Healing Within Families Following Youth Suicide

Family Healing

HEALING WITHIN FAMILIES FOLLOWING YOUTH SUICIDE

Ruth Grant Kalischuk

RN, Medicine Hat College School of Nursing, 1979 BN, The University of Lethbridge, 1985 MEd, The University of Lethbridge, 1992

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF

THE REQUIREMENTS FOR THE DEGREE OF

DOCTOR OF PHILOSOPHY IN NURSING

THE FACULTY OF GRADUATE STUDIES

School of Nursing

We accept this thesis as conforming to the required standard

THE UNIVERSITY OF BRITISH COLUMBIA

October, 1999

© Ruth Grant Kalischuk, 1999 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission.

The University of British Columbia Vancouver, Canada ,

DE-6 (2/88) Healing Within Families ii

HEALING WITHIN FAMILIES FOLLOWING YOUTH SUICIDE

ABSTRACT

Despite preventive efforts, youth suicide is identified as a public and mental health problem of epidemic proportion in Western society. The short- and long-term health and human consequences associated with youth suicide are enormous, affecting each family survivor, the family, and ultimately, the community and society. Youth suicide has its greatest impact on the family, yet health care responses to these grieving families remains inadequate at best. This grounded theory study, based on a health promotion philosophy that embraces the strengths and resilient nature of grieving individuals, examined how individuals within the context of the family heal in the aftermath of youth suicide. Eleven families from rural and small urban centres were interviewed for the study during an 18 month period.

Individual healing following youth suicide is conceptualized as Journeying Toward

Wholeness. This journey is characterized by the inter-relationships among three enfolding, fluid, and iterative themes, which in themselves, each represent one portion of the overall journey:

Cocooning (Journey of Descent); Centering (Journey of Growth); and Connecting (Journey of

Transcendence). Within each theme, five self-organizing and inter-relating patterns (i.e., relating, thinking, functioning, energizing, and finding meaning/exploring spirituality) operate in mutual rhythmical interchange with the other patterns unbound by time. Each pattern describes one facet of the individual's experience in response to youth suicide. Journeying toward wholeness (i.e., healing) varies in expression and intensity over time in response to a variety of contextual factors including personal history, factors related to the suicide, social considerations, and the health care environment. Importantly, healing emanates, as an act of volition, from the survivor's consciousness (i.e., the healing epicentre) as a result of decision making.

love knot is based on the meaning the survivor attributes to his or her experience with youth

suicide and the relationship between the survivor and deceased youth prior to death. Ultimately, individual healing expands outward influencing family, societal, and global spheres.

The theory presented in this dissertation will be of particular interest to clinical nurse

specialists and mental health care professionals from a variety of disciplines who work closely with

families in the community. With its focus on health promotion, this theory captures some of the

intricacies and complexities of the healing process and is intended to serve as,a possible reference

to guide evidence-based health care practice. Healing Within Families iv

TABLE OF CONTENTS

Page

ABSTRACT ii

TABLE OF CONTENTS iv

List of Figures x

List of Tables xi

Acknowledgments xii

Dedication xiii

CHAPTER ONE - BACKGROUND TO HEALING WITHIN FAMILIES FOLLOWING YOUTH SUICIDE The Scope of the Problem of Youth Suicide 1 The Health and Human Consequences Associated With Youth Suicide 3 The Response of Society to Death 4 The Response of Society to Youth Suicide 5 The Response of the Health Care System to Youth Suicide 8 Influence of the Biomedical Model : 9 The Old Paradigm of Medicine - The New Paradigm of Health 10 Health-Oriented Research 11 The Response of Nursing to Youth Suicide 13 The Study: A Focus on Healing 14 Assumptions Underpinning the Study 14 Conceptual Issues 14 Research Questions 15 Definition of Terms 16 Summary 16

CHAPTER TWO - EMPIRICAL EVIDENCE SPECIFIC TO GRIEVING AND HEALING WITHIN FAMILIES 18 The Concept of Grieving 18 Traditional Theories of Grieving: Stages/Phases of Grieving 19 Healing Within Families

Underlying Assumptions 20 Contemporary Theories of Grieving: Grieving as a Dynamic Process 21 Influencing Factors 23 Grieving Within Families 24 Research and Practice Issues 26 Grieving Following Suicide 28 The Meaning of Suicide 29 The Concept of Healing 30 Summary 34

CHAPTER THREE - RESEARCH DESIGN AND IMPLEMENTATION 35 Methodology 35 Philosophical Stance 37 Theoretical and Personal Forestructures 37 Perspectives on Symbolic Interactionism 38 Perspectives on Families 41 Perspectives on Family Research 41 Perspectives on Gestalt Psychology/Humanism 44 Personal Situatedness 46 Grounded Theory Research Method 49 Eligibility Criteria 49 Data Collection and Procedures 50 Informed Consent 50 Theoretical Sampling 52 Interviews 54 Participant Observation 56 Data Management 60 Data Analysis 61 Coding 62 Memoing 64 Establishing Scientific Rigor 64 Credibility 65 Transferability 67 Dependability 68 Confirmability 68 Ethical Considerations 68 Healing Within Families vi

Summary 69

CHAPTER FOUR - JOURNEYING TOWARD WHOLENESS: A CONTEXTUALIZED EXPERIENCE 70 Description of Participants (The Sample) 70 Individual Healing Process Following Youth Suicide: A Preview 72 Overview of the Grounded Theory 76 The Precipitating Event 78 Hearing the News 78 Initial Responses 79 Horror or Discovery 82 Dealing with Suicide Notes 83 Breaking the News to Others 84 Summary of Precipitating Event 85 Contextual Factors 86 Personal History 86 Relationship with the Deceased Youth Prior to Suicide 86 Gender 87 Religious Affiliation 88 Cultural Practices 89 Previous Experience with Loss 90 Health Status 91

Factors Related to the Suicide 93 Unexpected, Sudden, and Violent Death 93 Suicide or Homicide 93 Social Factors 94

Social Stigma 95 Social Support 95 Health Care Environment 96

Summary 97

CHAPTER FIVE - COCOONING: JOURNEY OF DESCENT 99 Relating Pattern (Struggling) 100 Struggling Within Oneself 100

Finding Psychological Safety 100 Processing Intense Emotional Trauma 101 Healing Within Families vii

Loneliness : 102 Anxiety and Fear 102 Anger 104

Pain and Suffering 106 Depression 108

Guilt : 109 Regret 110 Struggling With Others Ill Withdrawing from Others Ill Effect on Relationships 112 Dealing with Others' Reactions , 112 Thinking Pattern (Chaotic Thinking) 113 Experiencing Cognitive Dissonance 114 Experiencing AlteredThinking 115 Contemplating Own Suicide 117 Functioning Pattern (Autopiloting) 118 Decreased Functioning 118 Living with Physical Absence 119 Using Addictive Substances 120 Taking Risks 120 Energy Pattern (Consuming) 121 Surviving the Trauma 121 Asking Why 122

Finding Meaning/Exploring Spirituality Pattern (Awakening) 123 Waking Up to Life 123

Doubting Oneself and Experience 124

Visiting the Dark Side of Life 124 Summary 125

CHAPTER SIX - CENTERING: JOURNEY OF GROWTH 127 Relating Pattern (Getting a Grip) 128 Confronting Emotional Experience 128 Addressing Unfinished Business 129 Thinking Pattern (Making Decisions) 130 Making Decisions 130 Validating Own Reality 130 Healing Within Families viii

Releasing Self of Responsibility for the Suicide 131 Allowing Healing to Occur 131

Functioning Pattern (Re-Engaging) 132 Increasing Activity Level 132 Participating in Healing Activities 133 Energizing Pattern (Replenishing) 136 Resolving the Why Question 137 Releasing Energy 137 Finding Meaning/Exploring Spirituality Pattern (Transforming) 138 Forgiving Self and the Deceased Youth 138 Finding Meaning in Experience 140 Summary 141

CHAPTER SEVEN - CONNECTING: JOURNEY OF TRANSCENDENCE.. 143 Relating Pattern (Reaching Out) 144 Seeking Help 144 Linking with Others ' 146 Facilitating Others' Healing 150 Thinking Pattern (Learning) 151

Thinking Differently 151 Developing Creativity 152 Trusting Intuition 154 Functioning Pattern (Orchestrating Life) 158

Reordering Life Priorities 158 Breaking the Silence 159

Energizing Pattern (Channeling) 160

Redirecting Energy 160 Focusing on the Positive Aspect of Experience 161 Finding Meaning/Exploring Spirituality Pattern (Transcending) 162 Re-birthing 162 Trusting Experience 163 Summary 165

CHAPTER EIGHT - TOWARDS AN UNDERSTANDING OF THE HEALING PROCESS 167 Healing Strategies 167 Healing Within Families ix

Intervening Variables: Healing Characteristics 170 Saying Yes to Life 170 Stepping Out and Speaking Up 171 Achieving a Sense of Peace, Harmony, and Balance 172 Expanding Personal Consciousness 173

Outcome of Individual Healing Following Youth Suicide: Creating of a Love Knot 175 Individual Healing Following Youth Suicide: A Summary 176 Transition, Transformation, and Transcendence 178 Relationship Between Healing and Grieving 180 Discussion 182 Summary 189

CHAPTER NINE - HEALING WITHIN FAMILIES FOLLOWING YOUTH SUICIDE: IMPLICATIONS AND CONCLUSIONS 191 Implications for Health Promotion Practice 193 Understanding the Healing Process 193 Creating Community-based Partnerships 198 Working with Rural-based Families 201 Implications for Future Research 203

Conclusions •••• 205

REFERENCES 208

APPENDICES

Appendix A-1: Genogram 227

Appendix A-2: Ecomap 229

Appendix B: Family Member Information Letter and Informed Consent 231

Appendix C: Media Invitation 234

Appendix D: Interview Guideline 236

Appendix E: Oath of Confidentiality 238

Appendix F: Demographic Questionnaire 241 Healing Within Families

List of Figures

Figure 4-1: Individual Healing Process Represented by a Love Knot 74

Figure 4-2: Individual-Society Healing Process Following Youth Suicide 78

Figure 8-1: Healing Expanding Over Time 176

Figure 8-2: Individual Healing Within Families Following Youth Suicide 178 Healing Within Families xi

List of Tables

Table 4-1: Residence of Sample Population 70

Table 4-2: Sample Population Data ; 72

Table 4-3: Individual Healing Template 75

Table 8-1: Journeying Toward Wholeness: Healing Strategies 169

Table 8-2: Differences Between Healing and Grieving in Response to Youth Suicide 182 Healing Within Families xii

ACKNOWLEDGEMENTS

I have been inspired by those with whom I have journeyed. I extend my heartfelt thanks to the fourty-one individuals from eleven families that, in a spirit of generosity, opened their hearts and souls as they shared their stories with me. I feel privileged to have learned so much from each of you.

This work has been enhanced by my association with many kind and caring people. Warmest thanks are extended to my brother, Ronald Grant, and to my dear friend, Corliss Burke, both of whom have always been there for me. I adore my son-in-law, Wilco Tymenson, and value his contribution to this work. My grandson, Tyson Bailey Kalischuk, helped me to maintain perspective while doing this kind of work. His light, laughter, and love sustained me during the tough times. To my friends and colleagues in the School of Health Sciences at the University of Lethbridge, I offer thanks —to Dean Patricia Wall for creating the space and for believing in me; to Dr. Gary Nixon for his depth and brilliance; to Howard and Dr. Kathryn Higuchi for helping me to maintain balance in my life; to Dr. Judith Kulig and Dr. Virginia McGowan for their unwavering support and encouragement, to Dr. Bradley Hagen for sharing the journey, and to Dr. Karran Thorpe for her support and friendship over many years. I acknowledge and appreciate the expert technical assistance provided by Wendy Herbers. A special thanks goes to Brad Keim, my research assistant, for his interest in and commitment to this research.

Indeed, I am fortunate to have been skilfully guided in this endeavor by a world-class committee. With gratitude, I thank Dr. Betty Davies for guiding the way. I have been forever changed because of her passion for excellence and her calm and caring presence along the way. My sincere thanks is extended to Dr. Virginia Hayes who has taught me much about the essentials required for the journey. Dr. Katharyn May's incredible vision for the big picture has inspired me to stay focused—for this I am thankful. My involvement in this research study has been the highlight of my doctoral program.

I gratefully acknowledge the financial contributions of the organizations that provided funding for this research including the Alberta Association of Registered Nurses and the Regional Center for Health Promotion and Community Studies at the University of Lethbridge, Lethbridge, Alberta. Healing Within Families xiii

!for Victor %alischuk\

My True 'North

and

for Our Children, Our Stars

Andrea, %pcfoj, 9/CeCanie, and Lisa Healing Within Families 1

CHAPTER ONE

BACKGROUND TO HEALING WITHIN FAMILIES FOLLOWING YOUTH SUICIDE

Death is one of life's few certainties. Despite its inevitability, widely accepted within

society is the notion that it is unnatural for children to predecease their parents; unfortunately, in

some instances, reality proves otherwise.

The idea of a youth willfully ending his or her life is incomprehensible to most people.

Suicide, an unnatural, unanticipated, and psychologically violent death is often viewed as an act of

aggression that has been committed by the victim against both self and survivors (Norton, 1994).

The staggering increase in the incidence of youth suicide in recent years is a complex and disturbing fact of contemporary society. Indeed, this increasingly common mental health care problem challenges some of the strongest and most sacred beliefs and convictions held by family

survivors. Youth suicide is especially tragic for family survivors because it involves not only the death of a young person, but death that is sudden and violent.

The initial blow of hearing the news of a youth suicide is likely to elicit a disturbing response among family survivors, much like the ripple-effect of an earthquake and its resultant aftershocks. In the midst of tremendous upheaval, survivors are challenged in terms of making sense of their grievous experience and healing in response to this life-altering situation. This dissertation is primarily concerned with how family survivors heal in the aftermath of youth

suicide.

The Scope of the Problem of Youth Suicide

Youth suicide has been identified as a compelling global and national public health problem

(Leenaars, Wenckstern, Sakinofsky, Dyck, Krai, & Bland, 1998; Low & Andrews, 1990), and a mental health concern of epidemic proportion (Thornton, Whittemore, & Robertson, 1989). The magnitude of this problem and its concomitant untoward sequelae cannot be overstated. At both the national and provincial levels, the increased incidence of suicide among our youth is alarming. Healing Within Families 2

The recent rise in suicides among young males is a complex and perplexing problem. In

Canada, in 1993, male youngsters aged 15 to 19 killed themselves at a rate of 19.4 per 100,000

(Wilkins, 1996). From 1981 to 1991, Canadian males aged 10 to 14 showed a startling increase of

60 percent in the rate of completed suicides, the highest percentage increase of any age group in the country (White, 1993).

It is disturbing to note that the highest incidence of suicide occurs within the aboriginal youth population (Royal Commission on Aboriginal Peoples, 1995), including American Indians

(both status and non-status), Inuit, and Metis (Isaacs, Keogh, Menard, & Hockin, 1998; Leenaars et al., 1998; Mardiros, 1987; May, 1990). According to Statistics Canada (1994b), during 1987-

1991, Canadian and registered Indian males, aged 15 to 19 years, completed suicide at a rate of

117 per 100,000. Not surprisingly, Quebec and Alberta, Canadian provinces with the largest aboriginal populations, have the highest incidence of youth suicide. Within a one-year period in

Alberta, the rate of suicide among youth aged 15 to 19 showed a substantial increase of almost 39 percent—from 18.8 per 100,000 in 1990, to 26.0 per 100,000 in 1991 (White, 1993). Moreover, the majority of aboriginal youth live in rural areas. During 1996, in Alberta, the incidence of suicide among rural youth exceeded that of their urban peers (Alberta Justice Office of the Chief

Medical Examiner, 1997). Approximately 5000 Canadian aboriginals under the age of 25 die from suicide each year, a rate six times higher than that for non-aboriginals (Regnier, 1994).

More male youth suicides occur in Canada per capita than in the United States (Leenaars &

Lester, 1990; Leenaars et al., 1998). Even still, in the United States, suicides among youths have quadrupled within the last three decades (Gartrell, Jarvis, & Derksen, 1993). In 1988, a total of

2,059 youths aged 15 to 19, and 243 children under 15 years of age, took their lives in the United

States (National Center for Health Statistics, 1968-1991). Suicide is now the second leading cause of death among the youth of America (Leenaars et al., 1998; Low & Andrews, 1990).

Even though health and human service professionals are committed to providing youth suicide prevention programs (Blumenthal, 1990; Boldt, 1987; Brent, 1995; Brent et al., 1993;

Garland & Zigler, 1993; Rudd, Dahm, & Rajab, 1993), each year, more than 300 families in

Canada (Statistics Canada, 1994a, 1994b) are confronted with youth suicide. This statistic is Healing Within Families 3

insignificant in comparison to the devastation that youth suicide casts in its wake, especially for family survivors. Moreover, this fact is a conservative estimate of the problem; it under-represents reality (Garland & Zigler, 1993) and this under-representation may be linked to the inherent difficulties associated with reporting self-inflicted deaths. These problems center on concern for the family's well-being, religious implications, and financial considerations regarding insurance payment restrictions (Garland & Zigler, 1993). Additionally, many sudden deaths are probably suicides, but without direct evidence such as a suicide note, the cause of death may be reported as accidental or undetermined. Adding to the enormity of the problem, it has been suggested that a minimum of 50 people, many of whom are family members, are affected by each incidence of youth suicide (B. Shawanda, personal communication, May, 28, 1998). Further, it is estimated that 50 to 100 attempts occur for every completed youth suicide (Smith & Crawford, 1986), and this begins to give some indication of the true magnitude of the problem.

The Health and Human Consequences Associated with Youth Suicide

The short- and long-term health and human consequences associated with youth suicide are enormous, affecting each family survivor, the family as a unit, and ultimately, the community and society. Family survivors of youth suicide often experience a number of stressors including increased vulnerability to illness and disease (Rudestam, 1992), increased incidence of drug and alcohol abuse (Silverman, Range, & Overholster, 1994-95), and extensive emotional and personal suffering (Ness & Pfeffer, 1990; Parkes & Brown, 1972; Solursh, 1990; Van Dongen, 1990).

Although sometimes overlooked, grandparents (Ponzetti & Johnson, 1991) and sibling survivors may also experience adverse health consequences (e.g., Balk 1983, 1990a, 1990b, 1991a, 1991b;

Fanos & Nickerman, 1991; Grogan, 1990; Hilgard, 1969; Hogan & Balk, 1990; Hogan &

DeSantis, 1994; Krell & Rabkin, 1979; Martinson, Davies, & McClowry, 1987; Pollock, 1986;

Zelauskas, 1981). The situation is further complicated in that families who have endured such trauma are often confronted with subtle, yet powerful, forms of stigma (Brown, 1994; Thornton,

Whittemore, & Robertson, 1989; Van Dongen, 1993; Schlump-Urquhart, 1990; Solomon 1982-

1983; Somme-Rotenberg, 1998); social isolation (Ness & Pfeffer, 1990; Rudestam, 1992; Van Healing Within Families 4

Dongen, 1991); role uncertainty (Van Dongen, 1993); and strained relationships which often lead

to marital discord (Ness & Pfeffer, 1990; Parkes & Brown, 1972; Van Dongen, 1993). Moreover,

the deleterious effects of multi-generational loss, especially common among Canadian Aboriginal

families, place heavy demands on existing health care services (B. Shawanda, personal

communication, May, 28, 1998). Multi-generational loss arises from an accumulation of

unresolved loss issues inadvertently passed down from one generation to the next (B. Shawanda,

personal communication, May 28, 1998). Some of these loss issues include a lack of integration of

the individual within society (Durkheim, 1951); ego identity crisis, and the resulting trauma that

may result from grappling with the question "Who Am I?" (Erickson, 1968); and, the loss of one's ethnic identity (Phinney, 1989). Family survivors of multi-generational loss often become

"families of trauma" (B. Shawanda, personal communication, May 28, 1998) who access the health care system more frequently than persons who are able to confront their loss soon after it occurs. Ultimately, individual and family responses to death in general, and to youth suicide in particular, are influenced by societal responses.

The Response of Society to Death

In the past, death was recognized as a natural and normal life event. However, within the last century, death has been socially reconstructed as a 'medical event.' Within our death-denying and death-defying society, the medicalization and bureaucratization of death has led to its depersonalization. Thus, for many, death has become an enigma. The social aspects of death have been removed from the home and family and have been transplanted within institutions. "With the growth of the secular and rational outlook, hegemony in the affairs of death has been transferred from the church to science and its representatives, the medical profession and the rationally organized hospital" (Blauner, 1966, p. 385). Blauner's message still applies 30 years after he wrote it.

Today, in Canada, about 70% of all deaths occur within hospitals (Lockard, 1989). With a prime focus on efficiency, hospitals continue to manage the crisis of dying. Within the hospital environment, death becomes the arena for experts rather than families and friends. The high-tech Healing Within Families 5

hospital environment is often sterile, efficient, and depersonalized. Machines, not people, are the common features of the death room. Family members often become visitors and children are

shielded from death. The separation of death from the family minimizes the average person's exposure to death with its disruption of social processes (Blauner, 1966). The ever present

avoidance of death-related issues within society is even more pronounced with respect to youth

suicide.

The Response of Society to Youth Suicide

Youth suicide is a stark and powerful reminder that all is not well within society. A number of forces have had an impact on society's response to youth suicide, including: the sociogenic view of youth suicide, changing views of death and suicide, the social value accorded to our youth in

society, the stigmatization surrounding youth suicide, and educational deficiencies.

The alarming increase in the incidence of youth suicide within contemporary society is indeed difficult to comprehend. In spite of growing concern about this problem within the health care sector, as yet, we do not understand the multiplicity of forces that underlie this complex health problem. According to Shneidman (1993b), suicide occurs when an individual experiences intolerable psychological pain or "psychache" (p. 145). Emile Durkheim (1951), a renowned

French sociologist, views suicide not as a voluntary act, but as an individual phenomenon etiologically explained within the parameters of our Western social structure. Espousing a similar

view, Boldt (1987) maintains that "Suicide is virtually always a forced act to resolve what are perceived as overwhelming problems" (p. 4). Further, he argues that the idea of moral culpability needs to be reintroduced with the responsibility for suicide shifted from the individual to society.

Several sociological phenomena have been attributed to the increased incidence of youth

suicide including: issues related to changing social and economic structures (Farrow, 1993;

Shneidman, 1993a ); changing family and community dynamics (Boldt, 1987; Bushy, 1994c;

Leenaars et al., 1998); declining religious affiliation; an increased prevalence of depression among

youth (Sakinofsky, 1998); and the influence of popular media (Biblarz, Brown, Noonan Biblarz,

Pilgrim, & Baldree, 1991; Stack, 1992). Cultural change, increased personal freedom, uncertainty Healing Within Families 6

about the future (Cotton & Range, 1993), and "value heterogeneity" are also considered to be factors (Boldt, 1987, p. 6). Moreover, social and economic structures often impose barriers to youth attempting to seek professional help, especially for concerns that have moral overtones— such as suicidal thinking, intense emotional responses to stress, symptoms of mental illness, or problems with addiction, pregnancy, sexuality issues or infractions of the law (Bushy, 1994c).

Proponents of the sociogenic view emphasize the need to focus on trying to change environmental realities that cause psychological pain and minimizing the moral and social stigmata that act as barriers to survivor help seeking (e.g., Atkinson, 1978; Boldt, 1976; Calhoun, Selby, &

Faulstich, 1980, 1982; Klass, 1996; Paicheler, 1988; Rudestam & Imbrol, 1983).

Within societal institutions, views about death and suicide are also changing. Many social systems (e.g., health care, legal, political) within the Western world are beginning to show, not only tolerance of, but whole-hearted support for individual rights to self-autonomy and self- determination. These personal freedoms have been enacted in a variety of personal rights, for example, the right to die. These ideas have had a corresponding effect on contemporary and social conceptions of suicide. Especially disturbing, Boldt (1987) contends that "We are moving from predominantly negative conceptions of suicide toward a consensus that there is a time and situation when suicide is acceptable, if not appropriate" (Boldt, 1987, p.6). Boldt (1987) notes that a

"worrisome reconstruction of the meaning of suicide has occurred for the young" (p. 6) in a pro- suicidal direction, in that suicide is now being interpreted by youth as a viable option to seemingly intolerable life situations. The youth of today frequently speak of 'rational suicide' and 'the right to suicide.' This trend suggests that youth are influenced by and vulnerable to societal views.

In the past, the stronghold of Judeo-Christian values and beliefs has limited our understanding of the experiences of family survivors of youth suicide. Until recently, both sacred and secular standards defined suicide as a morally abhorrent act. In recent years, secular laws against suicide have been repealed, and the Church has abandoned its moralistic and punitive attitude toward suicide (Boldt, 1987). Even so, change has been slow and family survivors of suicide often continue to be the recipients of society's harsh judgment. Healing Within Families 7

The value placed on youth within society is questionable. Society, favoring deeds and accomplishments among its members, bestows high regard and recognition on those able to make significant contributions to the welfare of its citizen. When those who die (i.e., youth) have not contributed to the social fabric of society, they may not be viewed as a loss within society (Glaser

& Strauss, 1964). Thus, when a youth ends his or her life, it is common for members of society to dismiss the incident along with any reminders of this 'unwarranted act.' Such responses not only negate the life of the deceased individual, they also invalidate, to a great extent, the experiences of family survivors.

Stigmatization surrounding suicide remains pervasive within society. Societal attitudes and related perceptions about bereaved family members contribute to stigmatization. The "no talk rule" becomes the modus operandi within society (B. Shawanda, personal communication, May 28,

1998). When suicide strikes, others are often not there for bereaved family members to the same degree as is the case with other kinds of deaths (Sheskin & Wallace, 1976; Thornton, Whittemore,

& Robertson, 1989). Further, those who are uncomfortable with the topic frequently 'blame the family' (Rudestam, 1992) for the suicide. Survivors often feel silenced. Sensitive to others' discomfort about suicide-related matters, they frequently respond by withdrawing from other people, especially those external to the family unit. Hence, the stigma associated with youth suicide often blocks the family from seeking needed professional help and social support. The stigmatization surrounding youth suicide isolates and ostracizes family survivors during a time when understanding and compassion are sorely needed (Solomon, 1982-1983; Thornton,

Whittemore, & Robertson, 1989).

Educators generally respond to the expressed needs of those within society. In keeping with society's general disdain of death-related matters, educational programs currently provide minimal preparation (Morgan, 1990) to assist human service professionals in caring for families who have experienced youth suicide. More than 30 years ago, Quint (1967) indentified the need to develop a systematic plan for educating nurses about death and dying. However, within most curricula, minimal emphasis is placed on issues related to death and bereavement generally, and on the health care needs of family survivors of youth suicide specifically. In addition, teaching faculty often lack Healing Within Families 8 adequate preparation specific to youth suicide and its impact on the family. Without sound theoretical understanding and skill acquisition, it is unrealistic to expect human service professionals to provide quality care (Grant Kalischuk, 1992) to this population. In part, this educational deficit may be attributed to the low priority placed on death-related issues within the health care system.

The Response of the Health Care System to Youth Suicide

It is important to address the shortcomings of the health care system in dealing with bereaved families, especially families who are bereaved due to youth suicide. In the past, the philosophy and organization of the health care system perpetuated a context in which the humane side of care giving was often left to chance (Benoliel, 1988; Watson, 1999). The shroud of silence and secrecy surrounding suicide has contributed greatly to maintaining the status quo position (i.e., silence prevails) within the existing health care practice arena. Family survivors of youth suicide are sensitive to the "no talk rule" that permeates every level of discourse within the health care system. In an effort to reach out to others in similar circumstances, suicide survivors have often initiated the organization of informal suicide support groups. While these groups provide much needed support to individuals and families, they fail to address concerns related to youth suicide within the broader community and society.

The Canadian health care system remains heavily influenced by the medical model and as a result spends a disproportionate amount of the health care budget on institutional care (Minister of

Public Works & Government Services Canada, 1998). In Canada, the portion of the provincial mental health care budget that is spent on community support services averages 13%, ranging from

3.1% in Manitoba to 46% in New Brunswick (Nasir, 1994). In regard to youth suicide, most of these community-targeted funds are spent on preventive measures. While such efforts are commendable, families that have been traumatized by youth suicide are often overlooked.

Ultimately, this ever-growing segment of the population is often left to manage and cope on its own within a deficiency-based health care system that provides minimal support and assistance.

The biomedical model has had a strong influence within the health care system. Healing Within Families 9

Influence of the Biomedical Model

Within the Western world, the problem-focused, deficiency-based biomedical model has adversely influenced health care research and practice in three distinct ways. First, within the last century, the medicalization of death has had a corresponding effect on the care provided to bereaved families in that medical treatment and cure have been given priority over psychosocial and spiritual care. It appears as if there are social rules about what to ignore within health care, and death-related matters seem to engender the ultimate in denial (Rudestam, 1992). Seldom is a suicide survivor's suffering recognized as a psychosocial and spiritual crisis worthy of attention and care by health care professionals. When such a crisis is identified, medical personnel often prescribe medication rather than sitting with and listening to family survivors share their stories about loss.

Second, much of the research literature published to date focuses on the difficulties and problems confronted by families in the aftermath of youth suicide (Adams, Overholser, & Spirito,

1994; Brent, 1995; Brent et al, 1993; Pataki & Carlson, 1995; Reifman & Windle, 1995; Rudd,

Dahm & Rajab, 1993). Correspondingly, this problem-focused approach to research has led to' problem-based practice which often fails to address individual and family strengths. Generally, suicide survivors only enter the health care system when grieving becomes unmanageable.

Bereaved individuals and families are often identified by health care professionals as an extremely vulnerable population (Thompson & Range, 1992-93), and because they are labeled in this way, they are treated accordingly—as individuals and families in need of help from external sources.

Patterson (1995) contends that individuals and families often are unaware of their own strengths because professionals tend to focus on deficiencies and problems rather than on individual and family strengths and competencies. Hence, one of the major barriers to family-centered health care delivery has been the failure of health care professionals to assist individuals and families in the discovery and development of their own capabilities. To a great extent, problem-oriented research has unintentionally impeded health-focused practice.

Third, the biomedical model with its emphasis on parts rather than wholes has influenced researchers and clinicians to focus on individuals rather than families. However, individuals do not Healing Within Families 10 exist in isolation; rather, they live in families within a mosaic of social interaction. Family members derive meaning in life from their interactions with others. The practice of exclusively focusing on the individual fails to take into account the many important aspects that are common to both individuals and families (e.g., relationships and communication). According to Kissane and Bloch

(1994), "the family virtually always constitutes the most significant social group in which grieving is experienced" (p. 728). Since grieving occurs within the context of the family, it is important to consider the influence of the individual on the family, and the influence of the family on the individual. The family, with its rich, dynamic, and complex characteristics is a major social agency for human growth. In effect, the reductionistic biomedical model fails to take into account the inherent complexity and vastness of human existence and, therefore, it has been ineffective in terms of providing a vision for holistic health care practice. However, within the last three decades, the biomedical model's stronghold on both health care research and practice has been waning.

The shortcomings of the past have provided the impetus for the future transformation of the health care system. During the past two decades, unprecedented changes have been occurring within the health care system. Beset by economic, performance, and credibility crises, the health care system is currently undergoing a massive overhaul (Ferguson, 1980; Laurence & Weinhouse,

1994; Rachlis & Kushner, 1989). Increasingly, health care consumers are beginning to withdraw legitimacy from the medical establishment, long the bastion of barren efficiency. Consumers are beginning to assert their right to be included as equal partners in the co-creation of health for both themselves and their families. Now more than ever before, consumers are holding the health care system accountable for high quality, patient- and family-centered health care delivery. Increasingly, the influence of the "New Paradigm of Health" (Ferguson, 1980, p. 246) is catching the attention of researchers and clinicians alike because of its fit with the aim of promoting holistic health care practice.

The Old Paradigm of Medicine—The New Paradigm of Health

Almost two decades ago, Ferguson (1980) laid the groundwork describing the transformation that is now occurring within the health care system. According to Ferguson (1980), Healing Within Families 11

"We have oversold the benefits of technology and external manipulations; we have undersold the importance of human relationships and the complexity of nature" (p. 246). The "old paradigm of medicine" (Ferguson, 1980, p. 246) with its focus on disease and illness is slowly being replaced by the "new paradigm of health" (Ferguson, 1980, p. 246) which stresses the importance of health

and well-being.

Congruent with the biomedical model, the "old paradigm of medicine" was based on the following assumptions: a mechanistic approach to disease; separation of the mind and body; treatment of symptoms rather than cause; an emphasis on quantitative data; primary intervention with drugs and surgery; the patient as dependent upon the authoritarian health care professional; and prevention largely determined by environmental factors (Ferguson, 1980, p. 247). In contrast, the emergence of the "new paradigm of health" embraces ideas such as: an integrated concern for the whole patient and an emphasis on achieving maximum wellness or "metahealth;" the body being viewed as a dynamic system, context, and field of energy within other fields; the minimal use of technological intervention complemented by a vast armamentarium of non-invasive techniques; the patient being seen as autonomous and the professional as a therapeutic partner; an emphasis on qualitative data to unveil the human perspective; and prevention that is synonymous with wholeness, work, relationships, goals, and the body-mind-spirit (Ferguson, 1980, p. 247).

This latter perspective underscores the inherent value of holistic professional nursing practice based on health-oriented research.

Health-Oriented Research

Within the Western world, health care has been significantly influenced by the adoption of primary health care as a means of achieving "health for all" (Lalonde, 1974). Widely purported as the hallmark of the Canadian health care system, "primary health care is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation, and at a cost that the community and country can afford" (World

Health Organization, 1978). Specifically, primary health care promotes maximum individual and community involvement meaning that "all persons have the right and duty to participate Healing Within Families 12

individually and collectively in the planning and implementation of their health care" (Canadian

Nurses Association, 1988, p. 5). Primary health care serves as the forerunner of a newer concept, that of health promotion, which is the process of enabling people to increase control over, and to improve their health (Raeburn & Rootman, 1998; WHO, 1984). While this reconceptualization of health care has been espoused in theory, a corresponding emphasis in research is still in the neophyte stage.

In order for individuals and families to increase control over their health, and to participate in their own health care, it is imperative that they be included in research that is designed to offer them a voice in the redirection of existing health care delivery. Health-oriented research that investigates the tremendous strengths and capabilities of individuals and families is pivotal to the development of healthy communities. English and Hicks (1992) note that in order to promote the health of families and communities, that it is important to identify and build on human strengths.

Antonovsky (1996) suggests that "the persistence of the disease orientation and the limits of risk factor approaches for conceptualizing and conducting research on health" (p. 11) poses a serious threat to the concept of health promotion. He goes on to claim that it is morally

"impermissible to identify a rich, complex human being with a particular pathology, disability or characteristic" (p. 14). Instead, Antonovsky (1996) proposes that the "Salutogenic Model" (p. 14) with its focus on health promoting factors, could well serve as a viable, useful, and powerful guide for both practitioners and researchers. This approach is opposed to a dichotomous classification of persons who are either healthy or diseased, characteristic of the biomedical model (Antonovsky,

1996). Rather, this model directs both research and practice efforts to encompass all persons, wherever they are on the health-disease continuum (Antonovsky, 1996; Jensen & Allen, 1993).

Through the use of this model, health-promoting questions such as "How can this person be helped to move toward greater health?" have significant relevance. In terms of facilitating a movement toward health, Antonovsky, (1996) suggests that one's "sense of coherence" (p. 15), or ability to find meaning in, and make sense of one's world, is essential. Further, he claims that it is the combination of cognitive (a belief that the challenge is understood), behavioral (a belief that the resources to cope are available), and motivational (the wish to cope) factors that determine the Healing Within Families 13

strength of one's sense of coherence, and thus one's movement toward health. This health- oriented, yet highly individualized model is congruent with nursing's holistic approach to health care delivery, and thus influenced the approach taken during the early conceptualization of this dissertation study.

The Response of Nursing to Youth Suicide

Aligned with medicine by necessity, nursing has also contributed to the shortfalls within the health care system. In the past, nursing has also been negatively influenced by the biomedical model. However, positive and exciting changes within the nursing profession are emerging with increasing frequency. The proliferation of research-based nursing knowledge in recent years has validated and fortified the scientific basis of nursing practice. As the scientific knowledge base of nursing expands, and as the level of education among nurses increases, nurses are further able to define, claim, and take responsibility for their legitimate scope of practice. Nursing, charged with the responsibility of providing holistic health care to individuals and families in a variety of settings

(Alberta Association of Registered Nurses, 1993), has the potential to make a significant contribution in terms of assisting bereaved families. As Rogers and Vachon (1975) claim: "Nurses, by virtue of their personal caring roles and their positions within institutions and in the community at large, are uniquely suited to carry more responsibility in providing service to the bereaved" (p.

16). Nurses are members of the health care team who have the most contact with bereaved families; they are often in contact with individuals and families on a 24-hour basis. This increased contact time facilitates nurses establishing therapeutic relationships (Quinn, 1989; Watson, 1999) with individuals and families. In addition, nurses are strategically positioned within the community and prepared to coordinate the activities of the multidisciplinary health care team.

"Nurses are at the vanguard of the quickening of the transpersonal currents of healing"

(Dossey & Dossey, 1999, p. x). Quinn (1989) asserts that healing is a major goal of nursing and that nurses may be the midwives who facilitate healing in others, while Wells-Felderman (1996) purports that it is time for nurses to take the initiative by introducing healing nursing interventions that acknowledge compassionate and knowledge-based caregiving. Similarly, Leftwich (1993) Healing Within Families 14 contends that "Nursing has a heritage of healing that was highly valued in the past" (p. 13), and maintains that nurses need not be timid about insisting that healing is an inherent element of nursing practice. In order to claim that healing is a major goal of nursing practice, nurses need scientifically-based nursing knowledge (i.e., theory) that explicates the process of healing.

The Study: A Focus on Healing

This purpose of this research was to develop a substantive theory that explains how individual family members heal in the aftermath of youth suicide. This study adopted a health- focused, health promotion perspective that embraced the strengths and resilient nature of grieving individuals and families.

Assumptions Underpinning the Study

This research was based on the following assumptions:

1. Individual family members possess innate healing capabilities which they can draw upon during times of hardship (e.g., youth suicide).

2. The process of healing can be studied. Further, it was assumed that family survivors are the best sources of data to describe and, hence, promote an understanding of the individual healing process following youth suicide.

3. The perceptions and ideas of all family members are relevant and therefore contribute to the development of theory about healing in individual family members following youth suicide.

Conceptual Issues

As I approached this study, two issues soon became apparent. First, during the conceptualization of this research study, I intended to study the concept of 'family healing.'

However, the study was well underway when I discovered that although family survivors were attuned to the thoughts and feelings of other family members, they were only able to reflect on their personal experiences. As I individually interviewed several survivors from the same family, I began to understand that each person had a personal and unique story to tell that sometimes Healing Within Families 15

differed from the stories shared by other family members. Even during family interviews, the individual perspective, albeit shared from several vantage points, was still evident. I therefore considered that each story represented a unique understanding that contributed to a comprehensive understanding of the whole. Since this approach offered much insight pertinent to the research questions, and because limited scientific research specific to healing within this population has been conducted to date, I decided, in consultation with my dissertation committee, to focus this research on the experience of the individual within the context of the family.

Second, I wondered how to best portray an understanding of survivors' accounts of healing as a complete process, in and of itself, and at the same time, provide an understanding of the intricacies inherent in the parts comprising the whole. As data collection and analysis proceeded, I discovered that the individual experience was also comprised of many parts, each part adding to an understanding of the embodied whole. Ransom et al. (1990) maintains that there is a mutual recursive relationship between individual family members and the family unit that results in the co-evolution of both over time. Thus, "we cannot understand wholes without understanding parts and their relationships and vice versa" (Robinson, 1995b, p. 11). Similarly, understanding the individual experience also involves gaining insight about the various facets of one's experience.

Because we know little about how the healing process occurs, the theory presented herein focuses on the individual's experience which is also comprised of many parts. Within this dissertation, the individual's experience of healing is presented in its parts only for the purpose of understanding.

In reality, the parts comprising the whole are enmeshed in a dynamic, recursive, and seamless process. It is anticipated that such knowledge will increase our understanding about how individuals within families heal which, in turn, may provide some insight about healing within the community and ultimately within society.

Research Questions

The following four research questions were used to guide this scientific inquiry:

1. What is the meaning of youth suicide to individual family survivors? What sense, or meaning, can be made of the suicide from their perspectives? Healing Within Families 16

2. Following youth suicide, how do family survivors grieve?

3. How do these same individuals engage in the healing process following youth suicide?

Specifically, what factors promote healing and what factors inhibit healing?

4. What is the relationship between grieving and healing?

Definition of Terms

Three concepts are central to the study. They are defined as follows:

• Youth Suicide. Youth suicide is the "willing and willful self-termination" (Boldt, 1988, p. 93)

of a youth aged 10-19.

• Family Survivors. Individuals from the deceased's family of origin in addition to those

identified by this group as being part of the family.

• Grieving. Grieving refers to "the full range of our coping responses to loss through death,

including, but not confined to, socially defined mourning practices, or what we do within

ourselves to redefine our relationship with the deceased" (Attig, 1996, p. 9).

Summary

The health care system has been slow to respond to the health care needs of family

survivors of youth suicide for a number of reasons, some of which have not been fully explored as

yet. For the past few decades, health care professionals have laudably focused their efforts on

youth suicide prevention programs. Even so, the incidence of suicide among youths continues to

soar, signifying a portentous global and national mental and public health problem. In the aftermath

of youth suicide, family survivors continue to be deeply affected throughout life. Family survivors

sustain both short- and long-term health and human consequences as a result of such trauma.

Within the Western world, the strong influence of the biomedical model has resulted in health care

delivery that often emphasizes treatment and cure over humane and compassionate care.

Unfortunately, youth suicide family survivors often have been left to manage on their own within a

health care system that provides minimal support and assistance. Healing Within Families 17

Nursing, with its mandate of providing holistic health care to individuals and families, can assist in extending comprehensive health care to bereaved families, including families bereft by youth suicide. To this end, in order to facilitate healing, it is important for nurses and other health care professionals to have a theoretical understanding of how individual healing occurs. This research was concerned with the development of theory that explains how the individual within the context of the family moves toward healing following youth suicide.

This dissertation is presented in nine chapters. In Chapter One, the background related to healing within families following youth suicide was established. Chapter Two provides an overview of the empirical evidence specific to grieving and healing within families. Chapter Three is devoted to the methodological forestructure, including the philosophical, theoretical, and personal perspectives of the researcher, as well as the. method, analytic approach, and ethical considerations that underpin this work. In Chapter Four, an overview of the grounded theory is provided in addition to the contextual factors that influence the healing process. Chapters Five to

Seven are concerned with the presentation of the theory that was developed as a result of data analysis. Chapter Five portrays the first theme of the healing process, Cocooning, which embraces the survivor's journey of descent within self. Chapter Six explicates the second theme, Centering, which illuminates the survivor's journey of growth. Chapter Seven elucidates the third theme,

Connecting, which captures the survivor's journey of transcendence. Chapter Eight addresses the relationship between healing and grieving and enriches the description of the content through a discussion of selected elements of the constructed theory. Concluding this dissertation, Chapter

Nine outlines implications of the research. Healing Within Families 18

CHAPTER TWO

EMPIRICAL EVIDENCE SPECIFIC TO GRIEVING AND HEALING WITHIN FAMILIES

Family survivors of youth suicide are often left to carry on with day-to-day life at a time when they may feel that their world, as they once knew it, has been turned inside out and upside down. The death of a family youth due to suicide may represent many things to family survivors— the loss of a child, the loss of one's hopes and dreams, the loss of a shared future, and the loss of part of oneself. In the face of catastrophic loss, it is inevitable that family members undergo an extensive period of grieving as they journey toward healing.

A thorough examination of the literature provided minimal scientific evidence specific to healing within families following youth suicide. However, grieving, an important aspect of healing, has been studied extensively. Since this study is located within the domain of grieving families, this chapter highlights current knowledge related to grieving within the context of the family. It also identifies a gap within the current literature. The following topics are discussed: the concept of grieving, traditional and contemporary theories of grieving, grieving within families, research and practice issues, grieving following suicide, the meaning of suicide, and also a brief description of the empirically-based literature that addresses the concept of healing.

The Concept of Grieving

The study of grieving is relatively new. Freud began the analysis of the concept when he compared the subjective experience of grief to the experience of melancholia (Burnell & Burnell,

1989; Haig, 1990; Worden, 1982). He proposed that the primary difference between the two was that one experiences an extreme loss of self-esteem and a persistent sense of self-denigration only in melancholia (Haig, 1990). Later, in a classic study of survivor reactions to a fire in the Coconut

Grove nightclub in Boston, Lindemann (1944) described grieving according to a predictable pattern accompanied by certain identifiable reactions to loss (Burnell & Burnell, 1989). These early conceptualizations of the concept of grieving provided the basis for further study.

Various definitions of grief appear in the literature. Grief is defined as: an adaptation to loss

(Bowlby, 1973; Haylor, 1987); an illness (Engle, 1961; Volkan, 1970); an acute crisis or series of Healing Within Families 19

crises (Caplan, 1974; Lindemann, 1944); an indirect pathogen (Sanders, 1982-1983); a syndrome

(Lindemann, 1944; Parkes, 1972); and as an active learning process (Attig, 1991, 1996; Feldman,

1989). Parkes (1970) described grieving as "a complex and time-consuming process in which a person gradually changes his view of the world. ... It is a process of realization, of making psychologically real an external event which is not desired and for which coping plans do not exist" (p. 465). Based on a comprehensive and systematic review of both current and classic literature, Cowles and Rodgers (1991) further expanded previous definitions of grief. These

authors defined grief as "a dynamic, pervasive, highly individualized process with a strong normative component" (p. 121). According to Martin and Elder (1993), "Grief arises from an awareness that the world that is and the world that 'should be' are different" (p. 73). Moreover, our understanding of this universal phenomenon has been influenced by both traditional and contemporary views of grieving.

Traditional Theories of Grieving: Stages/Phases of Grieving

In her classic work, On Death and Dying. Kubler-Ross (1969) categorized the experience of dying into five stages—denial and isolation, anger, bargaining, depression, and acceptance.

This ground-breaking book spurred scholars and clinicians to begin a dialogue about death-related topics that continues today. Because of perceived similarities between dying and grieving, interested individuals extrapolated from Kubler-Ross's work other descriptions of grieving. For instance, Martocchio (1985) described five phases of grieving: shock and disbelief; yearning and protest; anguish, disorganization, and despair; identification in bereavement; and reorganization and restitution (pp. 328-331). Averill (1968) specified three stages of grieving: shock, despair, and recovery, while Parkes (1970) identified four stages of grieving: numbness, pining (searching behavior), depression, and recovery (Burnell & Burnell, 1989, p. 34). A number of authors identified the tasks related to grieving, specifically: acceptance of the loss; acceptance of pain associated with grieving; adjustment to life without the beloved; and investment of energy into a new life or relationship (Burnell & Burnell, 1989; Haig, 1990; Steen, 1998; Worden, 1982).

Walsh and McGoldrick (1991) incorporated two additional tasks designed to promote grief Healing Within Families 20

adaptation within families. These tasks included acknowledgment of the reality of the death and sharing of the experience of loss, as well as reorganization of the family system and reinvestment in other relationships and life pursuits. Weiss (1988, cited in Haig, 1990) proposed three steps in the adaptation to loss: cognitive acceptance, emotional acceptance, and identity change.

Most of the literature describes grieving as a multi-phased process based on common assumptions. Traditional theorists recognized the physical, emotional, behavioral, and psychological aspects of the grieving process. They, responded by specifying several parameters of the grieving experience. These theorists envisioned grieving as a linear and progressive phenomenon in which the bereaved individual passively moves through a series of stages or phases that begins at the time of loss and ends at some definitive point in the future. Grieving was viewed "as yet another thing that happens to bereaved persons, a process into which they are thrust against their will, which they undergo or endure, and which they must somehow survive" (Attig,

1991, p. 386). Traditional theories often labeled aberrant manifestations of grief as pathological.

Such labeling has not always been helpful in terms of securing needed help for grieving individuals and families.

Underlying Assumptions

It has been suggested that conceptualizations of grieving are most likely related to assumptions that underpin the development of knowledge (Wambach, 1986). Hogan and DeSantis

(1992) contend that the major assumptions underpinning the traditional views of grieving and bereavement are derived from multiple perspectives. Understanding the assumptions upon which theories of grieving are based is essential to determining their efficacy in the practice setting. Based on Western tradition, five assumptions prominent within the literature on grieving are: 1. distress or depression is inevitable; 2. distress is necessary, and failure to experience distress is indicative of pathology; 3. working through loss is not only important, but necessary; 4. recovery from loss will occur; and 5. resolution of grief will be attained (Wormian & Silver, 1989). However, these authors claim that empirical evidence suggests that harm may result if we practice according to these mistaken assumptions. Healing Within Families 21

The majority of traditional theories of grief are, in fact, based on these assumptions

(Bowlby-West, 1980; Eliot, 1932; Freud, 1915; Kubler-Ross, 1969; Lindemann, 1944; Parkes &

Weiss, 1983). However, these theories do not account for all cases of grief. As indicated by

Wortman and Silver (1989), "Traditional theories of grief and loss are able to account for those who move from high to low distress and resolve their grief over time. But these theories offer little explanation of why some people might consistently respond with less distress than expected and others fail to recover or resolve their loss over time" (p. 353).

Contemporary Theories of Grieving: Grieving as a Dynamic Process

Contemporary theorists question traditional interpretations of grieving (Arnold, 1996;

Copp, 1998; Cowles & Rogers, 1991; Doyle, 1994; Klass, Silverman, & Nickman, 1996; Rando,

1988; Stroebe, 1992-1993; Stroebe, Van Den Bout, & Schut, 1994). These authors maintain that grieving is a dynamic rather than linear process (Cowles & Rogers, 1991) which is "oscillatory in nature rather than purely sequential" (Trunnell, Caserta, & White, 1992, p. 279). Instead of following clearly demarcated steps as proposed in the stage and phase models of linear and cyclical grieving (Worthington, 1994), reactions to loss may ebb and flow over an unspecified period of time. This implies a certain chronicity of the grieving process (Haylor, 1987) or, as stated by

Parkes (1970), "in some senses it [grieving] never ends" (p. 464). However, even though some authors suggest that the impact of grieving may be long-lasting, there is surprisingly little empirical data to support this claim (Lehman, Wortman, & Williams, 1987).

Attig's model of grieving (1996), in contrast to traditional models, describes grieving as an active coping process of how to be and act in a world where loss disrupts the individual's biography. As a multifaceted transitional process, grieving involves investing ourselves as whole persons in a process of relearning our world in the absence of our loved one. Attig suggests that

grief is not something we get over, but learn to integrate within our lives. He contends that we do not cease loving those who die. Rather, Attig (1996) maintains that "one of the most important

aspects of grieving is finding ways to make a transition from caring about others who are present to caring about them when they are absent" (p. 39). Based on current research, a number of other Healing Within Families 22

contemporary theorists support this view of grieving (Klass, Silverman, & Nickman, 1996;

Rosenblatt, 1996; Silverman & Nickman, 1996a, 1996b; Stroebe, Gergen, Gergen, & Stroebe,

1996).

Although representing the views of a minority at present, the romanticist notion that values bonding with the deceased person is being revived. This view presents a case for the healthy presence of the deceased person in the ongoing lives of survivors (Klass, Silverman, & Nickman,

1996; Marwit & Klass, 1996). Many authors maintain that the expectation that people should get over their grief is unrealistic and based on a misunderstanding of the grieving process (Klass,

Silverman, & Nickman, 1996; Rosenblatt, 1996; Silverman & Nickman, 1996a; Stroebe, Gergen,

Gergen, & Stroebe, 1996). A growing number of researchers and clinicians now contend that grieving a major loss extends throughout the life of the bereaved individual (Hogan & DeSantis,

1996; Rosenblatt, 1996; Silverman & Nickman, 1996a; Klauss, Silverman, & Nickman, 1996).

Silverman and Nickman (1996b) assert that survivors maintain a "continuing bond" (p. 349) with the deceased; they profess that "survivors hold the deceased in loving memory for long periods, often forever, and that maintaining an inner representation of the deceased is normal rather than abnormal" (p. 349).

Based on contemporary ideas of grieving, Martin and Elder's (1993) Pathways Through

Grief Model provides an explanation of individual grieving. This model is based on the work of

Bowlby (1973) who maintains that attachment precedes grief. Several assumptions underpin this model, specifically: grieving is triggered by losing someone important; grieving affects the total person within the context of the present and past; grieving occurs throughout life and thus is a process rather than an event; and grieving changes over time with no end point (Martin & Elder,

1993). Martin and Elder's model portrays the unending nature of grieving in addition to the contextual influences that affect individual grieving. Most theories of grieving to date focus on the

individual perspective. Individual grieving is influenced by a number of factors. Healing Within Families 23

Influencing Factors

Many contemporary theorists contend that individual grieving is influenced by a number of contextual factors. Worden (1982) identified several factors that affect how one grieves. One factor is the identity of the deceased person in relation to the grieving individual. If the deceased individual was a child or spouse, the grief response is stronger than it is for a distant relative. The strength and security of the relationship between the deceased individual and the bereaved person is an important factor as well. If there was ambivalence in the relationship, grieving is often difficult.

Whether the death is expected or unexpected, prolonged or sudden, homicidal or suicidal also determines how the survivor grieves. Death that is sudden and/or unexpected, or that occurs as a result of suicide, provokes prolonged, difficult grief (Steen, 1998). The health history of the grieving person also plays a role in the grieving experience. A diagnosis of clinical depression or mental illness may complicate grieving for survivors. The nature of previous losses and the way in which these losses were dealt with modifies subsequent grief experiences. If the bereaved individual was unable to grieve for previous losses, then a new loss may elicit a previous grief response and, therefore, compound the present grief experience. The personal characteristics of the bereaved are important as well. The bereaved person's age, sex, coping skills, level of anxiety, and whether he or she is an introvert or extrovert affect the grief experience. Older people often have an advantage because they have developed coping skills that assist them in grieving. Younger people do not expect to be faced with the death of a loved one and, hence, may lack well developed coping skills.

Besides those determinants identified by Worden (1982), social support has also been identified as an important factor that influences grieving (Gass & Chang, 1989; Martin & Elder,

1993). A supportive social network and adequate financial support aids the grieving person.

Higher education also may impact the course of grief. Those with higher levels of education tend to utilize more problem-focused coping strategies (Gass & Chang, 1989) which facilitate healthy psychosocial functioning. In addition, having someone available to participate in appropriate death rituals positively influences the grieving person's adjustment to the death of a loved one (Myss,

1996, 1997; Rosen, 1990). If the grieving person believes that he/she is totally or even partially Healing Within Families 24

responsible for the death of a loved one, then grieving may be more difficult. The existence of other major crises in the grieving person's life may also compound grieving.

Contextual factors such as ethnic, cultural, and religious beliefs are critical determinants of the grieving experience (Cowles, 1996; Rosen, 1990; Stroebe, 1992-1993). These beliefs are based on certain assumptions. For example, Stroebe (1992-1993) contends that the grief work

hypothesis, which stresses the importance of bereaved persons completing their grief work, has been neither confirmed nor refuted as a result of empirical studies. Rather than assuming that all people grieve in the same way, Stroebe (1992-1993) maintains that there are societal and cultural factors, and preferred styles of coping with loss that need to be taken into account. Stroebe (1992-

1993) asserts that "not only do beliefs in some societies fail to show any equivalent of the grief

work hypothesis, but an absence of grief work in some cultures does not seem to be associated

with [a] high [incidence of] depression, illness, or pathology" (p. 28). Rosen (1990) suggests that when families do not observe the appropriate ethnic/cultural rituals of mourning, their grieving may be affected by deep-seated beliefs based on their ethnic background. A reaction that appears to be denial or an absence of grief may, in reality, be a culturally-mediated grief response (e.g., the Irish wake or the New Orleans up-beat jazz march during the return from the interment).

Current theoretical perspectives recognize grieving as an individually unique experience;

hence, grieving unfolds according to each individual's way of being in the world. Recent conceptualizations also acknowledge both the inner and outer work that are required of the grieving individual, the continuity and fluidity of the grief experience over time, and especially, the importance of creating new meaning in response to the suffering associated with the loss (Attig,

1991, 1996; Klass, Silverman, & Nickman, 1996; Martin & Elder, 1993).

Grieving Within Families

While a substantial amount of conceptual and empirical research has been conducted on

individual grieving, the literature that addresses grieving from the perspective of the family remains

scarce in both quantity and scope (Kissane & Bloch, 1994). A majority of this literature focuses on

maladaptation and pathology. However, while this literature is not specific to grieving associated Healing Within Families 25 with youth suicide, it does provide the necessary background needed to understand grieving, and hence, grieving families as the context for individuals' experiences of grieving.

Within the structure of the family unit, family members occupy certain "roles." The death

(i.e., suicide) of a family member calls for the reorganization of the family unit. According to

Vollman, Ganzert, Pincher, and Williams (1971), "the single most important factor in the reorganization of a family as a continuing social system following a death is the role the decedent had been assigned and which he [or she] assumed within the family system" (p. 104). Similarly,

Bowen (1976) and Worden (1982) maintain that the loss of a family member whose role was

"emotionally" or "materially" critical is followed by greater family disruption than the loss of a comparatively neutral family member. Hence, it follows that youth suicide is exceedingly disruptive to families, both individually and collectively.

Notable contributions to the literature related to grieving within the context of the family have been made by Bowlby-West (1980), Lieberman and Black (1982), and Raphael (1984).

Bowlby-West (1980) identifies six maladaptive responses that families resort to in order to cope with the death of a family member. Raphael (1984) describes seven patterns of family responses to loss that are often subtle in presentation and may be either constructive or destructive.

Lieberman and Black (1982) address the interplay between individual and family responses to loss. They identify three categories of pathological family grieving, specifically: avoidance, idealization, and prolongation. These authors suggest that these response patterns parallel, and indeed amplify, those encountered in individual grieving. Further, Kissane and Bloch (1994) maintain that unresolved grief cannot be dealt with until issues related to family dysfunction are addressed. In addition, multi-generational loss issues may further compound grieving within families (B. Shawanda, personal communication, May 28, 1998). This refers to unresolved loss issues inadvertently passed down from one generation to the next. In a very real sense then, grieving needs to be understood from a family perspective, especially in cases where dysfunction is present.

These explanations of family grief response patterns inform us that powerful and pervasive ways of coping with loss may be quite well established within the family unit at the time of youth Healing Within Families 26 suicide. Moreover, family responses to death are often predicated on previous learning, commonly handed down from previous generations. Not surprisingly, Ainsworth and Eichberg (1991) suggest that a significant correlation exists between patterns of parental attachment behavior (e.g., secure-autonomous, insecure-avoidant) and the quality of attachment found in children. Moreover, the concept of family script (Byng-Hall, 1988, 1991) incorporates the beliefs, values, and rules within the family unit that encode the family's behavior for future situations. Such cross- generational influences suggest that families adopt styles of grieving that are readily transmitted to subsequent generations, either overtly or covertly. A number of research and practice issues influence our understanding of this complex phenomenon.

Research and Practice Issues

Ambiguity and confusion surrounding the concept of grief contributes to problems related to both research and practice. In part, this ambiguity is related to the plethora of definitions of grief-related terms found within the literature, as well as the lack of clarity regarding operational definitions. In addition, research efforts to illuminate the multidimensional aspects of grief and the issue of researchers working in isolation contribute to this confusion. An awareness of the complex nature of grieving is essential to research that endeavors to understand how family survivors grieve and move toward healing following youth suicide.

Even among experts, there is a conspicuous lack of consensus regarding the definition of grief (Burnett et al., 1994). In spite of being a "universal human response" (Cowles and Rodger,

1991, p. 119), the concept of grief remains plagued by vagueness and ambiguity. In addition to a lack of consensus regarding definitional clarity, terms like grief, bereavement, and mourning are often used interchangeably, and without explanation of operational definitions (Middleton,

Moylan, Raphael, Burnett, & Martinek, 1993). This deficiency makes it very difficult to understand and compare, the research that has been done because of uncertainty about whether the studies are actually looking at the same things. Such variation among definitions most likely depicts the diverse disciplinary background of the many professionals involved in bereavement care. Furthermore, these definitions appear to reflect an evolving understanding of the concept of Healing Within Families 27

grief which is not yet fully developed. In an attempt to address this deficiency, Jacob (1993) offers an operational definition of grief as "a normal, dynamic, individualized process which pervades each aspect (physical, emotional, social, spiritual) of persons experiencing the loss of a significant other" (p. 1789). Clarification of this type is definitely helpful and serves as a first step toward the resolution of concerns associated with definitional clarity.

Definitional fuzziness or ambiguity may also be related to efforts intended to capture the multidimensional quality of the grief experience. According to Jacob (1993), "the multi- dimensionality of the grief process makes an accurate assessment of the concept difficult. . . . This difficulty is largely due to the individual and dynamic nature of grief which varies from person to. person and from situation to situation" (p. 1791). Even research measurement instruments such as the Grief Experience Inventory (Sanders, Mauger, & Strong, 1985), developed to objectively measure the multidimensional aspect of grief, have limitations in that they have been developed in reference to specific populations and according to certain assumptions that do not, and cannot, address all possible variations in relation to a highly complex concept such as grief. In addition, a lack of cultural sensitivity is evident in a majority of the instruments currently in use. In effect, this leads to an under-representation of the cultural aspect of grief.

Another factor that contributes to the ambiguity surrounding grief is that researchers and clinicians often work in isolation and, as a result, rely on their own familiar terminology when communicating research findings. This may be particularly problematic in written communication where assumptions may not be clearly identified. Further complicating this situation, research consumers frequently interpret written information according to their own set of assumptions which may, or may not, be congruent with those intended by the author. To enhance knowledge development, assumptions need to be clearly stated and definitions need to be clarified at the onset of a study if efforts to develop a comprehensive data base regarding grief are to be realized. The generation of knowledge related to the topic of grief is dependent on researchers and clinicians being able to effectively communicate the assumptions upon which their research is based. Healing Within Families 28

Grieving Following Suicide

Sudden and unexpected death has a dramatic effect on grieving. Martocchio (1985) asserts that "Death is always difficult but premature death disrupts the normal cycle of events" (p. 334).

Based on a research study that examined the long-term adjustment to sudden, traumatic loss of a loved one (spouse or child), the results suggest that "sudden, unexpected loss of a spouse or child is associated with long-term distress" (Lehman et al., 1987, p. 227). Vargas (1991) found four prominent factors in family survivors of sudden and unexpected death, specifically: 1. depressive symptoms (most common); 2. preservation of the deceased person; 3. suicidal ideation; and 4. anger directed toward the deceased (p. 36).

Death by suicide is a traumatic event. Judith Herman (1992) describes the impact of traumatic events this way:

Traumatic events overwhelm the ordinary systems of care that give people a sense of

control, connection, and meaning. Traumatic events are extraordinary, not because they

occur rarely, but because they overwhelm the ordinary human adaptations to life. . . . They

confront human beings with the extremities of helplessness and terror and evoke the

responses of catastrophe, (p. 33)

Self-inflicted death poses specific problems for family survivors. Silverman, Range, and

Overholster (1994-95) suggest that suicide survivors experience unique grief responses and, in some cases, may be unable to fully resolve their grief. According to these authors, grieving following suicide is more intense than from other causes of death (e.g., homicide, accidental death, natural anticipated death, natural unanticipated death). In addition, survivors face the difficulty of constantly feeling the need to explain the reason(s) for their loved one's tragic demise (Range &

Calhoun, 1990). Unfortunately, survivors of suicide are more likely to assume responsibility for a loved one's death and they frequently experience an increased fear of their own self-destructive impulses (Worden, 1982). Ultimately, the suicide of a family youth may draw the entire family into distress. Moreover, the joint experience of suffering may render family members unable to provide much needed support to one another (Vachon & Stylianos, 1988). Healing Within Families 29

In comparison to all other types of death, suicide survivors receive the least amount of

community support (Range & Calhoun, 1990; Thompson & Range, 1992-93). Because having a

supportive network makes a positive difference in terms of coping with loss, a lack of social

support leaves grieving families in a compromised position. Societal attitudes toward suicide and

related perceptions of bereaved family members suggest that friends will not 'be there' to the same

degree and in the same ways that they would following other types of deaths (Thornton,

Whittemore, & Robertson, 1989). In the apt words of Davies (1991), "Working through grief

does require the encouragement, empathy, support and caring gained through relationships with

significant others" (p. 94). A lack of social support may also have far-reaching consequences, not

only for individuals and families but, ultimately, for communities and society.

The Meaning of Suicide

The full impact of youth suicide occurs within the context of the grieving family. Making

sense out of the experience of youth suicide is, indeed, a major challenge faced by family

survivors. Survivors of suicide suffer more than those bereaved by other causes of death in that

they are often unable to find meaning in their suffering (Silverman et al., 1994-95). An important component of grieving is the construction of meaning related to the loss at both the individual and family levels. At the individual level, this construction of meaning may entail "understanding the bereaved's history; who the loved one was; what that person meant to the survivor; how they were

together; what their hopes, dreams, and shared experiences were; and the nature of the events

surrounding the death" (Carter, 1989, p. 357). At the family level, the construction of meaning

may involve coming to terms with the physical absence of the deceased person on a day-to-day

basis; the reorganization of the family unit; understanding the meaning of the loss and its impact on

the family unit; and continuing with family life without the presence of the deceased person.

According to Patterson (1995), families construct and share meaning on three levels: 1.

meaning related to the stress-inducing situation; 2. meaning related to family identity; and 3.

meaning related to the family member's view of the family. Family identity emerges in response to

values, beliefs, and relationships shared among family members. Stressful situations (e.g., youth Healing Within Families 30

suicide) hold cognitive and subjective meaning for family members. Often family members cope with stressful situations by changing their perceptions in regard to their circumstances. Family identity may be threatened during stressful situations. Hence, family members may purposefully focus on the inherent opportunities for growth rather than the difficulties they encounter in such situations.

The family member's world view, or Weltanschauung, is the most enduring characteristic of the family, but it too can change in response to a non-normative crisis. This aspect of meaning encompasses the family member's perception of reality: it is based on existential beliefs (e.g., the purpose of the family as a unit), assumptions about the environment, in addition to cultural and religious beliefs. When both the world view of family members and the identity of the family as a unit are challenged or altered, the family is especially vulnerable (Patterson, 1995). If a resolution does not occur in such situations, the family may even dissolve.

Several authors maintain that any attempt to understand the impact of suicide on the individual and family must take into account the socio-cultural meaning of suicide (Balk, 1994;

Boldt, 1988; Gartrell, Jarvais, & Derksen, 1993; Krai, 1994; Van Dongen, 1993). Given that the meaning of suicide is influenced by socio-cultural values and beliefs, these aspects need to be explored with individuals and families in an attempt to understand the meaning they ascribe to their experiences (M. Boldt, personal communication, March 16, 1997). I now turn to address the concept of healing.

The Concept of Healing

During the last decade, the concept of "healing" has been mentioned in the health care literature (e.g., Brooke, 1995; Dossey, 1995; Frisch & Kelley, 1996; Herruck, 1992; Kahn &

Saulo, 1994; McDonald & McDonald, 1997; Mannino, 1997; Montgomery, 1993), and studied with increasing frequency. This "healing consciousness" (Achterberg, 1990, p. 187) was born out of the perceived limitations of the biomedical model and an emphasis on current models of health care that emphasize human potential (Achterberg, 1990, Ferguson, 1980) and healing (Myss,

1996, 1997; Watson, 1999). This interest was also the result of scientific findings that validate the Healing Within Families 31

necessity of addressing the triune nature of humankind (i.e., body-mind-spirit) in the promotion of health and well-being (Achterberg, 1990; Myss, 1996, 1997; Peirce, 1997; Pennington, 1988;

Stokes, 1998; Watson, 1999).

According to Webster (1989), "heal' is defined as "to make whole or sound; restore to health" (p. 653). Healing, synonymous with restoring and optimizing health, is the aim of all health care delivery. In the past, the concept of healing was associated with quacks, evangelists, and others who did not understand standard allopathic treatment. Primary interventions with drugs and surgery were used extensively as a means of treating and curing illness. Hence, the pathophysiology of illness and disease was better understood than health and healing (Myss,

1997). In fact, healing in response to personal loss, was often understood from a pathophysiological perspective. Engel (1961) likened grieving to healing from an illness or wound, as a passive happening. In general, wound healing was seen as a model for healing (Weil, 1983).

Weil (1983) maintained that this view can be extended to include the psychic analog of wound healing, for example, in relation to the death of a loved one:

There is the same initial shock and intense pain that claims all attention and totally shatters

one's equilibrium. There is a flood of emotion, perhaps the psychic analog of bleeding, and

with time and normal grieving the gradual but steady development of scab and scar

[evidence of trauma], the regeneration of positive feelings, and adaptation to the loss. The

wound may ache on occasion, even years later, but it is then an old wound, a healed one,

no longer a threat to equilibrium, (p. 68)

Weil (1983) viewed healing as a universal property of all creation composed of three distinct components or phases including reaction, regeneration, and adaptation. He maintained that healing depends on the secret wisdom of the body and that medicine can only facilitate healing.

While remnants of Weil's view persist today, most of our knowledge about the concept of healing has been gained as a result of empirical evidence, that is, evidence based on experience or experiment (Webster, 1989).

Achterberg (1989, 1990) maintains that our understanding of the term "healing" requires a redefinition within the Western health care system. Eastern physicians have been aware of the Healing Within Families 32

mind's healing capacity for more than two thousand years (Goleman, 1997). Recent collaboration between Eastern and Western thinkers has resulted in an unprecedented exchange of ideas about ancient wisdom and the modern quest for wholeness (Goleman, 1997). An evolving understanding of the healing process is currently underway.

Dombeck (1995) defines healing as the process of re-establishing health and well-being following some type of trauma. Healing, she purports, is an active and internal process that includes investigating attitudes, memories, and beliefs with the desire to release oneself of all negative patterns that prevent full emotional and spiritual recovery. This internal review inevitably leads the person to recreate his or her life in a way that serves to activate the will—the will to see and accept life truths, and the will to begin to use energy for the creation of love, self-esteem, and health. According to Dombeck (1995), "Whatever the degree of trauma, the pathways to healing involve a symbolic awakening, a receptivity or hospitality to new learnings, and a commitment to intentionally tend to the practical activities of healing (Dombeck, 1995, p. 60). Other aspects of healing include "being restored to health or wholeness, being aware of one's connectedness, and finding a sense of hope, purpose, and direction in one's life" (Dombeck, 1995, p. 40). Healing is accomplished by releasing inner pain, establishing new meanings, restoring integration, and emerging into a sense of renewed wholeness (Dombeck, 1995). Frankl (1984) contends that healing involves finding meaning in suffering. Moreover, healing, according to Katz & St. Denis

(1991), is viewed as a "transition toward meaning, wholeness, connectedness, and balance" (p.

24).

Jeanne Achterberg (1990), author of Woman As Healer, contends that a balanced view of healing includes the following ideas: 1. Healing is a lifelong journey toward wholeness; 2. Healing is remembering what has been forgotten about connection, and unity and independence among all things living and non-living; 3. Healing is embracing what is most feared; 4. Healing is opening what has been closed, softening what has hardened into obstruction; 5. Healing is entering into the transcendent, timeless moment when one experiences the divine; 6. Healing is creativity and passion and love; 7. Healing is seeking and expressing self in its fullness, its light and shadow, its male and female; and 8. Healing is learning to trust life (p. 194). This understanding portends that Healing Within Families 33

healing is primarily concerned with the internal aspect of the individual's experience of achieving

health and wholeness.

The concept of healing has been mentioned in popular literature, primarily in the form of

anecdotal accounts (Achterberg, 1989, 1990; Dossey, 1991; Goleman, 1997; Hover-Kramer,

1989; Minkowski, 1992; Moyer, 1993; Otto & Knight, 1979; Quinn, 1989; Sulmasy, 1997; Swift,

1994; Vargas, 1991). Within the last decade, the concept of healing has been found in the research

literature with increasing frequency (Demi & Howell, 1991; Frank, 1995; Myss, 1996, 1997).

Most of these authors make the assumption that readers understand the meaning of the term

"healing." Seldom is a definition of the term provided in the literature. Hence, confusion still exists

about the meaning of the concept.

Commonly held beliefs also have an impact on our understanding of the healing process.

Myss (1997) identifies five central myths about healing that can interfere with the person's capacity to move toward healing. These myths include: 1. My life is defined by my wound; 2. Being

healthy means being alone; 3. Feeling pain means being destroyed by pain; 4. All illness is the result of negativity, and we are damaged at our core; and 5. True change is impossible (pp. 31-53).

These myths have power over the individual because "hopeful, optimistic beliefs are about the future, about possibilities, whereas illness is a reality and the myths that support it are in the present time. Healing is intangible, but you can feel and see your illness" (Myss, 1997, p. 30).

Indeed, these myths about healing often keep people from understanding and experiencing healing.

Healing has been studied with respect to adult male survivors of childhood sexual abuse

(Burke Draucker & Petrovic, 1996), breast cancer survivors (Predeger, 1996), survivors of parent

or sibling suicide (Demi & Howell, 1991), survivors of suicide (Robinson, 1989; Smolin &

Guinan, 1993), and adult female survivors of incest (Trucker, 1992). However, the literature revealed no family-based research studies that focus on healing following youth suicide.

Moreover, few research studies that focus on grieving families are based on a health promotion philosophy (Anderson & Yuhos, 1993), and even fewer studies are aimed at uncovering the resilient capabilities and innate strengths possessed by individual grieving family survivors. This Healing Within Families 34 gap in the scientific literature substantiated a need to develop a grounded theory that explains healing as experienced by individual family survivors of youth suicide.

Summary

The empirical study of grieving spans approximately three decades. Although early theorists recognized the multi-dimensional nature of grieving, they viewed it as a linear process involving a series of stages or phases. In contrast, contemporary theorists argue that grieving is a dynamic rather than static phenomenon, influenced by a number of contextual variables. Although presently representing the views of a minority, recent theorists claim that family survivors maintain healthy continuing bonds with deceased persons throughout the course of their lives.

Youth suicide poses a unique set of challenges for survivors of suicide. They face the challenges of dealing with the death of a young person and the stigma associated with suicide.

Finding meaning in relation to suicide remains the greatest challenge of all. Despite these challenges, survivors often speak of healing in relationship to their experiences. Although the experience of healing in response to trauma has been studied with specific populations, minimal scientific evidence has been found that addresses how individual family members heal in response to youth suicide. This gap in the literature was identified as an area requiring further study; it was the major focus of this dissertation research. The methods and procedures for conducting this research are described in the following chapter. Healing Within Families 35

CHAPTER THREE

RESEARCH DESIGN AND IMPLEMENTATION

Many families are confronted with the suicide of a family youth each year in Canada, and the numbers are increasing (Leenaars et al., 1998). Understandably, the major emphasis in the past

has been on preventive measures, and while such efforts have been somewhat successful, many families are still confronted with this public health problem (Leenaars et al., 1998; Low &

Andrews, 1990). While research shows that family members who experience youth suicide often experience prolonged grieving in addition to short- and long-term health consequences (Ness &

Pfeffer, 1990; Parkes & Brown, 1972; Rudestam, 1992), little emphasis has been focused on the strengths and resilient capacities of these grieving persons. Surprisingly little is known about how family members engage in the healing process in response to youth suicide. Hence, initially the goal of this study was to generate a substantive theory that explicates how individuals within the context of the grieving family heal following teen suicide. A qualitative approach, specifically grounded theory, was used to develop such a theory.

This chapter focuses on the philosophical, theoretical, and personal orientations that guided the methods. Three theoretical perspectives integral to this work are discussed, specifically, symbolic interactionism, systems theory/family research perspectives, as well as gestalt psychology/humanism. These perspectives influenced the development of the research questions, the methodology used to generate theory, and the approach used in the interpretation of the findings. Second, an overview of the method is provided along with the rationale for its use. The study is described in terms of the sample population, and procedures used for data collection and analysis. Strategies for establishing scientific rigor are provided. This chapter concludes with an explanation of the ethical considerations applied during the study.

Methodology

Cushing (1994), in discussing research about issues connected with nursing, defines methodology as "the philosophical approach adopted for a nursing science question," and the Healing Within Families 36

method as "the technique used to gather data" (p. 406). Guba and Lincoln (1994) contend that questions and issues related to the method are of secondary importance to those of the philosophical perspective of the researcher. That is, the researcher always approaches a study with a particular philosophy or set of beliefs. Generally, the subject matter of philosophy is concerned with the "search for meaning in the universe" (Gortner, 1990, p. 101). The researcher's philosophy is situated within a particular paradigm or worldview (Guba & Lincoln, 1994). Each paradigm perspective embraces a certain set of beliefs that determine the "what" and "how" of scientific inquiry. A philosophy has three components: an ontology, an epistemology, and an ethic.

The first two components are addressed here, and the third aspect, ethical considerations, is discussed later in this chapter.

Essentially, the way in which knowledge is gained is directly related to the paradigm perspective adopted by the researcher and the corresponding ontological and epistemological claims. The ontological component is concerned with the nature of reality, that is, whether a "real" world exists that can be known (a realist philosophical viewpoint); or whether reality is assumed to be relative, and thus, constructed by the individual (a relativist philosophical position) (Guba &

Lincoln, 1994; Salsberry, 1994). The epistemological constituent addresses how we know and learn about phenomena that are deemed to be the focus of study. Specifically, epistemology is concerned with the relationship between the knower and what can be known (Guba & Lincoln,

1994). Invariably, such a relationship is influenced and/or constrained by the researcher's ontological perspective.

Research methodology focuses on how an inquirer gains knowledge about the research question(s) (Guba & Lincoln, 1994). It is especially important that the methodological claims and research method be congruent with the state of existing knowledge related to the research questions being asked (Siegel, 1983). The method can only be determined once the ontological and epistemological perspectives have been determined. For this reason, my philosophical orientation will be addressed next, followed by the theoretical and personal forestructures that I bring to this study. Healing Within Families 37

Philosophical Stance

Ontology addresses one's beliefs about reality and what can be known. As a researcher, my ontological views are congruent with the relativist paradigm. A relativist posits that facts and principles are inextricably embedded within in a particular historical and cultural setting (Tinkle &

Beaton, 1992, p. 654). Further, this position subscribes to the notion that "realities are apprehendable in the form of multiple, mental constructions, socially and experientially based, local and specific in nature . . . and dependent for their form and content on the individual persons or groups holding the constructions" (Guba & Lincoln, 1994, pp. 110-111). This philosophical stance views meaning as multifaceted and multi-layered. Within the relativist paradigm, I identify myself as a constructivist. That is, I hold the view that reality is constructed and re-constructed by the individual during the course of his or her life. Moreover, I believe that reality can only be known by understanding the constructions of those involved (e.g., grieving family members) through dialectic discourse.

Congruent with a relativist ontology, epistemologically my approach to knowledge acquisition is based on transactions which emphasize the importance of interaction, context, interpretation, and subjectivity (Chinn, 1985; Silva & Rothbart, 1984). Consequently, the data of particular interest in this inquiry included participants' stories, observations of study participants, non-technical information sources such as diaries and poetry, as well as my intuitive grasp of all these data sources. My approach to this study is closely aligned with constructivism which adopts a relativist ontology, a transactional epistemology, and an interpretive methodology (Guba &

Lincoln, 1994). In addition to stating my philosophical stance, it is important that I, as researcher, disclose the theoretical and personal forestructures I bring to the dissertation process.

Theoretical and Personal Forestructures

The theoretical frameworks underpinning the methods used in this study included symbolic interactionism, systems theory/family research perspectives, and gestalt psychology/humanism.

Symbolic interactionism served as a framework for approaching the individual, while systems theory provided the basis for examining family context. A humanistic approach provided the lenses Healing Within Families 38

for making sense of participants' stories. Humanism, an outgrowth of gestalt psychology, emphasizes the importance of understanding the personal perspective, validates the worth and uniqueness of each individual, and embraces the development of human potential (Babcock &

Miller, 1994). This approach was deemed to be appropriate in my attempt to understand how individuals and families heal in response to youth suicide.

Perspectives on Symbolic Interactionism

Symbolic interactionism refers to a distinctive approach to the study of human social life

(Schellenberg, 1990). Based on the philosophical writings of James, Cooley, Dewey, Mead, and

Blumer, symbolic interactionism focuses on the meaning of events to people in natural and everyday settings. Like phenomenology, it is concerned with the study of the inner or experiential aspects of human behavior. Symbolic interactionists are concerned with understanding one's values and beliefs; they are interested in how people define events or reality and how they act in relation to their perceptions of reality. This view purports that humans act on the basis of meaning

(Blumer, 1969; Chenitz & Swanson, 1986; Spradley, 1979). However, a stage of deliberation or definition of the situation precedes action. Action is influenced by several antecedent variables such as feedback from significant others, perceptions of the social environment, and contextual variables such as economic, cultural, and religious factors. The reality or meaning of a situation is created through interaction within a particular environment. People act based on their perception of reality and, in turn, face the consequences of such action.

Blumer (1969) cites three premises as constituting the foundation of symbolic interactionism. First, "that human beings act toward things on the basis of meanings that the things have for them" (p. 2). These things may be objects, other human beings, institutions, others' activities and situations, or a combination of these. The meaning attached to things governs the actions of people; hence, behavior is comprehensible only when one understands the meaning of something from the perspective of the individual.

The second premise states that "the meaning of such things is derived from, or arises out of, the social interaction that one has with one's fellows" (Blumer, 1969, p. 2). Symbolic Healing Within Families 39 interactionists contend that social behavior and culture are inextricably intertwined. According to

Spradley (1979), culture refers to "the acquired knowledge that people use to interpret experience and generate social behavior" (p. 5). Culture, or a shared system of meaning, is developed and modified within the context of interaction among people (Spradley, 1979). Symbolic interactionists do not assume that culture is composed of commonly shared signs and symbols that are uniformly understood. Rather, they believe that to understand social behavior, it is necessary to understand the meaning various signs and symbols hold for the individual. How one interprets a situation is invariably related to the meaning the situation holds for the person, and the meaning may vary from time to time and from situation to situation.

The last premise maintains "that these meanings are handled in, and modified through, an interpretive process used by the person in dealing with the things he encounters" (Blumer, 1969, p. 2). In addition to cultural influence, the interpretive process is mediated through a number of variables which include: past experience, educational level, language, and physical and cognitive abilities (Chenitz & Swanson, 1986). Essentially, meaning is "co-created" through a process of social interaction. These premises are based on the assumption that human beings are in constant interaction with the environment and are largely able to choose the psycho-social stimuli to which they respond.

Spradley (1979) suggests that the interpretive component can be likened to a cognitive map.

In turn, interpretation is culturally determined and best thought of as:

A set of principles for creating dramas, for writing scripts, and, of course, for

recruiting players and audiences.... Culture is not simply a cognitive map that people

acquire, in whole or. in part, more or less accurately, and then learn to read. People are

not just map-readers; they are map makers. People are cast into imperfectly charted,

continually shifting seas of everyday life. Mapping them out is a constant process

resulting not in an individual cognitive map, but in a whole chart case of rough,

improvised, continually revised sketch maps. Culture does not provide a cognitive map,

but rather a set of principles for map making and navigation. Different cultures are like Healing Within Families 40

different schools of navigation designed to cope with different terrains and seas. (Frake,

1977, pp. 6-7)

Meaning is negotiated through the use of symbols (e.g., language, artifacts).

Communication is symbolic because we communicate via languages and other symbols; through communication we create or produce significant symbols. Through an interpretive process, meanings are established. Specifically, "The actor selects, checks, suspends, regroups, and transforms the meanings in light of the situation in which he is placed and the direction of his

action. . . . Meanings are used and revised as instruments for the guidance and formation of

[future] action" (Blumer, 1969, p. 5). These meanings are products of collective situations; that is, meanings arise out of interaction with others. Through the interactive process as'it is mediated by language, one acquires a self.

According to Blumer (1969), individual behavior, group conduct, and even culture are all matters involving meaning and interpretation. Consequently, if one wishes to understand an individual's behavior or a collectivity's actions, one must 'get at' the meanings being assigned and the interpretations being made. Blumer reduces all social processes, however complex, to meaningful interpersonal behavior. Grounded theory, based on symbolic interactionism, aims to discover underlying social processes; consequently, grounded theory methods were selected for this study.

Informed by symbolic interactionism, within this study, I needed to be highly sensitive to the meaning(s) that individuals and families attached to people, things, and situations. It was important to understand the layered meaning that survivors individually and collectively constructed in response to their experiences with the suicide of a family youth. Additionally, I

assumed that each survivor might hold different views, resulting in different meaning being

subscribed to each individual's experience. Hence, it was important for me to elicit the precise meaning related to experience, both individually and collectively. In part, this entailed 'getting at'

(via questioning) the meaning embedded within the language being used by participants. Since

meanings are in people rather than words, it was important that I listened carefully and sought Healing Within Families 41

clarification frequently in my attempt to capture the richness (i.e., thick description) within participants' stories.

In this study, symbolic interactionism guided the selection of the grounded theory procedures used to explore the process of individual healing following youth suicide. As previously mentioned, individuals live their lives within the context of their families. Therefore, my perspective on families must also be articulated.

Perspectives on Families

My perspective on families is guided by family systems theory, von Bertalanffy (1968;

1975) recognized living systems as complex organizations composed of many parts in constant interaction with other systems. According to systems theory, the family is conceptualized as an open system that interacts within a broader sociological and historical context (Whall, 1986).

Specific concepts inherent within this perspective include:

1. A family system is part of a larger suprasystem and as well is composed of many

subsystems;

2. The family as a whole is greater than the sum of its parts;

3. A change in one family member affects all family members;

4. The family is able to create a balance between change and stability; and

5. Family members' behaviors are best understood from the view of circular rather than

linear causality (Wright & Leahey, 1984). Of particular significance, these concepts validate the view that families possess inherent strengths and coping capabilities that can be drawn upon during times of great need. In addition, these concepts allude to the powerful influence that family members have on one another.

Perspectives on Family Research

Increasingly, the family has become an important focus for the provision of nursing care.

Within this section, two issues that are central to this study are addressed, the definition of family and the decision regarding who should be included as informants. Healing Within Families 42

The first issue pertains to the definition of family used in this inquiry. Numerous

definitions of family are found within the nursing literature. Traditionally, the family has been

defined in terms of structure and/or function (Wright & Leahey, 1984). For instance, Kristjanson

(1992) defined the family as '"individuals' bonded by a biological or legal relationship ... as

those persons having a functional relationship to one another" (p. 39). Family members may or

may not cohabitate, and the family may be described as nuclear, inter-generational, or extended.

Other definitions of family are broad-based, inclusive, and flexible, and thus reflect the constant

state of change readily apparent within society today. For example, Gilliss (1991) defined family

as "a complex unit with distinct attributes of its own but containing component parts that are

significant as individual units, both independently and collectively" (p. 198).

Within current nursing research, the definition of family is often externally imposed by the researcher, for example, a family consisting of a mother, father, and at least one child. Externally

imposed definitions may inadvertently introduce bias (Patterson, 1995) (e.g., social, cultural, or

gender) within a research study. Further, the artificial delineation created by an externally imposed

definition may not accurately represent boundaries that the family would view as meaningful

(Kristjanson, 1992).

Within this inquiry, and congruent with the Alberta Health (1993) document, Palliative

Care In Alberta, family was understood in its broadest sense to include not only next-of-kin family

members, but also significant others identified by family members as being part of the family

(Stuart, 1991). An inclusive rather than exclusive definition of family was adopted: "a complex

unit with unique attributes of its own" (Gilliss, 1991, p. 198). The decision regarding "who" to

include as family was collectively determined by the family members themselves. This definition

was used because it preserves participants' voices and validates the dynamic nature of families, as

well as the powerful influence that family members have on one another (e.g., Alberta Association

of Registered Nurses, 1992, 1993).

The second issue centered on the use of a single individual versus multiple family members

as informants about the family. Uphold and Strickland (1989) maintain that the "choice of who

should be the source of data collection must be based on the purpose of the study, the research Healing Within Families 43

question, the theoretical basis of the study, and the specific unit about whom the researcher intends to generalize" (p. 415). The emphasis in this study was on the individual within the context of the family system, hence, a "unifying conceptualization" (Robinson, 1995b, p. 8) of family was used in which data were collected from both individual family members and subgroups within the family, and whenever possible, the family as a unit. This approach addressed the artificial

separation between the individual and family (Davies, 1995; Hayes, 1993; Robinson, 1995a;

Robinson, 1995b) commonly encountered in family research. The individual perspective is not less than the family view; it is different from the family viewpoint. Even though a single informant can provide family-level data, it must be remembered that restricting family data to a single family member or subset has the potential to present a biased view of the family. Neither the individual nor the family view is complete in and of itself. Thus, because both the individual and family are a part of the conceptual picture (Davies, 1995; Robinson, 1995a; Robinson, 1995b),. the views of both were considered important and contributed to a greater understanding of the phenomenon

under study (Davies, 1995b, Robinson, 1995a; Robinson, 1995b). In addition, simultaneously focusing on individual and family systems captured the dynamic and complex nature of families

(Robinson, 1995a; Robinson 1995b), an important element in understanding individual healing

within the context of the family.

A common challenge confronted by researchers is that of obtaining accurate family data. In this study, data were gathered from both individual family members and the family as a unit. This

schema focused on the parts comprising the whole by including the individual perspective, or that part of the person which is separate from the family. In addition, views about the family as a collective were also of interest in this study. This conceptualization of family recognized the influence of the family on the person, and vice versa (Mangham, Reid, McGrath, & Stewart, 1995;

Robinson, 1995a; Robinson, 1995b). The single-informant approach was used to allow freedom

of expression (Uphold & Strickland, 1989) while the multiple-informant approach was used to

gather transactional-level data about individual and family systems. Transactional-level data are

concerned with interaction and reciprocity on both the personal and family levels (Robinson, Healing Within Families 44

1995a: Robinson, 1995b). These data simultaneously focused on the person as both an individual and as a member of a family system.

There is agreement in the literature regarding the effect of context on family data

(Kristjanson, 1992). It is recognized that an individual may respond differently to the same question when posed individually, and when other family members are present. Thus, context becomes an important variable in the conceptualization of the research questions. The research questions in this study were written to 'get at' the views of the individual within the context of the family. This was accomplished by interviewing each person individually, and then interviewing the family as a unit whenever possible. Two sets of interview questions were prepared—one set directed toward the individual and the other set specific to the family as a unit. It was recognized that there may be a lack of consensus amongst family members in response to the research questions. In some cases, data obtained from one family member were congruent with that obtained from another family member; in other cases, these data were inconsistent. Inconsistent data were therefore reported to reflect the inconsistencies so often apparent within families.

Inconsistent data provided information about the family that otherwise might have been unavailable. Schless and Mendels (1978) claim that interviewing as many informants as possible provides significantly more data about the family by capturing the density and complexity of the family system. Therefore, all sources of data were valued and viewed as contributing to a broader, all-encompassing perspective on the family context for individual grieving and healing.

Symbolic interactionism and systems theory provided the theoretical foundation for the analysis of individual and family level data. Based on Gestalt psychology, a humanistic approach guided data collection and analysis and the overall approach to the conceptualization of the theory presented in subsequent chapters.

Perspectives on Gestalt Psychology/Humanism

As pioneers in the field of Gestalt psychology, Wertheimer, Koehler, Koffka, and Lewin insisted that psychologic phenomenon need be studied by introspection and observation. Gestalt is a German word that means "the whole or totality" (Babcock & Miller, 1994, p. 38). Within the Healing Within Families 45

field of psychology, this concept refers to the idea that the whole is more than merely the sum of its parts. Gestalt theorists maintain that human beings are irreducible wholes which cannot be understood simply by analyzing their perceptions of events (Babcock & Miller, 1994; Perls,

Hefferline, & Goodman, 1951; Schiffman, 1971). Perception refers to the portion of the world that is grasped mentally through sight, hearing, touch, taste, and smell (Neufeldt, 1991).

Gestaltists see perception as contextually-based, as an active process influenced by a myriad of factors including history, genetics, and environment. Hence, contextually situating this work was critical and is addressed in Chapter Four.

As an outgrowth of Gestalt psychology, humanism is the name given to a cultural and intellectual movement that developed during the Renaissance. Developed by theorists such Rogers,

Goldstein, Angal, Maslow, Murray, and Combs, humanism has historically been concerned with human worth, individuality, humanity, and the individual's right to determine personal action

(Babcock & Miller, 1994; Lefrancois, 1988; Rogers, 1951, 1961, 1969). While acknowledging the importance of the individual's developmental history, humanists focus on contemporary experiences and conscious awareness in the present. Humanism is concerned with the uniqueness of each individual; one's uniqueness is one's self. The development of self results from interactions within one's world (direct experience) and from beliefs and values about one's self learned through interactions with others (indirect experience). Humanists believe in human potential. Based on the assumption that the individual is striving toward healthy and creative functioning, the prime motivating force is self-actualization, a continuous effort to achieve the maximum development of one's potentiality. This view was selected as a basis for this study because it is congruent with the concept of health promotion discussed in Chapter One.

The humanists' vision for the human experience is closer to the frameworks of Eastern theorists and their understanding of the higher levels of consciousness. Humanism is an holistic approach to understanding people concerned with topics including: love, creativity, self-growth, becoming fully human, joy, transcendence, play, humor, affection, naturalness, autonomy, responsibility, extrasensory perception, and peak experience (Babcock & Miller, 1994). Healing Within Families 46

My analytic approach in this study, aligned with that of humanism, is based on Frank's

(1995) idea of "thinking with" rather than "thinking about" stories. According to Frank (1995):

To think about a story is to reduce it to content and then analyze that content. Thinking

with stories takes the story as already complete; there is no going beyond it. To think

with a story is to experience it affecting one's own life and to find in that effect a certain

truth of one's life. (p. 23)

Participants' stories are thus woven into the theory that begins in Chapter Four. These stories need to be heard as once told for they leave "us right where we always already were, with the actual play and interplays of life, with all its difficulty and ambiguity, unredeemed or, better, not in need of redemption but only thoughtful savoring, reflection, conversation and understanding" (Jardine,

1990, p. 224).

The grand narrative is used as a way of avoiding over-analysis of the content, of avoiding too much dissection (Neufeldt, 1991), and as a means of remaining close to the truths embedded within these stories (e.g., Clarke, 1995; Cohler, 1991; Lewis, 1961). Best told by the participants themselves, these stories restore life to its "original difficulty" (Caputo, 1987, p. 1). Considering the highly personal and sensitive nature of the topic being discussed, I wondered how to best portray the participants' stories; I therefore asked them how they preferred to have their stories represented. Unequivocally, participants proclaimed that they wanted their stories presented with as much detail as possible. These stories, therefore, are not presented to support my views; rather, they are the source from which the grounded theory was developed However, I do place these stories within the theoretical framework that emerged from the analysis of the data, which I believe is only a means of illuminating the richness and truths embedded within each and every story in singular or combined presentations. My approach to this research was influenced not only by these theoretical forestructures, but also by my personal situatedness.

Personal Situatedness

When conducting highly personal and emotion-laden research such as this, despite all efforts to represent the views of participants adequately, the researcher becomes implicated Healing Within Families 47

(Lincoln & Guba, 1985). The researcher's philosophical position always has an impact on the research process in terms of both content and process. Hence, the researcher must acknowledge that his or her values will influence the inquiry, make explicit all relevant personal values, and account for these (Lincoln & Guba. 1985). Here, I briefly describe pertinent aspects of my biography that I bring to this work.

I am a white, middle-class, middle-aged wife and mother of four adult children, and grandmother of one. Over the past thirty years I combined the traditional female role of primary care provider and homemaker with that of counselor, public health nurse, nurse educator, researcher, and nursing leader in my community. I see myself as a caring and committed person and as one who approaches life and living with great enthusiasm.

My professional interest in working in the area of palliative care stems from my personal experience involving the death of my mother in 1971. As a young woman, I knew the pain associated with loss long before I understood the grieving process. Following the death of my 50- year old mother in the impersonal environment of a big city hospital, with my husband and brother at my side, we made our way to a nearby elevator. We left the hospital alone, without guidance or support from any staff person. I realized how vulnerable and powerless I felt and how little I knew about death. I realized how I longed for support and guidance from the nurses who were with my mother at the end of her life. I made a promise to myself to pursue this area of study as a basis for helping nurses and others to assist grieving families.

My doctoral program presented me with the opportunity to contribute to this field. While working as a research assistant during my doctoral program, I had the positive experience of being involved in a sibling bereavement study working under the supervision of my dissertation supervisor. I was involved in a pilot study involving families where a child had died due to either short- or long-term causes of death. Eighteen families volunteered to participate in this study.

Within those 18 families, five youngsters had died as a result of suicide. The incidence of this occurrence had an impact on me. As I listened to the stories shared by family members, I was

"grabbed" by their honesty and forthrightness. My curiosity was piqued as I listened to how some individuals consistently spoke of "healing" in relation to their experiences with horrific death. I Healing Within Families 48 wondered about how such healing occurred, and why some individuals spoke of healing and others did not.

My professional background includes experience in the areas of individual and family counseling, psychiatric nursing, public health nursing, palliative care nursing, and nursing education. My counseling education provided me with an opportunity to hone and refine my interpersonal skills. From my experience as a counselor, I learned about the powerful influence that family members have on one another and how such influence affects the health of each individual. From my experience as a professional nurse I suspected that loss issues may often be related to poor health and dis-ease. By working closely with families for more than two decades, I developed an appreciation for the strengths and resilient capacities of individuals and the synergy that becomes possible when families become empowered to take responsibility for their own health. In response to these counseling and nursing experiences, I developed a belief that individuals and families often have the answers to their problems. I also believe that it is the responsibility of health care professionals to facilitate health promoting interventions among individuals, families, communities, and ultimately within society. This background provided fertile ground for the seeds of interest in 'healing' that were sown by the families in the aforementioned research study.

During the process of conducting this dissertation research, several experiences reinforced the relevance of this work. I was invited to present the preliminary findings of my research on several occasions within both academic and community settings. For example, I was invited to be a member of a panel presentation during Suicide Prevention Week in Lethbridge, Alberta. During the same week I spoke about the findings of my research during a Memorial Service for suicide survivors. A month later (April 21, 1999), I was interviewed by a reporter at a local television station regarding the increased use of violence among youth in response to the slaying of several teens and the suicides of the two teenage gunmen at a high school in Littleton, Colorado. Then one week later, in the rural community of Taber, Alberta, a young high school gunman opened fire fatally injuring an innocent youth. Once again I was asked to talk about my research from the Healing Within Families 49

perspective of helping families heal in the aftermath of horrific death. This community involvement renewed and reaffirmed my commitment to and enthusiasm for this work.

Grounded Theory Research Method

First developed by Glaser and Strauss in 1967, grounded theory is a highly systematic research approach for the collection and analysis of qualitative data for the purpose of generating explanatory theory that furthers the understanding of social and psychological phenomenon

(Chenitz and Swanson 1986; Strauss & Corbin, 1990, 1994; 1998). In essence, grounded theory research is aimed at understanding how a group of people define their reality via social interactions

(Hutchinson, 1986). Essentially, "The grounded theory method results in concepts and constructs grounded in data that reflect theoretical sensitivity and have imagery and "grab" for those involved in the experience. Good grounded theory is holistic, parsimonious, dense, and modifiable"

(Wilson & Hutchinson, 1991, p. 274).

Grounded theory is an appropriate method when an area to be researched is characterized by a low level of conceptualization. Since theoretical explanations related to healing within families following youth suicide have not been found within the literature, it was important to use a 'ground up'—from practice to theory method for theory generation (Hutchinson, 1986). Moreover, grounded theory methods are appropriate when attempting to gather data of a unique and highly personal nature that describes experiences and perceptions with contextual meaning. Finally, since social processes are fundamental to families, it follows that the grounded theory method is appropriate for the study of individual healing within families.

Eligibility Criteria

The population of interest in this study were individuals who identified themselves as having had experience with healing following the suicide of a beloved family youth. Participants were required to meet the following eligibility criteria:

1. At the time the study began, participants needed to have experienced a youth (10-19 years of

age) suicide prior to the study, and be able to speak about the concept of healing (either pro or Healing Within Families 50

con) in response to their experience. However, as the study proceeded, theoretical sampling

indicated the value of including two older adults and their families in the study.

2. Informants were required to be able to read, write, speak, and comprehend English.

3. Participants were members of a family. Various family constellations were included (e.g., two

parent families, single parent families, blended families, gay and/or lesbian families).

4. Individuals and families from all socio-economic, racial, cultural, and religious groups were

invited to participate in this study.

5. Voluntary participation in the study was a basic requirement.

Data Collection and Procedures

In accordance with grounded theory methodology, the main methods of data collection were interviews with individual family survivors and family units whenever possible, supplemented by participant observation (Lofland & Lofland, 1984; Spradley, 1979). In this study, data included textual data, observational data, and non-technical data. In addition, genograms and ecomaps (McGoldrick, 1982; Wright & Leahey, 1984) were completed for each • family as part of the data base (see Appendices A-l and A-2). These tools provided a means of gathering family-related information and were especially helpful in terms of understanding family dynamics. The genogram is a three generational diagram depicting historical, structural, functional, and relational aspects of the family system (McGoldrick, 1982; Wright & Leahey, 1984). The ecomap is a diagram representing the quantity and quality of each family member's connections with external resources (McGoldrick, 1982; Wright & Leahey, 1984).

Informed Consent

Prior to collecting data for the study, informants were provided with a complete description of the study, including: an explanation of the purpose of the research; a description of the procedures to be used (e.g., use of interview and observation) and time commitment involved; an explanation of the voluntary nature of the research; and an assurance of confidentiality related to all aspects of the research. Participants were informed of their right to withdraw from the study at any Healing Within Families 51

time without reason. Further, they were provided with an opportunity to ask questions and to discuss any aspect of the research. Each participant was provided with an information letter and an appended consent form containing the names and phone numbers of appropriate contact people

(see Appendix B). Following this information session, I obtained written informed consent from all informants. I retained one copy of the signed consent form for my file and provided a personal copy for each participant. Because children cannot legally provide consent, parents were requested to sign a consent form (included in Appendix B) for minor children (less than 10 years of age).

However, children also gave assent for participation. Assent implies that the child understands the purpose of the research study and his/her participation in it, and agrees to participate in the study.

In an effort to be sensitive to the needs of each participant, informed consent was continually negotiated during the research process (Germain, 1986). This negotiation process entailed constantly educating the participants about the research process, and making sure that informants felt free to act in their own best interests, regardless of what that may have meant in terms of the research study. For example, in one instance I was invited by a mother to interview a family in their home. When I arrived at the family home, I was warmly greeted by the mother in the front yard. The father, who was working in the yard at the time, acknowledged my presence by a brief nod of his head. The mother invited me into the house where we sat at the kitchen table. I began to set up the tape recorder. Moments later, the father appeared in the kitchen. He began to make comments about my research, and as he spoke it was apparent that he was angry. I listened to him and did not interrupt. When he finished expressing his views, I once again provided a detailed explanation of the purpose on my study. I emphasized that voluntary participation was a basic requirement. I assured him that the health and well-being of his family was of prime importance, far above the importance of the study. I suggested that if he was uncomfortable with any aspect of being involved in the study, that he may wish to decline the opportunity to participate. Subsequently, he asked to sign the consent form, and requested that I interview his family. When I turned the tape-recorder on (with permission), he spoke for 45 minutes non-stop about his experience related to his son's suicide. This interview took place three years post-suicide.

Apparently, he and his wife had not discussed the suicide of their son prior to the interview. When Healing Within Families 52

I left the family home, both husband and wife walked me to my car. The husband thanked me for including him and his family in the study and both he and his wife gave me a hug.

Theoretical Sampling

Theoretical sampling, or "sampling on the basis of concepts that have proven theoretical relevance to the evolving theory" (Strauss & Corbin, 1990, p. 176) was used during the data collection process. As the study progressed, participants were deliberately selected according to the theoretical needs and direction of the data analysis. This approach helped to ensure that the evolving theory was representative of the concept under investigation. Moreover, it allowed for examination of a full range of variation of the phenomenon under study (i.e., healing following youth suicide).

First, at the onset of the study, "information-rich cases" (Patton, 1990, p. 169) were identified. Two families, who had participated in a previous research study, and who were known by myself to be rich sources of relevant data, indicated an interest and willingness to participate in this study when contacted to follow-up on their expressed interest.

Second, potential participants were sometimes located via "network sampling" (Burns &

Grove, 1993), or snowballing as it is sometimes called. This technique takes advantage of previously established informal social networks that often exist among those who have shared a common experience. Individuals within the first two families interviewed referred other potential participants to this study. This strategy was, in fact, an extremely valuable recruitment strategy, especially during selective sampling that occurred as the study progressed.

Third, I recruited families through contact with palliative care personnel in health care institutions and community health agencies in southern Alberta (e.g., Lethbridge, Medicine Hat,

Taber, Brooks, Claresholm, Bow Island). These were individuals with whom I already have established working relationships. I met informally with these individuals at times convenient to them. During these meetings, I described the purpose of my study, outlined eligibility criteria, required time commitments, and other pertinent information. Healing Within Families 53

Finally, I accepted an invitation to be interviewed by the local media (e.g., newspaper and television) for the purpose of recruitment. During an interview with the local newspaper, I provided a description of the study, the eligibility criteria, and an invitation for local individuals to participate in the study (see Appendix C). This strategy extended the invitation for participation to individuals and families who may not have had access by other means. In addition, this strategy raised the profile of the study within the community and led to networking with other interested professionals from a variety of disciplines who were then able to also recruit potential participants.

When potential participants were identified through personnel in institutions or agencies, or by other participants (via network sampling), those individuals obtained verbal consent from the potential participants for me to contact them. I then followed up by telephoning potential participants to describe the project in greater detail and to arrange to meet with them at a convenient time and place.

Once an individual indicated a willingness to participate in the study, I informed the participant about my interest in understanding the individual healing process. I invited the participant to encourage other family members to participate in the project. I requested that the participant obtain verbal consent from other potential participants, allowing me to initiate contact with them. I then contacted these potential participants via telephone or in-person during a scheduled home visit with a previously identified participant. In each case, I then described the study in greater detail, determined their willingness to meet with me, and arranged a mutually convenient time and place to meet.

Theoretical sampling guided data collection. As categories emerged, cases which further explicated the category and cases where the category was nonexistent, were sought and examined.

In order to further enrich and expand the evolving theory, cases that offered a different perspective were also purposefully included. For example, the healing processes of family survivors who had experienced the suicide of an adult were purposefully included to enrich and expand the evolving theory. Nine families who experienced the suicide of a family youth and two families who dealt with the suicide of an adult were included in the sample population. The data obtained from families who experienced the suicide of an adult were comparable to other study data in terms of Healing Within Families 54

representativeness of the concept (Strauss & Corbin, 1990), and thus were included to further expand the phenomenon of interest (i.e., healing) in this inquiry. In this sense, diversity was explained and integrated to enrich rather than disprove the emerging theory, consistent with Glaser and Strauss's (1967) idea of seeking conceptual density and theoretical sensitivity.

The number of interviews per individual and family was dependent upon ongoing data analysis. As stated by Sandelowski (1995), "Determining adequate sample size in qualitative research is ultimately a matter of judgment and experience in evaluating the quality of the information collected against the uses to which it will be put, the particular research method and purposeful sampling strategy employed, and the research product intended" (p. 179). Theoretical sampling continued until: 1. no new or relevant data seemed to be emerging regarding a category;

2. category development was rich and dense, meaning that all paradigm elements were accounted for, along with variation and process; and 3. the relationships between categories were well established and validated by the participants (Glaser, 1978; Glaser & Strauss, 1967; Strauss &

Corbin, 1990). I judged that theoretical saturation had occurred following 18 months of fieldwork with forty-one individuals in eleven families.

Interviews

Interviews were conducted most often in participants' homes or other preferred locations such as in my work office or, in one instance, in a restaurant. This study involved at least one two- hour in-depth interview with each individual family member and the family unit whenever possible. Individual family members were interviewed separately, and then in dyads and/or as family units. This strategy was designed to engage participants in a discussion of their experiences to the greatest extent possible. In some instances, I interviewed participants a second or third time to clarify and expand upon ideas that were shared during the initial interview. The interviews were tape recorded and verbatim transcripts were prepared by a transcriptionist.

Forty-four informal, semi-structured, in-depth interviews (Fontana & Frey, 1994) were conducted during an 18-month period during 1996 through 1998. Although 41 individuals participated in the study, 12 persons (7 children, 3 adults, and 2 grandparents) were present only Healing Within Families 55

during the family interviews. These individuals preferred not to be individually interviewed. An interview guide was used to initially focus the interviews (see Appendix D). During individual interviews, participants were encouraged to reflect on their experiences related to healing following youth suicide. Broad open-ended questions and comments were presented at the beginning of the interviews. For example, I generally began individual conversations with something such as: "Tell me about your life since X took his life." or, "What has this experience been like for you?" As the interviews progressed, more focused questions were asked, for example, "What does healing mean to you?" and, "How did you heal following X's suicide?" Specifically, I wanted to understand the individual's views about healing, as well as what helped and hindered this process.

During family interviews, questions were framed to include the perspectives of others within the family unit. For example, family interviews often began with questions such as: "Tell me about life in your family since X took his life." and, "What has this experience been like for your family?" As family interviews progressed, I used specific questions to focus the conversation. For instance, I asked a father the following questions: "Can you describe the effect of X's suicide on your children?" and, "What helped them to heal?" Flexibility during the interview process was vital to allow for further exploration of leads and cues provided by participants.

Similarly, it was important to remember that neither the content of the interviews nor the needs of participants could be predetermined.

Interview data were supplemented by other non-technical literature (e.g., diaries, photographs, letters, newspaper clippings, art work, and poetry) shared by participants.

Informants were invited to share their stories about these items. These discussions were tape- recorded, transcribed, and textually analyzed. These data supplemented and enriched the interview

and observation data.

During the research project I hired a transcriptionist and a research assistant. The transcriptionist prepared the verbatim transcripts of all participants' interviews. Working under my

direct supervision, the research assistant helped during certain phases of the project. Initially, he

gathered relevant literature and helped with data management. Later, after he gained an in-depth

understanding of the study, he assisted with data analysis. For example, both the research assistant Healing Within Families 56

and I separately coded several interviews and then compared our findings. This process helped to

validate the emerging theory. Both the transcriptionist and the research assistant were requested to

sign an oath of confidentiality (Appendix E) prior to being involved in this research.

Participant Observation

Data were also collected through the use of participant observation. Observations generally

occurred during home visits and lasted the duration of the interview (i.e., approximately two

hours). Since meaning creates behavior and behavior is constructed through interaction, it follows that it was necessary to examine participants' interactions in natural settings whenever possible. If family members have a choice regarding the location of the interviews and observations, they are more likely be more relaxed and comfortable while sharing personal and intimate details about their

lives.

Participant observation usually occurred once or twice for each participant and once for most families. I was interested in gaining insight about alterations in day-to-day family life and

learning about the meaning that individuals and families attributed to their experiences in relation to

youth suicide. Family dynamics (e.g., communication patterns and interactions) that further illuminated an understanding of individual healing were of particular interest. I observed for

symbols used in communication (e.g., use of artifacts, language—verbal and nonverbal), for individual behaviors (e.g., readiness and/or willingness to participate), and for patterns of interaction amongst family members (e.g., who speaks to whom? who speaks, and who does not?). I checked my perceptions about my observations with informants immediately following an

interaction to clarify informants' self-definitions and shared meanings.

Based on the symbolic interactionist perspective, the researcher is viewed as necessarily

both an observer and a participant in the research project. It is only as the researcher enters the

world of the participant that he or she is able to understand the complexity of that world (Atkinson

& Hammersley, 1994; Chenitz & Swanson, 1986; Schatzman & Strauss, 1973). In order to

capture this complexity to the best extent possible, I became an instrument for data collection

(Lincoln & Guba, 1985) by immersing myself in the lives of these families to the extent that such Healing Within Families 57 involvement was agreeable to all concerned. In an attempt to get to know these families, I readily

accepted invitations to spend time with them. For example, I was invited to join families for meals,

view mementos and treasured family photo albums, and, in one instance, to partake in a memorial

service. Often this exposure to participants' private lives provided sensory data and insights that enabled me to formulate immediate comments, probes, and prompts, in addition to relevant questions for future interviews. Fieldnotes depicting observations, social processes, and reflections were prepared immediately following contact with participants. In each and every situation, I gained a fresh perspective about what was important to these families. Moreover, I

learned about their insight, courage, and strength despite difficult life circumstances.

As previously mentioned, I was interested in understanding the participants' community and home environment. For instance, I was invited to interview a family of six who lived on a farm. The large farm was located on prime farmland about thirty kilometers from a small town. I arrived at the farm at the pre-arranged time of 1600 hours. As I turned into the driveway I noted two houses in the farmyard. I made my way to the larger of the two houses as previously instructed. When I stopped my car, a big dog came running toward the car. Soon the owner came to my rescue.

I was greeted by Jan (a pseudonym for the mother of a deceased youth) who had forgotten about the interview. She soon recalled that we had agreed to meet and invited me into the house.

We walked through a huge laundry room and I observed that the washing machine and dryer were in use. We then entered a spacious country kitchen with lots of light, and many oak cupboards with a huge matching oak table in the center of the room. The furnishings and decor were of fine quality. I immediately sensed the aroma of fresh garden vegetables mingled with the pleasant smell of home cooking. This added to the characteristic warm atmosphere I readily sensed. I soon noted that another female adult was present. Jan informed me that her sister from the east coast was visiting for the summer.

As I began to set up for the interview, I noted that the two youngest children (both daughters aged 11 and 9) settled themselves at the far end of the large table. They began to occupy themselves with paper and pencil activities. The interview took place at the kitchen table with Jan Healing Within Families 58

and her husband, Martin, and their two daughters present. The third surviving child in this family,

a 16-year old male youth, was not at home during the time of the interview. The mother's visiting

sister continued to work in the kitchen during the interview. The whole family seemed relaxed and the mother's sister even participated every now and then in the interview process. Coffee was

served as we conversed.

I was invited to stay for dinner—I accepted. A well-balanced meal was served (roast beef, potatoes, vegetables, salad, home-made bread, and beverage). While the girls did not participate during the interview, they were both the center of attention during the meal. There was much light talk and laughter shared among family members during the meal. Both parents spoke very positively about the girls in their presence, and it was evident that they appreciated the attention.

After dinner, Martin invited me into their tastefully furnished living room to look at a photo album and other cherished mementos. I noted that there were no pictures of the deceased youth in the house. Martin commented that he could not bring himself to display photos. He commented that his parents, who live in the other house in the same yard, have a big picture of Paul (deceased son) on the wall of their living room.

In a second case, I was invited to conduct an interview with a surviving sister, Clare, who was diagnosed with schizophrenia. She was living on social assistance at the time of the interview.

Clare lived in a basement suite in a low-income, multiple family dwelling in a small urban center.

As I entered her suite, I noted that it was dark because all the blinds were drawn. She turned on a light as I stood in the entrance. She then guided me to the living room. On the way, I noted that her place was generally unkempt with dishes piled on all the available counter space. Also, there were items of clothing strewn along the narrow hallway. The doors to the other rooms in the suite were closed. When we entered the small living room, Clare turned on an overhead lamp. She then picked the cat up off the sofa and cleared a small space for me to sit. She cheerfully offered me a cup of coffee. Clare informed me that she was getting married soon. She said that she wanted to

show me something. She disappeared down the hall and returned with a jacket that she had made.

Proud of her accomplishment, she pointed to the cross-stitch work on the back of the jacket. She

seemed pleased that I commented positively about her work. She then sat down on a well worn Healing Within Families 59

recliner rocker and began talking about her experience related to her brother's suicide. As we carried on our conversation, I observed some figurines lined up along the opposite wall of the living room. I inquired about them. Clare said that she had made them as a way of dealing with her brother's death. Each figurine represented one facet of her grief.

In a third situation, I was invited to visit Liz, a single mother of two children, in her mobile home in a small urban center. Liz was very warm and most receptive to being interviewed. It had been over a year since her husband had taken his life. She had made a decision to return to school and was in the process of moving to another country at the time of data collection. On the day of the interview, the youngest child was in kindergarten and the older child was in school. Because the movers had just removed the furniture from her home, we sat on the livingroom floor with our ' legs crossed in front of us. As we sat there, Liz pointed out many features of her home, and I could see that she took a great deal of pride in her surroundings. As we continued our conversation, Liz folded a big basket of children's clothing. She talked easily and effortlessly.

After about an hour and a half, the telephone rang. Apparently, Liz had forgotten to pick up the youngest child from kindergarten. The caller suggested an alternative child care arrangement and we continued our conversation. I concluded the interview shortly thereafter.

As part of the fieldwork experience, I kept a two-part "reflexive journal" (Lincoln & Guba,

1985, p. 327) in which I documented my thoughts, ideas, and reflections about the study. These authors recommend including the following information in a reflexive journal: a chronological log containing pertinent details related to the organization and execution of the study, the researcher's personal notes about the total research experience, and a methodological log documenting the decision making process used during theory development. The first part of my journal contained a calendar that served as a chronological log of the progression of events throughout the study.

Here, I recorded the interview schedule along with technical information related to the study. In the second part of the journal, I documented my thoughts and ideas about the study including: emotional reactions to participants' stories, ideas gleaned from conversations with other grounded theorists, and methodological decisions along with supporting rationale. This journal was invaluable because, in it, I was able to write detailed notes describing my views about what was Healing Within Families 60

happening in the study, draw conceptual diagrams representing the data, and experiment with my ideas about the meaning of the data. For instance, I was able to reflect on the dichotomy (e.g., experiences of great pain and great joy) I often sensed during my encounters with families and its relevance to the study. At other times, I simply wrote about my feelings related to hearing participants' stories. Journaling also facilitated the conceptualization phase of theory development.

For example, one particular incident stands out in my mind. I had just attended the funeral of my brother-in-law and the following day embarked on the long drive home (a 13-hour journey). As my husband was driving, I was thinking about my research when I experienced a strong urge to attempt to represent the data through drawing. Within moments our vehicle was transformed into a suitable work space. Data were spread out along the dashboard and on the floorboard; some even flowed into the back seat. Almost like magic, responding to my felt sense, I drew a diagram of my conceptualization of the data. This diagram has since become an integral component of the theory presented in this dissertation. May (1986) supports this method for studying abstract concepts such as healing. The creation of this diagram represented an important methodological decision because it captured my interpretation of the healing process as experienced by family survivors of youth suicide, and served to further my conceptualization of this process.

Data Management

Initially, each family was assigned an identification number (e.g., family 001, 002, etc.).

Each individual family member was also identified by a letter following the family identification number (e.g., family member 001-A, 001-B, etc.). A family file was then created with transcripts chronologically organized according to the date of each interview. Field notes were handled in a

.similar manner. As categories emerged from the data, other files were created. For example, a file name specific to a category was created and a second copy of pertinent data from all families was then stored in that file. Both hard and computerized copies of the data were prepared. A back-up disc containing the data was stored in a locked filing cabinet. As the theory developed, other files were created and handled in a similar fashion. Organizing data in this way allowed me to analyze it Healing Within Families 61

from many perspectives. This method of data management permitted easy access to a large volume of data and worked well during the process of manual analysis.

Data Analysis

Data collection and data analysis occurred simultaneously with analysis guiding subsequent data collection (Strauss & Corbin, 1990). The constant comparative method (Glaser, 1978) was utilized to allow for modification according to the advancing theory. Using the constant comparative method, I compared newly collected data with previously obtained data in an on-going fashion to further refine theoretically relevant data (Polit & Hungler, 1999). Subsequently, data were categorized (Swanson, 1986a) and named. I sought participants' input regarding the naming of categories.

As stated earlier, at the onset of the study I had originally planned to study 'family healing.'

It was only as I began to listen to the stories shared by family members that I realized their stories focused only on their personal experiences related to healing. Consequently, the prime focus of the study was modified to reflect an emphasis on the experience of individuals within the context of the family. This modification was negotiated with my dissertation committee and justified on the basis of what the research field would allow. Because limited scientific knowledge is currently available specific to healing following youth suicide, a focus on the individual experience of healing was deemed appropriate for the purposes of this study.

The NUD*IST (Non-numerical, Unstructured, Data Indexing, Searching and Theorizing;

Richards & Richards, 1991, 1995) software package for qualitative data management was investigated. This program would have required considerable time for me to learn to use it efficiently. Given my unfamiliarity with computer technology at the time I began this project, and given the limited time available to devote to this research while resuming my regular teaching responsibilities, I chose to use manual methods of managing the data. More importantly, I perceived that the familiar "hands-on" methods allowed a sense of greater immersion in the data.

This, in fact, turned out to be true. Healing Within Families 62

During the process of data analysis, I solicited input from several "experts." As data collection and analysis progressed, I communicated with my dissertation supervisor on a regular basis via telephone and electronic mail. During the early stages of data collection and analysis, I met first with my supervisor to discuss and compare some of the early interviews and to review the code lists as they evolved. Later as the theory evolved, I met with my entire committee to discuss a matrix that represented my early conceptualization of the emerging theory and the original version of the diagram presented in Chapter Five. As the study evolved, communication with my supervisor and committee continued. This ongoing dialogue definitely enhanced my first research experience focusing on theory development.

As mentioned previously, taped interviews and field notes were typed by a transcriptionist using Microsoft Word 6.0.1 (Gookin, 1994). Hard copies were transcribed on the left half of the page only, leaving the right half of the page blank for hand analysis. The right half of each page was then divided into three sections, one for each level of coding.

Coding

As soon as the verbatim transcripts were prepared, the data were read two or three times to become familiar with them (J. Anderson, personal communication, September 20, 1996). Coding, the link between data and theory (Glaser, 1978), began with open coding. The open coding technique was used as the first level of data analysis. Open coding entailed breaking down, examining, comparing, conceptualizing, and categorizing data for the purpose of theory generation

(Strauss & Corbin, 1990). This process yields codes which have been labeled descriptive

(Charmaz, 1983; Swanson, 1986b), objective (Seidel, 1995), or substantive (Carpenter, 1995;

Glaser, 1978) because they represent the uninterpreted facts within the data. This procedure often involves coding each event or happening, usually in a line-by-line fashion, to get at the ideas within the data. In consideration of the subject matter, I departed from Strauss and Corbin's (1990) idea of open coding. In keeping with my analytic approach of "thinking with stories" (Frank,

1995), discussed earlier in this chapter, I opted to code textual data by using 'meaning units.'

Meaning units were words, phrases, or paragraphs representing some meaningful idea expressed Healing Within Families 63 by a participant or group of participants. I reasoned that this unit of analysis would more accurately reflect the informants' views. Meaning units were derived by asking questions of the data (Glaser,

1978) such as: "What is being communicated here?" and, "What does this mean in terms of healing?" I speculated that by analyzing data in this manner, I would be able to honor the wisdom within each story, and at the same time, preserve each informant's voice. Codes (i.e., meaning units) were then examined for similarities and differences and were then grouped into categories.

The conceptual name given to a category reflected the data that it represented. In an effort to remain grounded in the data, I used informant's terminology whenever possible to create "in vivo codes"

(Carpenter, 1995; Charmaz, 1983; Glaser, 1978, p. 70; Strauss, 1987, p. 33). In addition, selected participants were also invited to provide input related to the naming of categories. Initially, three major categories were developed from the data through the process of coding meaning units.

Using "in vivo codes" (Carpenter, 1995; Charmaz, 1983; Glaser, 1978, p. 70; Strauss, 1987, p.

33), these major categories were initially named: Holding On To Letting Go; Letting Go; and

Letting Go and Moving Beyond. Although each major category explained one aspect of the topic under study (i.e., individual healing following youth suicide), each major category had meaning only in relationship to the other two major categories. Moreover, within each of the three major categories, five elements were developed from the data, each element further defining the parameters within each major category. Similarly, within each element, a number of ideas emerged from the data. These ideas further defined each element.

Axial coding was used during the second level of data analysis. During axial coding, I put the data back together again by making connections between the major categories (i.e., concepts) and its elements (Strauss & Corbin, 1990). The three initial categories (i.e., concepts) were labeled as Healing Themes and renamed: Cocooning, Centering, and Connecting. These major concepts reflected a higher degree of abstraction than the initial ones. Similarly, the elements were further refined and sometimes renamed and/or combined with former elements.

The third level of analysis, selective coding, involved the synthesis of previously identified concepts and elements to formulate a "core" concept (Strauss & Corbin, 1990). The core concept emerged as a result of using constant comparison to analyze for relationship patterns between and Healing Within Families 64 among substantive codes (Chenitz & Swanson, 1986; Glaser, 1978). Selective coding, more abstract than substantive coding, was used to conceptualize how substantive codes were related and then to raise substantive coding to a theoretical level (Strauss & Corbin, 1990). The core concept represented the basic social psychological processes (BSPs) (Carpenter, 1995;

Fagerhaugh, 1986) that explained the story as portrayed in the data.

Memoing

Throughout the analysis, memos were kept documenting my thinking processes while coding the data, identifying and linking the data, and naming the core phenomenon (Glaser &

Strauss, 1967). A "conditional matrix" (Corbin & Strauss, 1988; Strauss & Corbin, 1990) representing the interrelationships among the categories was designed. Field notes documenting observations and my intuitive grasp of the participants' stories were prepared. On numerous occasions I referred back to these notes. For example, I originally separated "Intuitive Visioning" from "Finding Meaning/Exploring Spirituality." As I reviewed my notes about my thinking processes regarding this decision, I was able to determine that the second element should be collapsed within the first.

Establishing Scientific Rigor

While the worth of quantitative research is determined primarily by assessing its reliability and validity, the worth of a qualitative study is ascertained by assessing its trustworthiness (Elder

& Miller, 1995; Krefting, 1991; Leininger, 1994; Lincoln and Guba, 1985; Streubert, 1995). In qualitative research, reliability and validity are often explained in terms of credibility, fittingness of the data, auditability, and confirmability (Sandelowski, 1986). Similarly, Lincoln and Guba (1985) stipulate four criteria that can be used to determine the trustworthiness of qualitative inquiry, specifically: credibility, transferability, dependability, and confirmability. Findings are credible to the extent they represent the individual truths expressed by each participant involved in the study.

Transferability is addressed by ascertaining the extent to which the researcher has provided adequate descriptive data to enable others to apply or transfer the findings to other contexts or Healing Within Families 65

respondents. Because the naturalistic inquirer expects variability in every aspect of the research project, including changes in the informants, the setting, or the researcher, the concern regarding replicability or consistency of the study focuses on determining dependability, or the extent to which the researcher can account for the variability within the data. Finally, because it is understood that qualitative research is not value-free, the emphasis regarding the research findings being neutral or free from the biases of the researcher is shifted to a detennination of the extent to which the data are neutral, or can be confirmed. I elected to establish scientific rigor by determining trustworthiness according to the criteria set forth by Lincoln and Guba (1985).

Credibility

I used a number of strategies to establish credibility. First, triangulation, or the use of a number of different data collection methods, sources of data, investigators, or competing theories was used (Krefting, 1991; Lincoln & Guba, 1985). I triangulated a variety of data collection methods (e.g., interviews, participant observations; use of non-technical data sources, and my reflexive journal) to secure maximum variation within the data and to ensure accurate representation of the participants' experiences in developing the theory.

The second strategy involved the careful framing of questions. According to Krefting

(1991), "the reframing of questions, repetition of questions, or expansion of questions on different occasions are ways in which to increase credibility" (p. 220). In my effort to understand the views of each participant, I proceeded by asking questions clearly and concisely. In addition, I used paraphrasing to ensure that I received the participant's intended message.

A third strategy used to increase credibility was prolonged engagement with participants, defined by Lincoln and Guba (1985) as, "the investment of sufficient time to achieve certain purposes" (p. 301). To achieve my purpose of understanding participants' stories, I spent a minimum of several hours with each participant. Much attention and time were spent building rapport and trust with participants in addition to focusing on the research questions.

Prolonged engagement with participants accentuates one of the dangers inherent in naturalistic inquiry—the potential for the researcher to "go native" by becoming over-identified Healing Within Families 66

with respondents (Chenitz & Swanson, 1986; Krefting, 1991). I used two strategies to prevent this and thus maintain credibility: peer examination (Krefting, 1991) or peer debriefing (Lincoln &

Guba, 1985), and journaling (Chenitz & Swanson, 1986). Peer debriefing, defined as "exposing oneself to a disinterested peer. ... for the purpose of exploring aspects of inquiry that might otherwise remain only implicit with the inquirer's mind" (Lincoln & Guba, 1985, p. 308), was accommodated by sharing this work with professional colleagues and inviting their feedback.

Another helpful strategy was my routine participation in debriefing sessions with a trusted professional colleague. In addition, I felt free to contact my dissertation supervisor about any concerns during the course of my involvement in this study. Journaling, the second strategy, was discussed above in the section dealing with participant observation and fieldwork.

Credibility was also achieved through member checking. According to Lincoln and Guba

(1985), "the member check, whereby data, analytic categories, interpretations, and conclusions are tested with members of those stakeholding groups from whom the data were originally collected, is the most crucial technique for establishing credibility" (p. 314). Ongoing member checking

(Lincoln & Guba, 1985) with selected participants was carried out as the research study progressed. Minor modifications to the theory were made based on participant feedback.

Additionally, this work was presented at a conference where delegates were survivors of youth suicide. These individuals indicated that the substantive theory presented in this dissertation comprehensively reflected their experiences related to healing following youth suicide.

Negative case analysis was the final strategy I used to enhance credibility. The goal of negative case analysis is to refine the theory until it accurately reflects all those whom it intends to represent (Lincoln & Guba, 1985). One example of negative case analysis in my study was the need to account for two individuals who, in contrast to the other participants, did not consider themselves to be moving toward healing. In sharing the developing theory with them, they identified with the theory even though they were not yet ready to heal. Thus, even these two individuals validated the theory and the critical aspect of volition in healing. Healing Within Families 67

Transferability

To augment transferability of the study, I used two techniques. The first of these was the

use of "thick description" (Lincoln & Guba, 1985, p. 316) or "dense background information"

(Krefting, 1991, p. 220) gathered during the data collection process (Chenitz and Swanson,

1986). Second, I engaged in theoretical sampling, discussed previously, to ensure both depth and

breadth within the thick descriptions and to accommodate saturation of the data (Lincoln & Guba,

1985).

Dependability

Measures that enhanced the credibility of this research endeavor also helped to increase its

dependability. I took three additional measures to establish the dependability of this work. The first

of these recommended by Krefting (1991) was the "code-recode procedure" (p. 221) which

involves coding the data, waiting a period of two weeks, and then recoding. This technique was

used during the initial phase of the project, while working with the research assistant, to ensure

that we were thoroughly coding the data and arriving at categories that accurately reflected the data.

The second step taken to enhance dependability was to provide, in this chapter, "dense descriptions

of [the] methods" (Krefting, 1991, p. 221) used during the entire research undertaking.

The final measure used to increase the dependability of this study was to provide an

"inquiry audit" (Lincoln & Guba, 1985, p. 317). This involved examining the process of the study recorded as an "audit trail" (Lincoln & Guba, 1985, p. 319). Streubert (1995) defines the audit trail

as "a recording of activities over time which can be followed by another individual. . . [the]

objective [of which] is to, as clearly as possible, illustrate the evidence and thought processes

which led to the conclusions" (p. 26). A study is dependable to the extent that the audit trail

documents the sources of variability in the study. The audit trail I left included the thesis proposal

documenting the research plan, the raw data (e.g., interview data and field notes), the

chronological log of research events, my reflexive journal, a portfolio containing an assortment of

non-technical information shared by participants, and documentation related to data analysis and

synthesis contained in this dissertation. Healing Within Families 68

Confirmability

Confirmability is synonymous with the traditional notion of objectivity. It is concerned with ensuring that the data, interpretations, and outcomes of the study accurately represent the views of those who participated in the study. As the study evolved, selected participants were involved in identifying and naming key concepts and categories. This approach kept data analysis and synthesis grounded in participants' stories. In addition, the evolving theory was presented to suicide survivors at a research conference; these individuals further validated the research findings.

To further ensure confirmability, an audit trail was kept documenting the decision making process used during the theory development process. This strategy enhanced confirmability in that it allows others to trace the research findings to their original data sources.

Ethical Considerations

Prior to beginning the research project, approval was granted by the University of British

Columbia Behavioral Sciences Screening Committee for Research Involving Human Subjects

(November 6, 1996). Within this section, I address the steps taken to ensure that ethical standards were applied during the study and ethical care was provided to participants.

Issues related to informed consent have been discussed previously in this chapter within the data collection section. In addition, other steps were taken to ensure confidentiality during the research process. Pseudonyms were assigned by the researcher during the data collection process as one way of securing anonymity for participants. In one case, a participant indicated that she preferred being identified by her full name. Since the participant was flexible in this regard, it was jointly decided that a pseudonym would be used in this study. Participants were advised that identifying information would not be revealed in any publications or at any conferences related to this research study. During analysis, participants' names were coded so that no identifying information was recorded on the transcripts. Code sheets were stored separately from the data.

Data were secured in locked filing cabinets in my home. Data were accessible only to all dissertation committee members, the research assistant, and myself. Participants were advised that Healing Within Families 69

audio tapes would be erased and transcripts appropriately disposed of three years after the completion of the study.

Given the sensitive nature of the topic of this research, interviews were also conducted with great sensitivity toward family members. It was anticipated that participation in this research might be cathartic for some individuals. Several authors comment on the emancipatory potential that story telling often evokes in research participants (Alty & Rodham, 1998; Banks-Wallace, 1998; Demi &

Warren, 1995; Hutchinson, Wilson, & Skodol Wilson, 1994). However, it was also recognized that the interviews might induce intense emotional reactions for some participants. Although not needed, arrangements were in place for an appropriate referral for individuals and families in the event they required such assistance. Moreover, participants were advised that upon completion of the study, a summary of the key findings of the research project would be shared with them.

Summary

The research was designed as a grounded theory focusing on individual family members' experiences of healing following youth suicide. Congruent with a relativist philosophical position, a symbolic interactionism perspective guided the methods used in this inquiry. The study was conducted in a natural setting—the homes of individual or family members who consented to participate. Theoretical sampling guided data collection and the constant comparative method was used during data analysis. Interviews, supplemented by participant observation and non-technical data, were used to gain an understanding about family members' healing experiences. Eleven families participated in the study during an 18-month period of time. This study generated a detailed, contextually-grounded description and theoretical explanation of individual healing within families following youth suicide. Grounded theory was an effective method for addressing the research questions.

An overview of grounded theory that was developed from the data, and the contextual variables that influence the healing process, are described in the next chapter; a more specific description of the healing process is presented in Chapters Five, Six, and Seven. Healing Within Families 70

CHAPTER FOUR

JOURNEYING TOWARD WHOLENESS: A CONTEXTUALIZED EXPERIENCE

You think that something like this will never happen to you. That's what I used to think.

And then one day it happened. When it happens, you begin to understand things differently . . . you're treated differently after it happens . . . you're judged by others. (Dale, a father).

The purpose of this chapter is threefold. First, it provides a description of the participants.

Second, it presents a preview and an overview of the grounded theory that emerged as a result of

this study which will be further developed in the chapters that follow. Beginning with the precipitating event, this chapter also addresses several important contextual factors that influence the healing process.

Description of Participants (The Sample)

Eleven families from rural communities (8 families) and small urban centers (3 families) in three Western Canadian provinces participated in the study (see Table 4-1). These families ranged in size from 3 to 12 individuals. A total of 41 family members participated.

TABLE 4-1: RESIDENCE OF PARTICIPANTS

Number of Individuals Rural Characterization Number of Families Within Families N = 11 N = 41 Canadian Aboriginal Reserve 1 5 (more than 50 km from urban center) Town or village (population less 5 20 than 25,000) Area surrounding town or small 2 4 urban center (at least 25 km from town or urban center) Small urban center (population 3 12 less than 65,000—market center serving rural area)

A chronological profile of the participants in this study is presented in the form of a chart in

Table 4-2. The information in these charts was gleaned from data provided in response to the Healing Within Families 71

Demographic Questionnaire (see Appendix F) and information obtained during individual and family interviews. All potential participants with whom I spoke and explained the study agreed to participate. Although some chose to participate only during the family interview, all of those who became involved in the study followed it through to its completion.

In total, 44 interviews, including 33 individual and 11 family interviews, were conducted.

A little more than one half of the participants were female (n=26). The participants included mothers (n=9), fathers (n=8), sisters (n=8), brothers (n=3), grandparents (n=2), significant others

(n=7), wives (n=2), and children of the deceased (n=2). Participants ranged in age from 6 to 80 years with a mean age of 38 years. The average length of time since the suicide was 3.1 years, ranging from 6 months to 12 years. Two survivors from two different families had previous experience with the suicide of a significant other.

Socioeconomic diversity among families was evident with four families reporting an annual family income of less than $30,000; three families reporting an annual income of $30,000 or more and less than $80,000; three families reporting an annual income of $80,000 or more and less than

$150, 000; and one family reporting an annual income exceeding $150,000. The occupational status of adult family members included currently unemployed, students, homemakers, blue and white collar workers, semi-professionals, professionals, and retired persons. Educational status ranged from those without high school completion to those holding graduate degrees. All participants were fluent in English; all interviews were conducted in English. Three-quarters of participants described their health status as "excellent" or "very good" while one-quarter rated their health status as "fair" or "poor." Ten individuals were diagnosed with health problems. Nine participants had mental illness diagnoses including depression (n=5), and schizophrenia (n=4).

One participant had experienced the death of a four month old infant and had received a diagnosis of cancer a week prior to being interviewed. While most participants (33 of the 41) identified with the dominant English Canadian culture of Western Canada, eight individuals claimed links with one of the following ethnic minorities: Canadian Aboriginal, Danish, German Canadian, or French

Canadian. Just over half of the participants (n=24) specified a particular religious affiliation as

Protestant, Roman Catholic, Buddhist, Mormon, or Jehovah's Witness. Healing Within Families 72

All 11 persons who ended their lives were males. They took their own lives by hanging

(n=5), shooting (n=5), and drowning (n=l). Suicide notes were left by six individuals. Nine youths ranging in age from 14 to 19 years ended their lives; two others were older (29 and 24

years of age). Five individuals who took their lives were single, three were married, and three were living in common law relationships at the time of their deaths. Nine individuals who ended their lives came from families with married parents while two came from families where the parents were separated at the time of the suicide. Most (n=9) suicides occurred within the four years just prior to the time of data collection. Two of the self-inflicted deaths occurred on Halloween and one occurred on the deceased youth's mother's birthday.

TABLE 4-2: SAMPLE POPULATION DATA

Family Number of Individual Family Total Gender & Length of Persons in Inter-views Inter• Inter• Age of Time Family views views Suicide Since (including Victim Suicide deceased) (years)

001 9 5 2 7 M - 19 2.5

002 4 6 2 8 M - 14 2

003 7 6 1 7 M - 19 12

004 4 2 1 3 M - 14 6

005 8 2 1 3 M - 16 2

006 4 2 1 3 M-20 2.5

007 4 2 0 2 M - 24 1

008 5 1 1 2 M-19 .5

009 5 2 1 3 M-17 .5

010 4 3 1 4 M-16 1.5

01 1 6 2 0 2 M-29 4

Individual Healing Process Following Youth Suicide: A Preview

In this study, individual healing following youth suicide is conceptualized as a dynamic, ongoing, recursive, and seamless process that I have labeled Journeying Toward Wholeness. Healing Within Families 73

Survivors consistently described their healing experience as "a journey." They also spoke repeatedly about being "fragmented" and feeling "torn apart inside" by the tragedy. Survivors expressed the wish to regain a sense of "wholeness." They perceived this could be accomplished by embarking on a personal journey. The word toward, in the phrase Journeying Toward

Wholeness is not used to indicate linear direction. Within this study, this terminology is used in its broadest sense to indicate a direction rather than a destination. Similarly, this word has been used in expressions such as "toward an understanding." Understanding, like healing, seldom occurs as a solely linear activity.

The journey toward healing is graphically depicted as a love knot. The term love knot was selected because during the interviews, survivors repeatedly mentioned that, despite suicidal death, they continued to love the deceased youth. This bond of love between the survivor and deceased youth was emphasized several times over the course of the study. In addition, during my

"aha experience" mentioned in the previous chapter, I attempted to represent the data through the use of a diagram. I later found out that the diagram I drew represented an Israeli love knot. It also came to my attention through reading that 'the knot' is a preserver of the life force, and a symbol of attachment and unity (Petzl, 1998). Based on this background information and my felt sense df the data, I deduced that the term love knot accurately represented the study data.

The love knot represents the healing process depicted by the three major concepts in the theory that emerged from the data in this study. Collectively, I have labeled these three major concepts as healing themes. Based on survivors' stories about healing, I have also labeled each of the three healing themes (i.e., major concepts) in my theory as Cocooning, Centering, and

Connecting. The love knot is depicted as three endless ovals existing in separate realms at slightly different angles to one another and converging at the healing epicenter. The healing epicenter is the place where healing manifests itself, synonymous with the survivor's consciousness. Although each healing theme (represented by an oval) explains one aspect of the overall journey of healing, each one has meaning only in relationship to the other two healing themes (see Figure 4-1).

The three healing themes of the individual healing process are: Healing Within Families 74

• Cocooning - Turning inward as a means of survival following youth suicide.

• Centering - Experiencing personal growth as a result of making key decisions in the aftermath

of youth suicide.

• Connecting - Uniting with self, others, God/higher power, and the environment; moving

beyond mediocrity as a self-chosen response to youth suicide.

FIGURE 4-1: INDIVIDUAL HEALING PROCESS REPRESENTED BY A

LOVE KNOT

COCOONING J ourney of Descent

Journey of Transcendence Journey of Growth

Within each theme in the healing process, five elements or healing patterns were developed from the data. Although represented here as discrete entities, these healing patterns are individually identified only for the purpose of understanding the theory presented in this dissertation. In effect, each healing pattern remains inextricably intertwined with all the other healing patterns. The five healing patterns that portray the survivor's healing journey include:

• Relating - Interaction and communication (including the expression of emotion) with self,

others, and God or a higher power, embedded within a broader social context, in the aftermath

of youth suicide. Healing Within Families 75

• Thinking - Cognitive processes such as reminiscing, remembering, believing, learning,

decision making, and using intuition in response to youth suicide.

• Functioning - Behavior associated with activities of daily living in response to the suicide of a

beloved family youth.

• Energizing - Capacity for physical exertion, vigorous activity, and a felt sense of personal or

authentic power following youth suicide.

• Finding Meaning/Exploring Spirituality - Higher power source and/or information indicating

that meaning is beginning to emerge in relation to youth suicide.

Within each of the three healing themes, the five healing patterns are manifested somewhat differently. The following template illustrates the relationship between the healing themes and the healing patterns (see Figure 4-3).

TABLE 4-3: INDIVIDUAL HEALING TEMPLATE *

HEALING PATTERNS HEALING THEMES

COCOONING CENTERING CONNECTING

RELATING STRUGGLING GETTING A GRIP REACHING OUT

THINKING CHAOTIC THINKING MAKING DECISIONS LEARNING

FUNCTIONING AUTOPILOTING RE-ENGAGING ORCHESTRATING LIFE

ENERGIZING CONSUMING REPLENISHING CHANNELING

FINDING MEANING/ EXPLORING SPIRITUALITY AWAKENING TRANSFORMING TRANSCENDING

* This template is provided for the purpose of orienting the reader to the theory presented in this dissertation study. In a practical sense, the healing themes and healing patterns are enmeshed in a three-dimensional, recursive, and seamless process. Healing Within Families 76

Beginning in this chapter, and continuing in subsequent chapters, the stories of 41 individuals within 11 families are woven into a theory that explains their experiences of healing following youth suicide. This presentation format is used to provide an effective means of honoring participants' voices and capturing the truths embedded within their stories.

Overview of the Grounded Theory

Youth suicide was the precipitating event that created a crisis within each of the 11 families that participated in this study. Without mercy, this single, irreversible event catapulted suicide survivors on a perilous and uncertain journey. Survivors' lives were drastically altered when they received the news about the tragedy. Within this instant, survivors were left alone, left living, and left loving the one who had just taken his life. Drawing on inner strength and courage, survivors began the frequently scary and always demanding process of reconstructing their lives.

The theory described in this dissertation study does not conceptualize healing in terms of discrete stages or phases, nor does it explain healing in terms of achieving some final predetermined outcome. Rather, this theory represents the dynamic and uniquely individual nature of the healing process which varies in expression and intensity over the course of each survivor's life.

Within this study, individual healing following youth suicide is conceptualized as

Journeying Toward Wholeness. Individual healing is a personal and unique journey experienced by most, but not all, family survivors of youth suicide. This journey is characterized by the inter• relationships among three enfolding, dynamic, fluid, and iterative healing themes entitled:

Cocooning; Centering; and Connecting. Each healing theme represents one portion of the overall healing journey. Specifically, Cocooning focuses on the survivor's journey of descent into self;

Centering deals with the survivor's journey of personal growth; and Connecting addresses the survivor's journey of transcendence. Within each healing theme, five self-organizing and inter• relating healing patterns (i.e., relating, thinking, functioning, energizing, and finding meaning/exploring spirituality) operate in mutual rhythmical interchange with each other. Each of the five healing patterns describes one facet of the survivor's overall experience of healing Healing Within Families 77

following youth suicide. Within this dissertation, the healing patterns are presented as distinct entities, only for the purpose of understanding the various facets of the whole process.

The ongoing healing journey varies in expression and intensity over time in response to a variety of contextual factors including the survivor's personal history, factors related to the suicide, social considerations, and the health care environment. Importantly, healing emanates as an act of volition from the survivor's consciousness (i.e., the healing epicentre) in response to three key decisions made by each survivor of youth suicide.

The degree to which healing occurs depends on a number of intervening variables (i.e., healing characteristics) reflecting the survivor's capacity to say yes to life; step out and speak up; achieve a sense of peace, harmony, and balance; and expand personal consciousness. As a major outcome of the healing process, each survivor creates a love knot which represents a healthy and continuing bond of love between the survivor and deceased youth enacted through the use of healing strategies. These healing strategies are based on the meaning the survivor attributes to his or her experience with youth suicide, and the relationship between the survivor and youth prior to his death.

Individual healing is both a solo and shared experience that is created and re-created during the course of each survivor's life. Further, it is hypothesized that individual healing ultimately expands outward influencing family, societal, and global spheres (see Figure 4-2).

Conceptualized as a whole, the healing process is represented by the grounded theory developed in this research study. Healing Within Families 78

HEALING AS JOURNEYING TOWARD WHOLENESS

The Precipitating Event

The precipitating event that launched survivors on "a journey of no return" was that of hearing the news about the suicide of a young family member. Understandably, the psychological trauma associated with youth suicide initially evoked an overwhelming sense of terror and helplessness among family survivors.

Hearing the News

Hearing the news was an "earth shattering" and "emotionally traumatic" experience for all family suicide survivors. Sue, a bereaved mother, commented, "nothing in life even comes close to preparing one for that kind of news—sometimes I can't believe I'm still here." The harsh news evoked within survivors a sense of being mercilessly launched on a treacherous journey without time for preparation. Characteristically, survivors described their initial reactions to their unfortunate circumstances with phrases such as being "lost without a compass," and having "a map without a destination." Hearing the news was comprised of five concepts including: the Healing Within Families 79 survivor's initial responses, the horror of discovery, breaking the news to others, dealing with suicide notes, and dealing with issues related to suicidal death.

Initial Responses

Initial responses to the tragedy varied considerably. Survivors frequently became disoriented in response to hearing the news. They spoke of feeling "out of sync with the rest of the world," and as if one had "just awakened from a nightmare." Suicide survivors vividly recalled a variety of somatic sensations that appeared soon after the trauma such as being "in a strange awful place," immersed in a "dense haze," or suspended in a "thick fog."

The shock of hearing the news was traumatic. Survivors frequently experienced shock, denial, disbelief, emotional numbness, and a sense of unreality and depersonalization. Denial was a common initial response to the tragedy: "At first you deny it." This response provided survivors with much needed time to comprehend the shocking news. A few survivors struggled as they tried desperately to hold on to life as it once was when all was well. Not wanting to believe her reality,

Tanya, the fiancee of a young man who took his life commented, "I would close my eyes and make him come into the room. ... I could feel his touch and see his smile . . . sometimes I would think that it didn't really happen." Beth, a sibling, expressed a need to run from the experience as the reality of the situation was "just too much to bear." Carmen expressed initial disbelief, "it was like a nightmare.... I thought, this can't be happening to me and to my family." May reiterated

Carmen's point of view:

After what seemed like hours on that Father's Day, my dad and stepmother arrived. We

hesitantly exchanged greetings. I was apprehensive as to what was to come. I felt myself

back away as dad's words slowly poured out—"Ryan has taken his own life." Everything

in me wanted to turn, run, and scream 'No!' I felt like we were suddenly entering the

twilight zone, that I must be having a nightmare, this wasn't real and it couldn't be

happening to me! I turned to Randy and frantically began to repeat, "I knew it! I knew it!"

As his words began to sink in, I became aware of my dad's presence, his shakiness, his

awkward stance—he looked totally defeated and incredibly vulnerable. My heart went out^ Healing Within Families 80

to him. We began to hear some of the details—basically Ryan had entered their bedroom,

taken dad's gun and shot himself.

For the participants in eight families, news of the suicide came as "a complete surprise;" most survivors maintained that the suicide occurred "out of the blue." This was especially hard to cope with because survivors often recalled that life, prior to the suicide, was satisfying and that everything seemed to be going "pretty much as usual." Consequently, the sheer shock of hearing the news was overwhelming for most survivors as indicated by Jim, a father and husband:

It's overwhelming and you are dealing with all of it at the same time and

not seeing beyond it because it's just come out of the blue. . .. You would think that

somebody who committed suicide would be depressed and on the edge. This wasn't the

case. It just comes out of basically nowhere, and that's what you have to deal with.

Survivors in three families recalled not being surprised that the youth had ended his life. In one family, a survivor knew that "something wasn't quite right" but was unable to identify exactly what it was that was troublesome. In another family, Carmen recounted how her boyfriend had been dealing with a number of problems prior to the suicide:

When Kevin was growing up he had a really horrible life. His mom and dad were never

married but they had three kids and they separated. And then he'd always told me that his

real mom was dead. And so that's what I believed for years, like the whole time that we

were dating until our son was six months old. She showed up at our doorstep, and then I

didn't really ever understand why he told me his mom was dead. So when he died, we

were fighting and we were trying to move to [new town] and get our lives on the road. As

I look back and look at the note he left me, and I got to know his mom very well after he

died, and my question was, "Why didn't he do it sooner?"

Liz lived for years in a situation of not knowing when, and if, the suicide would take place. She recalled the "tragic relief she initially experienced: "And so where I have come from in this whole thing is that it was a tragic relief because he is not tormented anymore and neither am Healing Within Families 81

Upon hearing the news, a few survivors reported intense physical responses. Chris recalled her initial post-suicide response: "I backed up into a china cabinet and blacked out and fainted, and when I woke up, I was on the ground and I was kicking and screaming and yelling."

Three mothers indicated their physical experiences were 'guttural responses' to the pain associated with loss. Liz remarked, "Oh yes, there were times when I moaned so much pain, from the depths of my soul, it wasn't even a cry . . . when you are giving birth you don't even go there." Marie, a mother, writes about her experience this way:

The screams that erupted from my body on this day were the beginning of many such

screams over the next year and a half. They were screams that terrified your dog and he

began to howl. I have never heard sounds like that before, and I too, was scared. I later

came to compare that sound to the wailing of a pain filled animal. How true that I was

wounded.

Sara, a mother, was brought to her knees when she found out that her 16-year old son had taken his life. She vividly described her bodily experience of "grief at the cellular level." She recalled falling to her knees, immobilized by intense pain resembling that of labor pains.

Involuntarily, she felt the need to "bear down," as if giving birth. This spontaneous, intense, and total bodily experience was accompanied by deep wailing and crying out in agony for her deceased son. Sara felt a connection to her son through this experience.

Survivors' responses to youth suicide, to a great extent, mirrored society's avoidance of and discomfort with the topic of suicide. Survivors were sensitive to the discomfort of others and consequently avoided the subject in the hope of putting others at ease. Survivors characteristically succumbed to the "no talk rule." However, this response was not without consequences. Linda, a mother commented, "This [suicide] is a loss that we don't talk about." This 'conspiracy of silence' further compounded the isolation felt by many survivors.

In the midst of tremendous upheaval, many survivors demonstrated remarkable insight.

Immediately upon discovering the suicide of her son, Rose realized the potentially devastating impact of such tragedy on her family. Jim, Rose's husband, recalled his wife's initial response to the hearing the news: Healing Within Families 82

That morning we were all down in the basement with Jason [deceased son] and we were

all so emotionally distraught. She [Rose, Jim's wife] turned to me and the first thing she

said was, "Whatever happens, if I forget, remember, we don't blame one another for this.

We can't blame one another for this." Her strength has been what has brought us together.

This is something that we have experienced together. It's like you've seen the worst

together and that makes you stronger.

The Horror of Discovery

The "horror of discovery" was catastrophic for survivors who reported the experience:

"Finding the body is the worst possible experience that anyone could ever have to face in life."

The horrific discovery often haunted these survivors. As well, even the imagined discovery sometimes haunted those who were not present at the scene of discovery. Haunting thoughts frequently centered on the family survivor's imagined emotional state of the youth in the moments preceding the suicide: "I allowed myself to think about the actual process of what Tim might have gone through, and what he might have been thinking or feeling."

In several cases, it appeared that the youth had given considerable thought to staging the suicide. In three cases, family survivors perceived that the suicide was staged by the youth so that a particular family member (e.g., the father) would discover the body. It was suggested that the motive for staging the suicide was to protect certain other family members (e.g., the mother) from the trauma of discovery.

The 'scene of discovery' evoked a variety of responses among survivors. Some wanted to be present at the scene of discovery while others preferred to avoid the setting. Human service providers at the scene of discovery frequently took control of the situation by either including or excluding survivors in caring for the deceased. Having someone take charge of the situation worked well for most survivors as often they were in a state of shock. However, a few survivors preferred to take charge of the situation and requested involvement in the post-mortem care provided to their beloved family member. Martin, the father of a youth who ended his life, became assertive regarding his right to be involved at the scene of discovery. He remarked that it was Healing Within Families 83

better for him to be present and see for himself, rather than let his imagination "run wild with what might have been the case." He insisted on being involved in caring for his son's body as a way of showing respect to his deceased son. He needed to be assured that "things were done right," meaning that his son's body was cared for in a respectful manner. In another case, survivors avoided the scene of discovery because the emotions were too intense to endure. In most cases, memories associated with the scene of discovery haunted survivors over the long term.

Retrieval of the loved one's body for the purpose of burial or cremation was important to all family members. In one case, a youth ended his life by jumping off a bridge. Family survivors suffered immensely in the weeks and months that followed. At one point, the parents launched a canoe trip on the river where their son drowned as a way of coming to terms with the possibility that his body might never be located. Despite search efforts, the body was not discovered for six months. Sara, the mother, explained that it was only after she had released all hope of recovering his body that it was finally retrieved. Returning to the place where his body was found was important to both parents because it enabled them to acknowledge and accept his death, and thus bring closure to one facet of their experience with suicide.

Dealing With Suicide Notes

Survivors had difficulty dealing with suicide notes because they confirmed what survivors were struggling to believe—that a beloved family youth had ended his own life. However, in situations where suicide notes were left, survivors found them to be valuable sources of information. Suicide notes sometimes contained information that released survivors of the responsibility for the death, often gave clues as to the motive for the suicide, and always confirmed the intentions of the youth who took his life.

Suicide notes were left by six individuals. In cases where notes were left, survivors studied them endlessly, searching for answers to the many unanswered questions that haunted them both day and night. Suicide notes confirmed the loved one's decision to commit suicide, as illustrated in the following suicide note, written by a 14-year old male: Healing Within Families 84

I feel my time is over and my life is lived to its fullest in my own way. My life may seem

short to some by ending it today but in my life I found out the meaning of my life which I

was unable to succeed in fulfilling, yet on my journey to my conclusion, I was able to find

what true friends are, what enemies are and how a heartbreak feels. Although some might

feel it is wrong to take one's life I view it as God's way of saying that your life is fulfilled

and it is your choice on continuing it or joining me in heaven, and I hope I'm right but if

I'm not, "God I hope you can forgive me."

Bye! Yours truly Steve

Breaking the News to Others

Breaking the news to others, both within and outside the family, was difficult for at least two reasons. First, survivors were reluctant to break the news to others because of the traumatic nature of what they had to tell. Survivors realized that such news would forever change the lives of family members, and instinctively, they wanted to protect their loved ones. Second, survivors understood society's general "no talk rule" and sensed the discomfort and perturbation that breaking the news would elicit in others. Breaking the news to those closest to the deceased was a heart wrenching experience. Telling people external to the family was almost as difficult. The task was always dreaded and sometimes postponed. Clare, a sibling, recalled, "dropping this bombshell in the neighborhood was something else ... the silence says so much."

Upon hearing the news, several survivors spoke of their perceived need to be strong for the sake of others, although at a costly price to themselves. May recalled her response:

Dad shared scant details with us initially and we began to consider what had to happen

next, who needed to be notified, etc. At one point, I observed dad beginning to

crumble before my eyes as his knees gave out and he began to sink to the floor. I went

to his side and guided him to my bed, where he collapsed in my arms and we sobbed

together. I somehow determined at that point and in my own mind that I needed to be

strong for everyone else's sake. I don't think I was totally conscious of that decision at

the time, but years later I recognized that I had chosen to set aside some of my own grief. Healing Within Families 85

With great sensitivity, most parents immediately informed their surviving children about the suicide. However, an exception was noted; in one situation, the parents were so distraught that they were unable to speak to their surviving children about the suicide for an entire day. As might be expected, the children sensed that something was dreadfully wrong. Although shaken and saddened by the news, they were relieved when their parents finally spoke to them about their brother's suicide.

Summary of Precipitating Event

Within this study, youth suicide precipitated a major crisis for family survivors. Upon hearing the news of the suicide of a family youth, each survivors began his or her healing journey within the Cocooning theme. Soon after hearing the news, most survivors needed to find a sanctuary where they could begin to sift and sort through the remains of their "never to be the same again" world. Initial reactions to the tragedy were as varied as survivors. Indeed, processing the trauma was demanding and difficult work. With dignity and courage, survivors faced many challenges such as confronting the horror of discovery, dealing with suicide notes, and breaking the news to others. The suffering induced by dealing with these unpleasant but necessary aspects of suicide was an important element of the healing process. For most survivors, suffering entailed reliving the horror again and again. Reliving the time surrounding the suicide enabled survivors to grasp the reality of their drastically altered lives. It was as if this period of acute suffering provided the seeds for future growth.

The stigma surrounding suicide and the silence and secrecy that persist within society often isolated and silenced family survivors of youth suicide. This aspect of dealing with youth suicide intensified survivors' suffering. In response to their experiences with youth suicide, most survivors embarked on a life-long journey aimed at making sense of the grievous experience, and living a meaningful life despite horrific loss. A number of contextual variables influenced how this process occurred. Healing Within Families 86

Contextual Factors

Youth suicide is not an isolated event. It always occurs within the context of the family.

Similarly, families live within communities embedded within a broader social structure.

Consequently, survivors' healing experiences need to be understood within the context in which they occur. The following contextual factors emerged from the data and influenced the survivors' healing experiences: the survivor's personal history, factors related to the suicide, social factors, and the health care environment.

Personal History

Six personal history variables were identified as having an impact on the survivors' healing experiences: the survivor's relationship with the youth prior to suicide, gender, religious affiliation, cultural practices, previous experience with loss, and health status. Personal history variables that did not appear to influence how the survivor moved toward healing included age, occupational status, income level, and marital status.

Relationship With the Deceased Youth Prior to Suicide

The survivors' positive appraisal of their relationships with the deceased youth prior to suicide was the main variable that determined the survivors' propensity to move toward healing. .

Survivors who perceived they had a special and loving relationship with the youth and those who felt emotionally and spiritually close the youth prior to his death were more likely to embark on a healing journey sooner than those unable to make this claim. Rae described her relationship with her brother this way:

Two weeks prior to his death he had phoned me and asked me if he could move out from

[town] to [town] to live with me. And I was thrilled. I was really excited about it because

we were really close as kids growing up because he was my next sibling. And when the

family had moved to the farm we were the only two not in school. My younger sister

hadn't been bom yet. The rest of the kids were all in school, I was five and he was three,

and so we became the best of friends and we grew up that way. Healing Within Families 87

Although often overlooked, youth suicide had a tremendous impact on extended family members. In particular, grandparents had to contend with a "double-edged sword." They simultaneously grieved for the loss of a grandchild and witnessed the suffering endured by their own child. Consequently, youth suicide intensified the grieving process for grandparents.

Indelible on Jim's mind was the enormous sense of devastation experienced by his father at the loss of his grandson. Jim recalled his father's absolute adoration of his grandson:

My dad would sit in the coffee shop in town and he's getting up there—he just turned 80.

He would sit in the coffee shop in town and he would look out the window and Jason

would be working at the gas pumps. He was so efficient and such a diligent worker, and

so committed and dedicated, and he'd say to his friends, his coffee buddies, he'd say

"That's my grandson out there."

In part, the extra demands required to deal with this double exposure to loss, in addition to the life-threatening medical diagnosis of a granddaughter, may have accounted for the fact that these grandparents experienced tremendous difficulty following the suicide of their grandson.

Gender

Gender influenced the survivors' journey towards wholeness. Although more women

(n=26) than men (n=15) participated in the study, both men and women viewed themselves as moving toward healing. Not surprisingly, women were able to speak about their healing experiences with greater ease than men. Although based on a small sample size, this finding is most likely attributed to the fact that psychosocial support is generally more readily available to women than men. In addition, in this study, congruent with the traditional male role in society,

adult male survivors often deferred their grieving and healing in favor of "watching over" or

"shadowing" other family members. They needed to be sure that others in the family were coping

with the suicide before they were able to deal with their own issues related to the loss. Healing Within Families 88

Religious Affiliation

Religious practices affected the survivors' experiences with healing. Religious values and beliefs generally influenced survivors' ideas about death and suicide. Just over half of the participants specified a particular religious affiliation and the majority felt comforted by their religious practices. A few individuals questioned their faith, and some even felt abandoned by

God. Survivors who were able to understand youth suicide within the framework of their religious values and beliefs moved toward healing with less tension and turmoil than those unable to find this kind of peace.

The survivor's religious values and beliefs were occasionally questioned. Fundamental assumptions that formerly gave life value and meaning were sometimes challenged. A few survivors questioned former religious beliefs, while others turned either toward or away from religion after the suicide. Linda, a mother, gained a sense of strength and peace through practicing her faith: "The first three days [following the suicide] I felt compelled to be on my knees praying and fighting for Allan in prayer. ... I gained such a sense of peace." In contrast, Martin, a husband and father, remarked, "When a suicide claims someone who you have loved so very much, your religion is challenged." Jan, another mother, expressed a similar view, "For a long time I didn't go to church. I just couldn't. I could not understand how God could let this happen to our son and to us." A few survivors were angry and felt betrayed by God. Chris, an only surviving sibling, angrily contorted, "I'd go out in the cold ... I'd sit and I'd have a cigarette and

I'd yell, or I'd scream, or I'd cry and I'd ball, and I'd yell at God."

Western society has been strongly influenced by Judeo-Christian values and beliefs, which above all else, enshrine the sanctity of life. According to this belief system, only God determines who dies and when death occurs. Hence, youth suicide is viewed as a sinful act. In some cases, survivors felt judged by others. Youth suicide sometimes triggered a tension between family survivors and others within the broader community who, through subtle and sometimes subversive means, held the family responsible for the suicide. Dale, the father of a teen who ended his life described his experience this way: Healing Within Families 89

You think that something like this will never happen to you. That's what I used to think.

And then one day it happened. When it happens, you begin to understand things

differently . . . you're treated differently after it happens . . . you're judged by others

according to their religion.

Cultural Practices

Most families were Caucasian (predominantly of European descent); one family was

Canadian Aboriginal. Family survivors who honored their cultural practices moved toward healing with a degree of peace. These individuals were helped by the use of death-related cultural practices such as the use of ceremony and ritual.

Canadian Aboriginal family members found much comfort and support by acting according to their cultural values and beliefs. This family held certain cultural views that afforded survivors some sense of solidarity and support in dealing with the suicide of a 14-year-old family member. Within the Canadian Aboriginal culture, death is viewed as part of life, and the afterworld is a world of peace, regardless of the cause of death. Neither the individual nor family is blamed for the death. Death, including death by suicide, signifies that the deceased individual has departed on "a spiritual quest." Following a death, there is usually a four-day wake during which time the family may view the body. Family, friends, and food are all highly valued and very much part of the immediate post-death experience. During this time of mourning, family survivors usually receive much help and support from others within their community. Survivors gather informally to pray, share stories, and provide comfort to one another. During these gatherings, family members often seek the wisdom of their elders. Funeral services and burial are followed by a pipe ceremony performed or supervised by an elder who has earned and been given that responsibility by recognized others (B. Shawanda, personal communication, May, 28, 1998).

Moreover, "the presence" of the beloved continues to be part of the survivor's experience, with messages often being communicated from beyond the grave. Ed spoke about a cultural practice that supported his healing following his son's suicide: Healing Within Families 90

We still talk about it every once in a while, like when I feel his spirit in the house. ...

He's with me every day. He's part of my existence. ... To me, the suicide is part of me.

And I go back to our traditional ways to get help. Remember, I was talking to you about a

little rock we found inside his pocket. The rock, they use it for healing sweats. There's

different kinds of sweats where you go and pray of whatever. That's what helped me.

Previous Experience With Loss

Previous experience in dealing with loss also had an impact on survivors' healing experiences. In seven out of eleven families, other major losses in life had occurred prior to the suicide; for example, the death of another child, marital breakdown, life-threatening illness, and job loss. Dealing with these previous losses enabled survivors to draw on their earlier experiences. However, they also felt that death due to suicide posed a different set of challenges.

For example, lack of support from others external to the family, and decreased opportunity for conversations about their experiences, added stress to an already difficult situation. In a few instances, other losses followed the suicide and compounded the challenges faced by survivors.

In addition to dealing with the suicide of their oldest grandson, Jim's parents also had to contend with the life-threatening illness of their oldest granddaughter: "Yes, they had gone through a lot because our niece has leukemia too. It was a year after Jason's death that she found out she had leukemia. It was almost a year to the day that she was diagnosed."

Survivors who had previously grieved following the death of a loved one recalled that every subsequent death evoked memories of previous experiences with death. Survivors who felt supported during their earlier grieving experiences were able to move toward healing sooner than those without such support. Carmen, a significant other, experienced the previous suicide of a former boyfriend. When she was confronted with the second suicide, that of her fiancee, she recalled that the experience of surviving the first suicide enabled her to access needed help immediately.

In another case, Meg, the mother of four children, experienced the death of her six-year- old daughter due to accidental electrocution twelve years prior to the suicide of her oldest teenage Healing Within Families 91

son. She claimed that even though both deaths occurred suddenly, self-inflicted death was much more difficult to comprehend than accidental death. Meg's previous experience with grieving provided her with much insight in terms of dealing with her son's suicide. However, she felt that her husband did not experience the same advantage. Meg spoke of the heavy personal and family toll levied by her childrens' deaths. Following the death of their young daughter, Meg's husband,

Terry, started drinking heavily. His drinking continued over many years and dramatically increased following their son's suicide. Four years post-suicide, Meg was still involved in therapy. She was just beginning to seek help and support from others and was contemplating separation at the time of the interview.

Many survivors who had not previously experienced loss read voraciously trying to understand what was happening to them. In particular, Carmen commented that many of the books currently on the market over-simplify the "craziness" felt by suicide survivors which is so much a part of their experience. She mentioned that suicide survivors, especially those without previous experience in dealing with loss, could be helped by a frank discussion about this aspect of dealing with suicidal death.

Health Status

Finally, survivors' health status influenced their movement toward healing. Survivors who, over the long term, rated their health as "excellent'-' or "very good" were more likely to move toward healing sooner than survivors who identified health concerns and/or medical diagnoses.

Initially, many survivors experienced a variety of short-term'somatic symptoms.

Repeatedly, survivors spoke of the intense "pressure" they experienced immediately following the suicide. Marie, a mother, said, "I wished I could have cut a hole in my head to release the pressure." Survivors found ways to alleviate the pressure. For some individuals, confiding with a trusted other was helpful; for others, an increase in physical activity helped. Air hunger and feelings of suffocation were also common. Marie recalled her experience: "All of a sudden it would feel like the walls were caving in on me.... Sometimes I'd have to go to a window and just gulp air." Sleep disruptions sometimes deprived survivors of much needed rest and Healing Within Families 92

relaxation. "Flashbacks" and "nightmares" in the first few weeks following the suicide were prevalent: "I did have some terrible nightmares. ... I think that I was trying to solve the 'why question.'"

Survivors rarely neglected their health. On the contrary, most survivors maintained their former state of health and well-being. In one instance, Garry and his wife experienced improved health status: "I can hardly believe it—we were incredibly healthy after Jered's death and that is not the way it is supposed to be." Further exploration revealed that both he and his wife took extra precautions during this stressful time to ensure they both had a healthy diet, plenty of exercise, and sufficient rest and relaxation. Only one participant neglected his health: "I didn't know where

I was going or what to do. I didn't give a damn about myself."

Other survivors succumbed to illnesses that, in some cases, required hospitalization. Ann, unable to express her emotions in other ways at the time recalled: "I know that I stored all that emotion. I did not let it out of my body . . . my body was storing it somewhere ... it came out as pneumonia." Loma, a mother and wife, spent two months in a psychiatric unit following her son's suicide, and upon discharge from hospital took a year off work to re-establish her priorities in life. Loma found that she needed time to pamper herself as an important aspect of her healing.

Families in which at least one member had a mental health diagnosis faced additional stress. Three individuals within one family (including the father and two surviving children) had been diagnosed with schizophrenia prior to the suicide of a schizophrenic family youth. Suzanne, the mother and only family survivor without a mental illness diagnosis, chose to live alone because she needed respite from the pressure of family demands. Suzanne maintained that all she could do was "manage one day at a time." At the time data collection, Suzanne was separated from her spouse, planning her future, and attending classes at a nearby university. In the another family, Clare, the youngest of five surviving siblings, was also diagnosed with schizophrenia. In an effort to make sense of her brother's suicide, she withdrew from others and dealt with her loss in ways that made sense to her. Preferring solitary activity, Clare expressed her grief by sculpting a set of figurines, each depicting a unique facet of her experience with loss. Healing Within Families 93

Factors Related to Youth Suicide

Youth suicide was a traumatic event for all family members. Two factors had an impact on

survivors' healing experiences: the nature of the death and questions regarding whether the death

was caused by suicide or homicide. Survivors who were able to identify, grapple with, and eventually resolve these aspects of suicidal death were more likely to move toward healing sooner

than those who avoided, or chose not to explore these often ambiguous and always complex

facets of their experiences.

Unexpected, Sudden, and Violent Death

Dealing with youth suicide raised seemingly irreconcilable issues for some family

members which centered on the unexpected, sudden, and violent nature of the death. Some

survivors struggled with the fact that there was no possibility of directly resolving past

differences, nor was there an opportunity to say good-bye to the deceased loved one prior to

death. Realizing the finality of death was also difficult. Rose struggled with the realization of her

son's suicide: "I'm never going to see him again. . . . that's my struggle—to realize that." Family

members also struggled with the violence associated with self-inflicted death. Understandably,

these violent deaths caused horrendous anguish and suffering for survivors. Dealing with the

imagined state of the youth in the moments preceding suicide, and dealing with the painful

memories associated with the scene of discovery were especially difficult for survivors.

Suicide or Homicide

The uncertainty about the cause of death was troubling for some survivors. Survivors in

four families claimed that the death may have been the result of homicide rather than suicide: "I

don't know which it was [murder or suicide] and I can't cope. ... so I put it away." Ann, a

sibling, commented, "like maybe he did, and maybe he didn't [take his own life]." In these

situations, survivors felt that a romantic partner of the deceased youth may have been responsible

for the death. Rae, another sibling, expressed her thoughts: "Part of my confusion was related to

the cause of death. . . . And I think that part of it was that there was a question as to whether Tyler Healing Within Families 94 had pulled the trigger or whether his girlfriend had." She went on to describe how she dealt with her haunting uncertainty:

So, then to go back to how I dealt with the situation. I had to go back and re-address what

was going on and really analyze what I had dealt with and what I hadn't. I took a look at it

and I decided "Okay, I'm having problems because I don't know if it was murder; I don't

know if it was suicide, so I can't cope with either one because this is the way it is unless I

deal with both." So I separated the two, and I dealt with it as a murder. It was a murder

and this is what I'm dealing with. But I could get past the guilt because I knew that I was

also going to address the suicide stuff. And so I dealt with the murder stuff and how I felt

about her [romantic partner]. I came up with a scenario in my mind that made sense to me.

I didn't say that "It's okay that you shot my brother," but said "I understand that you shot

my brother," and that "I would have probably done the same thing in the same situation."

And then I went to the suicide issue and dealt with it as a suicide, and not the "Well, it

might have been murder stuff." It was, this is a suicide. So, I dealt with two scenarios

separately and completely.

In two families, suicide notes absolved others of any involvement related to the suicide; however, doubts still persisted for some family members. This uncertainty created tension within these families. After much self-analysis and reflection, in both families, survivors eventually accepted that the deaths were caused by suicide. In one case, Fred, a father and head of the household, thought that "too much ugliness" would surface if an extensive police investigation of the situation was undertaken. Ultimately, such an effort was considered to be futile, and thus curtailed, since it would not change the reality of the situation in any significant way.

Social Factors

The social environment had an impact on survivors' healing experiences. Survivors spoke of two social factors that permeated every facet of their healing journey; these factors included societal stigma and social support. Healing Within Families 95

Societal Stigma

The stigma surrounding suicide commonly manifested itself in what some family members

called the "no talk rule," that is, the unchallenged silence that surrounds suicide within Western

society. This nonverbal form of communication was powerful. Despite feeling supported and

validated by those with similar beliefs, even Canadian Aboriginal survivors felt judged by others

within society. Ed, a Canadian Aboriginal father, explained:

There's this stigma especially felt in the native community. You go from one extreme to

the other extreme, like religion. . . . They say the person who committed suicide goes to

hell or they end up in purgatory or whatever. ... It's kind of embarrassing for me that my

son comrnitted suicide because it is always interpreted according to European standards.

In two families, the stigma felt by family members was compounded when mental illness

was also present. In one family, the youth who took his life was diagnosed with schizophrenia.

Both parents recalled that prior to his suicide, they had advised him not to reveal his illness to

others. These parents intended to protect their child from being humiliated by his peers.

Unfortunately, the silence regarding his health status also limited possibilities for initiating

dialogue about his medical condition. Linda, the deceased youth's mother commented: "We experienced a double whammy.... There is stigma related to suicide, but there is also stigma

associated with mental illness."

Survivors' responses to stigma influenced their healing experiences. Individuals who felt empowered to change this societal stigma moved toward healing sooner than those who did not think they could "make a difference." Taking action aimed at helping others understand more

about suicide and its impact on the family often became an integral aspect of the survivor's mission in life.

Social Support

Not surprisingly, survivors who felt supported and understood by at least one other person were able to face the reality of their situation more readily than those lacking social Healing Within Families 96 support. Individuals who moved toward healing typically developed a coterie of friends with whom they could share their stories. In addition, whenever necessary, they accessed external resources such as counselors and support groups. Sara commented on the importance of social support:

I know beyond a shadow of a doubt that I would not have made it without the support of

my husband. There were times when I was so wobbly that I could hardly stand on my

own two feet. He [husband] just seemed to know what I needed and when I needed it.

He's such a good listener. He listened to me talk about the same thing over and over, and

that's what helped me the most. My friends were there for me too, and that really helped,

especially later on.

Health Care Environment

Survivors perceived the health care environment to be in a state of transition and, therefore, not always responsive to their needs. Survivors who were able to reach beyond the confines of the health care environment by drawing upon inner strength and wisdom, as well as previously established coping capabilities, moved toward healing sooner than those who relied solely on existing health care services. In addition, survivors who took the initiative in creating their own healing environments moved toward healing more expediently than those who did not take such action. For example, Dale, the father of a 17-year old youth who ended his life, took it upon himself to develop a web page in the hope of communicating with other suicide survivors.

Within six months after the suicide of his son, he began attending death education conferences. At the time of the interview, Dale was also investigating possibilities for changing his current employment so that he could devote more time to educating others about youth suicide and its impact on the family. He took the initiative to improve life for both himself and others; Dale said,

"If it is to be then it's up to me." Healing Within Families 97

Summary

The prime objective of this study was to explore how individual family survivors heal in the aftermath of youth suicide. The methodology utilized grounded theory informed by symbolic interactionism, systems theory, and humanism. Forty-one survivors from eleven families residing in rural communities and small urban centers in three Western Canadian provinces participated in the study, representing considerable diversity in terms of age, socioeconomic and health status, religious affiliation, and geographic location. Within these families, nine youths and two older individuals ended their lives. Intensely experienced by each family survivor, youth suicide always occurs at a particular point in time in the life of the youth who takes his life and each surviving family member. Situated within the context of grieving families, study participants offered rich accounts of their experiences of healing. Their stories were used to generate a substantive theory of individual healing following youth suicide.

(relating, thinking, functioning, energizing, and finding meaning/exploring spirituality), each descriptive of one facet of the survivors' overall experiences with youth suicide. The extent to which healing occurs depends on the survivors' capacity to respond to such adversity by deciding to move toward healing. Survivors who move toward healing create a Love Knot, symbolic of the healing strategies they develop to maintain a continuing bond of love with the deceased youth.

These healing strategies are individualized and creative expressions that represent the unique meaning of survivors' experiences with youth suicide. Individual healing is both a solo and shared experience that is created and re-created over the course of each survivor's life. It is also suggested that individual healing ultimately expands outward influencing the family, community, and society.

Four contextual variables were found to influence each survivor's journey toward healing: the survivor's personal history, factors related to the suicide, social factors, and the health care environment. Several personal history variables influenced the survivors' healing journey.

Survivors most likely to move toward healing were those who felt emotionally and spiritually Healing Within Families 98

close to the youth prior to his suicide. Although family survivors of both genders moved toward healing, adult males needed to ensure that other family members were coping with the unfortunate situation before they felt free to tend to their own psychological needs. In addition, survivors who were able to understand youth suicide from the perspective of their religious beliefs and cultural values experienced an advantage in terms of moving toward healing. Similarly, those who rated their health as "excellent" or "very good," and those who felt supported during their previous experiences with loss also moved toward healing more expediently than others unable to make these claims.

Certain issues related to suicidal death were particularly troublesome for family survivors including death by unexpected, sudden, and violent means, as well as questions about whether the death was the result of suicide or homicide. Survivors who were able to identify and work through their particular issues regarding youth suicide moved toward healing sooner than those who avoided or chose not to confront these aspects of their experiences.

Social factors including social support and societal stigma influenced survivors' healing experiences. Not suprisingly, survivors who felt supported by at least one other person experienced an advantage in terms of dealing with youth suicide. Survivors who felt empowered to take action aimed at changing the societal stigma surrounding youth suicide moved toward healing sooner than those who did not think they could make a difference. Moreover, survivors viewed the health care environment as in a state of flux and not particularly responsive to their needs. Those who moved toward healing were not deterred because of this perceived

unresponsiveness. Rather, these individuals assumed responsibility for their own health by

drawing on their innate strengths and coping capabilities. In the next chapter, I turn to a

description of Cocooning, the first healing theme of the healing process. The knot which symbolizes attachment and unity has its full expression in interlacings whose patterns, used in all sacred arts, represent a mixture of cosmic and earthly events, the complexity of social links and the various interconnections at work in the universe. As these designs also evoke the undulation and the overlapping of waves, the symbolism of these interlacings approaches that of the latest scientific theories which describe the universe, from the infinite cosmos to the human brain, as a vast network of interconnections within which interference occurs between energy waves of some kind, governed by what mathematical physics refers to as wave equations. (Petzl, 1998. p. 36) Healing Within Families 99

CHAPTER FIVE

COCOONING: JOURNEY OF DESCENT

It [healing] involves allowing or letting yourself go into those corners of your life and those areas and regions that are unexplored. . . that are scary, that are totally new, and that you don't have any answers for at all. (Liz, significant other)

This chapter provides a description of Cocooning, a major concept within this theory, and the first theme of the journey toward wholeness. In the aftermath of youth suicide, most survivors embarked on a 'journey of descent,' a downward spiral leading to the depths of human despair and suffering, to a "dark and dreary no man's land." Consistently, survivors spoke of "hitting rock bottom" at some point in time following the suicide. Liz described her journey of descent this way:

"You reach the bottom or the bottom reaches you . . . you are stripped to the bare nothings when this happens." Soon after hearing about the suicide of a family youth, survivors felt vulnerable and in need of protection for a period of time in order to face their harsh reality. Initially unable to articulate their views about their experiences, survivors often preferred to spend some time alone, escaping from the critical appraisal of others.

The Cocooning theme represents the survivors' need to retreat, to disassociate from their surroundings, to withdraw from others, and to gain truth and wisdom by going deep within themselves for an individually determined period of time following youth suicide. This dormant period allowed survivors time for introspection. Further, it kept them from having to be responsible, at least until they had a chance to make some sense out of their forever altered reality.

In several instances, it was as if their experiences with trauma (i.e., youth suicide) were the keys that unlocked the doors of self-discovery and self-growth.

The Cocooning theme encompassed survivors' experiences within the five healing patterns including: struggling in terms of relating, chaotic thinking, functioning on autopilot, energy being consumed, and spiritual awakening. Healing Within Families 100

Relating Pattern (Struggling)

Within the major concept of Cocooning, the relating pattern, an element in this theory, is characterized by survivors struggling within themselves and with others. The name for this element reflects the terminology frequently used by survivors in their descriptions of their experiences. They spoke about struggling in terms of relating to both themselves and others. They also talked about struggling to cope with the emotional and social aspects of living in the aftermath of youth suicide. Most survivors felt immersed, without mercy, in a tumultuous, all- encompassing and consuming struggle: "I felt like I had a witch's cauldron inside . . . like a witch was stirring a brew inside me." Initially, survivors had to contend with their inner struggling.

Struggling Within Self

Survivors initially felt inundated and overwhelmed by their struggle with intense feelings.

At the same time, they needed to find a safe place to begin processing their feeling about the suicide. Struggling within self includes finding psychological safety and processing intense emotional trauma.

Finding Psychological Safety

Characteristically, survivors experienced the need to retreat to a safe place where they could struggle with their feelings in their own time and in their own way. Ann, a sibling, commented, "There is a face that one shows the world, and then there is the face behind closed doors where one can let one's guard down." In safe, self-chosen surroundings, survivors were able to defend against, and sometimes deflect, a reality too painful to fully comprehend.

During their struggle, survivors felt an increased need for security within the family unit.

Instinctively, survivors tuned into the feelings of other family members. Sometimes, survivors even put others' needs ahead of their own: "Everybody looks after everybody and nobody looks after self." Even though survivors were aware of other family members' pain, they often remained emotionally unavailable to those closest to them. Consumed by inner struggling, they were seldom able to provide much needed assistance to other family members. Nonetheless, knowing Healing Within Families 101 that others within the family were "watching over each other" provided a sense of security for many survivors.

Some individuals identified themselves as the emotional stronghold in their families and postponed their own grieving in favor of "being there" for other family members. These individuals put their own struggle on hold while becoming alert, hypervigilant, and responsive to the psychological needs of other family members. Mike, a husband and father, explained:

I had a sense of trying to keep an eye on what was going on. I knew that I still had to be

strong and everything because I still had my family and my wife and everything. ... It

was extremely important to concentrate on my wife, almost shadowing her in terms of

making sure that my whole life wasn't going to fall apart. ... I had to kind of hang back a

little bit and make sure that the water was going to be safe. I just needed to make sure that

they [family] were secure. I had to be sure that that was the way it was going before I

could actually start grieving in my own way.

For many survivors, "finding a safe place" for processing their emotional trauma was of major importance. However, survivors quickly sensed that they needed to exercise discretion in terms of finding a safe place for sharing their struggle. Places deemed to be safe varied among survivors and included the family residence, with or without the presence of others; counselors' offices; local grief support groups; and natural habitats such as gardens and forests. Ann, a sibling, remarked:

I needed to find a place to express my emotions. . . . So.I joined a women's group, found

a group of friends . . . and began expressing my emotions on a daily basis. ... As soon

as I was able to express myself without feeling that I was going to be criticized for the

emotions that I was feeling ... I found unconditional love and acceptance, and I began to

heal.

Processing Intense Emotional Trauma

For most survivors, struggling with emotional trauma was like being on an "emotional roller coaster." They experienced a myriad of intense emotions ranging from apathy at certain Healing Within Families 102 times, to "explosiveness" at other times. Mike sought counseling as a way of processing intense emotions:

I got to a point where I knew that I needed to press on, and yet I couldn't. I just couldn't

move past certain situations. And so she [counselor] was able to break down the barriers

that were keeping me from breaking down, which was what I needed to do so that I could

release my emotional turmoil.

Most survivors struggled as they endeavored to address their loneliness, anxiety and fear, anger, pain and suffering, depression, guilt, and regret.

Loneliness. Feelings of "intense loneliness" and a "gnawing feeling in the pit of one's stomach" were common. Whether alone or in the presence of others, the intensity of the loneliness was new to those who experienced it. Not surprisingly, family survivors were sometimes astounded by the intensity of their loneliness: "I realize now how alone I am. ... I've never felt this way before." For the most part, survivors' loneliness was related to the physical absence of the deceased youth. Sometimes this vehement loneliness served to expand the survivor's capacity for emotional expression. Many survivors experienced intense emotions, often for the first time.

Anxiety and Fear. Family survivors often felt highly anxious and fearful following the suicide. Strong emotions were linked to the place where the suicide occurred, the fear of another family member committing suicide, and the fear of forgetting the deceased. Traumatized by the suicide, a few survivors developed phobias.

Many survivors feared the location where the suicide occurred. Initially, they avoided this place. However, as time passed, survivors confronted their fears in various ways. Martin developed his own unique way of dealing with his son's suicide. Martin's son ended his life in the bodyshop where both he and his son worked prior to the suicide. Since Martin could not avoid the place of death, he tried facing the memory: "I don't know, I'd go in there and I would even say, 'Good morning Paul.' And I would go and stand where he hanged himself and talk to him even." Martin found it difficult to work in the place where the suicide occurred. Two years post- Healing Within Families 103

suicide, Martin and his wife realized a dream and moved to an acreage (i.e., a small piece of land in the country) in the hope of finding a new beginning. In new surroundings, Martin felt the burden had been lifted.

In four cases, the suicide occurred in the family residence. Consequently, for some

survivors the home environment was disturbing, whereas for others, it was a place of comfort.

Within the first year following the suicide, two families moved while two other families remained in their homes.

Consistently, family survivors feared that another family member would also end his or her life. The "who's next?" fear loomed larger than life for some survivors. Rose and Jim were concerned that their only surviving son would join his deceased brother, his closest friend. Aware of this situation, they sought help for him from a counselor. Even though felt by most survivors, this fear was seldom discussed within the family unit. Because this fear was withheld, survivors frequently became hypervigilant, carefully watching for unusual behaviors in other family members.

Many survivors were afraid of forgetting their loved ones. Survivors were reluctant to address the emotional impact of the suicide because they feared forgetting the deceased youth:

"I'm almost afraid to deal with it because I'm afraid I'll lose the memories of him. I'm afraid of forgetting him." From a family perspective, the fear of forgetting was even more difficult to

acknowledge. Rose commented: "The family as a whole is dealing with Jason's suicide .. . it's the fear of forgetting and letting go within the whole family ... his place in the family is now

void."

A few survivors described phobias that began during the time surrounding the suicide.

Characteristically, survivors were able to recall, in great detail, the setting and other details related to the suicide. In a few cases, certain stimuli triggered phobias that continued for a long time.

Marie spoke of her fear that began soon after the suicide: "The sirens became terrors for me ... if

I ever heard a siren from an ambulance or fire truck . .. my heart was beating so fast that I felt like I was having a heart attack." In another case, while Jim was getting ready to go to work, his

son shot himself in the basement of the family home. Jim was still in the shower when panic Healing Within Families 104 stricken family members bombarded the bathroom with the tragic news. Subsequently, he struggled for a long time to overcome this fear: "For two years following the suicide, I couldn't take a shower on Monday morning."

A number of survivors felt claustrophobic following the suicide. Although claustrophobia is also common in depression, it is also related to fear, hence, it is addressed here. Liz, a mother, commented, "There were stores that I had to leave, and churches that I had to leave because of the feeling of overwhelming claustrophobia." Marie reiterated this claim as she expanded on her all- encompassing response to youth suicide:

I experienced claustrophobia, panic attacks, anxiety, loss of sleep, loss of weight, lack of

concentration, fears, exhaustion, lack of appetite, depression, intense pressure within my

body that made it feel as if my head was going to explode, and often I had the feeling that I

was going crazy.

Anger. Consistently, survivors commented on their intense fear and anger: "It's the fear that holds you back from allowing yourself to feel the anger." Anger was frequently directed toward self, others, and the deceased youth. A few survivors were angry at themselves for being unable to intervene and thus prevent the suicide. They wondered if the outcome may have been different "if only" they had acted differently. For instance, Jim questioned if his son would still be alive "if only" he had not been punished shortly before the suicide. Sara thought that she may have been able to prevent her son's suicide "if only" she had refrained from arguing with him on the day prior to the suicide.

Sometimes the anger was manifested as blame and directed toward others. Initially, an angry father blamed his son's girlfriend for the suicide:

She told us that she knew that Jason was going to kill himself and that he would have been

glad that she didn't tell us because, you know, he wanted to die or whatever. That's what

she wrote in the sympathy card. . . . So, at the time when we got the card I was so angry,

like I said, like I almost wanted to charge her. Healing Within Families 105

Sometimes, anger was directed toward the deceased youth. Survivors frequently expressed anger because they felt rejected and betrayed by their deceased loved one. Many survivors viewed suicide as the "ultimate form of rejection." Responding to such rejection, a father stated, "He made this decision, this choice, and if we're going to be angry at anybody, we should be directing our anger at him." In an effort to deal with her anger, in a letter to her deceased son, Marie wrote:

There has been so much anger in me because of your decision to commit suicide. Some of

it surfaced in ways that I didn't recognize. Six weeks after your death, I began to feel as if

I had Parkinson's disease. I remember teaching and having to stand with my arms

hugging myself as if I were cold. People looking at me would never have guessed the real

reason that I held myself like that—it was to literally hold my body parts together.

Chris, Marie's only surviving child, expressed anger toward her brother because he took his life on their mother's birthday: "He [committed suicide] on my mom's birthday . . . and that's why

I'm a little bit upset. I AM ANGRY. ... I still have a lot of anger boiled up inside ... I keep everything boiled up inside until it breaks."

Some survivors felt uncomfortable overtly expressing anger. However, beneath a calm exterior, these survivors struggled to contain a quiet but unrelenting rage. Their anger was often revealed in the form of somatic symptoms and atypical behavior. Jane, for example, withdrew from others and became totally incapacitated following the suicide of her son and eventually sought professional help.

Survivors' anger was often related to the shame associated with suicidal death. Feeling strong enough to put words to her anger, Carmen raised her voice and said, "I'm ashamed ... he wrecked my life, he wrecked his own life, he wrecked his son's life. ... I'll never get over it. I will never change the way I feel. NEVER EVER, NEVER."

Some survivors vented anger privately while others expressed it openly. Similarly, some sought help while others did not. Rose, a mother, recognized the importance of addressing anger as she searched for a way to help her only surviving teenage son deal with his anger. She claimed Healing Within Families 106

that the culprit was "the anger within him. And that's what we had to deal with... . Once you get on with that, then you can get on with other things."

Youth suicide not only triggered anger and frustration in relationship to the death, it prompted survivors to review other aspects of their lives as well. Mike described it this way:

The sources of the angers and frustrations weren't just the death of my son. I kind of

likened it to—as you go through life, you pick up little packages of complexity that you

carry with you. For boys, it's a little red wagon and for girls it's a little blue baby carriage.

They all have their little packages wrapped up in them and the complexities go with you.

Your keep dragging the packages, and if you are the type of individual who has a complex

life, you are dragging a pretty heavy load. All of these packages become a pretty heavy

bundle by the time that you have a major crisis. Then you have to go back and re-touch

and re-claim every one of those complexities and work your way through them

individually. It's almost like starting on a regressive basis and coming back to the reality

of what is current.

Pain and Suffering. Survivors' healing experiences were characterized by both physical pain and emotional suffering. Yet, the pain of suffering was an all-encompassing experience and a crucial rite of passage in terms of the survivors' movement toward healing. For all survivors, the trauma of youth suicide left in its wake, a pain that was "always there under the surface." Ed, a father, claimed that the pain lingers long after the assault: "You heal the wound but carry the scar."

Commonly, survivors expressed their pain with words such as "feeling hard" or "heavy:"

"It's a lot of weight that each person carries." One survivor felt as if she had become "encased in a

hard shell," while another spoke of being "solid as a rock." These emotionally numbing reactions protected survivors and allowed them time to process the impact of the suicide. As a survival

strategy, many survivors compartmentalized or shelved their feelings for a short period of time following the suicide: "I think I shelved it. I put it on the backburner and decided that I would deal

with my emotions later." Emotional numbness sometimes allowed survivors to live up to the self-

imposed expectation of being in control: "I just became solid as a rock. Something inside me said, Healing Within Families 107

you have to be stronger than anyone else in this because you are the strongest person in this family. I didn't cry." Even the most composed survivors eventually began allowing reality to surface by emotionally "working through" the trauma. This involved suffering. Moreover, the joint experience of suffering sometimes rendered family members unable to support one another.

Although family members watched over each other, they needed to process the trauma individually. Without exception, survivors commented on the need to privately revisit memories of the deceased within their own space and time. Eventually they were able to allow their feelings to surface: "At first I didn't feel anything. And then later, as I lay awake in my bed at night, I would start thinking about everything."

Though painful, many survivors reported the need to relive, in their mind, every emotion that the loved one may have felt prior to ending his life. Rae, a sibling, questioned, "I kept thinking, what was he thinking? ... It must have looked totally black, like there was no help for him. . . . Did he not know how much he was loved?" Jim, the father of a 16-year-old who ended his life, recalled spending hours 'staring into space' as a way of processing the horror:

It's always on your mind, it's always there behind you when you stare, and I stare now

more than I ever did. You know, you kind of look into space, and time stands still. . . .

The pain is always there as I'm staring. It's like a motion picture right up there in the

corner of my mind. That whole week plays through my mind, it's always there.

The loss of relationship, and consequently, the loss of a future together, also caused a great deal of pain and suffering for survivors. Marie shared her pain in a letter to her deceased son:

How things could have been different, if only you'd given yourself time to reflect on your

decision. When you made the choice to end your life, Kevin, I wonder if you ever

comprehended how much pain would be left behind for your family, your classmates,

your friends, and your teachers. You never gave yourself the precious gift of time, Kevin.

Time to look at whatever it was that became so humongous, in your mind, that you felt

that this was your only choice. Time to see if someone could help you. Time to share your

pain with people who loved you deeply. Time to get the pain out of you in a healthier way. Healing Within Families 108

Time to realize that you did have other choices. Time also for your family to see you

grow, time to see you graduate, time to see what career you would choose. Time to laugh

and cry at your wedding and time to celebrate the births of your children.

Depression. Several survivors became depressed in response to the suicide characterized by "falling apart emotionally." Even while recognizing that they were spiraling downward, they remained cognizant of their familial responsibilities. Dave, a father, remarked:

How much lower can you really go actually because you feel like what's the use of living?

. .. but it's not just you. You have a family and you have a wife, you have two other kids

and they are going to need you.

Although several survivors commented that "hitting rock bottom" was a jolting experience, they learned things about themselves they could not have known by gentler means. Carmen elaborated:

When you hit rock bottom you say, "I don't like this. I've got to get up there." You hit

rock bottom and you find your goal. . .. You make a goal to aim up. ... I found a

reason to stay alive ... if you can make it through the first year ... it's amazing what you

can do with your life.

For some survivors, depression occurred shortly after the suicide; for others it appeared years later. Jan, a significant other, recognized her depression six to eight months after the suicide. She commented on this difficult time in her life:

Sometimes when you are in a depression, then it's even hard to get help. Your mind just

doesn't work the same. Like I've explained it to other people, it's like something else

takes over, and you have no control over yourself, or very little. It's horrible—

depression.

For other survivors, the depression developed much later. Six years after the suicide of her brother, Rae recognized her depression:

It was a combination of problems. .. . That's when I hit the bottom and it wasn't a matter

of right after ... it was a few years later. Six years after his death I recognized, I don't Healing Within Families 109

know why, but Mom and I both that year had a harder time than we had in previous years

dealing with it. And at that point when I saw that the process each year, when it came to

the anniversary, was becoming more and more difficult, I thought, something's wrong.

This is not normal, it should be getting better, not worse. And it was getting worse. And

that's when I started going, okay, now how do I deal with it? What am I going to do with

this? I thought that I had coped with it, I thought that I had dealt with it but it's coming

back stronger. And that scared me, it really scared me, and it scared me into action to try

and figure out what was going on.

Rae's depression served as a reminder of unfinished business that prompted her to explore further her feelings in relation to the suicide.

Guilt. Some survivors expressed guilt in relation to the suicide while others did not.

Chris, a sibling, claimed, "I didn't feel guilt, I felt no guilt at all and I never felt angry at Kevin."

In contrast, Ed, a father, remarked, "I wondered what I could have done so that he would still be with us." Jim spoke of his pervading sense of guilt which was reinforced by a comment made by his only surviving son:

I disciplined Jason the night before and then the next morning, you know, he's gone. And

I tried to discipline my other son and he says, "I won't listen to you. You caused Jason's

death." He would say this to me, and so I just kind of gave up and just kind of let him do

his own thing. You know, it's always up and down ... the heavy guilt that you

experience.

In another case, Brenda had intercepted a fight between her two sons and disciplined one son. The disciplined son hanged himself in his bedroom during the time that he was being punished. Initially immobilized by guilt, Brenda eventually sought help which resulted in a two- month hospitalization. Upon discharge, both mother and surviving son sought therapy for several months. Through all the trials and tribulations, Brenda's husband remained attentively at her side.

In another situation, May, a sibling, spoke of the pent up guilt she had been carrying for many years: Healing Within Families 110

As I struggled to understand his death, I became acutely aware of some deep guilt that I

had carried for many years.... [I am referring] to my personal experience with a serious

and almost successful suicide attempt I had made almost five years prior to Ryan's death. I

felt guilty that I had not been able to recognize his pain or help him with it when I had felt

that same kind of despair and hopelessness as a 16-year old myself. I realized that I was

blaming myself for his death, believing my own earlier attempt had somehow

demonstrated to him that suicide was an alternative.

Family members also recognized the guilt felt by their friends. Jim elaborated on the guilt felt by his deceased son's girlfriend who was aware of the youth's intention to take his life:

I knew by the Christmas card, and what she [girlfriend] wrote in it. . . . It was obvious

that she was dealing with a lot of guilt. She said, "You know, I don't know how you

folks are managing, I just feel so devastated." She went on and on and then she said, "I

know that you must feel the same. He was everything to me. My life has just been hell

since."

Most family members struggled for a long time following the suicide. A couple of survivors admitted that they seemed to be "in a rut" years after the suicide. In spite of several attempts by family members to intervene, 12 years post-suicide, one mother vividly and painstakingly still recalls the details related to her son's suicide during each family get together.

Rae commented that it is as if her mother remains "stuck in the wallowing."

Regret. A few survivors expressed regret regarding some aspect of their former relationship with the deceased youth. Most commonly, regret was experienced in relation to deeds left undone and words left unsaid. Ann explained, "I regret not telling him how proud I am of him and how much I love him—and I have to live with that." Jan remarked, "Even the last day that he was over before it happened, I wanted to give him a big hug before he left and I didn't. And that bothers me of course." Marie expressed her regret in a letter to her deceased son:

When I left you, I just ruffled your hair and told you to rest and to take care of yourself.

Now I regret not kissing you and not grabbing you in a bear hug. Never again would I Healing Within Families 111

have this joy, never again would you and your dad wrestle, never again would you and

your sister bump shoulders in love or anger. Never, never, never, to do so many things. I

still find it hard to understand how you made the decision that removed you in such a final

way from everyone who loved you.

Struggling With Others

Survivors not only struggled with themselves, they struggled in terms of relating to others. Struggling with others includes: withdrawing from others, the effect on relationships, and dealing with others' reactions.

Withdrawing From Others

Family survivors varied in their need for contact with others following the suicide. Some survivors withdrew: "I pretty much just shut myself out of the world. ... I didn't come home much. And I didn't call my friends anymore." In one instance, Clare, a sibling, recalled being so emotionally traumatized that she was unable to articulate her needs one way or the other.

Diagnosed as schizophrenic, she preferred to withdraw from others for lengthy periods of time to process her grief in her own way.

Survivors consistently agreed that, initially, "processing trauma requires time away from others." In addition, a change in focus was sometimes needed: "I changed my focus from other people to me." Sometimes withdrawal helped survivors to avoid the critical appraisal of others:

"When all this first happened with me, there was an unwillingness to let my friends see where I was at.. . . Where I was at, and where they perceived that I was at, were two different things."

Sometimes, survivors became skeptical of others' intentions. Mike explained:

All sorts of people rush to your aid, you don't know how they are going to help you and

what they are going to be putting in front of you. ... I had a sense of trying to keep an eye

on what was going on. ... I just had to be sure that the people that we were going to be

with .. . that I was going to be comfortable with them. Healing Within Families 112

Effect on Relationships

The effect of the suicide on relationships varied—some relationships were strengthened whereas others became strained, and a few dissolved. Most survivors in this study experienced stronger ties within the family unit following the suicide. A sibling commented, "You get your priorities straight and get your family first."

A few families experienced increased tension in relationships both within and outside the family unit. Couples in approximately half of the families experienced increased stress that resulted in marital discord at some point following the suicide. In one case, a couple separated shortly after their son's suicide and were reunited two years later.

Many survivors experienced the loss of relationships with former friends: "Many of our so called friends disappeared." In general, survivors perceived that others had difficulty accepting the fact that a suicide had taken place. Even though some relationships dissolved, the quality of remaining relationships for some survivors improved significantly. Several survivors commented that they became "more real" in their relationships as a result of their experiences with youth suicide.

Dealing With Others' Reactions

Survivors frequently felt as though their family was under the constant scrutiny of others; they often felt blamed by others for the suicide. While survivors were treated by some people with kindness and compassion, a predominant sector within society still tended to be critical of the family. The enduring "blame the family" stance was the source of a great deal of frustration and concern among survivors. Survivors responded by fervently claiming that "youth suicide can happen in any family." Others' lack of empathy toward family survivors presented a challenge:

"Just going out in public was scary."

Others' reactions to youth suicide mirrored the death-denying and death-defying attitude prevalent within society. Survivors were often confronted by silence and avoidance from others.

Nonverbal messages were delivered with considerable impact: "Although they don't say it in Healing Within Families 113 words, I feel judged by others." This shroud of silence and secrecy was often manifested as the

"no talk rule," the unchallenged modus operandi assumed by many within society. In the words of one survivor: "This [suicide] is a loss of which one cannot speak." Survivors often sensed and respected others' uneasiness related to the topic of suicide. Hence, a lack of communication between survivors and others, created and maintained by both parties, maintained the "no talk rule." Survivors consistently identified the need for education about youth suicide and its impact on the family as a way of changing these entrenched views.

Survivors interpreted others' avoidance in several ways: others may have felt discomfort dealing with death-related issues or they may have sensed that bereaved persons need time and space to process loss. Carmen commented that grieving provided a "safety net" because "people leave you alone when you grieve." She further admitted that it was sometimes helpful to be left alone to "sift and sort through things" in her own way. Other survivors concurred with this view, sometimes appreciating the time to process the trauma without intrusion from others.

Even though youth suicide was deemed to be "the most difficult situation that anyone in life might have to face," a few survivors were able to put it within the context of being "part of life's inevitable suffering." Viewing suicide from this perspective enabled survivors to continue living despite their ongoing struggle. Not only did survivors struggle in terms of relating to themselves and others, they also experienced chaotic thinking.

Thinking Pattern (Chaotic Thinking)

Within the major concept of Cocooning, the thinking pattern is characterized by chaotic thinking. As an element of the theory developed from the study data, this thinking pattern encompasses three ideas including: experiencing cognitive dissonance, experiencing altered thinking, and contemplating own suicide. Healing Within Families 114

Experiencing Cognitive Dissonance

Survivors' experiences with youth suicide often created cognitive dissonance, a distortion between reality and one's perception of reality. This discrepancy reminded survivors of unmet expectations and verified the fact that life sometimes lacks coherent sequence. The idea of a youth taking his own life was incomprehensible to most survivors. This idea was incongruent with many of the cherished beliefs and values held, not only by survivors, but by society at large. Most survivors initially denied the reality of the situation—that a family youth had, in fact, taken his own life. Carmen recalled her initial experience:

The next morning, I woke up at seven and I went upstairs and I looked in Jim's room and

he hadn't even been in bed, so I thought that he probably slept outside, in my parent's van

just to keep the fight going or something I figured. So, I looked outside and there were

four apple trees along the driveway. I had lived in this house since I was a week old, and I

looked in the last apple tree and I saw his body hanging there, but in my mind I thought,

"No, he would never do that to me." So I went downstairs and went to bed because it

really didn't hit me. . . . And I was thinking that was really weird. . . . [Later] I went

upstairs because I could hear lots of people in my house and I thought something is

wrong. ... I remember my mom sitting down. My parents were just separating at the

time. My dad and his mom and my little sister went to the mountains the day before, so I

thought that something happened to them. So I asked my mom if it was my dad and she

said "No, it's Jim. There's been an accident," And in my mind I pictured .. . dad at this

intersection leaving [town] and going onto the highway and he was hit. Maybe something

like that—accidental. She told me that Jim had taken his life outside in the tree and so then

everything snapped in my head and I knew I had seen him.

This distortion in thinking protected survivors from having to face their bleak reality at a time when they were unable to comprehend this disturbing fact. This protective mechanism helped survivors by allowing them to process the trauma in their own time and space. Healing Within Families 115

Experiencing Altered Thinking

Survivors also experienced altered thinking in response to youth suicide. Altered thinking was demonstrated by decreased concentration and decision making capacity, pervasive thoughts of the deceased, thinking that one was going crazy, and post-death ambivalence.

Commonly, survivors experienced decreased concentration and decision making capacity immediately following the suicide: "It wrecks your mental state." Jim recalled, "It was like having short circuits within my mind," while Linda maintained, "It was difficult to concentrate on anything singular for a long time." Short term memory and the ability to make decisions were often notably altered. Rae recalled her inability to make a simple decision: "I was incapable of deciding what to wear to the funeral. My sister had to tell me what to wear."

Initially, most survivors were preoccupied with pervasive thoughts of the deceased: "From the very beginning ... I let it [suicide] control my mind. I couldn't think of anything else ... I was always thinking of him and stuff... I was just like a zombie." This preoccupation enabled some survivors to hold on to their precious memories of the deceased loved one until they were able to face the reality of the suicide. Most individuals spent considerable time reminiscing about the past when the deceased youth was alive and well. Family survivors often focused, in great detail, on the events and conversations that had taken place just prior to the suicide: "That week, that whole week plays through my mind, it's there." In several cases, family survivors reported the need to relive, often frequently, their recollections of conversations and events leading up to the suicide. Jim commented:

My memories are quite vivid because it's things that are always going to be with you,

those thoughts and those moments, one night before, two nights before, words,

conversations, events of the day will always be there very, very strong. It's something

that you'll never, never forget.

Frequently, survivors reported the experience of living in a world that had been

"shattered," "fragmented," "torn apart," and "turned up-side-down" as a result of youth suicide.

Carmen expressed the extent of disintegration when she said it was as if "my heart was being Healing Within Families 116 ripped out, and stomped on, and thrown away." Their ability to think things through as they had before the death no longer seemed to work; in fact, many survivors reported that things seemed hopeless and meaningless. In keeping with the characteristic chaos experienced by many, Rae commented, "everything has been uprooted, down to your very being. . . . Everything has to start all over again."

A few survivors questioned if, in fact, they were "going crazy." Jan recalled, "I looked around and everyone else seemed fine, so I thought "Why do I feel like I'm going crazy?" Rae expressed a similar view: "I was living on the edge. . . . I didn't understand what was happening to me ... at one point I thought that I was over the edge." Rae decided to access the literature in the hope of finding validation for her feelings. However, she was disappointed because "the books would just gloss over the feeling of 'going crazy'. . . the books just reinforced my feelings."

Finally, altered thinking patterns were characterized by post-death ambivalence toward the deceased youth because he had taken his own life. Ann vacillated between wanting and not wanting her deceased brother to be at peace in death: "It's pretty hard to wish him peace when he killed himself." Post-death ambivalence was sometimes altered by new perspectives of the deceased's pre-death situation. Looking through family photo albums was frequently the source of new perceptions. In a post-suicide review of family photo albums, survivors in three families detected sad expressions on the faces of their now deceased loved ones. One participant noted that her brother was isolated from other family members in a family photo. Discoveries such as this haunted survivors over the long term. Almost three years post-suicide, Jim gauged his healing by the contentment he experienced when viewing family photo albums: "I can't go through the photo albums—if I can ever get to the point where I can go through those with a degree of happiness and satisfaction and pleasure .. . then I would be healing."

Survivors often possessed remarkable insight regarding their altered thinking which then permitted them to take action. Brenda took a leave of absence from work for a year following the suicide because of her inability to concentrate within the work environment. Liz was concerned Healing Within Families 117 about her ability to make effective decisions and consequently postponed her decision to move for a year following the suicide.

Contemplating Own Suicide

Suffering sometimes overwhelmed survivors and they saw their own suicide as a means of resolving this inner tension. Surviving parents in two families questioned the purpose of living without their loved ones and perceived their own suicide as a way of being reunited with them.

Jan agonizingly recalled her thoughts on the night of her son's suicide:

I know that I thought about taking my own life the night that Paul died, and I think that the

thought was maybe there for a minute or two. And all that it was, was that I thought if I

could die, then I could be with him and I could find out why he did this.

Lana, a sibling, elaborated on her thoughts about the often tenuous dance between life and death:

There is a pain that runs through the core of one's being, a pain that won't disappear. The

pain nourishes a fantasy that suicide is the only option to end it. Wounded, I can now

appreciate how delicate, how fine the line is between life and death. I can fully appreciate

how suicide is a choice taken by those who, in many ways, succumb to the pain and

loneliness of personal suffering. For now, I have chosen life. But some days, I will

confess, it's a struggle to follow this decision. Again, I can appreciate why it may appear

just out of the blue that someone kills himself. Because the dance between life and death is

an ongoing struggle, it's so exhausting, and contributes to a loss of hope. ... When will

it ever end? It is the angst of this personal predicament.

Rose reported that at the time of her son's suicide, she was contemplating suicide herself and was angry when she discovered that her son had succeeded before she was able to do so:

Why couldn't it have been me? ... At first I just wanted to die and then I was angry that

he did it first. I wished that I had done it first because he would have known what it did to

everybody else and he wouldn't have done it.

In the aftermath of suicide, Rose discovered the far-reaching impact that her son's suicide had on others. She also became aware of the pain felt by both immediate and extended family Healing Within Families 118 members. As a result, she made several significant changes that impacted greatly on herself and her family. Her beliefs and values about life shifted, as did her priorities. Her family became her top priority. Rose made a concerted effort to share her thoughts and feelings with other family members. In addition, she began to do the things that brought her peace of mind. Periodically,

Rose lovingly cared for animals on the family farm, a comforting activity that brought peace to her as she remembered the "good times" shared with her son prior to his death. This meaningful activity enabled her to clarify her thinking and gain a fresh perspective. In addition to experiencing chaotic thinking, survivors also functioned on automatic pilot.

Functioning Pattern (Autopiloting)

While Cocooning, the survivors' pattern of functioning was characterized by autopiloting.

Following youth suicide, survivors characteristically functioned in a manner that required the least amount of effort: "For a long, long time, I just used automatic pilot." Autopiloting, an element in this theory, addresses several aspects of daily functioning including: decreased functioning, living with the physical absence of the deceased, experiencing altered health status, using addictive substances, and engaging in risky lifestyle behavior.

Decreased Functioning

Immediately following the suicide, survivors were exhausted much of the time. For most survivors, managing day-to-day activities was a challenge in and of itself. Commonly, survivors functioned in "survival mode, "and often "in slow motion" for a period of time following the suicide. Liz described her functional status this way: "And so I did the bare necessities, just getting us what we needed.... I went into the 'doing what it took' mode."

Decreased energy levels resulted in survivors being unable to function in their usual way in relation to preparing food, performing household chores, and socializing: "It's like your system shuts down and you're on automatic pilot for a while. You go through the motions, you go to work, and you go to school, but you're just on the fringe of things." Linda commented that she had "nothing left to give" because it took all her energy "just to survive." Participants recognized Healing Within Families 119 they needed more rest and sleep; however, sleep failed to restore their previous level of functioning. Emotional pain and exhaustion robbed survivors of the "good life." They missed out on opportunities to enjoy the little things in life and activities once enthusiastically pursued. Their former spontaneity and enthusiasm for life were gone.

Living with Physical Absence

Living with the physical absence of the deceased youth presented an ongoing challenge to survivors. Survivors had to continue living without their loved one and so they quickly slipped into autopiloting as a way of surviving their loss. They longed to see, touch, hold, and love their loved one. Survivors developed a number of comforting strategies that allowed them to function on autopilot while enabling them to deal with the physical absence of the deceased youth. Carmen wore one of her brother's favorite shirts as a way of maintaining closeness while Margaret slept in her deceased son's bed. Some families exhibited pictures and other mementos in their homes; others refrained from such practice. Jim, the father of a deceased youth, commented:

In my folks' house, they've got a large picture of Jason, right, and it's up high and proud

in their living room. It's there right front and center of all their pictures, and that's the way

their living room is and always will be. And like his achievement awards, they have his

achievement awards right there in the kitchen for everybody to see; they have never been

removed, I think probably from grade nine. So, those are good but I just can't bring

myself to do that in our house.

Tanya visualized her brother on a daily basis: "And I talked to Tim every night. I would close my eyes and make him come into the room ... I could feel his touch and see his smile." Jan frequently thought about how her son would look if he was still alive: "Well, there's still every day that I live that I think of him. You know, what would he look like now?" The thought of being unable to visualize the deceased was terrifying for a few survivors. Ed recollected, "I close my eyes and try to remember how he looks—I try but I can't, and that's scary for me. ... It's like I've lost him." Healing Within Families 120

Survivors consistently commented on the emptiness left by the physical absence of the deceased loved one and its impact on the family. This void was especially noticeable during certain times of the day such as mealtime and bedtime, and on certain dates such as birthdays and suicide anniversaries, as well as on holidays such as Christmas, Father's Day, and Mother's Day.

Using Addictive Substances

More than anything, survivors wanted to be spared from their pain and suffering; it seemed less demanding to take the easy way out. In an attempt to escape the pain of their loss, some survivors autopiloted by using addictive substances. A few began using alcohol and drugs while others increased their use of these addictive substances. For example, Carmen began drinking excessively following the death of her fiance: "The first month I went on a drinking binge, and I did not want my son anymore. ... I drank a lot after he [fiance] died, just trying so that it didn't hurt." While the alcohol temporarily numbed the emotional pain, the addiction created other problems such as relationship and parenting difficulties. Carmen's drinking continued for approximately one year. She then realized she had a problem and sought counseling with positive results. In another case, in response to the loss of his son, Terry increased his consumption of alcohol, a situation still present at the time of data collection. In yet another family with two surviving sons, one son began using street drugs shortly after the death of his brother, a situation uncovered just prior to the interview.

Taking Risks

In a few instances, the survivors' pattern of functioning included engaging in risky lifestyle behavior. Jordan, whose brother (and closest friend) ended his life, actively sought physical pain as a substitute for staving off emotional pain. Jordan's father explained:

Like he says to me, "Well it's just like you gave up. After Jason died, anything I do is fine

anymore." Now everything seems like trivia to us. This last weekend, he rolled our car,

like it rolled in the air five times, our new car, five times and it's just totaled and he got out

of it, he walked out of it, his shoulder is broke in two places. But to me, like I think that Healing Within Families 121

would be an awful big thing, and now it's just a matter of course. And afterwards, he's

got physical problems, he broke his leg soon after because he didn't take care of himself,

and he's accident prone. . .. And then he burned himself, he jumped on top of the

burning camp stove. ... He stood there and it caved in and his legs burned through—

third degree bums, and it's all carved out, and he was in the hospital for some time. And

like with him physical pain is nothing. ... He wants physical pain, he says "it takes away

the mental and emotional pain." You know, it's the emotional pain that he can't take.

Consumed by grief, Jordan's parents were barely able to deal with Jason's death. Although aware of the situation and concerned for the welfare of their surviving son, they were initially unable to take action to rectify the situation. Eventually, with the support of his parents and others, Jordan sought professional help. In addition, survivors functioned on autopilot because their energy was consumed by the trauma.

Energy Pattern (Consuming)

Within Cocooning survivors' energy was consumedby surviving the trauma and focusing on the "why question." Their energy reserves were depleted and life felt like "a chore." Ed, a father, spoke about the consuming nature of the suicide event: "It takes all the power out of the batteries and you are only operating on dim."

Surviving the Trauma

Following news of the tragedy, survivors experienced an immediate and dramatic decrease in the amount of energy available for living—strength, stamina, and zest for living were drastically diminished. Any available energy was directed toward "surviving" the trauma: "I never realized, we had to start looking at ways of surviving. . . . The end result is survival." Marie commented on the extent of her exhaustion following her son's death:

I used to talk about how tired I was, where at the end of half a day of teaching, I would

stand by the door and I would say if the door hadn't been there to balance me, I would

have gone like a fig leaf on the ground. After driving home one time, I didn't know if I Healing Within Families 122

was going to make it home because it was taking so much energy. I was so tired. I came

in and I made it to the bedroom and laid there for three hours.

Many survivors had little energy for concentration on things that they previously managed easily. In the beginning, survivors were unable to find ways of replenishing energy. They experienced strain and had little energy for dealing with day-to-day family concerns. Jan spoke of the tremendous amount of energy required for processing intense emotions: "Hate takes over . . . it makes you weak. ... I had no energy." Compounding this, survivors spoke about a pervading sense of anxiety and fear as they now realized that, "within the blink of an eye," all their hopes and dreams for the future were irretrievably lost. These feelings also were energy-draining.

Initially, in response to feeling "swallowed up" or "consumed" by the trauma, survivors were unable to find ways of replenishing energy. They became very selective in how they expended their limited energy supply. They withdrew from others and focused their finite energy reserves inward in order to survive: "I just changed my focus from other people to me. . . . Gee, I barely had enough energy to take care of myself so I knew that was what I needed to do." As energy slowly returned, survivors were then able to direct some energy toward attending to other family members.

Asking Why

Elusive attempts to find an answer to the pivotal "why question" consumed much of survivors' energy. Respondents in over half the families commented that a variety of factors may have influenced the youth's decision to end his life. These factors included: relationship difficulties, especially those that involved disappointment in a romantic relationship; undiagnosed depression; use of street drugs; infractions with the law; and, undisclosed homosexuality. Despite speculating on these possible explanations, survivors were initially haunted by the "why question." They spent every waking moment searching for a definitive answer to this perplexing question. For some, pursuing an answer to this confounding question became their raison d'etre.

Jill, a sibling, commented, "When it is a suicide...it's a big question mark." Uncomfortable with such uncertainty, most survivors needed to privately revisit this question over and over again. In Healing Within Families 123

particular, they needed to relive again and again the time just prior to the suicide, looking for clues

that might uncover some motive for the suicide. Despite the energy it required, asking the "why

question" was critical. Rae, an adult sibling, commented that it was only by asking this question

that she was able to find out that there is no answer to it.

Finding Meaning/Exploring Spirituality Pattern (Awakening)

Within the Cocooning theme participants' spiritual experiences were characterized by

awakening to life and its meaning. This life reassessment included: waking up to life, doubting

self and experience, and visiting the dark side of life.

Waking Up to Life

Youth suicide often provided a "wake up call" that served as a stark reminder of needed

change. For many, what worked and made sense in the past no longer seemed to fit with life in

the present. The suicide awakened many survivors to aspects of life previously overlooked. Rae,

a sibling, commented: "It [the suicide] was the kick that I needed to make some important changes

in my life." Martin, a father, explained his experience of waking up:

Maybe it took something like this to wake me up to life. You know, like I was going

around like I was still a young teenager myself. A lot of times I would have a beer with the

boys and stuff like that. I don't know if I was drinking that much with them. I may have

had a beer with them around Christmas if they would have been there or something like

that, but I don't think that I was drinking like I used to. But it certainly made me grow up

a lot, I'll tell you that. I don't know what triggered it. His death made me look at life a lot

differently.

Survivors often developed a new appreciation for both life and death. Characteristically, they began to pay more attention to "what's really important in life." For most, this involved focusing more on "family." Some survivors garnered profound "gems of wisdom" for dealing

with life's uncertainties. Others gained an understanding of the complexity and ambiguity often Healing Within Families 124 associated with living and loving. They also began to accept the coexistence of both pain and joy that is associated with all major life events, including birth and death.

Survivors became introspective and frequently turned inward to seek answers to their many questions. Moreover, they spent a great deal of time assessing self, family, and the situation: "I did a lot of self-analysis, a lot of very deep, deep thought processes." Another survivor said, "I have taken a little piece of it out at a time and looked around and investigated it— really doing an analysis of the different elements of it." Survivors frequently pondered many of life's difficult questions such as: Who am I without the deceased? When will the pain lessen?

How do I carry on with life without the deceased? What next? How has each family member been affected by the suicide? and, Where do I go from here?

Doubting Oneself and Experience

Soon after the loss, survivors not only questioned their beliefs but also doubted themselves, sometimes questioning their inability to have prevented the suicide: "What could I have done so that he would still be alive?" Expectations of self were high, and sometimes unrealistic: "I should have known." In one situation, a parent expressed guilt and self-doubt:

"Was I a good enough parent?" Another parent lamented, "Love was not enough—if it was, he would still be alive." When expressing such distress, most survivors doubted that any meaning could be derived from the tragedy. Rather, they viewed the suicide as an experience that had to be endured, at great personal expense, for the sake of the family. Responding in frustration and exasperation, a father claimed that "suicide has no meaning whatsoever." Other survivors described suicide as "a waste;" as a death that "served no purpose;" or "didn't have to happen."

Visiting the Dark Side of Life

Most survivors who claimed to be moving toward healing journeyed to the dark side of life. This exploration involved taking a serious look at many issues, specifically: addressing one's own pain and suffering; getting in touch with one's sense of deep loneliness; looking at past Healing Within Families 125 unresolved issues within one's life; questioning one's relationships; and facing one's own mortality. Liz described her visit to the dark side of life this way:

You need to destroy yourself of inhibitions [learned from within society] that stop one

from experiencing one's dark side—from feeling the pain and the love. ... It involves

allowing or letting yourself go into those comers of your life and those areas and regions

that are dark, into those regions that are unexplored . . . that are scary, that are totally new,

and that you don't have any answers for at all. ... It's the fear that holds you back. . . .

You conquer and you go on.

Sometimes visiting the dark side of life involved survivors facing their limitations. Linda openly talked about her son's mental illness and the helplessness she sometimes felt in dealing with it.

When I look at it today, with the kind of knowledge available today, maybe I could have

done something. You've got to remember that he was diagnosed as schizophrenic. The

doctor who diagnosed him told us that he was in trouble. ... It used to bother him. I can

remember when he was in school and we went to pick him up—he would hear voices and

all of that kind of stuff. ... He would say, "I can't do this anymore." Now when I think

back, I don't think he knew how to deal with it, and neither did we . . . his mind was

messed up. . . . He used to get phone calls from girls and I used to tell him, "Don't tell

anybody about your sickness." You can't just say, "I'm a schizo," you know.

Summary

Youth suicide precipitated a major crisis for the members of the eleven families who participated in this research study. Survivors began their healing journey within the Cocooning theme of the healing process. In response to the harsh news, survivors characteristically felt vulnerable and in need of protection from society's harsh criticism for an individually determined period of time. As a result, they embarked upon a journey of descent into themselves. During this period of dormancy, they experienced time alone to sift and sort through the remains of their once calm and ordered lives. Survivors suffered immensely during this time. They struggled in terms Healing Within Families 126

of relating to both themselves and others. Survivors recognized the need to address their own

issues before they were in a position to relate to others effectively.

Dealing with the intense emotions evoked as a result of youth suicide was an especially

difficult but important aspect of the healing process. Initially, survivors experienced chaotic

thinking. In the face of tragedy, some individuals thought they were going crazy and others

contemplated their own suicide. An incredible amount of survivors' energy was consumed by the

trauma, leaving them with barely enough energy to manage their lives on a day-to-day basis. They

merely went though the motions of living by functioning on automatic pilot. Further compounding

matters, the haunting "why question" loomed larger than life itself for most survivors, and they

spent an inordinate amount of time pursing the answer to this elusive question. Invariably,

survivors ventured to the dark side of life. It was here that survivors grappled with and confronted

their unique issues. In doing so, they learned from their experiences and moved along on their journey toward wholeness. In Chapter Six, Centering, the second theme of the healing process is

addressed. The oracle promised the Asian Empire to the man who could untie the Gordian knot. Alexander the Great cut it with his sword then conquered Asia. But he later lost it because cutting the knot with his sword was not the true solution to the problem, but a resort to violence. If knots only have a magical power because they are made according to certain rules, they also have to be untied with patience and method. A Buddhist parable teaches that the process of becoming free comes down to untying the knots of existence. But knots which are tied in a certain order can only be untied in the reverse order. And to untie them means to find in oneself the «mystic knot» which represents spiritual life, wisdom and continual awakening. (Petzl, 1998, p. 12) Healing Within Families 127

CHAPTER SIX

CENTERING: JOURNEY OF GROWTH

Healing involves decisions that lead to actions that increase one's quality of life—a commitment to

life and living. (Mike, a father)

Centering, one of the three major concepts in this theory, is the second theme of the healing process that was developed from the study data. Preceded by a period of Cocooning, this portion of the healing process involves a journey of growth. I labeled this concept Centering because survivors consistently spoke of needing to find the "quiet place within," or an "inner calm focus" of attention that allowed them to find the "inner peace" they had once experienced, and knew to be at the core of their being. Centering allowed them to make sense of their experiences and to "come to terms" with their drastically altered circumstances. Participants in this study spoke of needing and wanting to find a new way of "being in the world."

In Centering, the 41 survivors who participated in this study emerged from an inner journey of descent and made a commitment to life and living. These survivors also became aware of the effects of the suicide on both themselves and their families, hence, they decided to let go of the negative impact of the suicide. Instinctively, survivors tapped into their innate strengths and coping capabilities. Survivors developed healthy ways of coping in the aftermath of youth suicide; they directed their energy toward developing strategies for self-healing. These healing strategies provided a means of honoring the life of the deceased youth and, at the same time, enabled the survivor to move on and succeed in life despite tragic circumstances. Centering was not about letting go of the memories still treasured, and the love still felt for the deceased youth. Rather, this growth journey provided an opportunity for survivors to re-define their lives while preserving the love still felt for the deceased youth.

The Centering theme addresses survivors' experiences in relationship to five Healing

Patterns (the elements within this theory). These healing patterns include: getting a grip, making Healing Within Families 128 decisions, re-engaging in activity, replenishing energy, and transforming in response to youth suicide.

Relating Pattern (Getting A Grip)

Within Centering, the Relating Pattern was characterized by survivors getting a grip on themselves and their lives. This "in vivo" code (Glaser, 1978, p. 70; Strauss. 1987. p. 33) described the survivors' need to take constructive action that enabled them to move on with their lives. In the words of one mother: "I have got to try and get a grip on my own life here. I've got to start doing the things that I need to do in order to get on with my life." Getting a grip encompassed two ideas that influenced the survivors' capacity to relate to others, specifically, confronting emotional experience and addressing unfinished business.

Confronting Emotional Experience

In an attempt to get a grip on their lives, survivors confronted their emotional reactions to their experiences with youth suicide. This involved acknowledging and confronting their emotions—a step beyond simply feeling them. Confronting emotional experience involved accepting that the death was, indeed, caused by suicide, as well as acknowledging and working through the range and intensity of their emotions. It also involved dealing with their emotional reactions to the fact that many anticipated life events such as graduation, marriage, and the birth of children were now impossible. As survivors confronted their emotions, they were also able to deal with their emotional attachment to the deceased youth's possessions. Eventually, they were able to decide what to do with these items. Although easier said than done, survivors were able to confront their emotional experience by putting this experience into perspective within the context of their entire lives. They did this by viewing their tragic circumstances as a 'significant life event,' rather than as the 'only happening' that defined their lives.

Most participants managed to gain much needed perspective without the assistance of others, while a few sought help from external resources. Jan, a mother, explained: "I sat down and started writing about all of the thoughts that were in my head ... the feelings that I was going Healing Within Families 129 through, the kinds of fears, the anxieties, the claustrophobia, all the things I was feeling in my mind and in my body .. . writing gave me an opportunity to express my feelings." Getting a grip on one's emotions often required being up front about them. Suzanne described her experience this way:

We deal with it all of the time, and you know what? I do, I deal with it every moment of

every day because then it doesn't sneak up on me, it doesn't haunt me, it doesn't hurt me

any more so than if I tried to push it aside. So, this is another healing mechanism, and

another way to cope is for me to just face it and deal with it all the time. It doesn't mean

that I indulge my thoughts in that area always, but it means that I don't try and hide it from

people.

Addressing Unfinished Business

Getting a grip also evoked, within some survivors, a reminder of unfinished business.

Two families had previous experiences with suicide. In both families, survivors acknowledged the need to address unfinished business so they could move on with life. Marie, for example, described how she dealt with the unfinished business that lingered long after her son's suicide:

It wasn't until the night of our granddaughter's birth, and we had to leave [the hospital]

through the emergency room. This was a year and two months after Kevin's death. It was

about 11 o'clock at night and we had to walk through there because the rest of the hospital

is locked up at 9 o'clock. As we walked down, it was like somebody stopped me, and I

said to my husband, "I need to go and fight some ghosts," and he said, "Right now?" and

I said, "Yes." I said to the nurse in the emergency room, "I need to go into that cubicle,"

and she said, "Why?" I said, "I need to fight some ghosts." She looked at me as if I was

crazy. And I said, "Our son died and he was in that cubicle." I said, "It's a place of fear

for me." She asked if we wanted to go into this little room, and I said, "No, I need to be in

that cubicle." She got a nurse, and I don't know what her name was, but she was _

wonderful, and she spent about 15 minutes with me. My husband had disappeared; I

didn't know where he was. Then she asked me if I wanted to spend some time alone. I Healing Within Families 130

made myself lay three-quarters of my body on the bed and I looked around the room and I

told the room that I needed to put it back into perspective, that the room was also a room

used for healing people, and that it was not only a room of death. And that my son had

laid in there and that he wasn't in there now, and so I needed to put it back into a room just

in the hospital. And so I did some crying, and I did some remembering, and I did some

killing of ghosts, and when I left it was with a much lighter feeling.

Thinking Pattern (Making Decisions)

Within Centering, the thinking pattern was characterized by survivors making decisions that enabled them to move forward in life. The name that I gave to this pattern is descriptive of its main cognitive function. Following a period of chaotic thinking, survivors eventually began to find order and meaning in terms of their experiences. This new perspective enabled survivors to make decisions that allowed them to let go of the negative impact of the suicide on themselves.

This thinking pattern was characterized by survivors making three key decisions that facilitated their journey toward healing.

Making Decisions

In the midst of chaos, survivors found themselves at a "critical juncture," or "crossroads," that necessitated self-study, self-analysis, and soul-searching. By taking time for reflection, making decisions, and maintaining a positive focus, survivors were able to find order within the chaos they felt. Survivors reported making three key decisions which facilitated their journey of growth. These decisions involved survivors deciding to validate their own reality as separate from that of the deceased youth, deciding to release themselves of the responsibility for the suicide, and deciding to allow healing to occur.

Validating Own Reality

The first decision involved survivors validating their own reality as separate from that of the deceased youth. This decision had a freeing impact on survivors. It involved survivors Healing Within Families 131 recognizing and accepting the idea that their emotions differed significantly from those of the deceased youth: "You discover within yourself that you're okay, that you yourself are not connected to this person's emotions.. .. There comes a definite division where you recognize that your feelings are yours and his were his." Expanding on this idea, Liz commented:

I was trying to feel what he felt. I was trying to go through what he did. You know, it was

just part of my caregiving to totally feel for him and everything. It was really interesting

how I had to separate his actions and behaviors from my reality, and not even go there

because there is no way that I could ever know what he felt or experienced.

Separating one's own reality from the reality of the deceased youth, especially in the moments preceding suicide, was of particular significance. Carmen realized that she would never be able to fully comprehend her brother's thoughts and feelings just prior to suicide and that realization helped to validate her reality: "there are some places where you cannot possibly go— those places are just beyond anything that we might imagine."

Releasing Responsibility for the Suicide

The second decision, closely related to the first, involved survivors releasing themselves of the responsibility for the suicide. This decision was facilitated by the recognition that responsibility for taking one's life always rests with the individual who takes such action. Jill commented, "It took me a long, long time to realize that I am not responsible for Michael's suicide, but now I know that." Martin remarked, "I believe [that] with youth suicide there is no one else responsible ... it is the person who chooses to commit suicide." Making this decision was more difficult for survivors who expressed ambivalence toward the deceased youth than those who spoke positively about the youth who ended his life.

Allowing Healing to Occur

The third decision involved survivors making a clear and conscious decision to allow healing to happen. This decision involved identifying oneself as a survivor, recognizing the Healing Within Families 132 importance of attitude, and choosing to find goodness within the world despite tragic circumstances. Liz, a significant other, reflected on her decision:

You survive or you die, and I am a survivor. I won't let this kill my children or myself.

We have too much to live for. There is too much goodness out there amidst all of the

trauma, and it's just your attitude and how you face things. And you can find the ugliness

if you look for it, but you can also find the goodness. ... I've decided to invest my

energy in healing.

Making the decision to allow healing to occur led survivors to focus their efforts on finding ways of maintaining healthy and loving connections with the deceased youth. As a major finding of this study, healing was most often initiated by survivors who were emotionally and spiritually close to the deceased youth prior to death.

Functioning Pattern (Re-Engaging)

Within the Centering theme, survivors eventually re-engaged in daily activities.

Immediately following the suicide, survivors initially functioned by autopiloting for an individually determined period of time. As reported by one survivor, it was like "everything came to a grinding halt." Consumed by their grief, survivors functioned by "going through the motions" in life. However, as time moved on, and as they dealt with other issues (e.g., emotional responses to their situation) related to the suicide, they perceived the need to once again re-engage in former life activities. Most survivors spoke of being "fully engaged" in living prior to the suicide. I named this pattern re-engaging because of its fit with the data that described survivors' attempts to re-gain their former functional capacity. Survivors re-engaged in daily functioning by increasing their activity level and participating in healing activities.

Increasing Activity Level

Most survivors experienced a gradual return of their previous level of involvement in day- to-day activities such as meal preparation, housework, and leisure activities. Participation in routine daily activities was, in fact, helpful: "the process of just getting up in the morning [helped Healing Within Families 133 me]." Functioning was also restored in a number of areas—usual sleeping patterns returned, interest in living intensified, level of social interaction increased, life goals became more clearly focused, and general levels of health and well-being improved. Commenting on the gradual nature of this process, Rose commented, "It's just one day at a time," while another mother remarked, "I can't sit here and be down on myself anymore. I've got to do something to make my son's life worth living. So just a day at a time—I found myself." Survivors' increased activity levels resulted in their overall sense of well-being. Their improved disposition allowed them to focus on healing themselves: "Once I was able to get involved, I felt so much better. Now it's time to focus a bit on myself—doing some of the things that I've always wanted to do. .. . My healing has to start somewhere."

Participating In Healing Activities

Re-engaging also entailed participating in healing activities. Without exception, survivors found that it was necessary to focus on healing themselves before attempting to help others.

Instinctively, survivors began listening to themselves in terms of deciding which health promoting actions to pursue. A variety of uniquely individual activities were deemed to be helpful and meaningful to survivors as they journeyed toward healing. These healing activities were undertaken within the private sphere and included: narrative and poetry writing, using ritual, praying, drawing, listening to music, reading, sculpting, using meditation and imagery (e.g., visualization), experiencing nature's beauty, making a treasure box of mementos, returning to traditional healing practices (e.g., dance, ceremony), burning an eternity candle, and spending time alone. Involvement in healing activities afforded survivors a healthy and creative means of expressing their love for the deceased youth, and provided the means for making the life of the deceased youth count.

The healing activity most frequently mentioned by survivors was writing. Marie explained:

For about 6 months I slept only 3-4 hours a night, and there were many times that I

wished that I had a switch to the head because the mind wouldn't stop. So, this one

particular night, about a month after Kevin's death, I sat down and started writing all of Healing Within Families 134

the thoughts that were in my head. For about the first six months, the journal entries are

directed at Kevin-—about the feelings that I was going through on those particular days,

the kinds of fears, the anxieties, the claustrophobia, all of the things that the body and the

mind were feeling and thinking. Since that day I have written well over 3,000 pages. What

I realized was that the writing gave me an opportunity to talk to myself about my feelings.

There were many times that I would write things down that my mind wasn't even aware

of. I realized that it was a very healing thing to do.

Chris, a sibling, also found writing helpful: "I do a lot of writing, I have 300 poems, that's my way, it's my diary type thing. ... That's the way I deal with all of this." Ann, a significant other, commented that reading enabled her to gain valuable insights: "I read books ... just things that you could do to help people and I would just do it to help myself."

Survivors used creative and individualized means of expressing themselves. Within one family, three sisters who survived the suicide of their brother all sought different paths toward healing. The oldest sister became involved in a grief recovery program which led to a new understanding of her loss, as well as new opportunities for personal growth. The middle sister, motivated and inspired by her older sister, began her own journey of personal growth. She participated in a personal development program for women. Diagnosed with schizophrenia, the youngest sister developed her creative and artistic abilities as an expression of love for her deceased brother. These unique healing strategies helped to strengthen and fortify relationships between family members that, in turn, strengthened the family as a unit.

Another healing activity that was particularly helpful for many survivors was the use of ritual. Using rituals allowed survivors to periodically and purposefully remember their deceased loved ones. Rae developed a meaningful ritual which she practiced on an annual basis.

So every year on his birthday, which is July 7,1 bake his favorite cake and I have one or

two friends over, and usually, and they're different people each year. There would be one

or two people, no more than that, who have played a really significant role in my life, in

my self-development in the year previous. And we don't sit around and cry and talk about

death and talk about suicide or anything like that, we just have this cake in honor of Tyler. Healing Within Families 135

His favorite cake was Johnny cake with maple syrup on it... . It's the only time of year

we ever have Johnny cake which makes it even more significant.

In another case, Jan, a mother, gathered a number of mementos that reminded her of her deceased son and placed them in a special box. In private, and at a time of her choosing, she would savor the memory of these treasures. Motivated by her son's suicide, Rose wrote about the value and meaning of mementos for those left behind. She valued certain mementos because of the fond memories they stirred within her. In a pensive moment she wrote in her journal:

The meaning of some things cannot be imagined, let alone described for another. Here is

my attempt to describe the meaning of two objects which I take with me everywhere. . . .

The objects are functional, thank goodness. One is a gold pendant watch my husband

bought me in Switzerland. It opens, so it is like a locket. The other is a silver pendant

watch my sister bought me in Prince Edward Island. It also opens like a locket. On the day

of my son's funeral, I wore this watch. It has a black heart on the front, and it seemed

fitting. Not only was black my son's favorite color, but black is what my heart was that

day—the black of physics: the absence of all light. Every time I slip that locket over my

head, I am reminded of that day, and reminded that I cannot take anything for granted in

this life. During the week before the funeral, many of us had gone through our family

pictures, reviewing Jason's life. I had tried to pick out a picture of him to use in my locket

watches, so that I could carry his image with me always. How does one pick a picture that

will sum up the essence of a person? It is like Descartes' and Husserl's elusive search for

the foundation or the essence of experience. There was no one picture that could represent

Jason to me. Trying to choose one seemed to be making him less than he was. I choose to

remember all of Jason's life, from the moment we made eye contact in the delivery room,

to the moment I asked his spirit not to leave us, as he lay bleeding on his bedroom floor.

Jason is all of it—the special moments. ... Jason bringing me a beautiful picture of a

flower or rainbow, with such pride in his demeanor; Jason presenting me with a rose on

Mother's Day, just because; Jason at the piano, his long elegant fingers moving nimbly

across the keys; Jason dressed up to perform KISS in an airband concert; Jason on his Healing Within Families 136

horse, Silver, helping to herd in the cattle;... it never ends, and one cannot choose one

memory.

And so I cannot chose to put any picture of Jason in these lockets. Instead, every time I

open them, I picture Jason, either in one tender moment of time, or in his entirety. Within

these locket watches, close to my heart, I carry more than Jason's essence, I carry what he

meant to me. I carry my memories of him. I carry an undying love, and the hope of a

future rejoining.

My attempt to describe this meaning seems so flat and narrow when put into words. The

meaning of mementos cannot be put into words. It is almost a violation to do so. . . . The

memories, the feelings, the hopes, the dreams, the meanings that are inherent in simple

things cannot be envisioned.

Treasured by survivors, mementos were often the only tangible evidence of the previous existence of their beloved youth. Moreover, mementos held unique meaning for each survivor. Mementos were imprinted with precious memories of the past—a past that must be accounted for in the new life that unfolds. Unanimously, survivors agreed that treasuring mementos was a healthy healing activity.

Energizing Pattern (Replenishing)

Within Centering, the energizing pattern was characterized by survivors focusing on ways of replenishing their energy. Soon after hearing about the tragedy, survivors felt that their energy had been consumed. Later, as survivors re-engaged in life by getting a grip on themselves and making decisions, their energy became replenished. In essence, energy was replenished by taking action. The term replenishing is an "in-vivo" code (Glaser, 1978, p. 70; Strauss, 1987, p. 33) used to describe the resurgence of energy experienced by survivors during their journey of personal growth. Energy was replenished^ resolving the "why question," and finding helpful and healthy ways of releasing energy. Healing Within Families 137

Resolving the Why Question

In Cocooning, survivors focused on asking "why" their loved ones had to die and "why" it happened? Survivors searched aimlessly for an answer to this perplexing question. In

Centering, this focus shifted to resolving the "why question." This did not mean that survivors found an answer to the question; rather, they realized that the "why question" was unanswerable and so they consciously set it aside: Realizing that no answer would suffice, Linda said, "I put it

[the why question] into a drawer and closed it. . . . In my mind I locked up the search for it."

Putting the question aside served to release tension and thereby replenished survivors' energy levels. Similarly, getting a grip, making decisions, and re-engaging in daily activities also aided in tension release and replenished energy levels.

Releasing Energy

Survivors maintained that energy was embodied within their pain. When they expressed their pain, negative energy was released and subsequently replenished with positive energy.

Without exception, survivors found ways of releasing their pain that sometimes threatened to engulf them. Several participants mentioned the beneficial effects of allowing others to help them deal with their pain. One individual said, "I allowed people to do things for me when I didn't have the strength to do them for myself. I allowed myself to be surrounded by people to help ease the pain. ... I could feel my energy being replenished." In addition, giving oneself permission to ask any, and all, questions related to the suicide helped to replenish energy.

A variety of activities helped survivors in releasing their energy. Some individuals reported that establishing self-trust and trust in God enabled them to release energy. For others, energy was released through vocal expression: for example, through the use of singing and sometimes chanting. Survivors also commented that healing activities such as talking, reading, writing, and sculpting helped them to release energy.

Several respondents claimed that the ability of one family member to share feelings about the loss had a positive effect on other family members' level of energy. For some family members, energy was released by collectively sharing their memories about the deceased. Other Healing Within Families 138 family members reported that their involvement in rituals that honored the deceased, performed individually or collectively, helped release energy in a positive way. A sibling said, "Your energies are really important, where you are placing them. So the rituals have really helped ... I know that once a year I will honor Tyler." A few participants mentioned that the appropriate use of humor was a positive way of releasing and replenishing energy. Some family members commented on the benefits of physical contact (e.g., hugging) and its enhancing effect on one's level of energy. Chris commented that her energy was released and replenished as she cried while she was being held: "I just needed to be held .. . my friend just held me for hours and I cried and cried." Marie spoke about how her energy was released and replenished during her therapy sessions as she cried in the arms of her therapist: "I probably cried the deep tears for about an hour in her arms to the point where I almost fell asleep from exhaustion I just felt such a release."

Finding Meaning/Exploring Spirituality Pattern (Transforming)

Within Centering, the Finding Meaning/Exploring Spirituality Pattern was characterized by survivors transforming as a result of their experiences. In contrast to the awakening experience in

Cocooning, within Centering, survivors indicated they were on an ongoing "spiritual quest" or

"pilgrimage." Survivors became transformed by forgiving themselves and the deceased loved one, and finding meaning in their experiences following youth suicide.

Forgiving Self and the Deceased Youth

Transforming entailed survivors learning to forgive themselves and others for not being able to intervene to prevent the suicide. Meg explained, "I don't want to go back to what if? What if? What if I had only done this? What if they had done that?" They also learned to forgive the deceased loved one for taking his own life. Marie explained the benefit of forgiveness. In her journal, she wrote:

On [date], I gave Kevin the last gift that I could give him as his mother—I gave him

permission to go. I had known that Kevin was okay when I received the rose at his Healing Within Families 139

funeral. For me, those two years since that day had been spent on healing me and I felt

that the day had come to forgive my son, to tell him how loved he still was and to let him

know that I was okay. It was a process that I sensed was necessary for me. In letting go

of Kevin, I was also releasing me. In my mind, I made my love for Kevin into a cloak, I

wrapped it around him, expressed my love for him, told him that he would always be

carried around in a part of my heart, hugged him tightly, told him that I was okay and that

he could leave me. As I visualized this, I was gripped by intense tears because of the pain

within me and I knew this good-bye was different—this time it was done when I was

ready. The exhaustion from those tears left me almost asleep but with a more calming

effect inside.

By forgiving both herself and her son, Marie became positively transformed. This action released her of an unhealthy bondage and allowed her to assume responsibility for her own health.

Through forgiveness, she maintained her love for her son, and at the same time, reclaimed her own life. In contrast, Terry, a father, adamantly asserted, "I will never forgive Lome [deceased youth] and the pain he has caused our family. . . . I'll never get over this." By withholding forgiveness, Terry became negatively transformed and his life remained on hold. He dealt with his pain through the excessive consumption of alcohol. Unfortunately, this behavior proved costly as his wife, Meg, was contemplating separation at the time of data collection.

Finding Meaning in Experience

An integral component of the finding meaning/exploring spirituality healing pattern in

Centering was finding meaning in relation to the struggling and suffering endured as a result of youth suicide. Rose described her experience this way:

The themes that I saw in all of this were struggling and suffering. Life involves struggling

and suffering, but that is what gives life meaning. You never want everything resolved,

because if everything is hunky-dory, then what's life all about? It's the bad and the good

together that make you appreciate. You see, I never appreciated things as much as I do

now before we lost Jason. Now there's little things that I appreciate, and I stop to relish Healing Within Families 140

the moment. It's almost like I stop to relish it for Jason too. It's like he's not here for this,

but in another way he is here somewhere.

About half of the survivors who participated in this study found meaning by believing that death occurs for a reason, including death due to suicide. Rae reflected on her experience: "It's an internal journey. ... I have come to understand that it happened for a reason. ... I still don't know why. One day I will. . . and I'll have to wait till then." Some survivors reached a point where they were comfortable despite not being able to fully comprehend some things about suicide. They found meaning in their faith. Others found meaning in suffering. Marie consciously decided to reframe the meaning of her experience:

My knee was really bothering me, and so Mike [husband] was massaging it on the bed.

After a while, one of Kevin's [deceased youth] songs from the Crash Test Dummies

[deceased youth's favorite band] came on [the radio]. All of a sudden, I could just feel the

waves starting to come—I started with the real heavy crying. But now, when I am going

into one of those real deep pains, I tell myself that those are the moments when Kevin is

with me. That's when he is closest. So instead of only being in the pain and totally

missing him, instead, I visualize Kevin being beside me in those moments.

Many survivors expressed a renewed belief in a supreme being or a higher power.

Commonly survivors felt "as if someone was watching over" them. They felt comforted by the presence of this being. This experience helped some survivors to know that love goes beyond the grave. Linda identified with this view: "In my heart I think I have the key.... I know that he knows that I love him."

Survivors frequently found meaning in their new understanding about spiritual matters.

For instance, Rose said:

I often think that he's like our guardian angel, he's around. . . . There is a spirituality that

has come with the loss of our son. Like I wouldn't necessarily say that it's a religion, like

I'd say that I'm searching for the religion that I can fit with the spirituality that has come to

me. . . . Before I went to church and I believed in Christianity and I still do, but now it's

broadened and I believe in a lot more things than just the restrictive part of Christianity. Healing Within Families 141

I've come to believe in reincarnation and in souls . . . extending beyond lives ... soul

mates . . . that kind of thing . . . maybe some kinds of messages perhaps from the grave.

Mike, the father of a 14-year-old youth who took his life, spoke about his spiritual views this way:

We are not humans in this world to have a spiritual existence, but spirits in this world to

have a human existence . . . We come for the human experience, whatever it is going to

be. The only things that we are going to be able to take with us are: the feelings .. . our

spirits . . . the experience. . . . Maybe there is a here and before. And maybe we get to

pick the study of our choice.

Marie, Mike's wife, pondered the meaning of her experience:

I don't know if you have ever read Proud Spirit. It's a book by Rosemary Elvia, and she

was doing a course one time. She was asking people if they could give someone a gift for

Christmas—What would you give? Somebody said, you know, "Peace and joy and

happiness." Then this older person in the group said, "I would give people pain."

Everybody sort of looked at her and she said, "I could never give a greater gift than to give

people pain because it is through pain that people experience the greatest growth. When

people are happy and relaxed and whatever, people don't grow." . . . When I look back,

my greatest growth has been in dealing with my son's suicide.

Summary

Following the Cocooning experience, survivors embarked on another aspect of their journey toward wholeness. Survivors experienced Centering, characterized by the survivors' journey of growth. With the realization of their forever changed circumstances behind them, survivors found themselves in a position of needing to press on with their own lives. Toward this end, they needed to attend to certain aspects of their experiences with youth suicide including confronting their emotions and, in some cases, addressing unfinished business.

Of significance, survivors made three key decisions, the most important being the decision to move toward healing. Taking such action positively changed the course of their lives. They Healing Within Families 142 began re-engaging in activities of daily living and individually-focused healing activities.

Involvement in healing activities served a useful purpose in that they served as the means by which survivors gave meaning to their experiences. These activities were symbolic of the relationship between the survivor and the deceased youth, and the meaning survivors attributed to their experiences with youth suicide.

During Centering survivors replenished their energy stores by resolving the "why question." Essentially, survivors realized that they could not alter the fact that a family youth had, in fact, ended his life; instead, they decided to direct their finite supply of energy toward those aspects of their experiences that could be changed. Moreover, survivors often experienced a spiritual transformation which occurred as a result of forgiving themselves and the deceased youth, and finding meaning in relation to their experiences with youth suicide. While the Centering experience focused on the individual survivor, this focus expands to include others in the third and last theme of the healing process, Connecting, discussed in the next chapter. In Ancient Egypt, the knot symbolized life. The knot of Isis that can often be found in the characters' hands or at their belts, signified immortality. But if the knotted rope symbolized individuality, this is to say the stream of life giving birth to a person by turning back on itself and thus becoming a whirlpool, the knot of Isis echoed the links which connected the individual to a mortal life, and which must be untied to gain immortality. (Petzl, 1998, p. 28) Healing Within Families 143

CHAPTER SEVEN

CONNECTING: JOURNEY OF TRANSCENDENCE

Healing is about not having the answers. It involves allowing oneself to feel, to trust, to risk—

something not always taught in society. (Sara, a mother).

In Chapters Five and Six, the first two themes of the healing process, Cocooning and

Centering, were described. Cocooning focused on survivors' experiences of fragmentation and descent within self following youth suicide. Centering addressed their journey of personal growth in response to the trauma they endured. In this chapter, Connecting, the third major concept in this theory, and the final theme of the healing process, is explained. Connecting is concerned with survivors once again bonding with others and fully participating in life despite the suicide of a family youth.

Transformed by their experiences with youth suicide, within Connecting, survivors experienced a qualitatively different "way of being in the world." Most survivors transcended their tragic circumstances by reaching out to others, especially those within the family unit, in more meaningful ways. Survivors felt compelled to use their misfortune to help others in similar circumstances and, ultimately, to "make a difference" in the world. Specifically, they began to connect with others and with life once again by speaking about suicide and its impact on the family within the public arena. During their journey of transcendence, survivors orchestrated their lives by opening themselves to new possibilities for their own success in life. Their purpose in life came into clearer focus, as did the changes that were needed to accomplish their goals. The

Connecting theme emerged from the data as an "in vivo code" (Glaser, 1978, p. 70; Strauss,

1987, p. 33) representing 41 survivors' experiences within five healing patterns, specifically: reaching out, learning, orchestrating life, channeling, and transcending (refer to Chapter Four -

Table 4-3: Individual Healing Template). . Healing Within Families 144

Relating Pattern (Reaching Out)

Within the major concept of Connecting, the relating pattern is characterized by survivors reaching out to others and connecting with life once again, albeit from a new vantage point. This healing pattern was named according to the terminology that survivors used; they frequently spoke about "reaching out" to others. Within this healing pattern, reaching out involves three concepts, specifically: seeking help; linking with others; and facilitating the healing of others.

Seeking Help

Reaching out was accomplished by seeking help. The importance of seeking help was recognized by most survivors: "You have just got to have people around you, you have got to get help . . . you need to find a way out of the pain." Fewer than half the survivors accessed professional help in the form of personal counseling: "Part of my healing from the trauma of

Ryan's suicide came through professional counseling." In one case, an entire family sought counseling. In another instance, an individual sought help six years after her brother's suicide. In yet another situation, concerned about the impact of the loss on herself and her family, Rose stated:

I was worried that we would start getting physical sicknesses because of the stress and

that we wouldn't be able to cope with our occupations. . . this was too difficult to handle

on our own. ... I started searching for someone who dealt with grief.

The benefits of seeking assistance were highly valued by those who took such action.

Marie confirmed this view: "She [social worker] made me feel like I had a second chance . . . she had faith in me.... It was really neat to know that somebody cared."

Nearly all survivors sought help by informal means. Survivors from five families joined grief support groups, usually within the first year following the suicide. Rae explained how attending a support group helped her to become more analytical about her situation:

The way I would describe it is you put it all up on the shelf somewhere. You take it and

you put it away. It doesn't mean that it's gone, it's just put away. And every once in a

while you're going through life and something happens and it all falls out on you. All the Healing Within Families 145

feelings, all the thoughts, all the good and the bad, everything. The intensity of it is there,

just the same as when it first happened. And I think that the difference for me now, since a

year ago when I started going to the support group, is that instead of waiting for it all to

fall out on me, I have taken a little piece of it out at a time and looked at it, and investigated

it, and turned it around to see the other side of it. I have really done an analysis of it.

Jim spoke about the positive effect that spending time with others in similar situations had for him and his family. He felt inspired by what others had done with their lives, and this helped him to feel that he was not so alone in his situation:

And then you sit there as a group and you say, "They are still here, they've survived it,

they're still here." Then I can say that I can go on too. . . . They talk about what they have

developed as a hobby or are trying to do to find enjoyment in life. They're striving too so

that they can develop a degree of,happiness. ... It's always the idea that if other people

can do it, then we can too, and we're not the only ones that this has ever happened to.

For several survivors, their circle of friends expanded to include those facing similar circumstances. Indeed, establishing such friendships was a benefit of seeking help. Jim also spoke of a valuable relationship that developed through his participation in a support group:

There were about 35 people sitting there when I joined this group. I made contact with

Dan. His son, Lyle, committed suicide under almost the identical circumstances . .. with

Kurt Cobain's music just blasting away on the stereo. He's publicized so much. Dan

wanted to gain support for banning his music—this heavy metal or whatever it was. You

know, because that was so much of Jordan's [Jim's deceased son] life, he was so much

into music. I went to visit Dan and his wife and we had a good evening together and he

went right through showing me the room and exactly what happened. We spent a long

time together and then we went out to the Compassionate Friends group and spent some

time there too. And that helps I find.

Survivors felt "a real kinship" with others who had endured similar circumstances. The positive influence of these friendships had a beneficial snowball effect on survivors which, in Healing Within Families 146 turn, helped them reach out and link with others facing similar circumstances within the community.

Linking With Others

Reaching out was concerned with linking with others. In the aftermath of suicide, survivors felt vulnerable because they recognized the fragility of life. As a way of managing their vulnerability, survivors began reaching out and linking with others, both within the family unit and beyond. The realization that people need other people was sometimes striking. Kim said, "I realized ... it was a strength to be interdependent. . . . I just began reaching out." As survivors began reaching out to others, they were able to offer support to others, and in so doing, they also gained much needed support. Survivors realized that if they did not pull together in both deed and spirit within the family unit, the family too might dissolve.

In response to youth suicide, bonds within most families in this study were intensified and strengthened. Ann, a sibling, remarked, "I believe that this reconnection with my sister has, in some sense, happened as a result of Tyler's death." Sometimes family members linked with others by using their own special form of communication. For example, Liz, a former partner of one of the deceased individuals, used a single word as a cue to her children, symbolic of the need for family members to reach out to one another and stick together, especially during the tough times:

The story that we read is about this Chinese gentleman whose three sons were just fighting

and scrapping like crazy, and he said, "Bring me two chopsticks each," and they did. He

said, "Take a chopstick and snap that sucker." And they each did, you know, they're like

all tough and we can do this. [Then the father said to his sons,] "Now take three together

and try to break them." And there was no way that they could. And so the dad proceeded

to ultimately have them understand the fact that, "You know you guys, eventually if we

don't unify as a family in love and purpose, then we will break, we will not survive, but

together we can endure anything." And so all I have to do when things get tough is to say

"chopsticks," and then we know that... we will always be there for each other. Healing Within Families 147

Most families responded to their situation by pulling together. Survivors who moved toward healing found effective ways of dealing with their pain. They tended to view their pain as an indicator of needed change rather than as evidence to justify their victimization. To effectively deal with their pain, survivors began reaching out and sharing their pain with other family members.

This action strengthened familial relationships which, in turn, helped survivors to link with others external to the family.

Even within the safety of the family unit, survivors often found it easier to speak with other family members with whom they had previously established trusting relationships.

Previously unable to reveal the depth of her emotions, Rae was finally able to express her feelings to her ex-husband, a person with whom she felt a great deal of trust and comfort:

All of a sudden I had this feeling that I had to have a friend with me ... we [sibling

survivor and her ex-husband, also considered a family member] went down the hall to the

bedroom to talk alone and that's just when I finally let go.

Linking with other trusted family members enabled survivors to get in touch with their own fear and pain. Once survivors were able to deal with their fear and pain, they were able to experience the love they still felt for the deceased youth. Finding ways of reaching out and linking with others enabled survivors to process their feelings and, hence, to take actions which promoted their health and well-being.

Linking with others was established in a variety of ways. Sometimes this link was initiated by quietly "watching over" others and making sure that they remained free from harm. At other times, connection was supported by attentively listening to the other person: "We listen to one another more. Not just the words that are said, but the words that aren't said." For the most part, survivors who were able to talk about their emotions were able to deal with them. For example,

Liz maintained a connection with others by openly expressing her concerns:

You lash out at the people you love, that's a reality. So, I haven't allowed that to happen. I

say, "You know what. . . even though you [other family member] are hurting, we

[family] are all hurting. Let's work through this together, instead of trying to hurt each

other so that we drive each other apart. Healing Within Families 148

Sometimes linking with others was established through joint participation in meaningful activities. For example, as a way of maintaining their connection, two sisters met every Thursday evening at a local restaurant. During these visits, they nurtured one another by sharing their stories and offering love and support to one another.

Survivors influenced one another in powerful ways. One survivor spoke of the effect that family members have on one another: "I just saw a gradual process of healing for her [mother-in- law], and the more she healed, the better I felt." Although separated by a great distance, survivors in another family continued to influence one another. Following the suicide of her brother, Rae felt disconnected from her mother. She perceived that her mother had buried herself in her pain. In an attempt to reach out and rebuild her relationship with her mother, Rae wrote a letter in which she reflected on the impact of her brother's suicide:

It seems that Tyler's death has intensified each of our needs, but as our needs are so

different, this is threatening to drive us apart. Tyler accepted me unconditionally, and is

the only person I feel ever has. I buried myself in a relationship with Tom immediately

after Tyler's death. By focusing my emotions on that relationship, however unhealthy it

turned out to be, and by virtue of the fact that I live in [province] where Tyler was not part

of my daily activities, I was able to shelve all the issues and pretend everything was okay,

and in particular, that I was okay. With the breakdown of that relationship, I have been left

once again feeling like I am not significant to anyone. As you know, this resulted in a

series of short-term relationships, with the breakdown of each adding to the knowledge

that nobody really cares for Rae. Knowing the pain of that, I have tried to spare you from

it by making sure you understand how important you are to me, and perhaps I needed to

reaffirm to myself that I am important to you as well. I have been working on self-

development issues so I won't attach to a relationship for unhealthy reasons again. This

process I have been addressing for two years. Now has come the time to deal with the

issues directly relating to Tyler's death. This is the hard part, but I know I must do it. I am

reaching out now for the healing I need. Last night I attended my first suicide support Healing Within Families 149

group offered through the Samaritans Suicide Crisis Center. It is ten and a half years later

than it should be, but it has taken this long to get the courage.

Rae hoped that by writing the letter, her mother might begin to understand that others in the family also experienced a great deal of pain related to the suicide of her brother. Even more important, Rae anticipated that her mother might even begin to reach out to others by sharing her own story. At the time of the last interview with Rae, she felt that her relationship with her mother was slowly improving: "My mother who lives 3,000 miles away has been influenced and helped by what has happened to me."

In addition to linking with others who were living, finding healthy ways of connecting with the deceased youth was also an important part of the healing process. Sometimes this link with the deceased youth was maintained through the recall of precious memories. The following letter captured some vivid childhood memories that helped a surviving sibling maintain a connection with her deceased brother:

My dearest Tyler,

I know not where you are but sense that you will know what I write. It is so

tranquil here. There is a pond, frozen over, behind me. A rope swings from a tree branch,

reminiscent of summer days and laughter as children swing themselves out over the pond

to drop into its coolness.

A beaver dam to my right prevents the water from escaping and the pond from

disappearing. It reminds me of the dam we built as children so we could have a swimming

hole in the creek. I am facing down the stream below the pond. The trees are touching

overhead creating a tunnel of tranquillity. The water below the dam is not frozen over; it

slips past the rocks.

It's so peaceful Tyler. Somehow I know there is a peacefulness wherever you are

and perhaps that is why I have chosen this spot to come to and connect with you inside

myself.

I miss you terribly. Eleven years is such a long time to be without someone you

love, and yet it seems like yesterday [that] mom called me to tell me you were gone. Healing Within Families 150

I carry you with me in my heart, and hope someday to be with you once again.

Forever in our hearts

Rae

As survivors moved toward healing, they characteristically perceived themselves to have developed artistic and creative abilities. These talents enabled them to create meaning within their experiences.

Facilitating Others' Healing

Reaching out involved facilitating the healing of other family survivors. For example,

May, a sibling who had attempted suicide herself many years prior to her brother's completed suicide, mentioned that helping others was an important aspect of her healing:

Through my Crisis Line work, I met others who'd survived suicide, and my greater

awareness of the issue led to my participation in the first Survivors of Suicide Support

Group in [name of city]. That step was important to my healing as I was able to use my

understanding and insight to help others in crisis. I learned a lot about how great the

impact of suicide was on other people and the community as a whole. I no longer felt so

alone and I just knew I had to help others.

Within most families, an individual who was emotionally and spiritually close to the youth prior to the suicide often assumed responsibility for facilitating others' healing. These individuals facilitated others' healing by sharing their stories and encouraging others to do the same. In addition, they moved beyond their comfort zone by stepping into the public arena and sharing their stories with a broader audience. They anticipated that this action might facilitate dialogue about youth suicide and its impact on the family, and serve as an effective means of decreasing the stigma surrounding youth suicide. As survivors began reaching out, they also started learning about other facets of their healing journey. Healing Within Families 151

Thinking Pattern (Learning)

Within the major concept of Connecting, the thinking pattern is characterized by learning.

As an element in this theory, its name evolved from the terminology used by study participants.

Survivors frequently mentioned that in order to move on with their own lives, they needed to learn how to use their misfortune to help others. Liz commented:

It's incredible what you learn . . . there are so many things from this situation that I

learned to help me become a better person. . . . You just benefit so much by admitting that

you have faults, and going on from there, and trying to make your life, and the lives of

those you love, better and more profound in any way that you can.

Learning includes three ideas, specifically: thinking differently, developing creativity, and trusting intuition.

Thinking Differently

As a result of their experiences with youth suicide, survivors began to think differently.

Most survivors knew at a deep level that things could not have been different. They learned that they could not have prevented the suicide, and thinking that things could have been otherwise was unproductive. As a result of their new understanding, survivors discovered new meaning in relation to the suicide event. Such discovery allowed survivors to succeed in their own lives. Liz, a significant other, remarked "I dwell on the fact that there's a purpose [behind the suicide] and

I'm moving on in my thinking. ... I realize that I need to go back to school." Even though the suicide was a horrific experience, survivors began to think differently about themselves. One mother commented, "I just have had to learn to cut myself some slack in my life." Rose, another mother, stated, T am a stronger person, I can do more, I can think better, I can think differently."

This positive mode of thinking was characteristic of survivors who, in the post-suicide period, recovered well from their experiences with adversity. Survivors who began to think differently were in a position to address other issues related to youth suicide.

Survivors began to understand the many myths surrounding suicide that exist within society. Moreover, they realized their responsibility in helping to change these myths. For Healing Within Families 152 instance, they learned that "suicide can happen in any family." At least one individual within most families took on the responsibility of educating others about suicide. This commitment to suicide education ranged from sharing personal experiences to national public speaking. Individuals within two families became alarmed at the prevalence of youth suicide and decided to do something about it. They initiated formal action to educate the public about youth suicide and its impact on the family. One mother became an accomplished expert and speaker within the community in the field of youth suicide and its impact on the family, while a father developed a web site with the hope of initiating dialogue about youth suicide within the broader population.

Their dedication and commitment to educating others was well received within the community.

Health care professionals and other families within the community often consult with these individuals.

Survivors also began to think differently about their post-suicide experiences. Despite tragic circumstances, survivors learned much about unconditional love—the love that persists when all else vanishes. They learned not to deny their feelings; rather, they learned to fully embrace the multitude of feelings that dominated their experiences following youth suicide. In particular, Ann commented that she learned how to think differently. She learned how "to love from beyond the grave." She asserted that death by suicide does not alter the love she still feels for her deceased brother and this learning provided her with a sense of peace. Not only did survivors learn how to think differently, they also began developing their creative abilities.

Developing Creativity

Within this thinking pattern, survivors learned about themselves and their world by developing their creativity. By developing their creativity, survivors were able to focus on the balance they were striving to achieve. They knew they needed to keep their emotions in perspective, and creative endeavors provided a healthy means for them to express themselves. For example, Ann, the youngest surviving sibling in a family with five children, described the impact of suicide on her family. At 15-years of age, she wrote this poem about three days after her brother's suicide: Healing Within Families 153

Family Suicide

He took his life the other night, His family keeps asking, "Why?"

"His problems weren't that bad Why didn't he even try?"

His mother cries and asks the Lord, "He was good, loved and respected; Why him Lord, why?"

His father sits, not saying a word, Pretending it isn't true, he didn't die.

His brother hides his grief by joking all the time, His feeling shown only at home, he breaks down and cries.

His three older sisters, all far away; Came home together to help through those days.

The youngest child, the baby girl, She was so confused, what happened to her world?

Her brother is gone, her family is sad. What could she do to bring him back?

They miss him so, he was so great. Telling him now is too late.

He killed himself, that is true. But he killed his family too.

They all hurt so dreadfully much, Life is empty without his touch.

Just remember before you try, You won't just kill yourself, You'll commit family suicide.

Clare, Ann's sister, found that she was able express herself through sculpting—it was as if her emotions were poured into the figurines she created. In this same family, Rae, the oldest of the three sisters, also dealt with her emotions through poetry writing. She wrote:

Liquid Emotions

Swirling eddies of emotions

Fighting the undertow Healing Within Families 154

Water is a necessity of life

Yet.... if you let it engulf you

for too long a time

you will drown in it

So it is with emotions....

Riding the waves

the pleasures in life are so simple

Staying atop in the clean open air

is a balancing act achieved by only the most skilled

for to slip is to become engulfed by

the cool, tumultuous waters

So it is with emotions....

Lana, a sibling, felt that her creativity had blossomed as a result of being tested by misfortune: "I am extremely grateful for creativity. It comes to each of us in different forms, sometimes through such things as writing, music, movement, or art. To quote author Julia Cameron, creativity can

'metabolize injury into art.'" Creative expressions were as varied as individuals. Survivors unanimously agreed that developing their creative abilities enhanced their health and well-being and helped them derive meaning from their experiences. They also learned from their experiences by trusting their intuition.

Trusting Intuition

Within this thinking pattern, survivors continued their learning by trusting their intuition.

By trusting their intuition, family survivors developed a heightened sensitivity and responsiveness to "strange occurrences and coincidences" that enabled them to feel connected with the deceased Healing Within Families 155 youth. Survivors gained access to important information by trusting their intuition. They developed their intuition by paying attention to cues, analyzing their dreams, and being receptive to messages communicated from "beyond the grave." For instance, Rae spoke of a cue she received just prior to her brother's death:

I was on the dance floor and I had a premonition that something was terribly wrong. It's

really difficult to describe. Every sense that I had went completely blank, except my sense

to phone Tyler. I could hear it in my head, I could see it inside my head, not out in front of

me, inside my head. I thought I'd phone him in the morning and see what was happening.

But as it turned out, I had this experience 20 minutes before he died.

Rae also reported a strange occurrence during the first festive season following her brother's suicide:

So, I'm sitting there and I just reached out and touched one of the leaves on the wreath that

I had brought for Tyler and the whole room chilled, like cold and I just kind of like,

"Whoa," and I just looked around really nervous and I felt like he was there but I can't say

that I honestly felt a presence, but I felt like he was there. And it had gone cold, like that

was what actually happened, it had gone cold.

Questioning if it was all in her head, and yet knowing that it was not, Jan spoke about her experience with a strange occurrence, also involving temperature variation, following her son's suicide:

Shortly after he died, I can't remember how many days after, it might have been three or

four days or a week after. I was at home alone, and I come walking through our hall into

the dining room and it felt like, I don't know if this was all in my head or what. Anyway,

it felt like it got really cold right there in that one spot, and it scared me because I actually

turned around and looked and I said, "Jason." That was my first thought.

Survivors within five families reported meaningful and powerful dreams in which they received messages from their deceased loved ones. Survivors always described these dreams as being helpful and positive experiences. Frequently, these dreams revealed messages that let family survivors know that the deceased youth was in a safe place. This information always brought Healing Within Families 156 peace to family survivors. Within this thinking pattern, survivors who claimed to be moving toward healing spoke of the insights they gained from their dreams. During that same holiday season, Rae mentioned that her significant other had a dream which she considered to be more than coincidental:

And a little while later, Paul came out of the bedroom and he said, "Rae, the strangest

thing has just happened and I know that I shouldn't tell you." And I said, "Well, you have

to now, what happened?" He said, "I dreamt that I met your brother." And I went, "Okay,

describe him to me." And he describes him. No big deal—he's seen pictures of him

before, he knows what he looks like. So he described him wearing the clothes that we last

saw him alive wearing, that last time any of us saw him. Like when Mom described him to

me, what he looked like when he was leaving, the last time she saw him alive, which was

within a week before his death, is what Paul saw him wearing. And Paul hadn't met my

mother, he had never even spoken to my mother, and he describes the same clothes. And

then he said, "Your brother gave me something. He held it out to me like this and he said,

'Give this to Rae and she will know that I'm okay.'" And I said, "Well, what was it?"

And he said, "I don't know, I can't remember. All I have is this sense that it was dark and

it was really skinny and it was tall." And I went, "Okay, I know what it was. I wanted it

as a keepsake, I asked my mother if I could have his arrowhead pendant."

Dreams were powerful sources of information for a few survivors. Occasionally, survivors received messages during their dreams that influenced future careers and life pathways.

Marie received direction for her life's work through a powerful dream on the night of her son's suicide:

The night that Kevin died, I had a dream of standing in the gymnasium talking to kids and

for 30 nights I had the same dream. And there was never a word that I could remember in

the morning, just the recollection of me standing in the gymnasium talking to kids. And

about three months after Kevin's death, I knew that I wanted to become a speaker and to

talk to adolescents about the impact that suicide has on the family. Healing Within Families 157

Subsequently, Marie pursued her dream of speaking about suicide to school-aged children. She even solicited help from a variety of local community organizations to help defray the costs associated with preparing a video for educational purposes and traveling across Canada to speak in schools.

In another instance, Marie spoke about her experience that involved trusting and honoring her intuition:

There is a woman who I know that I have connected with and we were doing a session on

the beach one time. She is very much a healer, and she is also very psychic. We were

talking about my growth and what I want to do with my public speaking or whatever. All

of a sudden, I just had this wave that came over me of missing Kevin. I sensed that Kevin

was beside me and then her next words were, "Kevin is here, beside you." And so when I

have these moments, it's also an honoring of my intuition, of my trusting. So in the

process she was holding my hand and she said, "He wants you to know that he is okay

and that he likes where he is." And I just went into this heavy sobbing. These girls who

were with me said that they thought that I was upset that he was okay. I said, "No." I

said, "As a mom, what hit me was I wanted to touch him, I wanted to hold him, I wanted

to be with him." So I said to this woman, "If I hold your hand tighter, can you touch his

hand and touch mine?" So as she was holding my hand, I mean, the pressure was just

getting heavier and heavier. This is a 73-year old woman; she's a very gentle lady. I asked

her about this afterwards. She said, "I would sense that that was the essence of him that

was coming through." Then she said, "There's a lot of love there from this son for you."

Survivors learned from their experiences with youth suicide by thinking differently, developing their creativity, and trusting their intuition. They began to view their tragic circumstances as part of life rather than as the only event that defined their lives. Survivors who began to trust their intuition became aware of new possibilities for their own success. They also learned from their situation by tapping into their creative capacity. Their involvement in creative endeavors served as a means of constructively dealing with their emotions and finding meaning within their experiences. Tuning into the creative aspect of learning also helped survivors to trust Healing Within Families 158 their intuition which, in turn, often helped them to feel a connection with the deceased youth.

Within Connecting, survivors not only learned a great deal from their experiences with youth suicide, they began to orchestrate their lives, often for the first time.

Functioning Pattern (Orchestrating Life)

Within Connecting, the functioning pattern extends beyond the individual survivor to include the family and community. Orchestrating life is concerned with survivors taking charge of their lives and pursuing a leadership role within the public sphere in terms of helping others understand youth suicide and its impact on the family. The functioning element included two ideas, specifically, reordering life priorities and breaking the silence.

Reordering Life Priorities

Following youth suicide, many survivors orchestrated their lives by reordering their priorities in life. Loma commented, "It's just kind of made everybody look at their lives and look at what's important and what's not." Characteristically, survivors shifted their priorities toward valuing family unity: "You get it right and put your family first. ... I think we're closer, I think that we understand each other better. I mean there are good things." Lynn, another mother, spoke about shifting her priorities to include sharing her feelings and paying attention to her health:

His death made me realize that our time with our loved ones can be fleeting and that it can

change in an instant.... As a result, I took more time to let people know how special they

were to me and I began to set priorities to keep myself healthy.

The trauma induced an "existential shift" within many survivors. As their values and beliefs shifted, so did their actions. Survivors reordered their priorities in life to more accurately reflect the importance of family and friends, and the necessity of "making the world a better place" for future generations. Taking on the challenge of breaking the silence surrounding youth suicide became part of many survivors' mission in life. Healing Within Families 159

Breaking the Silence

Orchestrating life also entailed breaking the silence surrounding youth suicide within the public arena. Most participants spoke of needing to "take control" of their lives once again.

Breaking the silence of their own pain was the first step toward taking control of their lives: "I just needed to get it [pain] out, and to let it go." The second step involved talking about suicide within the public arena. Jim, a father, realized the importance of consciousness-raising within the public sphere: "The risk that I think my family has taken is that I think we are prepared to step out... to put things in perspective for community leaders. ... It's extremely important to be able to do it in a public way." Linda, a mother, commented, "It is a death that needs to be talked about and not hidden," while Ed, another father, said, "Suicide has to come out of the closet."

Helping others to break the silence surrounding youth suicide became the raison d'etre for many survivors. They used a variety of strategies for breaking the silence within the public sphere including: preparing a video to be used in elementary schools, speaking about youth suicide and its impact on the family in public forums, pursuing formal education specific to youth suicide, participating in conferences related to youth suicide, forming self-help groups for bereaved families of youth suicide, and making a web page dedicated to youth suicide as an educational tool directed toward a broad audience.

Breaking the silence sometimes involved survivors regaining a sense of personal control in their lives by taking appropriate and meaningful action. Liz, a significant other, maintained that grieving persons are sometimes exploited by the media. Liz felt that the suicide of her loved one had been sensationalized at the expense of both herself and her family, and she felt compelled to correct the injustice. She took control of the situation by informing the merchant (who sold a gun to her loved one and then spoke to a journalist about the sale of the gun) about the consequences of his actions:

Part of my healing is related to coming to terms with some of the people who hurt me

through this whole process. As part of my healing, I needed to face him [the merchant]

and tell him about the hurt that he imposed upon us, to kind of stand up for what I knew

was right in that case. ... It was hard, I just bawled and bawled because I felt so bad for Healing Within Families 160

confronting this gentleman because he was so upset about it; And even though it's not

something that I had done bad, I felt badly that I upset the egg basket, you know that kind

of a thing, but it was something that I needed to do. I felt very good about myself doing

that.

Creating opportunities to break the silence surrounding youth suicide was an integral aspect of the Connecting theme of the healing process. Breaking the silence began with each survivor recognizing and privately talking about his or her own pain. The silence was broken, and needed dialogue began, when survivors were able to share their views about suicide within the public arena. In addition to orchestrating their lives more effectively, survivors began to channel their energy in ways that promoted their health and well-being.

Energizing Pattern (Channeling)

Within the major concept of Connecting, the energizing pattern was characterized by these

41 survivors channeling their energy so they could accomplish their goals in life. I developed the name for this element based on survivors' accounts of the effect of energy on their healing experiences. Survivors consistently spoke about enhancing the quality of their lives by positively directing their finite supply of energy toward "what is really important in life." Channeling energy includes two ideas, specifically, redirecting energy and focusing on the positive aspect of experience.

Redirecting Energy

Within Centering, discussed in the previous chapter, survivors realized the futility of continuing to ask the "why question." In Connecting, they stopped asking this elusive question; instead, they redirected their energy by channeling it in a direction that added to, rather than detracted, from life: "Instead of taking all my energy and continuing to search for why, I needed to file it away and move on with my life." This "in vivo code" (Glaser, 1978, p. 70; Strauss,

1987, p. 33) emerged from the data. Linda commented that all of us have only so much energy and that it is important to exercise care, and sometimes caution, with its use. She remarked, "there Healing Within Families 161 is a conscious effort to redirect my energy to the things that I can change." Marie extended this thought by redirecting her energy toward healing: "I knew that the energy I had needed to be spent on healing." Energy was also channeled by focusing on the positive aspect of experience.

Focusing on the Positive Aspect of Experience

Survivors who moved toward healing knew that energy can be consumed, replenished, and channeled in a direction that enhances health and well-being. These survivors not only purposefully redirected their energy, they also began focusing on the positive aspects of their experiences with youth suicide. For instance, Marie and Mike felt energized following a positive experience during a brief interlude with nature following the suicide of their son. Marie explained:

We were driving back from the long weekend in May after Kevin died, and both of us

were finding it really difficult because we have some friends whose child is called [same

name as the deceased youth]. We were both in some pain as we were driving, and then all

of a sudden, there was a rainbow that we could see in the distance. As we came closer, it

looked like it started on one side of the road and went right across to the other side. I had

noticed it, but Mike was driving and we were both really into ourselves. Suddenly, Mike

pulls over and he said, "I feel like Kevin has sent us a hug with the rainbow." So we sat

there for 10 or 15 minutes just inhaling the rainbow. Without a mistake, we felt his

presence and we felt energized by this experience.

In another family, Liz spoke of an instance when she felt energized by focusing on the positive aspect of her experience following her husband's suicide. She recalled a familiar energizing experience:

At one point when I was on the telephone giving a message to a friend, I just said, "I wish

somebody would hold me until the owies go away," because sometimes you just aren't

strong enough to do it yourself. At that point, I literally felt arms around me and I know

this isn't the first time that I have been totally taken care of by the universe. I really know

that there are forces that I can't see but that I feel. I know that those forces are there to love Healing Within Families 162

me through this, and so it is really a beautiful and peaceful feeling. I went from there....

It was an energizing experience.

Focusing on the positive aspect of experience had an energizing effect on survivors. Their positive attitude and approach to their situation ultimately enabled survivors to transcend previously perceived limitations as they journeyed toward healing.

Finding Meaning/Exploring Spirituality Pattern (Transcending)

Within Connecting, most of the 41 survivors who participated in this study became positively transformed as a result of their experiences with youth suicide; some experienced transcendence. I used my judgment to determine the appropriateness of this term to describe the data. Within this work, transcendence is synonymous with survivors rising above their tragic situation and fulfilling their potential to "make a difference" in their own lives, and in the lives of others. Survivors experienced transcendence by surpassing their previously perceived limitations.

They did this by finding meaning in their pain and suffering and deciding to move toward healing.

In so doing, survivors were able to re-cast their lives in keeping with their new-found understanding of the change that had taken place in their lives. Transcending includes the concepts of re-birthing and trusting experience.

Re-birthing

The name for this idea emerged as an "in vivo code" (Glaser, 1978, p. 70; Strauss, 1987, p. 33) that captures survivors' experiences of transcending tragedy by learning from their unfortunate circumstances. Survivors who experienced re-birthing viewed the suicide as part of their life experiences, rather than as the only event that defined their lives. These survivors were able to construct meaning in response to their suffering. They believed that someday, perhaps in the afterlife, they would understand the whole story. Meanwhile, they decided that in order to make the life of the deceased youth count, that they needed to "press on" with their own lives by helping others in similar situations, and "finding goodness" in the world. This balanced perspective simultaneously validated both the life of the deceased youth and that of the survivor. Healing Within Families 163

Moreover, this view allowed survivors to use their experiences as stepping stones rather than as stumbling blocks. Ray, a father, addressed this point:

It's always there and like your life revolves around it and everything that you look at has

to do with it. I myself am not shy about talking about it. It's something that is just always

there in my mind. I find that I make people uncomfortable because I'm always talking

about it; to me it's like it happened yesterday. But also it's given life more meaning. I

almost look at it like a butterfly, you know, like coming out of a cocoon or whatever. . . .

It's made me a different person. . . . There's been a rebirth of me ... a much stronger

person ... a more focused individual.

Family survivors who identified with the re-birthing experience were able to let go of the negative impact of the suicide and to move on and find success in their own lives. Liz commented that finding success in life was an important aspect of her healing journey:

I am so excited about going after my dreams and having them become realities. My

husband [individual who took his life] would have been proud of me and so excited for

me and so anxious for me to better myself and go on with things in different ways. I'm

not leaving him or anything behind, I'm just continuing this process in life, you know.

And I think that part of the healing is to allow yourself to succeed even though the person

left you. . . . You need to allow yourself to succeed and that's part of it, you feel guilty

and selfish about the happiness at first, but that's part of healing.

By allowing themselves to experience re-birthing, survivors experienced a qualitatively different "way of being in the world" that enabled them to succeed in life despite their unfortunate circumstances. Closely related, survivors began to transcend previously perceived difficulty by developing ways of trusting their experiences.

Trusting Experience

As a result of their experiences with youth suicide, survivors started to trust their experiences. In so doing, their faith in life itself became restored. Survivors constantly commented that they knew things that they could only have known from their experiences with the Healing Within Families 164 suicide of a family youth. They discovered personal coping skills beyond what they could have imagined. Liz described her experience as "moving toward total understanding, total honesty, and total trust." Those who experienced transcendence saw themselves as "more accepting, more giving, more trusting, kinder, and gentler." They also felt much stronger and more confident in their abilities to face life's challenges because they had survived "the worst possible situation."

Consistently, survivors found that the cause of death (i.e., suicide) did not alter their love for the deceased youth. They maintained that their loved ones' lives needed to "count for something."

They believed that it was their responsibility to find a suitable expression of love as a way of honoring the life of the deceased youths. These expressions of love, many of which were discussed earlier, were unique to each survivor who participated in this study. Liz reflected on the value of trusting her experience:

So there are times when you have to do what is best for you and go, you know, go with

your gut instincts, trust yourself and know that what you feel at this time is going to be

what is best for you and what is right for you, and if not, so what?

In a creative moment, Lana shared the following poem that captures her sense of trusting her experience:

All is unfolding as it should

I will know the whole story someday

There is a reason for life: there is a reason for death

I know beyond a shadow of a doubt that love goes beyond the grave

I have developed a lot of gratitude:

For my relationships, both past and present, especially those that support my healing,

For the initiative I've exercised, to sometimes step out of my comfort zone to help myself and

others,

For the independence I've developed in creating personal space and distance when I've needed it

for my own well-being,

For humor and the healing salve it's been in transforming the blackness into color, Healing Within Families 165

For the insight that has helped to sustain me and support others, as they have also sought to

understand why?,

For my faith in God and understanding the great resource of compassion.

Lana's ability to trust of her experience enabled her to find meaning within her situation.

Her capacity to find meaning in her situation brought her peace and harmony into her life. This innate capability, also possessed by most survivors of youth suicide, helped her to experience transcendence—or "moving beyond what was," to "what is."

Summary

The shock of hearing the news about the suicide of a family youth launched survivors on an irreversible and ongoing journey. They began their quest for wholeness within Cocooning, the first theme of the healing process, by experiencing a journey of descent within themselves. Within this theme, survivors were afforded protection from society's harsh criticism as they began to grapple with the meaning of their forever changed reality. Next, in Centering, the second healing theme, survivors experienced a journey of growth. Here they realized the impact of their altered reality and made three key decisions that qualitatively changed the course of their healing journey.

Of importance, as an act of volition, survivors often decided to move toward healing. Survivors who made this critical decision moved on to Connecting, the third and final theme of the healing process. Connecting was concerned with survivors bonding with others and fully participating in life once again, albeit from a new vantage point.

Within the Connecting theme, survivors experienced a journey of transcendence in which they became aware of their innate strengths and coping capabilities. They learned a great deal from their experiences. Survivors began to reach out to others in a variety of ways. Not only did they seek help for themselves, they began to see themselves as catalysts for the healing of others.

Consequently, they began to view youth suicide as part of their total experience in life rather than as the only event that defined their lives. These individuals often became more creative beings who trusted their intuition. As a result, they were able to further create meaning in relationship to their experiences. Congruent with such meaning, they often made major lifestyle and career Healing Within Families 166 changes that reflected their newly defined priorities in life. In particular, survivors became committed to breaking the silence surrounding suicide within the public arena. Moreover, they began to trust their experiences by positively channeling their energy toward those aspects of life where they believed they could effect change. Characteristically, they demonstrated a commitment to helping others in similar circumstances. In Chapter Eight, the healing strategies and healing characteristics are presented. In addition, the outcome of individual healing following youth suicide and the relationship between healing and grieving are addressed. The chapter concludes with a discussion of the findings of this study. From the Gordian Knot, symbol of the world's complexity and human powerlessness, to the cords used by sorcerers and shamans to exorcise, knots have always symbolized a magical power whether bad or good. As tied objects, they represent the tangled web of fate whose eventual unraveling is welcomed with relief. But associated with rope, they symbolize the power which ties and unties. They become a cosmic link with primordial life and the first cause, the creator Principal. Because they have so many uses, knots are imputed to provide protection against spells and death and to be preservers of the life-force. In the Alps we can find rupestrian images of strings of knots probably used to keep the evil spirits of the mountain at a distance. (Petzl, 1998, p. 6) Healing Within Families 167

CHAPTER EIGHT

TOWARDS AN UNDERSTANDING OF THE HEALING PROCESS

Healing is a journey, it is a direction rather than a destination. (Rae, a sibling)

In the previous four chapters, the process of individual healing as experienced by family survivors of youth suicide has been portrayed as Journeying Toward Wholeness. In this chapter, the healing strategies, intervening variables, and outcome of the healing journey are addressed. A conceptualization of healing following youth suicide is offered. The healing process is explained as movement from transition to transcendence. The relationship between healing and grieving is clarified and a discussion of the findings is presented.

Healing Strategies

Survivors developed an array of healing strategies to facilitate their journey toward wholeness following youth suicide. These strategies were specific to each of the three healing themes (i.e., Cocooning, Centering, and Connecting) of the healing process. Healing strategies were symbolic of the meaning survivors attributed to the suicide of a loved family youth. In addition, these strategies served as a way of validating the life of the deceased youth, and as an expression of the continuing bond of love between survivors and the deceased youth.

In Cocooning, survivors developed healing strategies that supported them during the initial period of crisis. Essentially, these strategies helped survivors 'survive the tragedy.' Survivors reacted to their grave situation by instinctively adopting individually-focused healing strategies that enabled them to gain a sense of safety and security while integrating a disconcerting and unwanted change within their lives. Within Cocooning, healing strategies helped survivors navigate their journey of descent. These healing strategies included: withdrawing from others, creating a healing environment, giving oneself permission to grieve, "shadowing" others, releasing oneself of the responsibility for the well-being of others, and living "one breath at a time." Healing Within Families 168

The first healing strategy, withdrawing from others, served a protective function. This strategy provided survivors with the necessary time needed to process the trauma. The creation of a healing environment, required a move away from externally-oriented, "hi-tech, low touch, fast paced" settings commonplace in today's society, to the creation of internally-oriented, "low-tech, high touch, relaxed" surroundings which served to promote healing. A healing environment was described by survivors as being "basic or simple," "quiet and comfortable," and preferably "close to nature." Healing environments were often close at hand. Sometimes healing was enhanced by something as simple as going for a walk in peaceful surroundings. The second healing strategy involved survivors giving themselves permission to grieve. Initially, survivors needed to direct every ounce of their strength and stamina toward surviving the tragedy; they needed their own space and time alone to reflect on their experiences and to grieve. They developed healing strategies which facilitated their grieving. They temporarily withdrew from others and released themselves of the responsibility for the well-being of other family members. Even though survivors felt consumed by their own grief, they frequently watched over or "shadowed" other family survivors.

Knowing that others in the family were safe was important. During this time of upheaval and uncertainty, the tentative nature of surviving the ordeal often became apparent as survivors adopted the healing strategy of living "one breath at a time."

During Centering, survivors developed healing strategies within the private sphere. These strategies helped survivors not only survive, but thrive, despite difficult circumstances. During this time of personal growth, survivors internalized the reality of their forever changed lives. In response to tragedy, survivors re-created their world. Specifically, they made three decisions that steered them in a new direction. Drawing on inner strength and innate coping capabilities, survivors developed strategies that facilitated their growth. These strategies included: journaling, ritual, prayer, art, music, reading, meditation, imagery, burning an eternity candle, leaving a legacy, appreciating nature, and treasuring mementos.

Within Connecting, healing strategies were expanded from an emphasis on the private sphere to encompass a focus on the public sphere. Survivors experienced a sense of renewed life and replenished hope. They adopted healing strategies that enabled them to move beyond perceived Healing Within Families 169 barriers by reaching out and helping others. For instance, they felt compelled to change the social limitations that made it difficult for them to speak publicly about their experiences with youth suicide. Consequently, the healing strategies they developed focused on ways of promoting dialogue about suicide within the broader community. Healing strategies within this theme included: public speaking (including storytelling), networking, pursuing further education, conducting research related to suicide, developing self-help groups, using the Internet as a medium for educating others about suicide, preparing an educational video, planting a tree in honor of the deceased youth, and attending suicide-related conferences. The following table (see Table 8-1) provides a list of the healing strategies used by survivors within the three themes of the healing process.

TABLE 8-1: JOURNEYING TOWARD WHOLENESS: HEALING STRATEGIES

Cocooning Centering Connecting (focus on survival) (focus on personal growth) (focus on reaching out) • Withdrawing from • Using j ournaling, ritual, • Seeking help others poetry, prayer, art, • Speaking about suicide • Creating a safe music, reading, within the public sphere meditation, and imagery environment • Networking with other • Giving oneself • Burning an eternity candle families bereft by youth permission to grieve • Leaving a legacy suicide • Shadowing other family • Developing a greater • Seeking further members appreciation for animals education • Releasing oneself of and nature • Educating others via the responsibility for family • Treasuring mementos Internet members' well-being • Preparing an educational • Living "one breath at a video time" • Planting a tree in honor of the deceased youth • Conducting research related to suicide Healing Within Families 170

Intervening Variables: Healing Characteristics

The degree to which healing occurred was influenced by a number of intervening variables or healing characteristics. These variables reflected the survivors' capacity to say yes to life; step out and speak up; achieve a sense of peace, harmony, and balance; and expand personal consciousness. . .

Saying Yes To Life

The first healing characteristic was the survivors' capacity to say yes to life. Those who moved toward healing made a commitment to life and living by identifying themselves as survivors, setting priorities, and clarifying their purpose in life.

Typically, individuals who moved toward healing identified themselves as survivors capable of succeeding in life despite tragic circumstances rather than as victims of tragedy.

Identifying oneself as a survivor was synonymous with unconditionally respecting and honoring the very essence of oneself. This involved "listening to the voice within" and "developing the confidence to nurture and pay attention to it." Moreover, it involved trusting that "something positive will come out of this," and knowing that "all is unfolding as it should." Survivors who trusted themselves also tended to trust other people and God or a higher power source. These individuals managed to survive their disquieting experiences with youth suicide and moved on to live rich and fulfilling lives. They became passionate about living according to their newly defined priorities. For instance, one survivor pursued post-secondary education with the intention of eventually counseling individuals and families traumatized by youth suicide. Another survivor believed that her mission in life entailed educating school-aged children about youth suicide and its impact on the family. She took a one-year leave of absence from her work to pursue her passion that involved educating children. This individual became well recognized by the health care community for her many contributions within the community and beyond.

Saying yes to life also involved survivors setting priorities congruent with their values and beliefs that were based on "what's important in life." Characteristically, survivors realigned their priorities in life by "putting the family first." For example, a father realized that he had been Healing Within Families 171 exclusively focused on the economic aspect of family living. In keeping with his re-ordered values, he chose to direct more time and energy toward family life. In particular, he decided to spend more time with his two young surviving daughters.

Saying yes to life induced an existential shift that enabled many survivors to begin "living more fully," often for the first time. As survivors began living authentically, that is, according to their beliefs and values, their purpose in life became more clearly focused. Some survivors made major lifestyle and work changes that more clearly reflected their beliefs and values and their purpose in life. Invariably, those who said yes to life demonstrated their commitment to life and living by taking action aimed at "making the world a better place to live."

Stepping Out and Speaking Up

The second healing characteristic was the survivors' readiness to step out and speak up in matters pertaining to youth suicide and its impact on the family. This involved taking risks.

Survivors who moved toward healing stepped out of their 'woundedness' by refusing to define their lives solely on the basis of the negative impact of the suicide. Dwelling on the wound, survivors thought, would induce a type of self-infected wound, a self-flagellation, in which their consciousness would be focused on weakness instead of recovery. They knew that emphasizing their wounds could damage their psyche as much as the original wound, and this they chose not to do.

Survivors moved beyond their usual comfort zone and began sharing their ideas in the public arena with the intent of educating others about suicide. They knew their experiences were powerful sources of tacit knowledge that could be used to help others understand what happens within the family when a youth ends his life. Some survivors actively took steps to increase public exposure to the topic of suicide. For example, several survivors engaged in raising the level of public awareness about youth suicide by participating in activities during Suicide Awareness

Week. Speaking up sometimes required survivors to address the stigma surrounding suicide still prevalent within society. This they accomplished by focusing their efforts on educating others about youth suicide and assisting others in similar circumstances to step out and speak up. Healing Within Families 172

Achieving a Sense of Peace, Harmony, and Balance

The third healing characteristic was the survivors' faculty for achieving a sense of peace, harmony, and balance in their lives in the aftermath of youth suicide. Survivors cultivated peace in - their lives by forgiving both themselves and the deceased youth, and through their positive approach to living. Survivors who forgave themselves for being unable to intervene and prevent the suicide, and those who forgave the youth for taking his life, eventually found peace. According to survivors, forgiveness did not mean that "it was okay" that the youth ended his life. Rather, it meant that survivors refused to continue "to pay the price for what he [the youth] did." The act of forgiving the deceased youth released survivors from an unhealthy bondage. They were then free to love the deceased youth which created a sense of peace within their lives.

Despite their horrific experiences, most survivors maintained an optimistic outlook on life.

Survivors who moved toward healing operated from a position of love which permeated every aspect of their lives. These survivors trusted themselves and their capacity to survive. The use of healing strategies further increased their sense of peace, harmony, and balance. Survivors continued to feel a bond with the deceased youth by involvement in activities formerly enjoyed by the youth. These activities included openly displaying affection toward animals and appreciating beauty within nature (e.g., rainbows, flowers, and forests). It may be that the trauma cultivated within survivors the 'essence of their humanity;' these individuals became "softer, gentler, and kinder," as well as "more generous," and "accepting of others."

Survivors also achieved peace, harmony, and balance by making an effort to improve their health status. Survivors realized their vulnerability to ill health resulting from increased stress and they chose to counter such risk by taking preventive measures. They chose to improve their health by finding ways to manage their stress and by creating a balanced lifestyle. They decided to refrain from asking the "why question;" they decided they could live without an answer to it. Instead, they created peace, harmony, and balance in their lives by focusing on the things that could be changed and developing their artistic abilities. For example, Bill achieved a sense of peace by putting words to music for the first time in a ballad he wrote and sang for his deceased son. Healing Within Families 173

Expanding Personal Consciousness

The fourth and final healing characteristic was related to the survivors' willingness to expand personal consciousness. Consistently, survivors reported that their experiences with youth suicide helped them "evolve as spiritual beings." They learned about energy and timing, the interconnectedness among all things within the universe, the meaning behind their experiences with youth suicide, as well as their intuitive capabilities.

Survivors viewed healing as positively directing energy, not only for the purpose of fulfilling their potential in life, but for the ultimate benefit of humanity. Survivors who claimed to be moving toward healing frequently spoke about the concept of energy. They understood that energy can be "consumed," "released," "replenished," and "channeled." Because they saw energy as an expendable resource, they focused their energy on those aspects of life where they could make a difference such as helping others in similar situations.

Survivors learned how to focus their energy on healing themselves. That is, they gave themselves permission to be healed. This involved making a clear and conscious decision to allow healing to occur. This act of volition positively influenced other decisions which, over the long term, increased survivors' commitment to fulfilling their purpose in life.

Survivors who claimed to be moving toward healing often possessed a very precise sense of timing. They knew when to take action. It was as if these individuals had a sense of the

'kaleidoscope phenomenon' with regard to timing in their lives. This concept refers to taking action at a point in time when various aspects of life simultaneously and synergistically work together to produce a positive outcome. Similarly, when one turns a kaleidoscope ever so slightly, there is a point in time in which all the pieces fall effortlessly into place, and a unique and beautiful creation unfolds. Such splendor and richness is the result of precise timing. This internal sense of knowing when to take action often helped survivors move on with life in the aftermath of youth suicide. For example, several survivors spoke about knowing when to act and when to refrain from taking action in terms of making major lifestyle changes. One survivor spoke about knowing that the

"timing was right" for her to move to another country about a year after the suicide. Another Healing Within Families 174 survivor recalled his experience of knowing when it was right for him to leave his employment and begin a new chapter in his life more closely aligned with his values and beliefs.

Closely related, survivors came to understand and value the interconnection that exists amongst all things. Several survivors commented on the deep respect and sense of connection they felt with other people and the environment. They often spoke of a renewed sense of appreciation for the 'miracle of life' and the 'mystery of death.'

Those who claimed to be moving toward healing found meaning within their experience.

Initially, survivors found it difficult to acknowledge that there could be any meaning related to the suicide. Eventually, most survivors viewed the suicide as an event with spiritual meaning. Those who found meaning within their experience fervently believed that the suicide happened for a reason, even though they were unable to express it to others. Moreover, they learned how to live without an answer to the "why question." They trusted that someday, perhaps in an afterlife, they would find the answer to this puzzling question. Moreover, survivors used their cognitive ability to construct meaning in their lives. These mental constructs simultaneously embraced dichotomy and ambiguity. For instance, survivors learned that despite great sorrow they could still experience happiness. In their relationship with the deceased youth they were sometimes amazed at the sense of 'connection' they still felt despite an over-riding sense of 'aloneness.' Similarly, although silence prevailed, survivors were struck by a sense of the deceased youth's ever present voice.

Survivors also expanded personal consciousness by tuning into their biorhythms, refining their intuitive abilities, and being receptive to new ways of learning. They learned how to listen to the messages that their bodies provided and they were able to use this information for personal growth. In several instances, survivors refuted information which suggested acceptable time frames for grieving. Rather than being influenced by societal views, survivors turned to themselves to find out what they needed to do in a particular situation. For example, in regard to healing, Rae knew what she needed: "I knew I needed to cut myself some slack." As discussed in the previous chapter, through survivors' awareness of synchronicity in their lives in the form of strange occurrences and/or coincidences, survivors often felt they were able to communicate with the deceased youth. For example, survivors in three different families experienced "cool bodily Healing Within Families 175 sensations" at certain times which they interpreted as a sign of the deceased youths' presence in their lives. As survivors expanded their consciousness, they began "taking in more of life;" they began accomplishing their goals in life and fulfilling their potential as human beings. As Linda, a mother said:

I found out that I could do more, I could do better. I became a different person—a much

stronger and more focused person. I really like who I have become. But, if given a choice,

I would rather have Allan back in my life.

Outcome of Individual Healing Following Youth Suicide: Creating a Love Knot

Based on survivors' stories of their experiences following youth suicide, I conceptualize individual healing as Journeying Toward Wholeness. This journey is characterized by the inter• relationships among three enfolding, fluid, and iterative themes, which in themselves, each represent one portion of the overall journey: Cocooning (Journey of Descent); Centering (Journey of Growth); and Connecting (Journey of Transcendence). Within each theme, five self-organizing and inter-relating patterns (i.e., relating, thinking, functioning, energizing, and finding meaning/exploring spirituality) operate in mutual rhythmical interchange with the other patterns unbound by time. Each pattern describes one facet of the individual's experience in response to youth suicide. Journeying toward wholeness (i.e., healing) varies in expression and intensity over time in response to a variety of contextual factors including personal history, factors related to the suicide, social considerations, and the health care environment. Importantly, healing emanates, as an act of volition, from the survivor's consciousness (i.e., the healing epicentre) as a result of decision making.

The degree to which healing occurs depends on a number of intervening variables reflecting the survivor's capacity to say yes to life; step out and speak up; achieve a sense of peace, harmony, and balance; and expand personal consciousness. As a major outcome of the healing process, each survivor creates a love knot, symbolic of the healing strategies he or she uses to facilitate healing within both private and public spheres. The love knot represents the creative expression of love as a healthy and continuing bond between the survivor and deceased youth. The Healing Within Families 176 love knot is based on the meaning the survivor attributes to his or her experience with youth suicide and the relationship between the survivor and deceased youth prior to death. Ultimately, individual healing expands outward influencing family, societal, and global spheres (see Figure 8-

FIGURE 8-1: HEALING EXPANDING OVER TIME

YOUTH SUICIDE

Individual Healing Following Youth Suicide: A Summary

Individual healing following youth suicide is conceptualized as Journeying Toward

Wholeness. This contextually-mediated process is composed of three themes, specifically:

Cocooning, Centering, and Connecting. Survivors entered the healing process within Cocooning, the first theme in this theory. Soon after hearing about the suicide of a family youth, survivors were catapulted into an extensive period of grieving. During this time of transition, survivors were awakened to a drastically changed reality. They were faced with the difficult challenge of Healing Within Families 177 incorporating an unwanted change into the scheme of their lives. Characteristically, survivors experienced a journey of descent into themselves. During this inward journey, they took time to sift and sort through the ruins that replaced their once calm and ordered lives. Survivors felt personally violated as a result of the suicide and consequently endured much pain and suffering.

They not only felt assaulted, survivors also felt robbed of many experiences never to be shared with the deceased youth. Survivors often became of aware of what was divided, fragmented, and negative in other aspects of their lives. Furthermore, previous ways of managing no longer worked and survivors struggled to manage simple activities formerly performed with ease; in fact, living became a chore.

Survivors experienced chaotic thinking and they struggled in terms of relating to others.

Grieving consumed their energy and they functioned on automatic pilot. Survivors realized their vulnerability as they were forced to deal with the negativity associated with youth suicide.

Commonly, they experienced a sense of profound loneliness which eventually prompted a longingness for reunion with themselves and others, and with life itself. Survivors who allowed themselves to experience the negativity confronted their pain and the inherent ugliness of their predicament. In doing so, they learned from it and moved on with their lives.

Survivors continued their journey by Centering themselves, the second theme of the healing process. With the reality shock behind them, survivors began to get a grip on themselves.

They re-gained control of their lives which, in turn, allowed them to relate to others in more spontaneous and authentic ways. During this journey of personal growth, survivors made three key decisions, the most important being the decision to allow healing to occur. This was a practical decision in that it permitted survivors to proactively re-engage in day-to-day living. Taking action also helped survivors to replenish their energy stores. These survivors continued to learn and grow despite difficult circumstances.

Survivors who became positively transformed began Connecting with others and with life once again, albeit from a new vantage point. They transcended their unfortunate circumstances by reaching out to others and channeling their energy toward those aspects of life that they could change. They learned much about themselves from their experience and they used their new found Healing Within Families 178 knowledge to help others in similar circumstances as well as to facilitate constructive change within society. My conceptualization of the healing process is presented below in Figure 8-2. The diagram presented in Chapter Four (Figure 4-2: Individual-Society Healing Processes Following Youth

Suicide) has been expanded to now include the healing characteristics and healing strategies that have been presented in this chapter.

FIGURE 8-2: INDIVIDUAL HEALING WITHIN FAMILIES FOLLOWING YOUTH SUICIDE

Transition, Transformation, and Transcendence

Youth suicide enlivens a tragic mosaic depicting a dark world where daily survival is a triumph. Soon after hearing the news, survivors were catapulted into an extensive period of grieving. During this period of transition, they were forced to deal with an unwanted change in their lives—the death of a family youth. While navigating the three passages (i.e., Cocooning,

Centering, Connecting) toward healing, survivors become transformed.

Congruent with Munford's (1970) idea, transformation following youth suicide began with each survivor. According to B. Davies (personal communication, August, 1999), transformation can be either positive or negative. Positive transformation results in the individual and family Healing Within Families 179 moving toward health and well-being, whereas negative transformation leads to illness and dis• ease. Within this study, most survivors experienced positive transformation. That is, they viewed their situation as both an end to life as it was prior to the suicide, and as a beginning of a new life without the loved one's presence. The pain of their emotional scars transformed these survivors.

Although the frequency of remembering the pain decreased with time, the intensity of the pain remained undiminished for most survivors. From this, survivors understood that healing was not synonymous with the removal of pain. Rather, healing involved integrating pain as part of their experience in life. These survivors were willing and able to learn from their experiences in life, and they eventually moved on to live rich and fulfilling lives. However, a few survivors defined their lives in terms of the negative impact of the suicide experience. These individuals, representing a minority of the participants (n=2 out of 41), experienced a negative transformation. These individuals stated that they would "never heal" from their experiences. They tended to look at every new experience through the lens of the wound inflicted upon them. Their views had a powerful influence and caused them to lead lives of minimal expectation and limited responsibility. It should be noted, however, that these two survivors were able to identify with the theory of healing described in this research even though they saw themselves as "not quite there yet."

What is it that moves survivors from transformation to transcendence? In the case of youth suicide, the survivor's decision to heal was the moment when transformation became imbued with transcendent possibilities. Survivors, in that moment of decision, chose to transcend their tragic circumstances. Transcendence involved survivors freeing themselves of the negative influence and impact of the suicide. It was concerned with survivors moving beyond perceived limitations and concentrating on future possibilities for success in life. In keeping with views expressed by other authors, transcendence involved expanding self-boundaries (Reed, 1991). Moreover, the move toward transcendence entailed bringing what was considered by society to be in the margin (i.e., survivors' experiences with youth suicide) and moving it to the center. Paradoxically, just as the youth was unable to speak about the emotional turmoil that led to his demise, a major thrust of healing for survivors involved speaking about the unspeakable (i.e., youth suicide). Through storytelling, survivors caught a glimpse of their own strength and courage and the ways they could Healing Within Families 180 use their positive attributes, not only to help themselves, but to help others as well. Survivors did this by reaching out and connecting with others in meaningful ways that enabled them to act as catalysts for others' healing. In essence, connection and transcendence occurred simultaneously.

This view is supported by Krieger (1990) who mentions that "man [sic] is capable of both transformation and transcendence which ... constitute a time-honored definition of healing itself

(p. 83).

Relationship Between Healing and Grieving

Family survivors of youth suicide indicated that healing was different from grieving.

Unanimously, survivors agreed that grieving was an important aspect of their healing. However, they maintained that grieving was necessary, but not sufficient, for healing: "healing is taking grieving to another level." One survivor commented: "Healing is a journey, it is a direction rather than a destination." Survivors speculated that healing happens when people are able to seize the opportunities for personal growth embedded within traumatic experiences.

Survivors viewed healing as being "more than grieving" in several ways. Survivors mentioned that they needed to grieve the loss of their loved one and heal in response to the personal violation they suffered as a result of the suicide. A survivor described the difference between grieving and healing this way: "Grieving is first level recovery and healing is second level recovery."

Survivors felt that the rejection associated with the sudden, violent, and self-inflicted death of a youth brought negativity into their lives and caused them an enormous amount of pain and suffering. They perceived that a major portion of this negativity was related to the silence surrounding suicide within society. Rae remarked, "healing is linked to giving voice to pain." As a necessary part of their healing journey, survivors embarked on a journey of descent to purge themselves of the negativity associated with youth suicide. During this solitary voyage, survivors often "fell apart" emotionally; sometimes they "hit rock bottom." The journey of descent provided survivors with an opportunity for introspection and reflection. Out of darkness eventually came light, and survivors moved toward personal growth. Healing Within Families 181

Healing was viewed by survivors as occurring in response to a deliberate decision to move toward healing, whereas grieving was deemed to be a normal and natural response to loss. Most survivors were able to recall a definitive point in time when they willingly decided to allow healing to occur. Often this decision followed their experience of "hitting rock bottom."

Survivors also maintained that healing, unlike grieving, involved a measure of social responsibility. Because death by suicide is not legitimized within society, survivors who moved toward healing felt responsible for helping others in similar situations. Survivors realized the merit of using the lessons learned as a result of their own experience to help others. Moreover, they felt compelled to take action aimed at helping to change societal views regarding the stigma surrounding suicide.

To survivors, healing in response to youth suicide was an all-encompassing experience. It involved not only dealing with the loss of a loved one, it also entailed dealing with other aspects of life. Survivors maintained that healing also focused on issues related to one's quality of life and the promotion of health and well-being that go beyond dealing with loss. For example, in one case, healing involved siblings making amends in relation to a long-standing dispute. In another case, healing not only involved dealing with the suicide of a brother, it also called into question a sibling's relationships with significant men in her life. It was as if dealing with her brother's suicide prompted her to review other important relationships in her life.

Healing was described by one survivor as a "synergistic entity" that begins within the individual and eventually extends beyond the individual to others within the family and broader community. Survivors recalled several instances when one individual's healing had a positive and catalytic effect on another person's healing, especially evident within the family unit. For example, a sibling was convinced that her experience with healing had a positive and catalytic effect on both her mother and sister. Survivors also maintained that healing is about the transformative and transcendent processes that invite, and sometimes challenge, survivors to fulfill their purpose in life and their potential as human beings. Table 8-2 summarizes the differences between healing and grieving. Healing Within Families 182

TABLE 8-2: DIFFERENCES BETWEEN HEALING AND GRIEVING

IN RESPONSE TO YOUTH SUICIDE

Healing Grieving "second level recovery" "first level recovery"

• Survivor personally violated by youth • Personal violation often not present, nor

suicide—(sudden, violent, and self- is there a degree of negativity

inflicted death of a youth)—context of

negativity

• Emanates from the survivor's • A normal and natural response to loss

consciousness as an act of volition that occurs without volition

• Involves social responsibility related to • Social responsibility not part of grieving

the stigma surrounding suicide process—grieving in response to death

from "natural causes" is legitimized

within society

• Prompts review of other aspects of life • May not result in a general life review

• Individual - Society phenomena • Individual phenomena

(Synergistic)

Discussion

Better understood within Eastern traditions, "healing" has a long-standing history of being associated with health and health care practice. Within the Western world, from the standpoint of scientific study, we know surprisingly little about how healing occurs. In the past, people were cared for in their homes by their families, often with the assistance of highly valued and respected

'healers' who resided in the community. However, with the advent of modern medicine, physicians, exalted as the pinnacle of status and authority within health care system, focused their efforts on cure and treatment. Drugs and surgical procedures were taunted as the panacea for most Healing Within Families 183 maladies. Health care consumers complied with the tenets of modem medicine, and in the process, inadvertently surrendered the responsibility for their own health at a costly price, both to themselves and the health care system.

Today, however, despite the impressive accomplishments of modem medicine, there is evidence that consumers are interested in health care that supports a return to the "sacred core of humankind," and "the natural human potential and capacity for self-care and self-healing possibilities" (Watson, 1999, p. xiv). We have come to realize that health care involves more than curing disease and treating symptoms of illness; it is concerned with the whole patient—the unity of body-mind-spirit and our being in the world (e.g., Lock & Colligan, 1986; Moyer, 1993; Myss,

1996, 1997; Ornstein & Sobel, 1987; Siegel, 1989; Watson, 1999). Within health care in general, minimal emphasis has been placed on these aspects of our existence to date. However, these facets of life affect our health in profound ways. The quality of our relationships, our ability to work effectively, the priorities we set and choices we make in life, and our capacity for healing depend on our way of being as whole persons in the world (Frank, 1995; Myss, 1996, 1997; Watson,

1999). Greene (1991) stresses that it is in the invisible world, which for generations has been ignored, that we authentically and adventurously rise to meet life's challenges. Our relationships and interactions in the world, to a great degree, influence our health.

Within Western civilization, there is a growing interest in the use of non-invasive techniques for achieving maximum wellness or "metahealth" (Ferguson, 1980, p. 247). We see an increase in the use of complementary therapies (Engebretson, 1996a, 1996b; Montbriand, 1993;

Petersen, 1996; Samarel, 1992), a growing interest in the use of energy (Andrews, 1993; Myss,

1997) and vibrational medicine (Gerber, 1988), and a call for holistic health care that honors the healing capacity of human beings (Frank, 1995; Gawain, 1997; Goleman, 1997; Myss, 1996,

1997; Siegel, 1989; Smolin & Guinan, 1993; Watson, 1988, 1990, 1999). Watson (1999) writes extensively about an intriguing phenomenon that has gained attention during the latter half of this century, specifically, "the symbiotic relationship between [sic] humankind—technology—nature and the larger, expanding universe" (p. xiv). This view of living in a constantly changing world, she maintains, holds yet to be imagined possibilities for health and healing. Aberdene and Naisbitt Healing Within Families 184

(1992) concur with Watson's ideas, speculating that the most exciting breakthrough of "the 20th century will occur, not because of technology, but because of an expanding concept of what it means to be human" (p. 16).

Increasingly, health care professionals are recognizing the relevance of practicing according to health promotion models of health care delivery. They are now beginning to entertain ideas such as the family's influence on health and well-being (McGoldrick, 1982; Maxwell, 1997; Wright &

Leahey, 1984), and the resilient capacity of individuals to transcend tragic life circumstances

(Frank, 1995; Myss, 1996, 1997; Watson, 1999).

For more than fifteen years, Myss (1996, 1997) studied why some people heal following illness and emotional trauma while others do not. She reminds us that, before the 1960s, we lacked the means for sharing with others the most intimate aspects of our emotional lives. The need to express and validate our emotional needs had not yet been introduced into our general culture.

Moreover, before the 1960s, society in general viewed those who sought help for emotional and mental concerns as mentally ill. Very few people willingly delved into these aspects of their health.

The notion of seeking therapeutic help for emotional needs was still unfamiliar, and thus people viewed any mental disturbance as a sign of mental illness.

The therapeutic age of the 1970s heralded an entirely new dimension of thought (Myss,

1997). Society endorsed emotional disclosure as a new found freedom. The notion that 'we create our own reality' seemed to spring into popular usage almost over night. The electric idea that we have personal power took hold, and self-responsibility was emphasized as a key concept in terms of health promotion. These ideas were applied to all aspects of our lives. In particular, we began to apply these thoughts to the healing process. Where speaking about emotions publicly had once been taboo, it now became a requirement for healing (Myss, 1997).

A major turning point occurred in the late 1980s as people began to ask why they were not healing despite speaking about their experiences (Myss, 1997). Myss (1997) mentions that during this time, the sharing of wounds had become the new language of intimacy—a bonding ritual for people just getting to know one another. In fact, Myss (1997) asserts that this ritual garnered a type of social authority which became very powerful and addicting for some individuals. Those who Healing Within Families 185 shared their stories experienced a type of power that reinforced their need to remain wounded.

Myss (1997) uses the term "woundology" (p. 12) to describe an intense focus on 'holding on to a wound.' She writes about the danger of wallowing in the pain of our wounds:

We are not meant to stay wounded.... By remaining stuck in the power of our wounds,

we block our own transformation. We overlook the greater gifts inherent in our wounds -

the strength to overcome them and the lessons that we are meant to receive through them.

Wounds are the means through which we enter the hearts of other people. They are meant

to teach us to become compassionate and wise. (p. 15)

Myss (1997) maintains that we may need to look at the assumption that everyone who is emotionally wounded or ill wants a full recovery. Moreover, she asserts that for some individuals, the secondary gains and seductive power of remaining wounded far exceed the perceived benefits of achieving health and well-being.

My dissertation study complements the work of other researchers and clinicians who suggest that consciousness and intention influence health and healing. This research supports

Newman's (1994) idea of health as expanding consciousness, and Watson's (1999) view of the

"transpersonal caring-healing" (p. 105) model of nursing. Located within a paradigm perspective that is interested in what lies behind the appearance of matter, Watson's model fits better within a quantum framework than it does within conventional science. Quantum theory emphasizes concepts such as "consciousness, intentionality, energy, and caring" (Watson, 1999, p. 106). It deals with both the "complementary and contradictory aspects of life; the paradox of the ordered and chaotic way in which the world works" (Watson, 1999, p. 106). Until recently, these aspects of our existence have been minimized in terms of their influence on health and well-being.

Consistently, survivors of youth suicide spoke about the social barriers that interfered with their expression of pain. A similar finding was discovered by Demi and Howell (1991) who completed a grounded theory study with 17 subjects describing the long-term effects of suicide of a parent or sibling during childhood or young adulthood. These researchers identified three themes related to the long-term effects of suicide including: "experiencing the pain, hiding the pain, and healing the pain" (p. 350). They found that the need to hide the pain often interfered with the Healing Within Families 186 process of healing the pain. Congruent with my theory, this important finding alludes to the social barriers (e.g., stigma) specific to suicidal death that often inhibit the expression of emotional pain.

Survivors in this research study became transformed by sharing their stories and they assumed personal responsibility for working to improve the social conditions that prevented others from speaking about their experience. This finding is supported by Frank (1995) whose work was based on personal experience and many years of working with narratives. Frank (1995) writes about the illness experience (e.g., cancer, heart attack) as a three-part journey that includes

"departure," "initiation," and "return" (pp. 117-118). He contends that through story telling survivors are able to transform their lives; in fact, "undergoing transformation is a significant dimension of the storyteller's responsibility" (Frank, 1995, p. 118) which he describes this way:

In wounded storytelling the physical act becomes the ethical act. Kierkegaard wrote of the

ethical person as editor of his life: to tell one's life is to assume responsibility for that life.

This responsibility expands. In stories, the teller not only recovers her voice; she becomes

a witness to the conditions that rob others of their voices. When any person recovers his

voice, many people begin to speak through that story. (Frank, 1995, pp. xii-xiii)

Survivors of youth suicide influenced the quality of their post-suicide experience by making the decision to move toward healing. A similar finding was found by Nixon (1992) who conducted a phenomenological hermeneutic research study to describe the experience, process, and themes of mens' quest for wholeness with a sample of five men. He makes specific reference to twelve themes of mens' experiences of questing, one of which included "the conscious choice" (p. iii). Other themes from Nixon's study that resemble the major categories described in my study include: "descent into pain;" "loneliness and solitude;" and a "deep connectedness" (p. iii-iv). In both my study and Nixon's study, survivors made a conscious decision to move toward wholeness.

The theory described in this study introduces the idea that healing involves a measure of social responsibility. In a grounded theory study conducted by Burke Draucker and Petrovic

(1996), the process of healing as experienced by 19 adult male survivors of childhood sexual abuse is described. Congruent with the findings of my study, these authors described healing as a Healing Within Families 187 journey that involves "breaking free, living free, and freeing those left behind" (p. 325). Similarly, survivors who moved toward healing assumed social responsibility for helping others in similar circumstances.

Weil (1983), a physician, identifies three distinct components of the healing experience as

"reaction, regeneration, and adaptation" (p. 68). Presenting a similar view based on empirical evidence, Smolin and Guinan (1993), suggest that survivors eventually move on to recovery and resolution. While these conceptualizations suggest that survivors move on in life, they negate the continuous and evolving nature of the healing process which is central to the theory presented in this dissertation study.

The theory that arises from this study suggests that healing is contingent upon the creation of a healthy and continuing bond between the survivor and deceased youth. This finding is congruent with the newer theories of grieving cited in the literature by Attig (1996), Klass,

Silverman, and Nickman (1996), and Rosenblatt (1996) which suggest that, as a healthy response to loss, survivors maintain "continuing bonds" with the deceased individual. Silverman and

Nickman (1996) go as far as to describe these relationships as interactive, even though the other person is physically absent. These authors describe the survivor's experience in terms of interfaces that influence each other. These interfaces include the survivor's inner representation of the deceased and his/her interactions with the broader living community. The survivor's relationship with the deceased person influences his or her response in the broader community and vice versa.

The survivor's interactions within the broader community, in turn, can influence the individual's desire and ability to remain involved with the deceased. At present, there is much discussion about the survivor's inner representation of and interactive relationship with the deceased person

(Silverman & Nickman, 1996). The nature of this relationship continues to be debated among researchers, educators, and clinicians.

In general, the findings of this study are congruent with both empirical and scientific evidence from a number of sources (Andrews, 1997; Dombeck, 1985; Gawain, 1997; Goleman,

1997; Zukov, 1990; Palmer, 1998; Quinn, 1989, 1992; Myss, 1996, 1997). The individual's capacity to move toward healing following youth suicide is supported by Morse and Carter (1995) Healing Within Families 188 who maintain that: "When people find themselves in the midst of a traumatic event, they instinctively find the capacity to survive immense physical and psychological assault" (p. 38).

Within the popular press, healing is understood to be concerned with wholeness and harmony of the body, mind, and spirit. Commonly, healing begins with the identification of the wound, often described as an awakening (Dombeck, 1995, Myss, 1997). According to Dombeck (1995), awakening is:

a metaphor for 'becoming conscious:' to become aware of things that were previously

unconscious; not only about oneself but also about one's context. Awakening is a symbol

for becoming alert to patterns, consistencies and inconsistencies in the symbolic and social

structures that define one's situation, (p. 61)

Dombeck (1995) contends that healing involves being aware of one's suffering and finding meaning within it, being restored to health or wholeness, being aware of one's connectedness, and finding a sense of hope, purpose, and direction in one's life. In an attempt to offer practical assistance to public audiences, Gawain (1997) makes reference to the four levels of healing.

Specifically, she talks about healing at the spiritual, mental, emotional, and physical levels.

Based on clinical practice and the study of the origin and meanings of the words used to describe healing, Quinn (1992) has come to understand healing to be fundamentally about "right relationship, relatedness, or connection" (p. 34). She maintains that "When we are alienated, isolated, estranged, fragmented, groundless, or rootless [as in the case of youth suicide], we are not whole; we are in wrong relationship; we are dis-eased" (Quinn, 1992, p. 34). Our broken connections can be with ourselves, others, or our environment. Healing, she purports, emerges from within the individual; it is about restoring wholeness within oneself. If healing is occurring, relationship is emerging, evolving, and changing. Quinn (1989) uses the term "haelan effect" (p.

553) to describe the healing response or "activation of the innate, diverse, synergistic, and multidimensional self-healing mechanisms which manifests as emergence and repatterning of relationship" (Quinn, 1989, p. 554). Based on more than fifteen years of research, Myss (1996) offers a definition of healing: Healing Within Families 189

Healing ... is an active and internal process that includes investigating one's attitudes,

memories, and beliefs with the desire to release all negative patterns that prevent one's full

emotional and spiritual recovery. This internal review inevitably leads one to review one's

external circumstances in an effort to recreate one's life in a way that serves activation of

will—the will to see and accept truths about one's life and how one has used one's

energies; and the will to begin to use energy for the creation of love, self-esteem, and

health, (p. 48)

Zukav (1989) extends this view of healing to include the far-reaching impact of individual healing. He maintains that "All the human experience is about the journey toward wholeness"

(Zukav, 1989, p. 157)." This journey toward wholeness "requires that you look honestly, openly and with courage into yourself, into the dynamics that lie behind what you feel, what you perceive, what you value, and how you act. It is a journey through your defenses and beyond so that you can experience consciously the nature of your personality, face what it has produced in your life, and choose to change that" (Zukav, 1989. p. 147). Further, Zukav contends that not only is each person evolving through his or her decisions but the entirety of humanity is affected as well. He goes on to say that "As you face your deepest struggles, you reach for your highest goal." (Zukav,

1989, p. 160). These ideas, predominantly based on anecdotal evidence, are congruent with the views expressed by many of the 41 family survivors of youth suicide who participated in this study.

Summary

The theory presented in this dissertation has been shaped by the stories shared by survivors of youth suicide. The stories serve witness to the human capacity to move toward healing following youth suicide. To help navigate their healing journey, survivors characteristically developed several individualized healing strategies. Initially, these strategies helped survivors maneuver within their private worlds. As survivors became comfortable with their way of being in the world without the deceased youth, they developed healing strategies that focused on helping others within the broader community. The extent to which healing occurred was dependent on four Healing Within Families 190 intervening variables or healing characteristics that addressed the survivors' capacity to respond in growth-promoting ways to youth suicide. Finally, the outcome of the healing journey was represented by the creation of a Love Knot, enacted through the use of healing strategies which were symbolic of the meaning survivors attributed to youth suicide and the ongoing bond between survivors and the deceased youth.

A theory of individual healing following youth suicide is presented. Within this theory, individual healing is viewed as a journey characterized by the inter-relationships among three enfolding, dynamic, fluid, and iterative healing themes (i.e., Cocooning, Centering, and

Connecting). Movement towards healing depends on the individual's capacity to journey from a state of transition to transformation, and ultimately to transcendence. Although all survivors have the potential to move toward healing, only those who undergo positive transformation (i.e., the majority of the survivors in this study) in relation to youth suicide move toward healing. Others remain in a state of inertia with the ever present capacity to move toward healing.

The relationship between healing and grieving is clarified. According to study participants, healing is more than grieving. Individual healing emanates from the survivor's consciousness as an act of volition. Healing prompts survivors to review other aspects of their lives in addition to youth suicide. Healing also involves social responsibility, in that those who experience healing are required to help others in similar circumstances. This theory fills a gap in the existing literature on healing and clarifies, to some extent, the empirical evidence that describes the healing process. On a practical level, the findings of this study might well serve as a basis for evidence-based practice.

This dissertation concludes with the implications for health-focused practice addressed in the next chapter. According to all traditions, the rope symbolizes ascent. It not only represents the means but also the desire of rising up to the heavens, whether physically or spiritually. The silver rope designates the sacred way which is inherent in man's consciousness and which links his mind to the universal spirit. It is the way to concentration through meditation. Often used as a magical artifact it also represents anything which links the earth to the sky. As the Japanese consider it as a protective symbol they place it in the Shintoist temples, in the rings of sumo wresting matches or on the doors of all the houses in the first week of the new year. But as the symbol of a double union, the one between Earth and Heaven, and that between initiates, linked by their shared knowledge, the rope only finds its meaning in the knots that make its use possible. (Petzl, 1998. p. 40) Healing Within Families 191

CHAPTER NINE

HEALING WITHIN FAMILIES FOLLOWING YOUTH SUICIDE:

IMPLICATIONS AND CONCLUSIONS

Sadness flies on the wings of the morning and out of the heart of darkness comes the light.

(anonymous)

As the dawn of a new millennium approaches, we find ourselves at a turning point in relation to the silent crisis among normal male youth in society (Pollack, 1998). Increasingly, our youth are turning to suicide as a means of resolving life's unbearable problems. The ultimate toll of such tragedy on the individual, family, community, and society is staggering. At the societal level, youth suicide evokes ideas about health and social systems that have failed to provide adequate services to families and communities; at the individual level, it stirs within family members a sense of profound sadness. This barrage of violence has been costly in terms of young lives being

"snuffed out in the blink of an eye," as one father commented, and families being left to cope with horrendous and horrific loss. Indeed, families who have endured youth suicide undergo tremendous hardship. Yet, despite much suffering, survivors who participated in this study frequently spoke of healing in response to their experiences. A theory of healing was developed from the stories shared by study participants following their experiences with youth suicide. I now turn to considering some implications stemming from this theory of healing.

Healing is conceptualized as Journeying Toward Wholeness. Influenced by several contextual factors, the healing journey is characterized by three ongoing, dynamic, and recursive healing themes, specifically: Cocooning, Centering, and Connecting. Each healing theme contains five healing patterns, each descriptive of one facet of the survivors' overall experience with youth suicide. The extent to which healing occurs depends on the survivors' capacity to respond to such adversity by deciding to move toward healing. Those who move toward healing create a love knot, symbolic of healing strategies that enable them to maintain a continuing bond of love with the deceased youth.

Although findings of this study are in some ways consistent with other accounts of healing mentioned in the popular press and empirically-based literature, this substantive theory brings into focus the resilient capacity of family survivors whereby they are able to draw upon their innate strengths and coping capabilities in times of great need. A major finding of this study suggests that as family survivors move toward healing, they readily assume responsibility for their health by making health-promoting decisions and engaging in healing activities. The study's contribution lies in its description of the healing process as a health-focused response to adversity. Documentation of this process assists in filling a gap related to our understanding of the empirically-based literature on healing. Although primarily focused on the individual, this study is situated within the context of grieving families. Hence, its relevance to family theory is that it addresses the influence of grieving family survivors on one another, and how their influence facilitates or impedes the healing process. By situating and studying the healing process within the context of the broader health and social structures within society, the findings have theoretical relevance because our understanding of this dynamic and complex process is enhanced. Further, from a health promotion standpoint, this theory lends credence to the idea that, indeed, survivors are capable of taking responsibility for their health, even in the face of tremendous misfortune.

In this chapter, in keeping with the health promotion philosophy addressed earlier in this dissertation, I discuss the implications for health care practice and research. These recommendations are not discipline specific; rather, they are offered to all those working closely with families, especially those engaged in rural health care practice. The implications of this study Healing Within Families 193 may be relevant to health care professionals working in the areas of nursing, medicine, social work, education, theology, addictions counseling, health promotion and community development, counseling psychology, and sociology.

Implications for Health Promotion Practice

At the very least, healing following youth suicide is a difficult and infinitely complex topic.

Yet, if we intend to facilitate healing among family survivors, we need to reflect on our own views of health and the ways in which our perspectives influence the care we provide. In our approach to working with bereaved families, do we capitalize on the many possibilities for promoting health and wellness, or do we tend to focus on illness and dis-ease? Do we direct the main thrust of our efforts toward the "solution," or the "problem?" Do we see youth suicide in relationship to our own lives, or do we remove ourselves from it with distancing behavior and rhetoric? Is youth suicide our problem in a collective sense, or someone else's problem? Are we free from bias, or are we judgmental? Do we offer "professional advice" to those who have endured this tragedy in their lives, or do we listen and learn from the stories of those who have been there? Our approach to working with individuals and families, to a great extent, influences their health and well-being and determines their capacity for dealing with adversity.

Within this section, health is viewed as "the ability to intervene on one's own behalf (B.

Shawanda, personal communication, May 28, 1998). Based on study findings, implications specific to three areas of health promotion practice are discussed, including: understanding the healing process; creating community-based partnerships; and working with rural-based families. In turn, each of these areas is addressed with respect to implications for health-focused practice.

Understanding the Healing Process

Within the Western world, despite an intensified focus on suicide prevention, the incidence of youth suicide continues to soar. Within the last three decades, substantial contributions in the area of youth suicide prevention have been made (for example, see Dyck & White, 1998; Masecar,

1998; White, 1998; Tierney, 1998), and these efforts must continue. Even though statistics fail to Healing Within Families 194 reflect the upheaval that youth suicide casts in its wake, the undeniable fact remains—many families are faced with the daunting challenge of "picking up the pieces" of their shaken and shattered lives following youth suicide. As health care professionals, our mandate is to promote the health and healing of those entrusted to our care. To achieve this end, we need to practice in ways that support the development of human potential. Furthermore, we need to remain open to new ideas to ensure that our knowledge keeps pace with consumer demand and the changing trends in health care practice.

The interpretation and discussion of participants' stories point to a need for the creation of new venues for learning about the healing process. Worthy of note, a renewed receptivity toward health-promoting ideas has recently occurred within the Canadian government. The Canadian

Minister of Health, the Honorable Allan Rock, has just announced the government's acceptance of all 53 recommendations contained in the report of the Standing Committee on Health entitled

Natural Health Products: A New Vision (1998). This means that previously dismissed natural health practices including herbal medicine, ayurvedic medicine (India's traditional medicine that believes that essentially life is immortal; Chopra, 1993), and native American medicine are now being acknowledged as valuable alternatives in the constantly expanding repertoire of health-related options available to health care consumers. To successfully implement these recommendations, additional educational programs will be required. In keeping with this move toward the use of non• medical treatment modalities, findings of this study support the need for educational programs designed to enhance health care professionals' understanding of the healing process.

The literature contains a great deal of healing-related information. While the idea of the triune nature of humankind (i.e., mind-body-spirit) has been espoused by philosophers and clinicians (Brown-Saltzman, 1994; Carlson & Shield, 1995; Dombeck, 1995; Gawain, 1997;

Goleman, 1997; Hay, 1994, 1998), the reality of the basic vibratory essence of life confirmed by quantum physicists (Chopra, 1989, 1993; Gerber. 1988; Myss, 1996, 1997), and the spiritual dimension of health care described by many (Dyson, Cobb, & Forman, 1997; Goldberg, 1998;

McSherry & Draper, 1998; Martsolf & Mickley, 1998; Sodestrom & Martinson, 1997; Sumner,

1998), the relevance of these ideas to the overall health and well-being of bereaved individuals and Healing Within Families 195 families has not been clearly demonstrated in practice. To address this concern, health care professionals need to work with curriculum experts to ensure that these healing-related topics are systematically included in curricula within professional schools. As a suggestion, a formal course on Health and Healing could be introduced within professional schools as one way of providing updated scientific, and empirically-based information about health and healing, and as a forum for discussing ideas about ways to improve practice.

A Health and Healing course could be taught by a multidisciplinary team (including professionals from nursing, medicine, counseling psychology, social work, and so on) to a multidisciplinary group of learners. As one component of this course, the subject of death might be introduced from a health promotion perspective. From this philosophical viewpoint, it would be possible to better assist family survivors as they move toward healing following youth suicide.

Both personal and theoretical perspectives need to be included as part of the educational experience. It would be helpful to provide learning opportunities for professionals working with families that would increase their understanding about their own concerns and/or issues related to death in general, death as a result of suicide, and death that involves young people. Such awareness could be gained by using a variety of interactive teaching strategies, for example, role playing, case studies, and family-focused, context-based learning experiences.

As indicated by survivors in this study, storytelling may be integral to the healing process.

In this respect, health care professionals may need to further refine their capacity to actively listen to stories shared by traumatized persons. Refinement of this high-level skill has often been overlooked in professional education. The development of this skill is an art that requires great sensitivity and considerable skill. Listening to survivors share their pain-filled stories is not easy because of what these accounts stir within the listener. To acquire proficiency in the development of this skill, thought might be given to accessing the expertise of mental health professionals from a variety of disciplines (e.g., clinical nurse specialist, clinical psychologist, social worker) to assist in teaching this segment of the course.

Topics for inclusion in such a course might include: historical, philosophical, personal, and theoretical perspectives related to the major concepts (i.e., health, healing, and grieving); Healing Within Families 196 parameters for healing (e.g., individual—family—community^society); understanding concepts relevant to healing such as transition, transformation, and transcendence; the physiological examination of the human energy system; strategies for working with grieving families (e.g., storytelling); the study of cultural healing practices; as well as, an examination of alternative and complementary health care practices. From a pragmatic point of view, those working with bereaved families need to be cognizant of the vast armamentarium of resources that may be of help to individuals and families (e.g., the use of journals, prayer, dream analysis, meditation, imagery).

Education that prepares health care professionals to work effectively with these modalities ought to be included in such a course. Study participants indicated that this content may be important to the healing process.

Understanding the healing process also entails learning about grieving, in that grieving is necessary, but not sufficient for healing. It is important for health care professionals to be aware of the newer theories of grieving (Attig, 1991, 1996; Klass, Silverman, & Nickman, 1996;

Rosenblatt, 1996). These theories validate the normalcy of survivors developing an inner representation of the deceased person and the importance of survivors forming continuing bonds with the deceased individual (Silverman & Nickman, 1996). The theory that emerged from this study, congruent with these newer theories of grieving, suggests that survivors who move toward healing form a continuing bond of love with the deceased youth. This finding is important for practice. It reminds us that we may need to offer understanding and support to survivors, as well as practical suggestions about healing strategies, discussed in the previous chapter, that have been successfully used by others in similar circumstances as a means of maintaining a bond with the deceased youth.

Health care professionals also need to understand that, without an opportunity for expression, grief may be held "at the cellular level" (B. Shawanda, personal communication, May

28, 1998) for long periods of time. Findings of this study confirm that survivors may even experience temporary "craziness" in relation to being traumatized. We need to be mindful in our interpretation of this phenomenon. We ought to refrain from labeling survivors who demonstrate this characteristic; instead, we need to focus our efforts on understanding the meaning that certain Healing Within Families 197 events and situations hold for survivors—we need to listen to their stories. While the frequency of the pain related to youth suicide generally lessens over time, according to survivors in this study, the intensity of the pain may not decrease. This means that family survivors may occasionally and unexpectedly experience intense emotional responses to trigger events. For instance, the intensity of survivors' feelings is likely to be magnified at certain times, for example, on the deceased youth's birthday, on the anniversary of the suicide, and at Christmas. The expression of intense emotion during these times needs to be viewed as a healthy and necessary part of both the grieving and healing processes.

Gaining an understanding of the healing process could also be accomplished by developing face-to-face continuing education courses and information sites. Based on an assessment of educational needs and interests, a seminar series focusing on health and healing could be offered in both rural and urban settings for those currently involved in professional practice. This option may appeal to health care professionals who learn best through face-to-face interaction. Another possibility with potential is the development of a web-based course (for interest or credit) for health care practitioners. As part of this course, and as an adjunct to professional practice, a list of current resources specific to health and healing could be compiled and made available. These resources might include: current books and journal articles specific to health and healing; names and addresses of professionals who specialize in complementary health care practices; and web addresses for locating information about health and healing. In addition, a web-based information site geared toward the general population might provide a springboard for further learning. This medium could then serve as a broad-based means of educating the general public and health care providers about complementary approaches to health care.

The ultimate benefit of learning about the healing process is improved health care practice.

As indicated by study findings, following an extensive period of sorting and sifting through their experiences, survivors knew what they needed to do to achieve healing for themselves. This finding suggests that health care professionals need to be guided by the expressed wishes of survivors, trusting that they themselves know what is best for them. Informed by this theory, health care professionals would understand the characteristic fluidity and uniqueness of the healing Healing Within Families 198 process. They would then be in a position to support survivors of youth suicide by acting in their capacity as client advocates and catalysts who facilitate healing. For example, advanced nurse practitioners who work closely with families are strategically placed within the health care system to facilitate healing by encouraging survivors to share their stories. Further, these highly skilled professionals may be able to create opportunities for survivors to raise the level of consciousness about youth suicide and its impact on families within the broader community.

Creating Community-based Partnerships

Survivors of youth suicide not only face significant personal loss, they are also confronted with another major problem—that of grieving in an environment that is not conducive to the open expression of grief following death, particularly death by suicide. Within our death-denying and death-defying society, grieving seems to be tolerated by most people, at least for a short amount of time and for certain types of death. However, such tolerance is frequently lacking in cases of youth suicide. There is a societal expectation that the family will look after its own, and when a family youth takes his own life, the family is often blamed. However, families are systems that live and grieve within a broader community. Survivors in this study commonly felt silenced and isolated from others and stigmatized as a result of the suicide of a family member. As well, an important finding of this study is that healing may ultimately depends on the survivor's capacity to connect with others and with life once again. Therefore, the idea of creating caring community partnerships might be considered. One example of a community-based partnership is the development of a family-centered suicide response team. This team could intervene soon after the tragedy by providing each family survivor, and especially bereaved siblings, with individualized care.

Understandably, members of the response team would need to possess grief counseling and crisis intervention skills. In addition, it would be helpful if members of the team understood the healing process. Another intervention that could be implemented is the formation of a community-based data base as a systematic method of linking these families with one another. Prior to implementation, willing partners would need to provide informed consent. The suicide response team might assume responsibility for compiling a list of families that could be kept at a designated Healing Within Families 199 social service agency. A member of the suicide response team might then be charged with the responsibility of informing bereaved family members about this resource. Importantly, this information would be helpful to families without previously established links in the community.

Survivors of youth suicide indicated that telling their stories was integral to their healing.

Hence, another strategy that might be considered is the implementation of a community-based telephone hot line for suicide survivors. This strategy will protect survivors' anonymity and, at the same time, enhance the healing process by providing them with opportunities to share their stories.

In order to be of assistance to families, health care professionals need to understand the issues that confront those to whom they provide care. To promote understanding, consideration might be given to bridging partnerships between family survivors and health care professionals.

For instance, a small group of health care professionals could attend a Suicide Support Group and offer to lead a focus group session for the purpose of identifying issues of concern to family survivors. It will be important to create an informal and comfortable environment (e.g., perhaps serve pizza and beverage) in which survivors will feel free to discuss their views. As a step beyond talking about their experiences, this strategy will enable survivors to take charge of their lives by developing feasible solutions to their concerns.

Findings of this study imply that it is important for survivors to find ways of giving back to their communities and to society. One way to accomplish this is to create opportunities for survivors to help youth succeed in life. A small group of health educators and social service professionals could form partnerships with interested youth, including those who have been personally affected by youth suicide, for the purpose of identifying issues and concerns that confront young people today. In particular, it will be important to identify the issues that might cause a youth to end his or her life. To increase the effectiveness of this intervention, attention and effort will need to be directed toward building rapport with participating youth, and creating a comfortable climate where they will feel free to express their views. Typically, as citizens and as professionals in society, we tend to shelter our youth from discussions of this sort. However, we might re-consider our protective stance. To effect change, the problem needs to be identified. Once Healing Within Families 200 the problem is identified, youth, working in collaboration with health care professionals, could work toward developing viable solutions to their concerns.

Another alternative for consideration is the introduction of a life-skills segment that addresses youth suicide within existing school programs. In the past, such education has been provided on a hit-and-miss basis, and considered by some individuals to be 'a frill.' Change is imperative. Education about youth suicide and its impact on the family needs to be incorporated within the core curriculum of school programs. In addition, other partnerships that draw on the expertise of community service professionals may also be highly effective. These kinds of partnerships will be advantageous to all. Youth will benefit by developing constructive problem- solving skills for dealing with life's unbearable problems. Moreover, this health-focused approach will facilitate the healing of youth by establishing a means for them to help both themselves and others. Involvement of this sort will also help youth realize the far-reaching consequences of suicide, and especially its impact on the family. Similarly, health care professionals will be alerted to the concerns of today's youth which will allow them to use their expertise wisely.

A word of caution may be necessary. Prior to undertaking a venture such as this, professionals may need to prepare themselves for what they might hear from these youth. As

Pollack (1998) contends, youth in Western society often suppress their pain. Seldom have they experienced opportunities to learn how to appropriately express their pain. At a community level, minimal emphasis has been placed on talking with youth about their issues and, in particular, talking about the issues that cause them pain. Unexpressed pain often manifests itself as fear, and violence takes over when fear replaces love. For example, youth often experience tremendous pain in relation to bullying which occurs in schoolyards across our country. Increasingly, ostracized youths are applying an irreversible solution (i.e., suicide) to a reversible problem (i.e., seemingly unbearable pain).

Our health care system reflects the interests and values of the dominant sector within society (Varcoe, 1997). Moreover, the efficient delivery of health care services remains a priority within the health care system. Congruent with this status quo position, low priority is accorded to family survivors of youth suicide and health care professionals focus their efforts on the efficient Healing Within Families 201 processing (Varcoe, 1997) of those who seek health care services. To some extent, this over• emphasis on efficiency has obscured our prime purpose—the delivery of 'effective care.' For example, within our health care agencies and institutions, the major emphasis remains on treatment and cure. Lesser value is accorded to listening to stories of bereaved family survivors. This aspect of practice requires change. We need to work toward change by taking the first step.

As health care professionals, we must raise the level of consciousness within society about youth suicide and its impact on the family, and advocate for change that places a priority on the health and well-being of family survivors. Since loss issues are often at the root of many health problems, the importance of facilitating healing among survivors of youth suicide cannot be overstated. To effect change within the health care system, the creation of community-based partnerships might be considered. The formation of partnerships comprised of families, health care professionals, and policy-makers have the potential to develop 'yet to be imagined' strategies for improving health care delivery to this growing segment of society. Some suggestions for consideration include: increasing exposure to this societal health problem through a variety of media including newspaper articles that address the family's perspective on youth suicide; television talk shows in which families share their experiences; in addition to motivated and interested groups (e.g., family members and health care professionals) speaking at local community organizations, and soliciting survivors' help with regard to ways of mobilizing community resources to facilitate healing within families following youth suicide.

Working With Rural-based Families

Although families from both urban and rural locations were invited to participate in the study, eight of the eleven families resided in rural locations. Hence, the findings of this study provide some insight for consideration when working with rural family survivors of youth suicide.

It is important to remember that survivors are not only healing psychic wounds, they are also striving to be heard within a society that upholds the "no talk rule." In addition, they are endeavoring to help others who face similar circumstances. Health care professionals play a key role in terms of facilitating healing by helping mral family survivors gain access to needed health Healing Within Families 202 care services, and supporting them as they re-connect with life and living once again. In particular, rural folks face unique challenges in terms of the availability, accessibility, and acceptability

(Bushy, 1994b) of health care services.

The availability of appropriate health care services in rural areas is influenced by limited economic resources (Keller & Dunkel, 1995). This suggests that rural health care professionals need to take a leadership role in the implementation of cost-effective ways of delivering needed health care services to rural survivors. As a suggestion, rural family survivors might find it useful to use computers as a cost-effective means of creating awareness about rural youth suicide and its impact on the family, and as a way of initiating much needed dialogue. In spite of the costs associated with setting up a supportive infrastructure, this strategy will facilitate healing by giving voice to those who have been inadvertently silenced.

Health care professionals also need to be politically active in terms of lobbying to secure needed government funding to ensure the availability of resources for families living in rural areas.

For example, Canadian Aboriginal family survivors, most of whom live in rural areas, are often left on their own to manage in the aftermath of youth suicide. Lacking the availability of needed resources, these families inadvertently transmit their pain and suffering to subsequent generations.

Eventually, these families become multi-generational families of trauma (B. Shawanda, personal communication, May 28, 1998). Serious thought must be given to averting the possibility of this situation. Personnel resources are needed to help those who have experienced youth suicide move toward healing. Securing adequate funding to ensure that resources are readily available within rural communities will be a first step toward improving the situation.

Even though rural residents deserve barrier-free access to health-care services, they may be denied access due to the unavailability of highly qualified personnel in rural settings, or the prohibitive cost associated with obtaining such services. For some survivors, the use of computers may offer some solution to this problem: as an interactive communication medium, computers can not only increase the amount of support available to suicide survivors in rural areas, they may also increase survivors' awareness of health care services currently available, as well as gaps in service. Healing Within Families 203

Ultimately, rural survivors who have experienced youth suicide play a pivotal role in identifying gaps in service and planning subsequent health-promoting interventions (Brown, 1990).

Health-care services provided to bereaved families need to be congruent with the unique needs of rural residents. Sensitivity must be demonstrated with respect to lifestyle constraints, belief systems, and the environmental context within which rural people live. Of major importance, mral people need to be involved in the planning and implementation of interventions affecting them. Whether these interventions include provider-community partnerships (Bushy, 1995 ), school-based health-care services (Whitener, 1995), community-wellness programs (Jenkins,

1991), informal rural-based support networks for survivors of suicide, or computer-mediated means of communicating with others facing similar circumstances, it is imperative that those affected are empowered to create and re-create health for themselves and their families. Health care professionals must not assume that health care interventions that work well in urban centers can simply be transplanted to mral communities.

Health care professionals need to be aware of the healing process in order to facilitate individual growth and healing. In turn, such understanding has the potential to influence the healing of families, and the larger community. A major finding of this research study indicates that health care providers can also offer support to mral family survivors of youth suicide by providing them with practical suggestions about specific healing activities that others have used successfully in similar situations. In particular, health care professionals can facilitate healing by supporting and encouraging each survivor of youth suicide to create a love knot—the symbol of a healthy, unique, and meaningful bond with the deceased youth.

Implications for Future Research

This study documented the individual healing process as experienced by family survivors of youth suicide. Findings of this study suggest that survivors have the potential to move toward healing in the aftermath of youth suicide, however, some individuals do this more expeditiously than others. As this process is only beginning to be understood, further research to generate knowledge about the healing process is warranted. For example, in addition to replication studies Healing Within Families 204 with urban families that have experienced youth suicide, investigating the idea of healing as an act of volition is suggested. The Healing Patterns that emerged from this study (i.e., relating, thinking, functioning, energizing, as well as finding meaning and exploring spirituality), especially as they relate to the healing process, also require further clarification and refinement. Since both the energizing and finding meaning/exploring spirituality patterns were central to participants' healing experiences, these two areas require further investigation.

Since scientific knowledge related to healing within families following youth suicide is limited, further research could take a number of different directions. Understanding the mechanism by which families influence the healing process is identified as an area worthy of further exploration. It is anticipated that such a study might unveil findings that could be used to design interventions to enhance family nursing practice. Survivors from nine of the eleven families described their families as "intact." To further examine the family's influence on the healing process, the next step is to design a comparative research study with both intact and non-intact families. The relational aspect of family life and survivors' propensity to move toward healing also emerges as an important area for further inquiry. This research study was limited in terms of family type and ethnic background. Therefore, longitudinal studies that consider the influence of contextual factors while focusing on the healing processes of specific populations would also enrich our understanding of this complex phenomenon. For example, studies that focus on individual healing following youth suicide could be undertaken with populations from diverse family constellations and ethnic backgrounds.

In this study, all of the deceased youths were male. Studies that investigate healing in families where female youths ended their lives have the potential of further expanding this theory.

Bereaved siblings in this study characteristically dealt with their pain by 'acting out.' Inquires specific to this grieving population are needed so that early and appropriate interventions can be designed and implemented.

Prior to this study, survivors from two different families had endured multiple losses (e.g., loss due to death, loss of health, loss of a significant relationship). Subsequent studies that specifically address the healing process following multiple losses would serve to fill a gap in our Healing Within Families 205 understanding of the healing process, which in turn, would expand the existing knowledge base in the loss and bereavement literature. For instance, inquiry might be directed toward exploring how grandparents heal following the suicide of a grandchild in addition to the loss sustained by their own child. Another possibility is to study healing from the perspective of families who have experienced multiple suicides. Comparative studies that account for the influence of contextual factors while investigating the healing processes of other traumatized families (e.g., sexual abuse survivors, survivors of natural disasters, and survivors of life-threatening illness) might further elucidate the dynamic nature of the healing process. Investigations that address the links among individual, family, and community healing would further add to the health promotion and community development literature. Of practical significance, the results of such inquiry could be used to design much needed interventions that promote the health and well-being among family survivors of youth suicide.

Conclusion

Within the Western world, despite a significant emphasis on prevention, the incidence of youth suicide during the past three decades has sky-rocketed, forever changing the lives of family survivors. In the aftermath of youth suicide, families are commonly left to manage on their own. In response to such catastrophe, characteristically, survivors tap into their innate strengths and coping capabilities. Eventually, most family survivors move toward healing. Precipitated by youth suicide, individual healing was found to be a contextually-mediated, ongoing, dynamic, and recursive process. Most often initiated by a family survivor who was emotionally and spiritually close to the youth prior to suicide, healing emanated from the survivor's consciousness as an act of volition. This study brings to light the idea that bereaved survivors of youth suicide heal in response to the decisions they make and the healthy bonds they create and maintain between themselves and the deceased youth. This study's findings also suggest that family survivors have the capacity to act as catalysts to facilitate the healing of other family members.

The challenges that confront family survivors of youth suicide are enormous. Yet, we need not underestimate their capacity to deal with one of life's great tragedies. In the face of such Healing Within Families 206 adversity, survivors experience a "broken-hearted tender vulnerability" (Nixon, 1992, pp. 163-

164) that enables them to get in touch with the very essence of their humanity, and the fact that "life that is fragile, impermanent, and precious" (Nixon, 1992, p. 164). Essentially, survivors embark on a venture of Journeying Toward Wholeness. During this voyage, not only do many of them experience transformation, many survivors encounter transcendence, tantamount to moving beyond the negativity associated with their experience, and ultimately connecting with others and with life once again. The theory presented in this manuscript is still in its early stages of development. Thus, it is offered for further theory development to eventually improve health care delivery to family survivors of youth suicide. With its focus on health promotion, this theory captures some of the intricacies and complexities of the healing process and is intended to serve as a possible reference to guide evidence-based health care practice. Healing Within Families 207

When somebody dies, a cloud turns into

an angel, and flies up to tell God

to put another flower on a pillow.

A bird gives the message back to

the world, and sings a silent prayer

that makes the rain cry. People dis•

appear, but they never really go away.

The spirits up there put the sun to

bed, wake up the grass, and spin the

earth in dizzy circles. Sometimes you

can see them dancing in a cloud during

the day-time, when they're supposed

to be sleeping. They paint the rain•

bows and also the sunsets and make

waves splash and tug at the tide.

They toss shooting stars and listen to

wishes. And when they sing wind-

songs, they whisper to us, don't

miss me too much. The view is nice

and I'm doing just fine.

(Ashley)

This poem was shared with me by one of the mothers and it brought her a great deal of peace. Healing Within Families 208

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APPENDIX A-l Healing Within Families 228

APPENDIX A-l

Sample Genogram Taylor Family, November, 1996

D I ROSE A if CANCER DEPRESSED TRUCK DRIVER HOMEMAKER

JAMES ( LYNN A 17

GRADE 11 GRADE 8 UNEMPLOYED

KEY

MALE

o FEMALE \~7 or 0 DEATH hO <5 CHILDREN ATTENDS / DAYCARE • IDENTIFIED PERSON D s DIVORCED CL o COMMON-LAW

(McGoldrick, 1982) Healing Within Families 229

APPENDIX A-2 APPENDIX A-2

Sample Ecomap — Taylor Family, November 1996

BOYFRIEND!

BROTHER JAMES FAMILY OR 17 HOUSEHOLD

FATHER / TYLER CL ANN 1994 18 \

UPGRADING

JASON 10 mo.

DAYHOME

KEY MALE o FEMALE

ATTACHMENTS: STRONGLY ATTACHED

MODERATELY ATTACHED

SLIGHTLY ATTACHED

VERY SLIGHTLY ATTACHED

NEGATIVELY ATTACHED (McGoldrick, 1982) Healing Within Families 231

APPENDIX B Healing Within Families 234

APPENDIX C Healing Within Families 235

APPENDIX C Healing Within Families 236

APPENDIX D Healing Within Families 237

APPENDIX D

Interview Guideline

The following questions will serve to guide the proposed research study:

Questions for individual family member interview:

1. Tell me about your life since X committed suicide. What has this experience been like for you?

2. What does healing mean to you? Generally, how does healing occur for your? Does the term "healing" have any significance to you in relation to your experience with X's suicide? Can you please tell me more about this?

3. What sense can be made of (name of the X's suicide from your perspective? What is the meaning of X's suicide to your family?

4. How did you heal following X's suicide? Can you provide some specific examples? For instance, what was most helpful to you? What was least helpful to you?

5. What is it that I have not asked about, but is something that I need to know about?

6. In terms of everything that we have talked about, what do you consider to be most important? Please help me to understand this.

7. Is there anything that you would like to add to our conversation?

Questions for family interview: 1. Tell me about life in your family since X committed suicide. What has this experience been like for your family?

2. What does healing mean to your family? Generally, how does healing occur for your family? Does the term "healing" have any significance to your family in relation to your family's experience with X's suicide? Can you please tell me more about this?

3. What sense can be made of X's suicide from the perspective of your family? What is the meaning of X's suicide to your family? How does your family make sense out of what has happened to them specific to the suicide? 4. How has your family healed since X's suicide? Can you provide some specific examples? For instance, what was most helpful to your family? What was least helpful to your family? 5. What is it that I have not asked about, but is something that I need to know about? 6. In terms of everything that we have talked about, what do you consider to be the most important? Please help me to understand this. 7. Is there anything related to your family's healing process since X's suicide that anyone would like to add to our conversation? Note: Other questions may arise during these interviews, based on sensitivity to the expressed needs of informants, and the evolving nature of the anticipated dialogue. Healing Within Families 238

APPENDIX E Healing Within Families 239

APPENDIX E

Oath of Confidentiality

In participating in this research project, "Family Healing Following Adolescent Suicide," I agree to respect the confidentiality of the information that I will be working with. I will neither identify, nor will I discuss with anyone, other than Ruth Grant Kalischuk, the contents of the interviews.

Research Assistant Date Healing Within Families 240

APPENDIX E

Oath of Confidentiality

Secretary Date Healing Within Families 241

APPENDIX F Healing Within Families 242

APPENDIX F

Demographic Questionnaire

Family Member Number:

Number of individuals in the family:

Genogram obtained Yes No

Ecomap obtained Yes No

Demographic Data:

Age: Gender: (as of July 1, 1996)

Marital status: Length of marriage:

Occupational status:

Current health status (as described by individual): .

Please rate your yealth status:

• excellent • very good • good • fair • poor

Household income: Ethnicity:

Relationship to adolescent suicide victim:

Date of the adolescent suicide: .

Details of Observation:

Dates of observations:

Dates of interviews: