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.

Memoir Reflections: Night Falls Fast, Understanding Suicide, by Kay Redfield Jamison

Anna H.

For Scott Wiessman, 6/27/09

Mental Health Practice

In the book Night Falls Fast are Kay Redfield Jamison’s personal attempts, shared with the world, to understand the nature of, reasonings behind, and struggles leading up to a person’s choice to end his or her own life, and the subsequent devastation, horror, and confusion experienced those left to behind. In exploring her own ruminations, fear, and sadness about the prevalence of suicide—Jamison herself has bipolar disorder, and has been suicidal several times throughout her life, nearly completing once— and our western society’s intense discomfort with it as a world-wide mental health crisis, Night Falls Fast is aimed at filling in our lack of understanding about and empathy for those who suffer from and sometimes succumb to the lead contributors to suicidal acts: depression, manic-depressive [bipolar] disorder, schizophrenia, and substance abuse. In reading the book, however, it was my experience that Jamison seemed to get lost in gory details and terrible stories of bright lives consumed, focusing instead on the same sensationalism and voyeurism which she condemns in the general public treatment of this terrible phenomenon. Jamison, in setting out to dispel the stigma of suicide, insomuch as she can persuade her readers to recognize the struggles with mental illness most often behind it, falls frequently into the same culturally-bound showcasing treatment of suicide-as-spectacle that she criticizes. In this paper, therefore, I will examine the ways in which Jamison— despite her goals of addressing the dearth of knowledge about why and how people come to a decision of suicide and its underlying causes in such a way as to remove its stigma, that it may be more swiftly and easily addressed for public health— nonetheless struggles in her writing to escape the ways in which suicide is often treated in America: as morbidly fascinating, but largely incomprehensible.

Jamison’s book is not strictly a memoir in that, while she does include small personal narratives as a woman with an intimate history of suicidal ideation and attempt, she largely treats it as a collection of discourses, studies, and essays, all trying to make sense of how and why so many have and continue to take their own lives, and what do we who are left, or who survived, do to try to curtail its prevalence. Her own experiences with major bouts of depression, as the result of having bipolar disorder, seem to have a major impact in the way in which she writes the book, both in the loving and admiring prose with which she describes the multiplicity of brilliant and inspiring historical figures, known and unknown to the general reader, who eventually took their own lives, and in the brutally vivid details she embeds in our minds of their decent into a personal hell only escapable through suicide. I have no doubt that she identifies with her subjects, and in doing so takes her readers on the same terrible journey that she and they felt for the first two thirds of the book.

This book actually came highly recommended for me prior to taking 698 Practice in Mental Health by a friend who himself has struggled for years with bipolar disorder, as a window into the downward spiral of hopelessness one experiences in feeling suicidal, written by someone who had “been there” herself. I had sought out and spoken with Jim about depression and suicidal thoughts, in response to my own most recent experience of both— the third such in my lifetime— looking for someone who would understand how dark my vision had become, and in the course of dinner he brought up identifying with Jamison’s depictions and writings. I purchased the book, but could not bring myself to read it until it became absolutely necessary to choose a mental health memoir for class and I found Night Falls Fast already in my possession; ultimately, given my personal mental states over the course of 2009, I wish I had chosen a different book to use for this assignment, but I did finish it, albeit with reluctance, after much discomfort and some with secondary trauma. Unlike Jim, I would never recommend this book to a person currently battling the personal demons of depression, hopelessness, or suicidal thoughts: rather than feeling like I could empathize and relate from a healthy distance, Jamison’s style of storytelling is so terribly detailed, and her depictions so graphic, that I found myself frequently only able to read a handful of pages at a time before becoming profoundly disturbed. There is no wall that one can construct to protect themselves from these stories of real-life, unbearable suffering and often violent, grisly endings sought when they have felt the pain described in the pages before them. I struggled mightily with this book, and ultimately finished it, but was unsatisfied by the treatment it gave to both its subject, and its prognosis for the future.

Jamison, perhaps in exorcizing her own feelings at coming so close to becoming another casualty of her book, repeats over and over stories of young lives lost and great minds destroying themselves, multiplicities of statistics which numb the heart at their prevalence and methods of terrible sought-after release which felt physically harmful to read over and over again. Given the pain I felt in reading the repetition of stories with wrenching, early endings, the amount of loss experienced and the enumeration about ways people have sought their own demise, I can only hope their purpose serves to drive home the point of suicide’s terrible reality, and the need to intervene in seemingly senseless self-destruction. I fear, however, that it may serve the opposite end of further cutting off communications, either through desensitization, making these tales like a macabre depiction from a crime novel, or overwhelming the reader to the point where they do not know how they might deal with such pain in their own lives, and therefore shut down the possibility of open communication. I can imagine how powerful these depictions would be for someone who had not had firsthand knowledge of these feelings, that now they might really begin to recognize the crushing weight of these feelings, and how such an otherwise awful end might seem like relief, but for anyone recovering or still battling with depression themselves, reliving it within these pages is traumatizing and can threaten to suck you back in. In the book’s first two thirds’ unrelenting reiteration of violence and despairing, Jamison seems to be searching for answers to why people must suffer so, on behalf of those left behind, those who have survived their own attempts, and those who still consider suicide to be an option worth considering; there does not, sadly, seem to be a good enough answer to justify the inclusion of so much pain which assaults the reader. However, repeating again and again the same pattern of promising lives full of accomplishments already, devoured by mental health problems incomprehensible to those who have not felt their oppression, and ended for lack of hope that life will ever get better, Jamison’s ruminations, though disturbing as intrusive thoughts or flashbacks, do serve a significant purpose: suicide is de-romanticized in the extreme and laid bare and raw for the horror that it is, that the concerned reader might address it in his or her life and community with urgency and a somewhat better understanding.

I struggle with Jamison’s conflicting viewpoints, as she writes this book both as one who has fought continuously against depression in her own life—and thus far, won—and an upper class psychiatrist who uses the terminology of mental illness to describe not only schizophrenia and manic-depression, but also substance abuse and major depression. Hers is not a strengths-based model of study, and perhaps due to that, she focuses greatly on the pathology of suicide, particularly as it relates to genetics and is compounded by drug and alcohol abuse, leading up to the terrible details that go into the deaths of so many of her discussed examples. In effect, due to her major focus being the horrors of depression as it leads up to suicide, Jamison seems to largely ignore the positives of biopsychosocial input, tempered with protective factors, personal strengths, and multiplicity of treatment options— now more than ever used together to help prevent depression from growing so unmanageable— and she approaches the majority of her book with little hope and less optimism. Coping with bipolar disorder, Jamison gives her whole-hearted support to lithium, the classic mood-stabilizing drug; I have concerns, however, with her terming it the “antisuicide medication”, as it is a dangerous tendency, among Americans in particular, to assume or expect that one can oversimplify treatment of something with as complex a set of contributing factors as suicide. Despite her warning to readers that it may not work for everyone, terming anything with a cure-all designation is dangerous in a book so desperately lacking in hope for its readers, and I fear too many would latch on to one such buoy as their only possible salvation from suicidal ideation and eventual completion. My greatest criticism of Night Falls Fast, however, is that despite her seeming understanding of the dangers inherent in a culture-bound search for a magic bullet to “cure” these mental health issues and the expectations for a true “antisuicide medication”, as she discusses in the “As a Society” chapter on the how the media ought not to treat suicide, Jamison herself persists in using language and storytelling techniques which undermine her otherwise sound understanding of how to address suicide. Jamison quotes the CDC’s recommended guidelines to the media regarding suicide treatment as a paradigm for how suicide ought not to be portrayed: by presenting simplistic explanations for suicide, engaging in repetitive, ongoing or excessive reporting of suicide in the news, providing sensational coverage of suicide, reporting “how-to” descriptions of suicide [acts], presenting suicide as a tool for accomplishing certain ends, glorifying suicide or persons who commit suicide, or focusing on the suicide completer’s positive characteristics, (Jamison, 280-282). While she does not ignore all of these guidelines, despite including them in her book, Jamison herself still falls into these same habits during the first two thirds of Night Falls Fast, recounting multiple times the specific details of horrible deaths with morbid fascination, including as examples wonderful and famous minds in literature and art, and getting caught by her own condemnation.

What Jamison does do well is give factual evidence of the terrible impact that depression and its too-often-successor suicide do to individuals, regardless of gender or ethnicity, and their survivors. Using comprehensive statistical information and examples from all eras, nationalities, races and gender groups, Jamison poignantly illustrates that depression and suicide are great equalizers: they spare no population. That she is a well-educated white woman does show through in her more elaborate case examples and stories, in that most are about white men and women of prominence or potential (though with a few notable exceptions). Jamison does try to point out explicitly the troublingly ignored populations of homeless mentally ill, many of whom suffer from bipolar disorder or schizophrenia and for whom suicide is perhaps a more common option that with the general public, but recognizing that the greatest impact will be made on her audience with examples from more prominent—and therefore, theoretically better off— spheres of life, she spends the majority of her ink tracing more well known or well off figures from history who have succumb to suicide. Despite her best efforts to show the devastatingly vast scope of life suicide touches, non-white, non-educated populations remain largely unrepresented in this book, reflecting our cultural concern which only becomes actively alarmed when those who somehow should not be so desperate are taking their own lives.

The last third of the book is far less overwhelming, as it offers some light at the end of the tunnel in the form of treatment discussions and the usefulness of medication and public health awareness work, both of which are promising steps. It includes a discussion of most effective treatment methods—“Modest Magical Qualities”, with a discussion of both medicinal and therapeutic interventions—a discourse on the positive efforts public health workers have been making towards suicide awareness and prevention, and a sober conclusion discussing the impact of suicide on surviving family, spouses, and friends. Given the book’s publication in 1999, I think it would behoove Jamison to update for her audience, to add in the hopeful advancements of psychopharmacology in the past 10 years beyond what she discusses regarding the older generations of mood stabilizer, MAOIs, and tri-cyclic antidepressants, including the now common usage of most SSRIs and the new class of antidepressant medication, SNRIs. Similarly, while Jamison creates a depiction at once poignant and resilient of the family and friends left to rebuild themselves after the suicide of a loved one, she gives very little of herself, either as a survivor who managed to cope with the suicide of her dear friend (though we know not how), or how her own family coped with the darkness she lived in on and off throughout her life. Neither does she offer anywhere near as detailed accounts from the lives of others as she does for the deaths of those whose stories she does tell: this imbalance of perspective deprives us from taking away anything therapeutic, and keeps us perpetually sapped of emotional vitality all the way through to the book’s end.

As a student of social work, I was very pleased to read Jamison’s endorsement of combining psychopharmacology with therapy (psychiatry, in her case) as both her personal salvation and the best means of combating suicidal action. I truly wish that she had spent more time using herself as an example of those who can and do recover; despite having personally lost a number of friends and acquaintances to suicide, in addition to almost succeeding in taking her own life, Jamison is an emblem of hope for those who fear they cannot make it, yet she does not use her status as a model for others. We do not get to hear what worked for her, beyond sticking with her lithium and psychiatry regimen, we do not get to experience her headway made out of the depths of despair and into normal, even stellar functioning. Other than her dedication to her husband and brother, we know nothing about her support systems, which are not at all addressed elsewhere in the book’s tally of losses either. It is a significant failing on Jamison’s part that she leaves us without her own example of recovery from depression, or at least a discussion of its remission, as hope, to counteract the overwhelming burden left by the other stories in this book. We are left feeling unmoored and helpless after an onslaught of depressive stories, and instead of stressing those people and actions which did reach her through the darkness, we are left with only the smallest glimmers and told merely to keep holding on.

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Jamison, Kay Redfield. (1999). Night Falls Fast, Understanding Suicide, Vintage Books: New York