizing this, I have tried hard, despite intermittent frustrations, to continue to engage clients who are leery of working with me and our team, elicited stories regardless of my initial impressions to look for what my biases may have caused me to miss, and continue to seek avenues to get the most comprehensive understanding of my clients’ stories as I can. These steps are the best way, under less than optimal client conditions, that I know to overcome prejudices and serve my client well.
Thursday, April 1, 2010
Wednesday, January 6, 2010
the natural
I am Lord Love’s natural:
Happily I pledge myself
to his service. Worshiping,
I will cry out his praises-
Eager to make obeisance-
Please Master Mars and Lady
Venus’s lusty Son here.
Praying on my grateful knees.
I make my dear offerings,
Inside and out I am Yours.
I’ll perform as dictated.
This is happy consumption,
To make of my body such
Provision that my Love may
Use, and feast upon me ‘til
we are both full, and sated.
~Anna H.
Happily I pledge myself
to his service. Worshiping,
I will cry out his praises-
Eager to make obeisance-
Please Master Mars and Lady
Venus’s lusty Son here.
Praying on my grateful knees.
I make my dear offerings,
Inside and out I am Yours.
I’ll perform as dictated.
This is happy consumption,
To make of my body such
Provision that my Love may
Use, and feast upon me ‘til
we are both full, and sated.
~Anna H.
Book Review: First Person Narrative on Grief and Loss- My Own Country, a Doctor’s Story, by Abraham Verghese
Anna H
Sallie Foley
SW 617- Death, Loss and Grief
Property of the author; do not use or reproduce without express permission.
Abraham Verghese’s narrative on his time as an infectious disease internist treating AIDS patients in the rural, east Tennessee town of Johnson City provides a vivid and compelling depiction of the manifestations of grief and loss which can overwhelm medical and familial care givers in ministering to terminal patients. In reading it, we may find a compelling and deeply personal account of the experience of death, both anticipated and sudden, and the vast array of emotions expressed and felt by those who are required to cope with such losses, as those anticipating their death, and those who are left to care for them, and others to follow. During the first stages of the AIDS epidemic, starting in the summer of 1985 when little was known about the disease and all the stereotypes and stigmas attached to its being an illness of only the urban, gay male and drug-using populations still held largely true, Dr. Verghese begins his tale of slow-dawning but horrific comprehension of the impact AIDS has on patients and family alike. Despite his seemingly pristine country location, as Verghese develops a burgeoning caseload of patients, most of whom are gay men, he unfolds for his readers the rising feelings of panic and helplessness experienced by both the medical and general communities in the face of a disease which is even still considered by many to be a death sentence. Along with the devastation of an HIV/AIDS diagnosis, Verghese opens our eyes to the myriad of losses accumulates through lifetimes of hardship for nearly all of his patients as members of these already pariah groups: familial rejection for sexual orientation, enormous struggles for daily survival in poor and rural areas, and wide-spread social dismissal combine to compound the grief expressed in this book. As he describes sometimes poignant and stirring, other times graphic and disturbing vignettes of living and dying with AIDS, we relive through Verghese’s memoir the acute pain of immediate threat to livelihood that the disease became to his patients. Through his personal struggles to provide care to this much-feared population, we experience again and again the wash of sadness and loss as one after another of his patients becomes a real person in his, and by extension our eyes, only to waste away in pain and die.
Patients are often aghast, even devastated by the news that he must give them, and the range of emotion his patients, and by extension he, feel in anticipation of their death runs the spectrum from nonchalance, denial, rage, courage, depression, and grief to empowerment and a sense of purpose. Family members’ reactions frequently extend as far, but the grief Dr. Verghese and his patients feel is at times compounded when family members react as much of the broader community does: with fear, prejudice, and condemnation for a lifestyle they do not understand or on which they look down. Deaths are often met with the same mixture of feelings from patients and Verghese, some are ready and it is a mercy to see their physical pain ended, others are a frightening indictment of a community’s lack of compassion, or grief- and anger-filled accounts of the seeming futility of trying to help those with this “virus from hell”. Similarly, these patients all cope with their grief in different ways, and in doing so, give Verghese an outlet to express both his and their mixture of emotions. Several patients, such as Fred, who renews his commitment to gay activism in leading the TAP support group for other patients like himself coming to terms with their diagnosis of AIDS, offer the readers bright spots of hope and comfort in the otherwise seemingly bleak remainder of their existence. Some, like the patient Luther, rage at their predicament and give outlet for Verghese’s own bitterness at being able to do little to save anyone he treats. Still others, such as Gordon, gently come to terms with their illness by first grieving, then integrating their loss of future, and often past missed opportunities with loved ones, into a calm and peace which touches us and begins to sooth his and our pain in their death even as it blossoms.
From Dr. Verghese’s point of view, the most difficult aspects of facing death by AIDS is the fear of further loss of self—either in the community, with family, or in one’s autonomy—before one has actually died, coupled with the immense and overwhelming loss of being able to do little, if anything to stave off that eventual loss of self. AIDS is not a quick death, nor is it painless, and it causes much frustration, fear, and grief in his patient’s anticipation of their decline, as well as with regard to Verghese’s sense of self as a doctor and the expected power to heal. As privy to Verghese’s personal experience, we come to realize the toll this cycle of connection with and loss of patients takes on him when he becomes the only doctor trained in AIDS or even willing to provide primary care for his part of Tennessee. Through his treatment of, attachment to, and loss of these patients, we feel the deepening sorrow and sense of despair Verghese has as the death toll rises among these people he can only nominally help, and we grieve with him for all the suffering, caused by both an unrelenting disease, a fearful, too-often hateful community, and the visible deterioration of autonomy held dear by all of these people. They grieve, for the loss of futures they no longer can experience, for the disconnect they often have experienced with their families and that the little time they have left with, for the pain of being shunned and the pain of having to depend on those who are willing to care for them as they physically fall apart.
Thankfully, Verghese learns over the course of the book that, in part with his help, there is much that can and does improve in the quality of this end of life care, so much so that the death sentence AIDS starts out as in 1985 commutes to a gradual decline of maybe years by 1989. With him we discover the profound importance of palliative care and personal connections as he focuses more and more on quality, as well as quantity of life, referring patients to the TAP support group as frequently as he prescribes antibiotics for opportunistic infections, and making personal connections which heal his patients’ souls in a community with only marginal tolerance for the “gay disease” and those who still live with it. His acceptance and even embracing of his patients offers him what his medical degree cannot: the chance to be accepted and cared for as fellow human beings. It is this, more than any other medical approach described in the book, which does the most good in alleviating or at least tempering the grief they all feel. Verghese feels kinship with his displaced patients as an un-rooted, Ethiopian-born Indian working in America; the displacement from community, disconnect from family and ascribed tainted quality that leaves AIDS patients with an untouchable feeling is echoed in the doctor’s own personal life, and, despite ultimately developing compassion fatigue which forces him to detach from this community at the end of the memoir, throughout it we feel the strength of the bonds he develops. These acts of care are the balm—both he as their caring and compassionate doctor, and from those family members and friends giving loving support—which enable many of Verghese’s patients to live out their days in relative peace. Regardless of poverty, which is pervasive in rural east Tennessee, or sexual orientation, the cause of much fear and hate in the community, Verghese is able to form bonds which help diffuse grief, aiding to shift the model from the stigmatization of dying from AIDS to finishing life as much on one’s own terms as possible.
The DeSpelder and Strickland quote that “death is inseparable from the whole human experience; the study of death touches on the past, present, and future” is very much true in the account My Own Country provides of people living with an AIDS diagnosis. For some it is an erasure of any possible future, for many, as Verghese describes and maps out, it is the culmination of a progression of past events for those gay men in rural America who began with a desire to leave home to find a life which fits who they are, and which cannot be obtained in their home communities, but who ultimately return home to their families to integrate past and present, to make up for a lack of future, and to die. By the memoir’s end, Verghese observes that AIDS has gone from an isolating killer of a small, shunned few to providing the surprisingly reassuring possibility of community and support which encompasses both the anticipation of death and the living of the rest of one’s life. This emissary of death has offered a way of living, coping, and loving to those who share its sentence, and rather than be the fugue of mourning for lost futures, AIDS provides the surprising victory march by which his clients come to embrace life more than they had before. Certainly, grief and fear of death are a strain in all the moments thereafter- there is no escaping that the disease is killing them. However, as Verghese comes to realize, the community formed to grieve and cope with the loss of such a diagnosis, which extends to include those family members affected and grieving themselves, becomes one which also makes room for his patients to have a sense of self again, and in doing so, they find reason to celebrate as well. Grief at the loss of community, of past displacement which sent them seeking lives away from their birth home, gives way to the growth of a new community home of their own, in which they may be welcome.
Sallie Foley
SW 617- Death, Loss and Grief
Property of the author; do not use or reproduce without express permission.
Abraham Verghese’s narrative on his time as an infectious disease internist treating AIDS patients in the rural, east Tennessee town of Johnson City provides a vivid and compelling depiction of the manifestations of grief and loss which can overwhelm medical and familial care givers in ministering to terminal patients. In reading it, we may find a compelling and deeply personal account of the experience of death, both anticipated and sudden, and the vast array of emotions expressed and felt by those who are required to cope with such losses, as those anticipating their death, and those who are left to care for them, and others to follow. During the first stages of the AIDS epidemic, starting in the summer of 1985 when little was known about the disease and all the stereotypes and stigmas attached to its being an illness of only the urban, gay male and drug-using populations still held largely true, Dr. Verghese begins his tale of slow-dawning but horrific comprehension of the impact AIDS has on patients and family alike. Despite his seemingly pristine country location, as Verghese develops a burgeoning caseload of patients, most of whom are gay men, he unfolds for his readers the rising feelings of panic and helplessness experienced by both the medical and general communities in the face of a disease which is even still considered by many to be a death sentence. Along with the devastation of an HIV/AIDS diagnosis, Verghese opens our eyes to the myriad of losses accumulates through lifetimes of hardship for nearly all of his patients as members of these already pariah groups: familial rejection for sexual orientation, enormous struggles for daily survival in poor and rural areas, and wide-spread social dismissal combine to compound the grief expressed in this book. As he describes sometimes poignant and stirring, other times graphic and disturbing vignettes of living and dying with AIDS, we relive through Verghese’s memoir the acute pain of immediate threat to livelihood that the disease became to his patients. Through his personal struggles to provide care to this much-feared population, we experience again and again the wash of sadness and loss as one after another of his patients becomes a real person in his, and by extension our eyes, only to waste away in pain and die.
Patients are often aghast, even devastated by the news that he must give them, and the range of emotion his patients, and by extension he, feel in anticipation of their death runs the spectrum from nonchalance, denial, rage, courage, depression, and grief to empowerment and a sense of purpose. Family members’ reactions frequently extend as far, but the grief Dr. Verghese and his patients feel is at times compounded when family members react as much of the broader community does: with fear, prejudice, and condemnation for a lifestyle they do not understand or on which they look down. Deaths are often met with the same mixture of feelings from patients and Verghese, some are ready and it is a mercy to see their physical pain ended, others are a frightening indictment of a community’s lack of compassion, or grief- and anger-filled accounts of the seeming futility of trying to help those with this “virus from hell”. Similarly, these patients all cope with their grief in different ways, and in doing so, give Verghese an outlet to express both his and their mixture of emotions. Several patients, such as Fred, who renews his commitment to gay activism in leading the TAP support group for other patients like himself coming to terms with their diagnosis of AIDS, offer the readers bright spots of hope and comfort in the otherwise seemingly bleak remainder of their existence. Some, like the patient Luther, rage at their predicament and give outlet for Verghese’s own bitterness at being able to do little to save anyone he treats. Still others, such as Gordon, gently come to terms with their illness by first grieving, then integrating their loss of future, and often past missed opportunities with loved ones, into a calm and peace which touches us and begins to sooth his and our pain in their death even as it blossoms.
From Dr. Verghese’s point of view, the most difficult aspects of facing death by AIDS is the fear of further loss of self—either in the community, with family, or in one’s autonomy—before one has actually died, coupled with the immense and overwhelming loss of being able to do little, if anything to stave off that eventual loss of self. AIDS is not a quick death, nor is it painless, and it causes much frustration, fear, and grief in his patient’s anticipation of their decline, as well as with regard to Verghese’s sense of self as a doctor and the expected power to heal. As privy to Verghese’s personal experience, we come to realize the toll this cycle of connection with and loss of patients takes on him when he becomes the only doctor trained in AIDS or even willing to provide primary care for his part of Tennessee. Through his treatment of, attachment to, and loss of these patients, we feel the deepening sorrow and sense of despair Verghese has as the death toll rises among these people he can only nominally help, and we grieve with him for all the suffering, caused by both an unrelenting disease, a fearful, too-often hateful community, and the visible deterioration of autonomy held dear by all of these people. They grieve, for the loss of futures they no longer can experience, for the disconnect they often have experienced with their families and that the little time they have left with, for the pain of being shunned and the pain of having to depend on those who are willing to care for them as they physically fall apart.
Thankfully, Verghese learns over the course of the book that, in part with his help, there is much that can and does improve in the quality of this end of life care, so much so that the death sentence AIDS starts out as in 1985 commutes to a gradual decline of maybe years by 1989. With him we discover the profound importance of palliative care and personal connections as he focuses more and more on quality, as well as quantity of life, referring patients to the TAP support group as frequently as he prescribes antibiotics for opportunistic infections, and making personal connections which heal his patients’ souls in a community with only marginal tolerance for the “gay disease” and those who still live with it. His acceptance and even embracing of his patients offers him what his medical degree cannot: the chance to be accepted and cared for as fellow human beings. It is this, more than any other medical approach described in the book, which does the most good in alleviating or at least tempering the grief they all feel. Verghese feels kinship with his displaced patients as an un-rooted, Ethiopian-born Indian working in America; the displacement from community, disconnect from family and ascribed tainted quality that leaves AIDS patients with an untouchable feeling is echoed in the doctor’s own personal life, and, despite ultimately developing compassion fatigue which forces him to detach from this community at the end of the memoir, throughout it we feel the strength of the bonds he develops. These acts of care are the balm—both he as their caring and compassionate doctor, and from those family members and friends giving loving support—which enable many of Verghese’s patients to live out their days in relative peace. Regardless of poverty, which is pervasive in rural east Tennessee, or sexual orientation, the cause of much fear and hate in the community, Verghese is able to form bonds which help diffuse grief, aiding to shift the model from the stigmatization of dying from AIDS to finishing life as much on one’s own terms as possible.
The DeSpelder and Strickland quote that “death is inseparable from the whole human experience; the study of death touches on the past, present, and future” is very much true in the account My Own Country provides of people living with an AIDS diagnosis. For some it is an erasure of any possible future, for many, as Verghese describes and maps out, it is the culmination of a progression of past events for those gay men in rural America who began with a desire to leave home to find a life which fits who they are, and which cannot be obtained in their home communities, but who ultimately return home to their families to integrate past and present, to make up for a lack of future, and to die. By the memoir’s end, Verghese observes that AIDS has gone from an isolating killer of a small, shunned few to providing the surprisingly reassuring possibility of community and support which encompasses both the anticipation of death and the living of the rest of one’s life. This emissary of death has offered a way of living, coping, and loving to those who share its sentence, and rather than be the fugue of mourning for lost futures, AIDS provides the surprising victory march by which his clients come to embrace life more than they had before. Certainly, grief and fear of death are a strain in all the moments thereafter- there is no escaping that the disease is killing them. However, as Verghese comes to realize, the community formed to grieve and cope with the loss of such a diagnosis, which extends to include those family members affected and grieving themselves, becomes one which also makes room for his patients to have a sense of self again, and in doing so, they find reason to celebrate as well. Grief at the loss of community, of past displacement which sent them seeking lives away from their birth home, gives way to the growth of a new community home of their own, in which they may be welcome.
Saturday, December 12, 2009
Survivors of Suicides: Struggles with Complicated Grief and Approaches to Treatment
Anna H.
Sallie Foley
SW617- Death, Loss and Grief
Intellectual property of the writer. Do not use without express permission.
In his book on addressing grief from a clinical perspective, Grief Counseling and Grief Therapy, Worden (2009) reserves much of a particular chapter specifically to address the issues that arise when faced with a death due to suicide. It is, he notes, a particular type of grief which causes much trouble beyond the normal feelings of pain and loss at the death of a loved one: “Nearly 750,000 people a year are left to grieve the completed suicide of a family member or loved one, and they are left not only with a sense of loss, but with a legacy of shame, fear, rejection, anger and guilt,” (179). Out of all the different experiences throughout the western world, few evoke as complicated and visceral a reaction as surviving a loved one who has died due to suicide. Suicide has been criminalized in countries and been deemed a sin by many cultures; many people frequently continue to see it as the ultimate act of selfishness. It is a type of loss where people don’t send condolence cards, one that is often left unacknowledged, and for which there are few, if any, good explanations. Suicide causes so much disruption among families and communities beyond the normal scope of grief for the death of a loved one that many surviving friends and family struggle for years with loss that stigmatization, coupled with shame, rage, confusion and guilt makes more complicated than any other type of death we encounter. There are, however, many therapeutic means through which people can alleviate these complex and burdensome layers of grief, so that in time they may uncomplicated their grief enough to incorporate it into their love and memories of the person they have lost. This paper will discuss in greater depth the various types of struggles surviving loved ones face when they shoulder the complicated grief of a completed suicide, and several modes of therapy which have been found particularly helpful in mediating their pain.
Grief reactions to the death of a friend, loved one, or family member always include sadness and periods of pain in missing the person whose life has ended. When a the loss is due to suicide, however, these normal feelings can become terribly enmeshed with a myriad of other, often more destructive feelings caused by stigma associated with this particular type of death. “Suicide survivor” is term which has come into clinical parlance to describe anyone who experiences these significant, painful consequences for a suicide within their social network, and there is a recognition that this term is applicable to a significant percentage of the population—perhaps as many as 7% of people in the United States (Jordan, 2009). While not everyone exposed to suicide feels its impact in the same way, the grief experienced by survivors of suicide is most commonly characterized by the shame and guilt they carry with regards to their connection’s death, compounded by other tumultuous emotions such as anger, hurt, betrayal, confusion, and— frequently— shock at the unprepared-for loss. There are thoughts that for many, these complications for survivors of suicide, like those who survive the loss of a loved one to an accident, are suffering in large part due to the sudden, unexpected nature of the death, for in such losses there is no time to say goodbye, or prepare one’s self for the absence of the deceased (Lindqvist, Johansson, and Karlsson, 2008). However, Jordan observes that there are no “clear operational definitions” for a suicide survivor, along with a notable lack of longitudinal studies with regards to their integration of the loss, further indicating that, at least within Western culture, there remains a significant taboo when to dealing with suicide and all that it touches, even when it comes to helping treat those who suffer in its aftermath (Jordan, 2009).
Feigelman, Gorman and Jordan (2009) discuss in great detail both the ways in which stigma in response to suicide has developed in Western culture and the damaging effects it can have on the dead person’s survivors. In Europe, from as early as the Middle Ages the punishment for suicide from the Church and the State extended beyond the deceased to their family: property could be confiscated and held by governing agents, and all immediate relatives could be excommunicated from the Church (Feigelman, Gorman and Jordan, 2008). It is the continuation of this stigmatization, coupled with guilt, which appears to be the primary cause for complicating the grieving process for survivors of suicide up to the present day. In a survey conducted with grief support groups, Feigelman, Gorman and Jordan observed that, when comparing the effects of stigmatization responses in a group of 462 parents who had lost children to suicide with 54 whose children had died to traumatic death and 24 from natural causes, those parents who encountered stigmatizing responses from their peer, support and family groups had greater difficulties with their grief, including the development of depression and suicidal ideation on the part of the survivor, (Feigelman, Gorman and Jordan, 2009).
Distorted communicative perceptions based upon stigmatization within family and social systems in reaction to the suicide can have a significant impact on the ways in which the survivors cope. Families can experience, or themselves develop feelings of blame (or being blamed) for the death, feel the need to keep the nature of the death secrete from extended family or the larger community, and undergo a sense of social ostracism (Jordan, 2008). Even for those who do not encounter any outright negativity regarding their loss, the experience of ambiguity and lack of social protocol for how to be supportive of a family grieving for this sort of loss can lead to exacerbated feelings isolation, shame, and condemnation (Jordan, 2008; Worden, 2009). Worden describes a client who came into his office and lamented that “‘no one will talk with [me]… they act as if it never happened,’” (Worden, 2009). This is not to say that there is no social support for survivors of suicide, nor that all social interactions produce feelings of shame or stigma; there is evidence to suggest that near to half of the survivors of suicide may experience a strengthened feeling of closeness to their remaining living family members and friends or support structure (Feigelman, Gorman and Jordan, 2009). For the other half, however, it does underscore the complicated reactions both felt by the survivors for themselves and as members of the community in which they live. What may be of most import when considering the negative effects of stigma is the expectation— prevalent throughout the centuries, despite the growing recognition in our present time that suicide is almost always predicated on mental disorders and psychological illness— that there will be little support for the survivors, and that they are somehow to blame for their loss (Feigelman, Gorman and Jordan, 2009).
The other, perhaps most pronounced experience for survivors of suicide is the often overwhelming sense of guilt they feel: for not anticipating the actions which caused their loved one’s death, for not recognizing their pain, for not being able to somehow save him or her, and in turn, save themselves the pain they and others sharing their experience now feel. As with stigma, Pridmore and McArthur note that feelings of guilt have been associated with suicidal loss since antiquity in the West; going back as far as ancient Greece they see maladaptive feelings such as guilt, shame, anger, and sorrow (Pridmore and McArthur, 2009). Worden discusses that while guilt is frequently a feature of normal grief responses, the amount of guilt felt by survivors of suicide is inordinate and often overpowering (Worden, 2009). People who feel this amount of guilt can end up feeling themselves deserving of punishment, which can be very damaging to the survivor’s psyche and in turn can have physical consequences (Worden, 2009).
This sense of pervasive guilt may be especially the case for children and adolescent offspring of parents who have died from suicide: apart from the negative indications parental suicide has for child mental health outcomes in the future, the disruption of family functioning both before and after a parental death from suicide can have a significant impact on the psychosocial functioning of offspring (Kuramoto, Brent, and Wilcox , 2009). Worden discusses the ways in which reality testing when working with youth is particularly important, that families and clinicians be alerted to self-blaming and guilty feelings in children, as there is a correlation between being affected by suicide as a survivor and the survivor experiencing suicidal ideation in him or herself (Worden, 2009). Higher levels of shame, anxiety and anger have all been found in adolescent children whose parents died by suicide than in those whose parents were killed or died in other, less traumatic ways, and there is an increased risk for behavioral problems, well as possible decrease in overall functioning within the bereaved family unit (Cerel, Fristad, Weller and Weller (1999) in Kuramoto, Brent, and Wilcox , 2009). Jordan notes that many people incorporate their feelings of guilt and self-blaming into an ongoing analysis after their loved one’s suicide to determine if they were somehow the cause of it; unfortunately, these feelings, and the need to assuage them, can cloud the survivor’s recognition that their loved one, like up to 90% of suicide completers, had severe mental health disturbances, and these—not their actions or inactions—were what led the loved one to take their own life (Jordan, 2008).
All grief incorporates these elements or guilt and a wish to blame, and while the expectation of stigmatization appears to be particular to survivors of suicides, the social isolation felt by those who are grieving can cause additional pain beyond their initial loss; in the complex grief of survivors of suicide, there is another piece, comprised of anger and feelings of abandonment, which prolongs and further complicates the survivor’s ability to integrate their loss back into the tasks of living. Worden discusses the intensity of angry feelings survivors may experience when they perceive the death as a rejection; children and spouses may feel betrayed or as though their loved one’s death was a direct means of leaving them, and their grief may take on qualities of resentment or even rage (Worden, 2009; Kuramoto, Brent, and Wilcox , 2009). These mixes of emotions often feed into their guilt, and can have an impact on self esteem, that they feel as though their worth as the survivor is less because they were the ones who were left. There may also be questions in the survivor’s mind as to whether their deceased loved one was driven to death, which can be compounded by feeling of anger and hurt that they felt the need to kill themselves, or were not ‘strong enough’ to continue living (Jordan, 2008). Guilt and unworthiness at surviving often war with rage and immense pain at being left alone. Particularly in the case of teenage suicide, where there may be little sign of severe emotional distress disclosed before the act of suicide, surviving parents struggle with the unexpected nature of the death, their anger at being deceived by their children, their overwhelming pain at the loss of a child, and their guilt as seemingly failed parents (Lindqvist, Johansson, and Karlsson, 2008). Without intervention, such complicated grief, especially if coupled with post-traumatic stress if the survivor was a person who discovered their loved one’s death or body, can mix to cause grief so complicated that it overwhelms a person’s ability to work through their loss on their own such that they can continue living (Jordan, 2008).
In order to help intervene in complicated grief for survivors of suicide so that they are not wholly overrun with their feelings and cease to experience life themselves, it is of primary importance that the clinician acknowledge the death of their loved one and the entire spectrum of grief they feel because of that loss, to aid in overcoming the first hurdle of dealing with an unspeakable loss (Worden, 2009). The stigma of such a socially unacceptable behavior must be undermined in the eyes of the client, both so that the therapist may form an alliance with them and that they may feel that here is a safe place to begin coming to terms with all their feelings regarding their survivorship without being judged for any of them. Given that barriers to grief experience stemming from negative experiences regarding their loss can be linked to depression and suicidal thinking on the part of the survivor, it is paramount that a therapist acknowledge the reality of the loss along with the client, and bridge the loss of community they may have experienced (Feigelman, Gorman, and Jordan, 2009; Worden 2009). In surmounting the feelings of social and community isolation, it may be necessary for the clinician and client to take stock of what relationships are healthy and supportive to that client, and which may be more painful than they are worth currently (Feigelman, Gorman, and Jordan, 2009). This may even entail supporting the survivor in instructing their support system how to better work for them, which in turn will help destigmatize the association with the type of loss they are experiencing. Establishing this groundwork of support and belief for the client’s feeling, whatever they may be, is important in all cases, but all the more so when they are the survivor of a socially unacceptable loss.
While accepting the losses and the tumult of emotions the survivor has faced, however, it is important to keep in mind that the therapist needs to reality test a client’s feelings of guilt and blame, gently challenging or correcting distortions as they come up in conversation. Such gentle questioning can be highly appropriate for a client who feels excessive guilt, shame, or abandonment, as these feelings can stand in the way of Worden’s second task, processing the pain of grief. He gives the example, for instance, that it is acceptable for survivors to feel some level of relief that a person who had been experiencing such emotional anguish might no longer be in pain, even as they also feel anger at that person for leaving: such a jumble of emotions not only needs to normalized, but examined from an outside perspective, in order for a client to come to terms with all that they feel in association with their loved one’s actions (Worden, 2009). Similarly, while relieving the guilt many people feel for just having emotions which might be deemed somehow inappropriate, it is also necessary to give them the permission to feel as they do. These normalizing and giving permission tactics can be utilized either in one-on-one or group grief work settings with success, as individual attention and contact with other survivors are both beneficial in acknowledging the unique horror and relieving the isolation associated with suicide (Jordan, 2008). The best supports for survivors may come from other family members and close social connections, and it may be useful to incorporate them into a therapeutic situation, to act as witnesses and, in doing so, assuage some of the guilt and stigma of grief of this nature (Feigelman, Gorman, and Jordan, 2009).
Stepakoff (2009) suggests that, since suicide explicitly is a destructive act, a treatment of particular use for survivors of suicide involves active and willful countering of destruction, in the form of finding meaning and solace in creativity. To this end, she recognizes poetry therapy, the “utilization of poetry and related forms of literature and creative writing in order to improve psychological functioning” as a technique which is of great help to some survivors of suicide (Stepakoff, 2009). Lindqvist, Johansson, and Karlsson (2008) suggest that one of the hardest things to cope with is a survivor’s attempt to see a meaning in the actions their loved one has taken, and it can play a vital role in the ways in which survivors struggle with or accept their loss. Poetry therapy, therefore, is a means by which survivors can break their silence and express their struggles regarding the meaning of the suicide in an externalizing manner (Stepakoff, 2009). She outlines what she sees as the four primary tasks of for using poetry in working with survivors of suicide as:
“(a) to describe, in a fresh, creative manner, common aspects of the grieving process after a suicide, thereby helping participants feel less isolated; (b) to model exceptionally honest and brave self-expression, thereby freeing participants to express themselves more frankly and fully; (c) to give external form to internal, difficult-to-articulate emotions and perceptions, thereby helping participants contain their psychological pain; and (d) to serve as objects of aesthetic beauty, thereby instilling in participants renewed feelings of vitality and hope.”
(Stepakoff, 2009).
The approach is in keeping with Worden’s thoughts on helping survivors make meaning of their experiences of pain and grief by participating in the search for an answer for why this terrible even occurred, as well as work through task three, adjusting to a world without the deceased (Worden, 2009).
There are two forms of poetry therapy—receptive, which relies on the use of preexisting poetry, and expressive methods, which invites a survivor to use their own words, in poetry, or other creative writing form—either of which can be used on one’s own, or and especially to start out with, as facilitated by a therapist. Stepakoff outlines the use of receptive poetry as following one of two general methods: the survivor may pick a poem themselves in which they can find meaning and an echo of their feelings about the loss, and can read it aloud or to themselves; alternatively, the therapist can guide the survivor through the process where they facilitate the interaction and chose a poem which seems most appropriate. The former is more often utilized in the context of individual work, while the latter tends to be more in grief group settings, but either way constitutes classic poetry therapy, wherein the client’s task is to discern what they relate to in the body of work, and use it as a catalyst to discuss how they are experiencing their loss (Stepakoff, 2009). The expressive form of poetry therapy utilizes the client’s own words and thoughts to achieve what Worden discusses as the process of grieving; it includes the survivor’s writing down and often reading aloud the thoughts and feelings he or she experiences throughout the therapy, and at specific point in time, as they feel certain things. The theory behind this work is rooted in the idea of catharsis— that it is necessary to come to some resolution of powerful and often hurtful emotions through a purification or purging of the thoughts or feelings—and the practice of externalizing feelings, such as what is used in narrative therapy work, to separate out how a survivor feels from who that survivor is (Stepakoff, 2009). In doing so, the goal is to build in the client the ability to pick up, examine, and feel for a portion of time the overwhelming set of emotions he or she has been fraught with, without being overwhelmed by the constant presence of those aspects of grief within themselves.
It is not the resolution of the grief that is sought, but rather the rebuilding of the survivor’s life with their grief integrated into their future which therapists attempt to achieve when working with such clients (Jordan, 2008). Incorporating poetry therapy and other externalizing models into a framework where the therapist is present and accepting of the pain and grief the survivor brings into the room is a key to working with this population, and in doing so, we as therapists offer a means of easing the sorrow enough that a survivor can, in time, begin to remember their loved one while moving forward with their life.
Bibliography:
Feigelman, William, Bernard S. Gorman, and John R. Jordan, (2009). “Stigmatization and suicide bereavement.” Death Studies, 33 (7) 591-608.
Guglielmi, Maggie Colleen, (2009). “The impact of stigma on the grief process of suicide survivors.” The Sciences and Engineering, 69(8-B) 5027.
Jordan, John R. (2008). “Bereavement after Suicide.” Psychiatric Annals 38(10) 679-685
Kuramoto, S. Janet, David A. Brent, and Holly C. Wilcox (2009). “The Impact of Parental Suicide on Child and Adolescent Offspring.” Suicide and Life-Threatening Behavior 39(2) 137-151.
Lindqvist, P., L. Johansson, and U. Karlsson, (2008). “In the aftermath of teenage suicide: A qualitative study of the psychosocial consequences for the surviving family members.” BMC PSYCHIATRY, 8:26.
Pridmore, Saxby and Milford McArthur, (2009). “Suicide and Western culture.” Australasian Psychiatry 17(1) 42-50.
Stepakoff, S., (2009). “From destruction to creation, from silence to speech: Poetry therapy principles and practices for working with suicide grief.” ARTS IN PSYCHOTHERAPY 36 (2): 105-113.
Worden, J. William, (2009). Grief Counseling and Grief Therapy. New York: Springer Publishing Company, 4th ed.
Sallie Foley
SW617- Death, Loss and Grief
Intellectual property of the writer. Do not use without express permission.
In his book on addressing grief from a clinical perspective, Grief Counseling and Grief Therapy, Worden (2009) reserves much of a particular chapter specifically to address the issues that arise when faced with a death due to suicide. It is, he notes, a particular type of grief which causes much trouble beyond the normal feelings of pain and loss at the death of a loved one: “Nearly 750,000 people a year are left to grieve the completed suicide of a family member or loved one, and they are left not only with a sense of loss, but with a legacy of shame, fear, rejection, anger and guilt,” (179). Out of all the different experiences throughout the western world, few evoke as complicated and visceral a reaction as surviving a loved one who has died due to suicide. Suicide has been criminalized in countries and been deemed a sin by many cultures; many people frequently continue to see it as the ultimate act of selfishness. It is a type of loss where people don’t send condolence cards, one that is often left unacknowledged, and for which there are few, if any, good explanations. Suicide causes so much disruption among families and communities beyond the normal scope of grief for the death of a loved one that many surviving friends and family struggle for years with loss that stigmatization, coupled with shame, rage, confusion and guilt makes more complicated than any other type of death we encounter. There are, however, many therapeutic means through which people can alleviate these complex and burdensome layers of grief, so that in time they may uncomplicated their grief enough to incorporate it into their love and memories of the person they have lost. This paper will discuss in greater depth the various types of struggles surviving loved ones face when they shoulder the complicated grief of a completed suicide, and several modes of therapy which have been found particularly helpful in mediating their pain.
Grief reactions to the death of a friend, loved one, or family member always include sadness and periods of pain in missing the person whose life has ended. When a the loss is due to suicide, however, these normal feelings can become terribly enmeshed with a myriad of other, often more destructive feelings caused by stigma associated with this particular type of death. “Suicide survivor” is term which has come into clinical parlance to describe anyone who experiences these significant, painful consequences for a suicide within their social network, and there is a recognition that this term is applicable to a significant percentage of the population—perhaps as many as 7% of people in the United States (Jordan, 2009). While not everyone exposed to suicide feels its impact in the same way, the grief experienced by survivors of suicide is most commonly characterized by the shame and guilt they carry with regards to their connection’s death, compounded by other tumultuous emotions such as anger, hurt, betrayal, confusion, and— frequently— shock at the unprepared-for loss. There are thoughts that for many, these complications for survivors of suicide, like those who survive the loss of a loved one to an accident, are suffering in large part due to the sudden, unexpected nature of the death, for in such losses there is no time to say goodbye, or prepare one’s self for the absence of the deceased (Lindqvist, Johansson, and Karlsson, 2008). However, Jordan observes that there are no “clear operational definitions” for a suicide survivor, along with a notable lack of longitudinal studies with regards to their integration of the loss, further indicating that, at least within Western culture, there remains a significant taboo when to dealing with suicide and all that it touches, even when it comes to helping treat those who suffer in its aftermath (Jordan, 2009).
Feigelman, Gorman and Jordan (2009) discuss in great detail both the ways in which stigma in response to suicide has developed in Western culture and the damaging effects it can have on the dead person’s survivors. In Europe, from as early as the Middle Ages the punishment for suicide from the Church and the State extended beyond the deceased to their family: property could be confiscated and held by governing agents, and all immediate relatives could be excommunicated from the Church (Feigelman, Gorman and Jordan, 2008). It is the continuation of this stigmatization, coupled with guilt, which appears to be the primary cause for complicating the grieving process for survivors of suicide up to the present day. In a survey conducted with grief support groups, Feigelman, Gorman and Jordan observed that, when comparing the effects of stigmatization responses in a group of 462 parents who had lost children to suicide with 54 whose children had died to traumatic death and 24 from natural causes, those parents who encountered stigmatizing responses from their peer, support and family groups had greater difficulties with their grief, including the development of depression and suicidal ideation on the part of the survivor, (Feigelman, Gorman and Jordan, 2009).
Distorted communicative perceptions based upon stigmatization within family and social systems in reaction to the suicide can have a significant impact on the ways in which the survivors cope. Families can experience, or themselves develop feelings of blame (or being blamed) for the death, feel the need to keep the nature of the death secrete from extended family or the larger community, and undergo a sense of social ostracism (Jordan, 2008). Even for those who do not encounter any outright negativity regarding their loss, the experience of ambiguity and lack of social protocol for how to be supportive of a family grieving for this sort of loss can lead to exacerbated feelings isolation, shame, and condemnation (Jordan, 2008; Worden, 2009). Worden describes a client who came into his office and lamented that “‘no one will talk with [me]… they act as if it never happened,’” (Worden, 2009). This is not to say that there is no social support for survivors of suicide, nor that all social interactions produce feelings of shame or stigma; there is evidence to suggest that near to half of the survivors of suicide may experience a strengthened feeling of closeness to their remaining living family members and friends or support structure (Feigelman, Gorman and Jordan, 2009). For the other half, however, it does underscore the complicated reactions both felt by the survivors for themselves and as members of the community in which they live. What may be of most import when considering the negative effects of stigma is the expectation— prevalent throughout the centuries, despite the growing recognition in our present time that suicide is almost always predicated on mental disorders and psychological illness— that there will be little support for the survivors, and that they are somehow to blame for their loss (Feigelman, Gorman and Jordan, 2009).
The other, perhaps most pronounced experience for survivors of suicide is the often overwhelming sense of guilt they feel: for not anticipating the actions which caused their loved one’s death, for not recognizing their pain, for not being able to somehow save him or her, and in turn, save themselves the pain they and others sharing their experience now feel. As with stigma, Pridmore and McArthur note that feelings of guilt have been associated with suicidal loss since antiquity in the West; going back as far as ancient Greece they see maladaptive feelings such as guilt, shame, anger, and sorrow (Pridmore and McArthur, 2009). Worden discusses that while guilt is frequently a feature of normal grief responses, the amount of guilt felt by survivors of suicide is inordinate and often overpowering (Worden, 2009). People who feel this amount of guilt can end up feeling themselves deserving of punishment, which can be very damaging to the survivor’s psyche and in turn can have physical consequences (Worden, 2009).
This sense of pervasive guilt may be especially the case for children and adolescent offspring of parents who have died from suicide: apart from the negative indications parental suicide has for child mental health outcomes in the future, the disruption of family functioning both before and after a parental death from suicide can have a significant impact on the psychosocial functioning of offspring (Kuramoto, Brent, and Wilcox , 2009). Worden discusses the ways in which reality testing when working with youth is particularly important, that families and clinicians be alerted to self-blaming and guilty feelings in children, as there is a correlation between being affected by suicide as a survivor and the survivor experiencing suicidal ideation in him or herself (Worden, 2009). Higher levels of shame, anxiety and anger have all been found in adolescent children whose parents died by suicide than in those whose parents were killed or died in other, less traumatic ways, and there is an increased risk for behavioral problems, well as possible decrease in overall functioning within the bereaved family unit (Cerel, Fristad, Weller and Weller (1999) in Kuramoto, Brent, and Wilcox , 2009). Jordan notes that many people incorporate their feelings of guilt and self-blaming into an ongoing analysis after their loved one’s suicide to determine if they were somehow the cause of it; unfortunately, these feelings, and the need to assuage them, can cloud the survivor’s recognition that their loved one, like up to 90% of suicide completers, had severe mental health disturbances, and these—not their actions or inactions—were what led the loved one to take their own life (Jordan, 2008).
All grief incorporates these elements or guilt and a wish to blame, and while the expectation of stigmatization appears to be particular to survivors of suicides, the social isolation felt by those who are grieving can cause additional pain beyond their initial loss; in the complex grief of survivors of suicide, there is another piece, comprised of anger and feelings of abandonment, which prolongs and further complicates the survivor’s ability to integrate their loss back into the tasks of living. Worden discusses the intensity of angry feelings survivors may experience when they perceive the death as a rejection; children and spouses may feel betrayed or as though their loved one’s death was a direct means of leaving them, and their grief may take on qualities of resentment or even rage (Worden, 2009; Kuramoto, Brent, and Wilcox , 2009). These mixes of emotions often feed into their guilt, and can have an impact on self esteem, that they feel as though their worth as the survivor is less because they were the ones who were left. There may also be questions in the survivor’s mind as to whether their deceased loved one was driven to death, which can be compounded by feeling of anger and hurt that they felt the need to kill themselves, or were not ‘strong enough’ to continue living (Jordan, 2008). Guilt and unworthiness at surviving often war with rage and immense pain at being left alone. Particularly in the case of teenage suicide, where there may be little sign of severe emotional distress disclosed before the act of suicide, surviving parents struggle with the unexpected nature of the death, their anger at being deceived by their children, their overwhelming pain at the loss of a child, and their guilt as seemingly failed parents (Lindqvist, Johansson, and Karlsson, 2008). Without intervention, such complicated grief, especially if coupled with post-traumatic stress if the survivor was a person who discovered their loved one’s death or body, can mix to cause grief so complicated that it overwhelms a person’s ability to work through their loss on their own such that they can continue living (Jordan, 2008).
In order to help intervene in complicated grief for survivors of suicide so that they are not wholly overrun with their feelings and cease to experience life themselves, it is of primary importance that the clinician acknowledge the death of their loved one and the entire spectrum of grief they feel because of that loss, to aid in overcoming the first hurdle of dealing with an unspeakable loss (Worden, 2009). The stigma of such a socially unacceptable behavior must be undermined in the eyes of the client, both so that the therapist may form an alliance with them and that they may feel that here is a safe place to begin coming to terms with all their feelings regarding their survivorship without being judged for any of them. Given that barriers to grief experience stemming from negative experiences regarding their loss can be linked to depression and suicidal thinking on the part of the survivor, it is paramount that a therapist acknowledge the reality of the loss along with the client, and bridge the loss of community they may have experienced (Feigelman, Gorman, and Jordan, 2009; Worden 2009). In surmounting the feelings of social and community isolation, it may be necessary for the clinician and client to take stock of what relationships are healthy and supportive to that client, and which may be more painful than they are worth currently (Feigelman, Gorman, and Jordan, 2009). This may even entail supporting the survivor in instructing their support system how to better work for them, which in turn will help destigmatize the association with the type of loss they are experiencing. Establishing this groundwork of support and belief for the client’s feeling, whatever they may be, is important in all cases, but all the more so when they are the survivor of a socially unacceptable loss.
While accepting the losses and the tumult of emotions the survivor has faced, however, it is important to keep in mind that the therapist needs to reality test a client’s feelings of guilt and blame, gently challenging or correcting distortions as they come up in conversation. Such gentle questioning can be highly appropriate for a client who feels excessive guilt, shame, or abandonment, as these feelings can stand in the way of Worden’s second task, processing the pain of grief. He gives the example, for instance, that it is acceptable for survivors to feel some level of relief that a person who had been experiencing such emotional anguish might no longer be in pain, even as they also feel anger at that person for leaving: such a jumble of emotions not only needs to normalized, but examined from an outside perspective, in order for a client to come to terms with all that they feel in association with their loved one’s actions (Worden, 2009). Similarly, while relieving the guilt many people feel for just having emotions which might be deemed somehow inappropriate, it is also necessary to give them the permission to feel as they do. These normalizing and giving permission tactics can be utilized either in one-on-one or group grief work settings with success, as individual attention and contact with other survivors are both beneficial in acknowledging the unique horror and relieving the isolation associated with suicide (Jordan, 2008). The best supports for survivors may come from other family members and close social connections, and it may be useful to incorporate them into a therapeutic situation, to act as witnesses and, in doing so, assuage some of the guilt and stigma of grief of this nature (Feigelman, Gorman, and Jordan, 2009).
Stepakoff (2009) suggests that, since suicide explicitly is a destructive act, a treatment of particular use for survivors of suicide involves active and willful countering of destruction, in the form of finding meaning and solace in creativity. To this end, she recognizes poetry therapy, the “utilization of poetry and related forms of literature and creative writing in order to improve psychological functioning” as a technique which is of great help to some survivors of suicide (Stepakoff, 2009). Lindqvist, Johansson, and Karlsson (2008) suggest that one of the hardest things to cope with is a survivor’s attempt to see a meaning in the actions their loved one has taken, and it can play a vital role in the ways in which survivors struggle with or accept their loss. Poetry therapy, therefore, is a means by which survivors can break their silence and express their struggles regarding the meaning of the suicide in an externalizing manner (Stepakoff, 2009). She outlines what she sees as the four primary tasks of for using poetry in working with survivors of suicide as:
“(a) to describe, in a fresh, creative manner, common aspects of the grieving process after a suicide, thereby helping participants feel less isolated; (b) to model exceptionally honest and brave self-expression, thereby freeing participants to express themselves more frankly and fully; (c) to give external form to internal, difficult-to-articulate emotions and perceptions, thereby helping participants contain their psychological pain; and (d) to serve as objects of aesthetic beauty, thereby instilling in participants renewed feelings of vitality and hope.”
(Stepakoff, 2009).
The approach is in keeping with Worden’s thoughts on helping survivors make meaning of their experiences of pain and grief by participating in the search for an answer for why this terrible even occurred, as well as work through task three, adjusting to a world without the deceased (Worden, 2009).
There are two forms of poetry therapy—receptive, which relies on the use of preexisting poetry, and expressive methods, which invites a survivor to use their own words, in poetry, or other creative writing form—either of which can be used on one’s own, or and especially to start out with, as facilitated by a therapist. Stepakoff outlines the use of receptive poetry as following one of two general methods: the survivor may pick a poem themselves in which they can find meaning and an echo of their feelings about the loss, and can read it aloud or to themselves; alternatively, the therapist can guide the survivor through the process where they facilitate the interaction and chose a poem which seems most appropriate. The former is more often utilized in the context of individual work, while the latter tends to be more in grief group settings, but either way constitutes classic poetry therapy, wherein the client’s task is to discern what they relate to in the body of work, and use it as a catalyst to discuss how they are experiencing their loss (Stepakoff, 2009). The expressive form of poetry therapy utilizes the client’s own words and thoughts to achieve what Worden discusses as the process of grieving; it includes the survivor’s writing down and often reading aloud the thoughts and feelings he or she experiences throughout the therapy, and at specific point in time, as they feel certain things. The theory behind this work is rooted in the idea of catharsis— that it is necessary to come to some resolution of powerful and often hurtful emotions through a purification or purging of the thoughts or feelings—and the practice of externalizing feelings, such as what is used in narrative therapy work, to separate out how a survivor feels from who that survivor is (Stepakoff, 2009). In doing so, the goal is to build in the client the ability to pick up, examine, and feel for a portion of time the overwhelming set of emotions he or she has been fraught with, without being overwhelmed by the constant presence of those aspects of grief within themselves.
It is not the resolution of the grief that is sought, but rather the rebuilding of the survivor’s life with their grief integrated into their future which therapists attempt to achieve when working with such clients (Jordan, 2008). Incorporating poetry therapy and other externalizing models into a framework where the therapist is present and accepting of the pain and grief the survivor brings into the room is a key to working with this population, and in doing so, we as therapists offer a means of easing the sorrow enough that a survivor can, in time, begin to remember their loved one while moving forward with their life.
Bibliography:
Feigelman, William, Bernard S. Gorman, and John R. Jordan, (2009). “Stigmatization and suicide bereavement.” Death Studies, 33 (7) 591-608.
Guglielmi, Maggie Colleen, (2009). “The impact of stigma on the grief process of suicide survivors.” The Sciences and Engineering, 69(8-B) 5027.
Jordan, John R. (2008). “Bereavement after Suicide.” Psychiatric Annals 38(10) 679-685
Kuramoto, S. Janet, David A. Brent, and Holly C. Wilcox (2009). “The Impact of Parental Suicide on Child and Adolescent Offspring.” Suicide and Life-Threatening Behavior 39(2) 137-151.
Lindqvist, P., L. Johansson, and U. Karlsson, (2008). “In the aftermath of teenage suicide: A qualitative study of the psychosocial consequences for the surviving family members.” BMC PSYCHIATRY, 8:26.
Pridmore, Saxby and Milford McArthur, (2009). “Suicide and Western culture.” Australasian Psychiatry 17(1) 42-50.
Stepakoff, S., (2009). “From destruction to creation, from silence to speech: Poetry therapy principles and practices for working with suicide grief.” ARTS IN PSYCHOTHERAPY 36 (2): 105-113.
Worden, J. William, (2009). Grief Counseling and Grief Therapy. New York: Springer Publishing Company, 4th ed.
Sunday, November 8, 2009
Biases and Dilemmas
Anna H
For Laura Nitzberg, Couples Therapy
Upon first consideration, I like to think that I don’t have much in the way of biases for practicing with couples in therapy. I consider myself an ally of folks within the BLGT communities, and therefore believe whole-heartedly that loving relationships between two people are good, no matter what their gender expression or orientations. In a related area of consideration, I consider myself a sex-positive person, and I include within that designation the feeling that, as long as the people within the relationship as they define it are practicing safe, sane, consensual and risk-aware kink—regardless of what their particular kink might be—then they are free to do what makes themselves and each other happy. There are boundaries to this acceptance, of course: all relationships must be consensual, and no partner should ever feel abused or taken advantage of within the context of their relationship, be that in an emotional, physical, sexual, economic, or psychological realm.
These being my base line for acceptance, I realize that I need to consider how I personally feel about relationship styles and communication to better recognize where my biases lie. I do not consider infidelity to be acceptable behavior unless it is within explicitly open and recognized parameters; that is to say, I think the idea of cheating, as opposed to open relationships or polyamory, is wrong. The deception and lying violates the trust and affection necessary for a healthy relationship, and I would probably have a hard time counseling a client who came to me having been unfaithful to his or her partner. I know that people can get over such hurts in their relationships, but personally I would have trouble remaining objective and neutral with a couple where one of the partners had betrayed their relationship with the other in such a way.
Interestingly, while I do consider myself at the very least non-damning of those sexual practices that run counter to my own, I do not agree with promiscuity, both for moral and health reasons. This gives me pause when I consider the separate, but related idea, of swinging, where married couples include other married couples in their sexuality. I feel somewhat conflicted regarding this, because I wish to be at least permissive of others’ sexuality, as it is really no business of mine what they do as long as they are being good to each other. In our culture, and to my way of thinking, however, it feels that marriage takes a couple into a different set of relational boundaries which swinging with other married couples seems to belie. Again, my concern is rooted in abuse and harm, because I have my doubts as to whether couples can truly remain happy and committed to each other, while having sex with other people, given that sharing sexuality is such a fundamental part of what it means to be bonded in romantic relationship with someone else. When a relationship becomes defined by marriage, it feels to me that people are saying they wish to only be with this one person for as long as they both may, whatever that ends up meaning. While polyamorous relationships may accept multiple partners on equal footing or a primary partner and other lovers, the boundaries of the relationships are necessarily set up to allow this, and therefore all parties involved are in agreement as to what that means. This expectation does not exist within the parameters of marriage, and therefore I struggle to accept that people married to one another would want to involve themselves with others, but not consider it infidelity. Other areas where I think I might struggle include circumstances where there is a significant age, socioeconomic, or other power disparity between the two halves of the couple, because I might be skeptical of the potential for abuse in some form.
For Laura Nitzberg, Couples Therapy
Upon first consideration, I like to think that I don’t have much in the way of biases for practicing with couples in therapy. I consider myself an ally of folks within the BLGT communities, and therefore believe whole-heartedly that loving relationships between two people are good, no matter what their gender expression or orientations. In a related area of consideration, I consider myself a sex-positive person, and I include within that designation the feeling that, as long as the people within the relationship as they define it are practicing safe, sane, consensual and risk-aware kink—regardless of what their particular kink might be—then they are free to do what makes themselves and each other happy. There are boundaries to this acceptance, of course: all relationships must be consensual, and no partner should ever feel abused or taken advantage of within the context of their relationship, be that in an emotional, physical, sexual, economic, or psychological realm.
These being my base line for acceptance, I realize that I need to consider how I personally feel about relationship styles and communication to better recognize where my biases lie. I do not consider infidelity to be acceptable behavior unless it is within explicitly open and recognized parameters; that is to say, I think the idea of cheating, as opposed to open relationships or polyamory, is wrong. The deception and lying violates the trust and affection necessary for a healthy relationship, and I would probably have a hard time counseling a client who came to me having been unfaithful to his or her partner. I know that people can get over such hurts in their relationships, but personally I would have trouble remaining objective and neutral with a couple where one of the partners had betrayed their relationship with the other in such a way.
Interestingly, while I do consider myself at the very least non-damning of those sexual practices that run counter to my own, I do not agree with promiscuity, both for moral and health reasons. This gives me pause when I consider the separate, but related idea, of swinging, where married couples include other married couples in their sexuality. I feel somewhat conflicted regarding this, because I wish to be at least permissive of others’ sexuality, as it is really no business of mine what they do as long as they are being good to each other. In our culture, and to my way of thinking, however, it feels that marriage takes a couple into a different set of relational boundaries which swinging with other married couples seems to belie. Again, my concern is rooted in abuse and harm, because I have my doubts as to whether couples can truly remain happy and committed to each other, while having sex with other people, given that sharing sexuality is such a fundamental part of what it means to be bonded in romantic relationship with someone else. When a relationship becomes defined by marriage, it feels to me that people are saying they wish to only be with this one person for as long as they both may, whatever that ends up meaning. While polyamorous relationships may accept multiple partners on equal footing or a primary partner and other lovers, the boundaries of the relationships are necessarily set up to allow this, and therefore all parties involved are in agreement as to what that means. This expectation does not exist within the parameters of marriage, and therefore I struggle to accept that people married to one another would want to involve themselves with others, but not consider it infidelity. Other areas where I think I might struggle include circumstances where there is a significant age, socioeconomic, or other power disparity between the two halves of the couple, because I might be skeptical of the potential for abuse in some form.
Friday, October 2, 2009
Personal Reflections on Grief and Loss
Anna H
9/15/09
In considering how I have personally come in contact with death and loss, or experienced grief, I must first acknowledge that I do not feel as though I have had much first-hand knowledge of what it is like to lose someone. I have been blessed to have not lost anyone immediately close to me, neither friend nor nuclear family member. That being said, however, it occurs to me that there are a number of different categories of loss which I tend not to consider to be “as important” somehow when applied to myself (though they are significant in the lives of others). When I allow myself to broaden my approach to loss- as I would with a client, though perhaps reticently for myself- I come to realize that there may be much for me to say on the topic which I can speak to personally.
My experiences with personal grief stem more from an awareness of people and opportunities I have not had. Some of my greatest losses are more concerned with the sense of lacking and wanting, rather than the traditional experiences of severed attachments due to death. I am the daughter of divorced parents, who separated when I was 4 years old; therefore, I have not had the experience of growing up in an intact family system, with the support and ready attention of both biological parents. While the divorce in and of itself might qualify as a major loss, in my mind the grief comes not so much from their separation as such, but from the losses that occur as a result of not having them together. I do not remember what it was to have my parents love one another, to model for me how a good working relationship functions, or for us to work as a happy family. These losses of what I could- perhaps feel I should- have had in my growing up are much more what I feel, as I was not old enough to know what things might have been like before my parents became unhappy with each other. Loneliness, and the awareness of missing good family relationships, has therefore been the most pervasive cause of grief in my life.
Beyond my parents, I have grown up with very few family ties: my parents each were isolated themselves from their extended and nuclear families, and, though for different reasons, the end result was that as their daughter, I know very little in the way of familial support or interaction. My mom’s mother died of breast cancer when I was two and my mother still grieves for her, but I do not know what it is like to feel that pain immediately, because I didn’t get the chance to know her; it is for that that I grieve. My father’s parents both lived in Florida and were very much out of regular contact with my Dad due to his strained relationship with them after they kicked him out of the house at age 18 for getting his first wife pregnant; they both died by the time I entered high school. My mother’s father, who died only this past April, was my last grandparent, but due to the falling out she as the result of much hurt and anger over my grandparent’s divorce and my grandfather’s marriage to the woman with whom he had an affair before that, I too lost the chance to develop a meaningful relationship with him. As much as family means to me in theory, my personal experiences with the ways in which families interact has been extremely curtailed by the actions of my parents, beginning long before I was even born. While I don’t often think of these things as losses per say- they are so far removed from my experiences that I again don’t know to miss them most of the time- when I allow myself to realize the extent of my family connections, I am aware that my ties with family beyond my mother, father and stepmother are only tenuous at best, and due to the nature of relationships damaged before I had a chance to experience them, I inherited the disconnection and isolation of my parents’ choices.
I can remember growing up in some ways very much alone, as both an only child, and the daughter of a single, working mother who out of necessity had to leave me at home, or with care-givers for extended periods of time from the age of 6 until I moved to college. That isolation seemed to follow me into my middle and high school experiences, and in reflecting back on my experiences as an adolescent, I am cognizant of a significant amount of time spent on my own, at home by myself. Because I had very little in the way of extended family connection, I have long been aware that my friends are in many ways my family of my own choosing, and as such the separation and drifting apart that occurs when life stages and physical closeness wane have been acutely and painfully felt on my part. This is my greatest source of fear for future loss, which in and of itself may play a part in my understanding of what it means to experience grief: after the initial pain of a loss has begun to subside, there still remains the fear that another, equally hurtful loss will follow the next time I engage in a close relationship or friendship, and either through loosing again and again, or else by never having the ability to find someone else, I will remain alone.
9/15/09
In considering how I have personally come in contact with death and loss, or experienced grief, I must first acknowledge that I do not feel as though I have had much first-hand knowledge of what it is like to lose someone. I have been blessed to have not lost anyone immediately close to me, neither friend nor nuclear family member. That being said, however, it occurs to me that there are a number of different categories of loss which I tend not to consider to be “as important” somehow when applied to myself (though they are significant in the lives of others). When I allow myself to broaden my approach to loss- as I would with a client, though perhaps reticently for myself- I come to realize that there may be much for me to say on the topic which I can speak to personally.
My experiences with personal grief stem more from an awareness of people and opportunities I have not had. Some of my greatest losses are more concerned with the sense of lacking and wanting, rather than the traditional experiences of severed attachments due to death. I am the daughter of divorced parents, who separated when I was 4 years old; therefore, I have not had the experience of growing up in an intact family system, with the support and ready attention of both biological parents. While the divorce in and of itself might qualify as a major loss, in my mind the grief comes not so much from their separation as such, but from the losses that occur as a result of not having them together. I do not remember what it was to have my parents love one another, to model for me how a good working relationship functions, or for us to work as a happy family. These losses of what I could- perhaps feel I should- have had in my growing up are much more what I feel, as I was not old enough to know what things might have been like before my parents became unhappy with each other. Loneliness, and the awareness of missing good family relationships, has therefore been the most pervasive cause of grief in my life.
Beyond my parents, I have grown up with very few family ties: my parents each were isolated themselves from their extended and nuclear families, and, though for different reasons, the end result was that as their daughter, I know very little in the way of familial support or interaction. My mom’s mother died of breast cancer when I was two and my mother still grieves for her, but I do not know what it is like to feel that pain immediately, because I didn’t get the chance to know her; it is for that that I grieve. My father’s parents both lived in Florida and were very much out of regular contact with my Dad due to his strained relationship with them after they kicked him out of the house at age 18 for getting his first wife pregnant; they both died by the time I entered high school. My mother’s father, who died only this past April, was my last grandparent, but due to the falling out she as the result of much hurt and anger over my grandparent’s divorce and my grandfather’s marriage to the woman with whom he had an affair before that, I too lost the chance to develop a meaningful relationship with him. As much as family means to me in theory, my personal experiences with the ways in which families interact has been extremely curtailed by the actions of my parents, beginning long before I was even born. While I don’t often think of these things as losses per say- they are so far removed from my experiences that I again don’t know to miss them most of the time- when I allow myself to realize the extent of my family connections, I am aware that my ties with family beyond my mother, father and stepmother are only tenuous at best, and due to the nature of relationships damaged before I had a chance to experience them, I inherited the disconnection and isolation of my parents’ choices.
I can remember growing up in some ways very much alone, as both an only child, and the daughter of a single, working mother who out of necessity had to leave me at home, or with care-givers for extended periods of time from the age of 6 until I moved to college. That isolation seemed to follow me into my middle and high school experiences, and in reflecting back on my experiences as an adolescent, I am cognizant of a significant amount of time spent on my own, at home by myself. Because I had very little in the way of extended family connection, I have long been aware that my friends are in many ways my family of my own choosing, and as such the separation and drifting apart that occurs when life stages and physical closeness wane have been acutely and painfully felt on my part. This is my greatest source of fear for future loss, which in and of itself may play a part in my understanding of what it means to experience grief: after the initial pain of a loss has begun to subside, there still remains the fear that another, equally hurtful loss will follow the next time I engage in a close relationship or friendship, and either through loosing again and again, or else by never having the ability to find someone else, I will remain alone.
Grandfather's Legacy
Things I learned from from/about my grandfather, briefly.
There once was a man from Dundee
Who was fucking an ape in a tree.
The results were most horrid:
All ass and no forehead,
Three balls and a purple goatee!
(Apparently, the penchant for dirty jokes is a family heirloom- see more)
* While studying at Indiana University, he was a member of the Delta Tau Delta fraternity chapter there. He may have even been president of the chapter at one point in his college career.
* To this day, doctors and nurses in Cincinnati still remember and revere him as a highly respected and skilled thoracic surgeon, who put in the first pacemaker of the city.
* Graeter's Ice Cream- chocolate with butterscotch topping, if one must put a point on it- is one of life's enduring pleasures, no matter what age or level of awareness, one can always enjoy it.
* Even twenty years after her death, and probably more than thirty since they divorced, my grandfather still, in his way, loves and respects my grandmother.
* It is a horrible thing to lose touch with reality away from your home and loved ones, with the dread and sense that when you die, it will be someplace that smells of talc, piss, disinfectant, and cafeteria food. No amount of stars awarded for best care facility can block out such fears.
* No matter how much we fucked up, fucked over, or are fucked up by our family, there is nothing else that compares to their presences at the end of our days. They are, in spite of all, the best comfort and most potent solace for our souls when our lives have burned down and gutter into the last days of light.
"Health nuts are going to feel stupid someday, lying in hospitals dying of nothing."- Redd Foxx
There once was a man from Dundee
Who was fucking an ape in a tree.
The results were most horrid:
All ass and no forehead,
Three balls and a purple goatee!
(Apparently, the penchant for dirty jokes is a family heirloom- see more)
* While studying at Indiana University, he was a member of the Delta Tau Delta fraternity chapter there. He may have even been president of the chapter at one point in his college career.
* To this day, doctors and nurses in Cincinnati still remember and revere him as a highly respected and skilled thoracic surgeon, who put in the first pacemaker of the city.
* Graeter's Ice Cream- chocolate with butterscotch topping, if one must put a point on it- is one of life's enduring pleasures, no matter what age or level of awareness, one can always enjoy it.
* Even twenty years after her death, and probably more than thirty since they divorced, my grandfather still, in his way, loves and respects my grandmother.
* It is a horrible thing to lose touch with reality away from your home and loved ones, with the dread and sense that when you die, it will be someplace that smells of talc, piss, disinfectant, and cafeteria food. No amount of stars awarded for best care facility can block out such fears.
* No matter how much we fucked up, fucked over, or are fucked up by our family, there is nothing else that compares to their presences at the end of our days. They are, in spite of all, the best comfort and most potent solace for our souls when our lives have burned down and gutter into the last days of light.
"Health nuts are going to feel stupid someday, lying in hospitals dying of nothing."- Redd Foxx
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