read Seasons of Love chapter:measuring a child's life after suicide. please answer the questions : reflect on what happens to the families when there is a suicide in the family, based on the Seasons of Love chapter...how should people be told? What details are best left unshared?
below is the story
These theories may have a certain face-validity, but they often neglect environmental or contextual factors that are innate to answering the question of “why” a person might engage in suicidal behavior. David Jobes (Berman et al, 2006) theorized that suicidality sometimes falls on a continuum between an intra-psychic orientation (with a focus on internal psychological pain – typically a male) and an inter-psychic orientation (with a focus on interpersonally-generated pain, typically a female). Thomas Joiner (2007) further theorized that every suicidal behavior requires three interpersonal elements: acquired capacity for lethal self-injury; a perception that one is a burden on others; and a perception of social isolation, or lack of connection to a social group, in what he calls “thwarted belongingness.” Developmental, and family system theories contribute a great deal to our understanding of child and adolescent response to suicide, as well as potential for suicidal behaviors. Research suggests that the role of relationships, in particular the quality of attachment within those relationships (as opposed to the number of relationships), are important in understanding the risk for adolescent suicide, as well as the protective factors that help mitigate these effects (Wright, Briggs & Behringer, 2005; Evans, Hawton, & Rodham, 2004; Agerby, Nordentoft, & Mortenson, 2002; Borowsky, Ireland, & Resnick, 2001). A study by Bostik and Everall (2007) demonstrates that adolescents’ perceived experience of quality attachments and relationships was important to overcoming suicidality, suggesting that interpersonal elements are a key factor in suicide for this age group. As early as 1988, Israel Orbach (1988), based on a careful examination of both clinical experience and research data, argued that “self-destructive tendencies in children, and to some degree in adolescents, are strongly linked to familial processes rather than to personality factors” (p. 7). Orbach further suggests that suicidal children are ambivalent about both life and death, and exhibit four types of attitudes of repulsion and attraction toward life and death that can profoundly influence relative suicidality (1988, p. 209). Attraction to life is influenced by feelings of love and security in interpersonal relationships, whereas repulsion toward life is reflective of the level of painful experiences such as abuse, rejection, and alienation. Attraction to death is characterized by a belief that death is somehow superior to life and that death is a “place” or “mode” of safety and all-embracing love, and in adolescents, this can be related to existential issues (meaning of life) in which death is romanticized. In this theory, attraction to death is a powerfully motivating force for suicide. Conversely, repulsion can act as a protective factor against suicide, by perceiving death as irreversible and frightening, or as a “place” or “mode” of punishment, or eternal solitude (Orbach, 1988). The link between suicide and suicidality on the one hand, and non-lethal self-injury on the other hand, is not clear. Some researchers have suggested that adolescents who engage in self-injurious behaviors are at an increased risk for suicide ideation and attempt; however, a recent study found that those who engaged in non-suicidal self-injury were more likely to experience early depressive symptoms, anxiety, and suicidal ideation than those who actually attempted suicide (Kim, et al., 2014). Behavioral and cognitive theorists have addressed suicide from a learned behavior perspective. Shneidman (1980, 1985) was one of the first to recognize the importance of cognition and suicide in his discussions of cognitive constriction and ambivalence, followed closely by the work of Beck and colleagues (Beck, Steer, Kovacs, & Garrison, 1985; Rush & Beck, 1978; Brown, Jeglic, Henriques, & Beck, 2006). Building on this, Rudd, Joiner and Rajab (2004) have suggested that suicidal individuals can be treated effectively using a cognitive- behavioral model that incorporates multiple variables (behavioral, cognitive, affective, motivational) that help the patient understand the time-limited aspect of suicidal crises, and help the suicidal individual understand his or her own unique “triggers,” emotional regulation, distress tolerance, interpersonal factors, social reinforcement, self-awareness, and skill acquisition. One of the reasons that cognitive-behavior therapies (CBT) are reported to be effective may be due to the fact that they target these cognitive distortions (Ellis & Ellis, 2006; Kekkel & Tringer, 2004). In one of the few clinical control studies to have explored these distortions, Jager-Hyman and colleagues found greater cognitive distortion in those who had attempted suicide than in a psychiatric control-group (Jager-Hyman, Cunningham, Wenzel, Mattei, Brown, & Beck, 2014). Decades of practical experience and research led Shneidman to formulate his theory of psychache as the cause of suicide (1995, 1996), which can be viewed conceptually as a multifaceted “cube.” Along one axis of the cube is psychological pain, another axis is “press” and the third axis is “perturbation” (1995). “Press” refers to any pressures that affect an individual’s feelings or behaviors. “Perturbation” is the individual’s level of “upsetness” or agitation. “Psychache” is the subjective experience of mental suffering. Each axis ranges from level 1 (low) to 5 (high) and meet in a 5-5-5 cubelet, the point at which an individual is most at risk of suicide. According to this theory, suicide is the result of intolerable (for that person) psychological pain or suffering, caused by thwarted or unfulfilled psychological needs. Pain and suffering in the mind combined with sufficient agitation and stress, Shneidman argued, are sufficient to drive suicidal thinking and action in a needful individual. The point of clinical intervention is to get the individual out of the 5-5-5 cubelet. Building on Shneidman’s approach, Jobes (2006) created a phenomenological structural model drawing on multiple theories, starting with psychological suffering and moving towards understanding suicide as a coping mechanism. His Collaborative Assessment and Treatment of Suicidality (CAMS) treatment framework, now in Randomized Control Trials, begins with assessing psychological pain, stress and agitation, and subsequently introduces additional key concepts: hopelessness (Beck), self-hate and the need for escape (Baumeister, 1990), and the behavioral perspective (will the person kill him/herself?). The CAMS approach is a treatment philosophy rather than a new therapy, and can be used with any clinical therapeutic approach. Once suicidality has been identified, CAMS begins with the Suicide Status Form, a multipurpose tool used by the client and clinician at every session to jointly assess suicidality (including suicide risk), create a treatment plan, track the ongoing suicide risk and document clinical outcomes. At the close of every session the client and clinician together identify five alternative coping mechanisms that can be used by the client if crisis looms, and written on a card that fits in the wallet. If the client goes into crisis, his or her responsibility is to try the strategies (part of the safety plan) and if the crisis is not reduced, the client can turn over the card and call the clinician directly. The idea of CAMS is to address the suicidality first and in an overtly collaborative way by identifying and addressing the specific drivers of suicide, enhancing reasons for living, reducing reasons for dying, and motivating the individual to learn new coping skills. Once the suicidality is ameliorated, the clinical treatment plan can shift to address the underlying issues that may have led to the suicidal crisis in the first place. Valach, Michel, Dey, and Young (2006) examine the notion of suicide as a coping mechanism from a slightly different perspective. Their research and clinical experience with those who attempted suicide demonstrates that social processes are prominent in suicidal thinking, and that the suicidal act is a joint social process rather than an individual one, since it occurs in a social context. Furthermore, suicide is a goal-directed action. Viewed this way, suicidal processes are similar to other goal-directed processes throughout life, and as such can be interrupted or circumvented. Their clinical approach, the Attempted Suicide Short Intervention Program (ASSIP), is a four-session intervention that involves the use of videotaped interviews offering, in narrative form, a window to the suicidal career of an individual and fosters a collaborative working relationship between the clinician and client (Michel & Gysin-Maillart, 2013). After completing the videotaped interview, the client and clinician meet a second time and view the video together, stopping at points and allowing the client to fill in the back story or augment the narrative. During this time, the client and clinician collaboratively identify potential vulnerabilities and stimuli, or “triggers,” and discuss the elements that might go into a safety plan. Between the second and third session the clinician creates a written version of the narrative and prepares a version of the folded personalized emergency card called a “Leporello” that fits in the wallet and contains helpful information including phone numbers and individually identified strategies for ameliorating a crisis. During the third session, the written narrative is discussed and the Leporello is examined for accuracy, and any changes are made between the third and fourth meeting. The narrative is viewed by the client and clinician a third time during the fourth meeting to facilitate safety protocol rehearsal, and the four session intervention is followed by regular outreach contacts (letters) over two years. Indeed, protocol rehearsal is key in many CBT approaches, as well as in these two promising suicide-specific treatment approaches, as a form of cognitive script-writing and maintenance. A “script” is any rehearsed (in real-life through practice, or repetition, or mentally via imagined scenarios) behavioral response in a given situation or context. It affords the individual an opportunity to create, rehearse, and utilize more adaptive behavioral “scripts” when in a vulnerable or stimulating situation. Tools like a crisis card in CAMS or the “Leporello” used in ASSIP can be helpful reminders of the newly-learned adaptive life skills. To concisely answer the question “why do people kill themselves” is difficult, if not impossible. Shneidman (1996) said it best: “Stripped down to its bones, my argument goes like this: In almost every case, suicide is caused by pain, a certain kind of pain – psychological pain, which I call psychache (sīk-āk). Furthermore, this psychache stems from thwarted or distorted psychological needs. In other words, suicide is chiefly a drama in the mind” (4). He goes on to say that suicide is multifaceted and includes “biological, biochemical, cultural, sociological, interpersonal, intrapsychic, logical, philosophical, conscious, and unconscious elements” (1996, 5). In short, no matter the risk factors, social context, or mental health status, people kill themselves because they are in intractable pain and are unable to conceive of life without intolerable suffering. Next Steps…what helps? The concept of children and young adults experiencing bereavement and grief due to suicide is hardly novel. What is new is the increased recognition of the needs and challenges these individuals incur after a suicide-related loss. Additionally, we can learn from the experiences of adults who were, as children, parentally bereaved because of suicide. Research indicates that the death of a parent is one of the most traumatic events a child can experience. Statistically, being related to someone who dies by suicide puts one at higher risk for suicidal behavior. The American Association of Suicidology’s list of risk factors includes: history of suicide in the family, parental history of hospitalization for major psychiatric disorder, and a tolerant/accepting attitude toward suicide. Based on the information thus far presented, the higher risk for suicide might include those “biological, biochemical, cultural, sociological, interpersonal, intrapsychic, logical, philosophical, conscious, and unconscious elements” identified by Shneidman (1996, p.5), and it could be argued that for the suicide-bereaved child, survival means grappling with the acceptability of suicide as a problem-solving strategy and separating that from the act of the parent. But is this true? Research on bereavement trajectories for parentally bereaved children due to suicide, compared to non-violent death, offers mixed results. Brown et al. (2007) analyzed data from the Family Bereavement Program, and found that cause of death is a weak predictor of the need for intervention services, and that other variables such as level of functioning, beliefs about self, and family environment were more important. They also found that cause of parental death is not a predictor with respect to risk and protective factors associated with problem outcomes. The studies by Cerel et al. (1999, 2000) offer a very different view. Their analysis of the experiences of 26 suicide-bereaved (SB) children compared to several hundred non-suicidebereaved (NSB) children suggests that SB children were more likely to experience anxiety, anger, shame, were more likely to have pre-existing behavioral problems, and displayed more behavioral and anxiety symptoms throughout the first two years after the death compared with NSB children (Cerel et al, 1999). Other researchers suggest that a child’s developmental stage at the time of experiencing a loved one’s death is an important variable, not only because of the loss-impact, but because death conceptualization is so closely linked to cognitive development, for example: Nagy’s 1948, and Koocher’s 1973 seminal studies. Children between 6 and 8 years of age understand the finality of death, but full understanding, including the absence of personal culpability for the death, may be elusive (Childres & Wimmer, 1971). They may be anxious and emotional and, especially after a parent’s traumatic death, may exhibit symptoms of traumatic stress over time (Christ, 2010). Grief is a journey and a process of adjusting to life after a significant loss. But suicide, as a traumatic loss, brings additional circumstances that can make healing more difficult. Children tend to move in and out of grief response, periodically revisiting a loss. Often, grief “work” is done through play instead of words. When the death itself is traumatic, especially if preceded by other traumatic experiences, the trauma can impede the grief process. Thoughts of how the person died or, in the case of some suicides, remembering the earlier trauma of suicide attempts, can lead to frightening images, dreams, and memories. Children may experience trauma if they found the deceased, or were present when police or first responders arrived to process the scene. Sometimes the memories are blocked from conscious memory, but the traumatic response is still evident in its after-effects. Traumatic reactions in children can be caused or exacerbated by multiple factors. Family or individual psychopathology, prior trauma, lack of support systems, avoidance, lack of opportunities to process the trauma, or isolation can make the situation worse (Schuurman & Decristofaro, 2010). Some individuals may report intermittent episodes of traumatic reactions. These may consist of nightmares, to waking events similar to classic Post Traumatic Stress Disorder-type “reliving” (Gilbertson, Orr, Rauch, Putman, 2008). Additionally, older children and young adults may experience survivor’s guilt for what they did or didn’t do, or did or didn’t feel (author’s unpublished anecdotal experience). For example, a child who grows up with a parent who has repeatedly attempted suicide may feel anger, or may distance him or herself as much as possible from the suicidal parent, and when bereaved after that parent’s death may experience profound regret, self-recrimination, or magical thinking. After a suicide, families sometimes struggle with what to tell the children. Wanting to protect children from additional pain and suffering is a natural desire, but wisdom from the field of child bereavement at-large suggests that it is best to answer a child’s questions with simple, truthful answers that inform without overwhelming a child with details that were not sought. It is beneficial to avoid euphemisms that children sometimes find confusing such as “passed on” or “went to Heaven.” A simple “died” or even “died by suicide” may suffice, without hiding the fact that the death was self-inflicted. For example, in one of the author’s experience, it has been helpful to compare death education for children with that of sex education … keep it brief, honest, and titrated to the child’s developmental level. When a four-year old asks where babies come from, she isn’t asking for details on ovulation and insemination, rather, how do they get here? A simple answer such as “from inside the mommy’s tummy” or “the baby has to live inside the mommy to keep it warm and safe until it is big enough to come out and play with you” may suffice, whereas that would be an inadequate answer for a nine-year old on the precipice of adolescence. A similar construct can apply here: “Daddy was very sad, and his heart was so broken we couldn’t fix it, but the pieces of his heart that worked loved you, and he is very sorry that he hurt you when he died” may be perfectly acceptable for a younger child, but would be appallingly inappropriate for an older child who can understand notions of mental pain and suffering, and is familiar with suicide. Parents can tell the children that their significant person died because he wanted to end the pain, explaining that he was wrong to end the pain that way but he could not think clearly, his judgment was clouded by the pain, and he made a poor decision (McCord, 2014). Younger children may wish to be with the person who died and worry that these thoughts are the same as the ones that caused their loved one to die. Parents can explain that these two situations are different, and can encourage the child to tell a trusted grown-up if she ever does think about suicide. In fact, parents can help their children to identify an adult at school who they can go to if they feel anxious or afraid in the future (McCord, 2014). Because suicide is a traumatic death, bereaved children can be at risk of depression and substance abuse issues. Brent, Melhem, Donohoe, & Walker (2009) demonstrated in their two-year study of 176 children (ages seven–25 following traumatic and sudden death including suicide) that there are many effects of parental bereavement from the time of death through the second year post-death, in particular depression during the second year. Youth whose parents died by suicide showed the highest risk for subsequent depression and for alcohol and substance abuse, but only a longer-term study would show whether or not those parentally bereaved by suicide actually suffer long-term effects of bereavement compared to other bereaved youth. Being cognizant that children and teens are at higher risk of suicide themselves after a significant person in their lives have died by suicide, it is important to recognize that some children are afraid that they, too, will die by suicide. Suicide is an extremely meaningful event in a child’s life, and the impact may be seen many years later. It is not unusual for child survivors of parental suicide to fear they will kill themselves when they reach the age of their parent at the time of death (Avrami, 2005; Loy, M & Boelk, 2013), what Avrami called the Agonizing Question: “I thought that when I will reach her age at suicide—it will happen to me, too” (Avrami, 2005, p.71). It is important to be supportive of these individuals’ feelings and thoughts, and not dismiss their concerns, as that may serve to alienate the individual, and exacerbate any unresolved grief, or fear and anxiety they are experiencing. What finally makes the difference? Losing a parent to suicide rocks the assumptive world of a child and at some point there must be appropriate resolution, and reconstruction of that internal perspective in order to adapt to the loss, and heal. A narrative approach to healing after suicide (Sands, Jordan & Neimeyer, 2011), the Tripartite Model of Suicide Bereavement, focuses on key themes that emerge in bereavement after suicide: the relationship of the survivor with the deceased, the self and the community. This approach is a “process of adaptation in recursive meaning-making processes concerned with the intentional nature of suicide, reconstruction of the death story, and repositioning of the suicide and pain of the deceased’s life” (Sands, Jordan & Neimeyer, 2011, p 262). Grief support groups can allow participants to control their healing, to make meaningful decisions regarding level of engagement, and to overcome barriers to processing traumatic memories. For traumatized individuals, for whom control is often elusive, well-facilitated groups can help the bereaving to move towards levels of pre-loss functioning. It is important though, particularly in the case of bereavement due to suicide, that the group is selected carefully. It is human to compare…weight, grades, incomes, and even Christmas decorations! Unfortunately, this can be an issue in group-counseling settings as well. In a recent, albeit short-running situational comedy, Go On (NBC, 2012), actor Matthew Perry’s character attends a loss and bereavement support group, and in accordance with the character’s career (sports-radio talk show host), creates a chart, wherein all the other individuals in the group rank their “trauma” or loss, with everyone voting on the “winner” (the person with the “greatest” loss). This competitive approach may not be as overt in a real-world support group, but may still be insidiously evident, particularly in the case of suicide. A person bereaved due to cancer may see the person who was bereaved due to suicide as partly responsible, or having experienced a less significant loss, since the person who died by suicide “chose” to die, whereas their loved one(s) did not. Because of this, it may be most helpful, when possible, to find a support group that focuses specifically on loss due to suicide. It “levels the playing field” of grief, where experiences may be more similar, and individuals more supporting of one another. Children and teens who are bereaved because of suicide may find it helpful to identify ways to memorialize the dead. They might compile a recording of favorite music, create a candle, or draw a picture. Parents and other trusted adults can help children and teens identify concrete coping strategies that help, for example, talking about the deceased, writing in a journal, playing with clay, planting a flower, or even mindfully taking a walk in the sunshine (McCord, 2014). Conclusion In the end, how does one measure a life – especially after death by suicide? The brief overview of this chapter is merely one attempt to understand the child’s perspective of suicide. The path of post-bereavement development is complex; it turns and twists down myriad roads, sometimes with substantial obstacles, as well as momentous triumphs. In the end, the life of the surviving child is measured in terms of love – the love received from the person who died by suicide, the love of caring adults during the bereavement journey process, and the love of self that is finally embraced.
* Suicide is an act of killing oneself. The reasons and causes of suicide could be personal failing, financial loses, incapable coping strategies, emotional reactivity, psychological disorders, physiological ailments, or societal pressures. The reasons could be any, but it'st truth is, it's a poor decision to end one's life without considering other ways to cope the problem. Suicide of parents lives a permanent scare in the lives of the children, because they not only loose their parent untimely, but also unnaturally to death. This makes the grief process difficult in such children. The adverse impact of parents suicide on the lives of children are as d following.
* Children should be told with honesty in plain, simple language about the suicide and it's reason. It should be according to their age and their level of understanding. But, they should be told that decision to take was not a solution or it was a poor decision made in those circumstances.
* While answering the questions of the children regarding the death of their parents by suicide, it should be always be best give an honest answer but it should be brief. Reasons should neither be exaggerated nor elongated, but it should be kept short and in simple language, so that they can understand the causes but that does not inflict pain on them. They should be told that suicide is not a solution to any problem, it was a poor decision and that it would have been difficult to reach that decision.
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