330 Intervention and Treatment of Suicidality • If someone has decided to commit suicide, there’s nothing that can be done about it. • Suicide is inherited. Presenting factual information to the group invites the group partici- pants to confront their own beliefs about suicide and, as needed, modify their understanding to align with fact and a healthy life perspective. Teaching Crisis Intervention Teaching what constitutes risk for suicidal behavior and what to do about it are essential for the suicide education of group participants. Perhaps this area of consideration is most obvious to many, presented often as knowing the warning signs for suicide. Crisis intervention, however, must involve not only knowledge but also appropriate action. Although you may assume this is merely common sense, many bereaved loved ones have learned of these warning signs only in retrospect, after a loved one has committed suicide. The literature about suicide abounds with information about crisis in- tervention, and the group leader is urged to learn more about this for ef- fective group education. In short, the group leader’s teaching of what to observe and how to respond may enable participants to achieve a height- ened awareness of suicide, a reduced helplessness and greater confidence in ability to help, and a greater attunement to the stress and demands of everyday life. Education about crisis intervention also may serve, to a great degree, as a means to deter or prevent future vulnerability or suicidal behavior among group participants. The greater the group awareness and em- powerment for addressing suicide, the more participants may become dynamic experts, facilitating earlier and more productive discourse about suicide-related thoughts and ideas as they become manifested in the group. Such group processing about suicide may be expected to help the participants eliminate risk for suicide before it becomes actualized in behavior. Understanding Suicide Bereavement As was argued previously, introducing suicide bereavement to the group is invaluable for preventing suicide. Educating participants about the degree c14.qxd 8/2/04 11:14 AM Page 330 Group Therapy and Suicide 331 to which suicidal behavior has a profound, detrimental impact on others may help participants confront their own personal investment in life and invite those who may be at risk for suicide to come out of their own narcissistic “bell jar” (Plath, 1971) and become more realistic in their ap- praisal of themselves, others, and life. Those who are suicidal are often unable to realistically view the suffer- ing that their action will cause in the lives of loved ones, constricted in a world of pain and deluded or myopic in perspective of life, overflowing with negativity, self-blame, helplessness, hopelessness. With their pain overwhelming them, they often assume its removal via suicide will relieve others and improve their life. Although they may be accurate that any burden of care that they have imposed will be removed, they fail to see the value and importance of their presence in life and the pain of its absence. Life may be better off for survivors, but not because the loved one is gone. To the contrary, life becomes better off for survivors because they choose the same commitment that is available to the suicidal loved one, that is, to choose life and recommitment to it in a manner that permits growth and development of well-being. An important issue for discussion in suicide education within the group is that risk for suicide itself may be significant for many following the suicide of a loved one. In a dissertation study of 509 persons who lost a loved one by suicide, results indicated that 131 or 26% of the survivors sampled had since the suicide death seriously con- templated suicide, and 73 or 15% of the survivors, at some time in their life, had attempted suicide (Fournier, 1997). CONCLUDING REMARKS Group psychotherapy may be an awesome and unique experience for sui- cide prevention and promotion of well-being. Group therapy is not the only method for treatment of suicidality, nor should it be viewed as such. Much of what pertains to group work with suicide is relevant also to other treatment modalities, such as individual and family psychotherapy. Groups, however, present a unique environment for understanding and di- aloguing about suicide and life. In groups, there are many reactions to any one issue, providing a rich tapestry of personal perspectives for formulat- ing and developing a healthy commitment in life, including prevention of suicide (Yalom, 2002b, p. 50). Regardless of its nature or objective, all c14.qxd 8/2/04 11:14 AM Page 331 332 Intervention and Treatment of Suicidality groups can and should address suicide, presenting this phenomenon as a part of human life and human vulnerability. Such a dynamic action in groups, it is argued, is essential for facilitating well-being and preventing suicide. To not address this potent phenomenon is a risk considered too great, one that offers few, if any, second chances. REFERENCES Buelow, G. (1994). A suicide in group: A case of functional realignment. In- ternational Journal of Group Psychotherapy, 44, 153–168. Campbell, R. J. (1989). Psychiatric dictionary (6th ed.). New York: Oxford University Press. Carroll, M., Bates, M., & Johnson, C. (1997). Group leadership: Strategies for group counseling leaders. Denver, CO: Love. Comstock, B. S., & McDermott, M. (1975). Group therapy for patients who at- tempted suicide. International Journal of Group Psychotherapy, 25, 44–49. Dlugos, R. F., & Friedlander, M. L. (2001). Passionately committed psychother- apists: A qualitative study of their experiences. Professional Psychology: Re- search and Practice, 32, 298–304. Dub, F. S. (1997). The pivotal group member: A study of treatment-destructive resistance in group therapy. International Journal of Group Psychotherapy, 47, 333–353. Farberow, N. (1968). Group psychotherapy with suicidal persons. In H. L. P. Resnick (Ed.), Suicidal behaviors: Diagnosis and management (pp. 328–340). Boston: Little, Brown. Fournier, R. R. (1987). Suicidal movement: An addiction to death or an invi- tation to spiritual formation. Studies in Formative Spirituality, 8, 175–185. Fournier, R. R. (1990). Social work, spirituality, and suicide: An odd mix or a natural blend. Social Thought, 16(3), 27–35. Fournier, R. R. (1997). The role of spiritual well-being as a resource for coping with stress in bereavement among suicide survivors. Ann Arbor, MI: Dis- sertation Services. Fournier, R. R. (1999). Spirituality as a resource for suicide prevention: A re- sponse to a fellow suicidologist. American Journal of Pastoral Counseling, 2(1), 49–74. Fournier, R. R. (2002). A trauma education workshop on posttraumatic stress. Health and Social Work, 27, 113–124. Frankel, B. (2002). Existential issues in group psychotherapy. International Journal of Group Psychotherapy, 52, 215–231. c14.qxd 8/2/04 11:14 AM Page 332 Group Therapy and Suicide 333 Frankl, V. E. (1963). Man’s search for meaning. New York: Pocket Books. Friedman, R. S. (1989). Hospital treatment of the suicidal patient. In D. Jacobs & H. N. Brown (Eds.), Suicide: Understanding and responding (pp. 379–402). Madison, CT: International Universities Press. Jacobs, D. (1989). Psychotherapy with suicidal patients: The empathic method. In D. Jacobs & H. N. Brown (Eds.), Suicide: Understanding and responding (pp. 329–343). Madison, CT: International Universities Press. Maltsberger, J. T. (1986). Suicide risk: The formulation of clinical judgment. New York: New York University Press. May, R. (1972). Power and innocence. New York: Norton. Menninger, K. (1966). Man against himself. New York: Harcourt, Brace & World. Peck, M. S. (1978). The road less traveled. New York: Simon & Schuster. Plath, S. (1971). The bell jar. New York: Harper & Row. Richman, J., & Eyman, J. R. (1990). Psychotherapy of suicide: Individual, group, and family approaches. In D. Lester (Ed.), Current concepts of sui- cide (pp. 139–158). Philadelphia: Charles Press. Shneidman, E. S. (1993). Suicide as psychache. Northvale, NJ: Aronson. Van der Kolk, B. A. (1987). Psychological trauma. Washington, DC: Ameri- can Psychiatric Press. Van Kaam, A. (1966). The art of existential counseling. Wilkes-Barre, PA: Di- mension Books. Werth, J. L. (1996). Rational suicide? Washington, DC: Taylor & Francis. Yalom, J. D. (1985). Theory and practice of group psychotherapy. New York: Basic Books. Yalom, J. D. (1995). Theory and practice of group psychotherapy (4th ed.). New York: Basic Books. Yalom, J. D. (2002a). The gift of therapy: An open letter to a new generation of therapists and their patients. New York: HarperCollins. Yalom, J. D. (2002b). Religion and psychiatry. American Journal of Psychother- apy, 56, 301–316. c14.qxd 8/2/04 11:14 AM Page 333 c14.qxd 8/2/04 11:14 AM Page 334 PART TH REE Special Issues c15.qxd 8/2/04 11:13 AM Page 335 c15.qxd 8/2/04 11:13 AM Page 336 337 CHAPTER 15 Easing the Legacy of Suicide David Lester Since death is inevitable, we should perhaps reevaluate our designation of death from suicide as an undesirable act (Lester, 2003). Faced with the alternatives of, for example, a person dying in pain as his or her body slowly shuts down in the end stages of a terminal cancer versus a digni- fied self-chosen death from suicide several months earlier, it is clear that suicide may not always be irrational, immoral, or a “bad” choice. It may, indeed, on occasions, be a good death, a euthanasia. In the past, only an occasional existentialist would argue that a suicidal act was appropriate. For example, Binswanger (1958), in his analysis of the suicide of Ellen West, argued that her existence had become “ripe” for its death and that her suicide was one of the rare authentic acts of her ex- istence. (It is possible to criticize Binswanger for his analysis of the case; see Lester, 1971; Rogers, 1961.) The cathartic effect of a nonfatal attempt at suicide has been noted (Farberow, 1950), and suicidal behavior can be seen as a useful and help- ful approach to crises. For example, Farber (1962) has described a certain kind of person for whom the idea of suicide is a solution to any difficulty that might occur in life. Such people respond to a crisis by saying to them- selves that, if things get worse, they will kill themselves. Although Farber condemned such an attitude, it may be a useful mechanism for dealing with depression and apathy. When depression descends on these people, rather than becoming morose and apathetic, they are able to say to them- selves: “If things get worse, I’ll kill myself.” They can then proceed to cope with the crisis. The suicidal ideation provides them with a possi- ble escape in the future, which thereby energizes them for the present. c15.qxd 8/2/04 11:13 AM Page 337 338 Special Issues Suicidal behavior (ideation, threats, and attempts) may also be effica- cious in changing the environment of the individual in a favorable way. However, I have gone further by viewing even completed suicide in a pos- itive light (Lester, 2003). COUNSELOR-ASSISTED SUICIDE Having a loved one commit suicide is extremely traumatic. Research evidence indicates that survivors of suicide attempts experience greater guilt, receive less social support, and feel more of a need to understand why the death occurred (Calhoun, Selby, & Selby, 1982). The emotions experienced include relief, anger, and depression; the cognitive reac- tions include shock, disbelief, and denial; the behavioral reactions in- clude smoking, drinking, and sleep disturbances; interpersonal reactions include changes in the interpersonal contacts and the type of communica- tion; and the physical reactions include illness and mortality. For exam- ple, Brent et al. (1992) found evidence for significant psychopathology, especially depression and posttraumatic stress disorder s ymptoms, six months after the suicide of a friend or acquaintance. A suicidal death is traumatic for the survivors, partly because often it is unexpected and sudden. Although the suicidal person may have given cues to the impending suicide (Robins, Gasner, Kayes, Wilkinson, & Murphy, 1959), some suicides do not give cues, while in other cases the significant others do not decode these cues accurately. The suddenness of the death leaves the survivors with unfinished business—issues and con- flicts that are unresolved and expressions of affection that went unsaid. Furthermore, in many cases, survivors are traumatized by being the ones who discover the body (McDowell, Rothberg, & Koshes, 1994). In a few cases, the suicide may take place in the presence of significant others. In some cases, there is great hostility on the part of the suicide, and the act of suicide serves to satisfy both a wish to die and a desire to punish the significant other by forcing him or her to witness the trauma of the death, creating an extremely unpleasant memory for the survivor. The following is a typical case: A 28-year-old female, who had been sexually abused as a child and who suf- fered from chronic low self-esteem, was having marital and financial prob- lems (she quit paying the household bills and did not tell her husband). She c15.qxd 8/2/04 11:13 AM Page 338 Easing the Legacy of Suicide 339 called her husband at work one day and asked him to come home for lunch, telling him that she had a surprise for him. As he entered the house, she walked up to him and shot herself in the head with a .38 pistol. (McDowell et al., 1994, p. 218) In other cases, the witness to the suicide may be a friend or acquain- tance who is uninvolved in the dynamics of the suicide: A 22-year-old male with a history of alcohol abuse and marital problems was depressed over a recent breakup with his girlfriend As he was riding with a friend in the other individual’s car, they were discussing his problems. He asked his friend to give him his gun. When the friend handed a .32 pistol to him, he calmly put it to his head and shot himself. (McDowell et al., 1994, p. 219) Even if the suicide is not witnessed, the body of the suicide is often discovered by significant others, who thereby are left with a very un- pleasant visual memory of their loved one (Lester, 1994). Survivors of suicides can often benefit from counseling. There is an active group of survivors in the American Association of Suicidology, and groups of survivors across America meet for support and counseling. In addition, many families go into counseling after a significant other commits suicide, and those who do not sometimes regret not doing so. Susan White-Bowden (1985) divorced her husband, but her husband re- fused to accept the finality of the divorce. In November 1974, he came to her house, tried to persuade Susan to continue their marriage and, when she refused, went upstairs in her house and shot himself. Susan had three children, two daughters and a son, Jody, age 14. Susan did not share her feelings with the children after this trauma, nor did she consider counsel- ing for the family. She tried to act as if everything was fine—she labeled herself as “Susie Sunshine.” By the age of 17, Jody had shown some be- havior problems (vandalism at school and driving while high on mari- juana), and, after his girlfriend broke up with him and refused to get back together, Jody went home and shot himself. In retrospect, Susan re- alized that she should have taken the family for counseling after the sui- cide of her husband. Some suicidal people kill themselves after a long period of considera- tion, accompanied by a cumulative succession of losses, chronic depres- sion, alcohol abuse, or medical illness. Their significant others may be c15.qxd 8/2/04 11:13 AM Page 339 [...]... to firearms and identifying high-risk youth 3 58 Special Issues Evaluation: An Ecological Study Garland, Shaffer, and Whittle (1 989 ) surveyed 115 agencies that implemented a school-based curriculum program for students, and they reported the number and proportion of adolescents exposed in each state Lester (1992) compared these numbers with the changes in the suicide rate of 1 5- to 19-year-olds in the... accidents, and disasters Suicide is also outside the range of usual human experience and, like other traumas, evokes “significant symptoms of distress in most people” (Leenaars, 1 985 ; Shneidman, 1 985 ) Traumatic stress disorder refers to those natural behaviors and emotions that occur during a catastrophe Figley (1 985 ) defined posttraumatic stress disorder (PTSD) “as a set of conscious and unconscious behaviors... moderately lethal and highly perturbed, and required considerable intervention 2 Verbal statements: The attitude is often negative toward individuals who make verbal threats of suicide Suicidal threats are frequently seen as only attempts to get attention This attitude results in writing off and ignoring the behavior of a person who is genuinely perturbed and potentially suicidal Also, it is a well-documented... defensive avoidance and thus increases the probability of depression alternating with cycles of intensive imagery and other symptoms of PTSD (Wilson et al., 1 985 , p 169) Posttraumatic stress disorder was initially intended as a description of a reaction to trauma for adults (APA, 1 980 ) However, Eth and Pynoos (1 985 ) have presented convincing arguments for applying PTSD to children and adolescents There... life-saving agents Nonetheless, professionally trained people, often outside the schools, continue to play the primary roles in intervention Misconceptions are rife, not only about suicide, but about treatment of suicidal people Often there are overly simplistic solutions, in part, because of the myth that suicide is due only to stress Even in youth, the common consistency in suicide and suicidal behavior. .. Suicide and Life-Threatening Behavior, 24, 213–223 Quill, T E (1993) Doctor I want to die Will you help me? Journal of the American Medical Association, 270, 87 0 87 3 Robins, E., Gasner, S., Kayes, J., Wilkinson, R H., & Murphy, G E (1959) The communication of suicidal intent American Journal of Psychiatry, 115, 724–733 Rogers, C R (1961) The loneliness of contemporary man as seen in the case of Ellen... out of an open window of his apartment, and, at another time, playing with a gun A 17-year-old teenager died in a single car accident on an isolated road after having had several similar accidents following his mother’s death Selfdestructive behavior is not rare Often alcoholism, drug addiction, Coping with Suicide in the Schools: The Art and the Research 365 mismanagement of physical disease, and. .. discussions 12 Suicide prevention training for school counselors 13 Suicide prevention training for teachers 14 Postvention program after student suicides Shaffer, Garland, Gould, Fisher, and Trautman (1 988 ) have also noted that school-based programs can aim to heighten awareness of the problem, promote case finding, provide staff and pupils with information about mental health resources, and improve adolescents’... program Only 4% of the students thought that the program was not helpful for preventing suicide Johnson (1 985 ) found that teachers given a curriculum on suicide prevention acquired more knowledge than they had before and developed a more positive attitude toward suicidal individuals Spirito, Overholser, Ashworth, Morgan, and Benedict-Drew (1 988 ; Overholser, Hemstreet, Spirito, & Vyse, 1 989 ) found that... that the event of attempting suicide need not have death as its objective It is useful to think of the attempter, sometimes referred to as a parasuicide or as Coping with Suicide in the Schools: The Art and the Research 363 a self-injurer, and the completer as two different parts of overlapping populations: one is a group of those who attempt suicide, a few of whom go on to commit suicide, and the other . awesome and unique experience for sui- cide prevention and promotion of well-being. Group therapy is not the only method for treatment of suicidality, nor should it be viewed as such. Much of what. objective, all c14.qxd 8/ 2/04 11:14 AM Page 331 332 Intervention and Treatment of Suicidality groups can and should address suicide, presenting this phenomenon as a part of human life and human vulnerability N. (19 68) . Group psychotherapy with suicidal persons. In H. L. P. Resnick (Ed.), Suicidal behaviors: Diagnosis and management (pp. 3 28 340). Boston: Little, Brown. Fournier, R. R. (1 987 ). Suicidal