SUICIDE BEREAVEMENT CLINICIAN TRAINING PROGRAM

Morgan Forum Series Presents:
SUICIDE BEREAVEMENT
CLINICIAN TRAINING PROGRAM
Wednesday,
April 1, 2015
9:00 am—4:30 pm
Developed in Collaboration with:
The American Association of Suicidology
The American Foundation for Suicide Prevention
Northeast Ohio Medical University Education and Wellness Center
4209 State Route 44  Rootstown, OH
The suicide of a loved one can have a profound and sometimes
devastating impact on those left behind, called suicide survivors.
Bereavement after suicide may entail high levels of disorientation,
guilt, regret, anger, shame, and trauma. Survivors sometimes also
find their relationships with other people changed, as they struggle
with the social stigma often placed on suicide, and the altered
family relationships that have been changed by the feelings of guilt,
blame, and failure that suicide may engender. Survivors may also
be at risk for elevated rates of complicated grief and future
suicidality themselves. All of this makes surviving the suicide of a
loved one a potentially life-transforming ordeal that requires a level
of support that goes beyond traditional grief counseling. Yet very
few mental health training programs devote any time to training
clinicians about the challenging work of suicide postvention –
helping survivors cope with the tragic loss.
This workshop will provide a focused overview of the impact of
suicide on survivors, and the clinical and support responses that
are needed after a suicide occurs. The workshop will include
didactic presentation, group discussion, case examples from the
presenter’s practice, and video clips from grief therapy sessions.
Topics to be covered will include:
• the psychological impact of suicide on survivors and
common themes in the bereavement of survivors
• the impact of suicide on family functioning
• what research with survivors tells us is needed
• the tasks of loss integration and recovery for survivors
• postvention options for survivors
• principles of postvention after client suicide
• principles of longer term clinical work with survivors
• examples of specific clinical techniques that can be of use
in grief therapy with survivors
Register Online Now: www.mcmfdn.org
John R. Jordan, Ph.D. - Instructor
John (Jack) Jordan is a
licensed psychologist in
private practice in Wellesley,
MA, and Pawtucket, RI,
where he specializes in
working with loss and
bereavement. He was also
the Founder and the Director of the Family
Loss Project, a research and clinical practice
providing services for bereaved families. He
specialized in work with survivors of suicide
and other losses for more than 35 years. As
a Fellow in Thanatology from the Association
for Death Education and Counseling (ADEC),
Jack maintains an active practice in grief
counseling for individuals and couples. He
has run support groups for bereaved parents,
young widows & widowers, and suicide
survivors.
For over 30 years, Jack has provided training
nationally and internationally for therapists,
healthcare professionals, and clergy through
PESI Healthcare/CMI Education, the
American Foundation for Suicide Prevention,
and as an independent speaker. He has also
helped to organize and lead dozens of
healing workshops for suicide survivors.
There is no cost to attend this
event, but registration is required.
Space is limited!
AGENDA
8:15 am Arrive and sign-in
9:00
Introduction & Suicide Survivors: Who Are They?
10:45
Understanding the Impact of Suicide Loss
12:15 pm Lunch (provided)
1:00 What Can We Do to Help Survivors?
2:45 Grief Therapy with Survivors
4:30 Adjournment
Objectives:
1. Offer a working definition of a suicide survivor
2. Identify at least five common themes in the impact of suicide on survivors
3. List tasks of psychological re-integration after suicide
4. Describe several options for intervention with survivors
5. Describe three categories of clinical technique with survivors.
Continuing Education
OhioMHAS Continuing Education Committee is an approved provider of Continuing Education for RNs and LPNs for the
Ohio Board of Nursing and has awarded 6.25 CE contact hours per OBN003 92-1885CO.
OhioMHAS has been approved as a provider of Continuing Professional Education credit by the Ohio Counselor, Social
Work, Marriage and Family Therapist Board. 6.25 CEs have been awarded to Social Workers per RSX088902-2109CO
and to Counselors per RCX068915-2093CO
OhioMHAS is approved by OPA-MCE to offer continuing education for Psychologists. 6.25 MCEs are awarded per
311334820-1280CO.
OhioMHAS is approved by the Ohio Chemical Dependency Professionals Board to offer recognized clock hours for
chemical dependency counselors and prevention professionals. The provider approval number is 09-1315-64PVNR for 6.25 RCHs.
To find out more about this workshop, contact:
Victoria Romanda  330-655-1366  vromanda@mcmfdn.org
The Margaret Clark Morgan Foundation
Phone: 330-655-1366
www.mcmfdn.org
Register Online Now: www.mcmfdn.org
This event is planned in partnership with:
John R. Jordan, Ph.D. - The Family
Loss Project
SUICIDE BEREAVEMENT
CLINICIAN TRAINING
PROGRAM
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Presented By:
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SUICIDE BEREAVEMENT
CLINICIAN TRAINING
American Association of
Suicidology – www.suicidology.org
American Foundation for Suicide
Prevention – www.afsp.org
Instructor:
JOHN R. JORDAN, PH.D.
Pawtucket, RI
Jjordan50@gmail.com
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John R. Jordan, Ph.D. - The Family
Loss Project
WORKSHOP OVERVIEW
Suicide Bereavement Clinician Training
Introduction
Suicide Survivors – Who are they?
The Impact of Suicide
What Can We Do to Help Survivors?
Grief Therapy with Survivors
Wrap-Up
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Workshop Educational Goals
At the end of this workshop, participants
will be able to:
Offer a working definition of a suicide
survivor
Identify at least five common themes in
impact of suicide on survivors
List tasks of psychological re-integration
after suicide
Describe several options for intervention
with survivors
Describe three categories of clinical
technique with survivors.
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FIVE QUESTIONS
A Guided Reflection
What is your own experience with
suicide?
Loss of a family member, friend,
colleague?
Loss of a client?
Attempts?
Work with suicidal clients?
Your own suicidality?
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John R. Jordan, Ph.D. - The Family
Loss Project
FIVE QUESTIONS (continued)
Why do people take their life?
Who is responsible when a suicide
occurs?
Can suicide be prevented?
Should suicide be prevented?
Rationale:
Important to be aware of your own attitudes
These are the issues with which survivors
struggle
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SURVIVORS – WHO ARE THEY?
Who Is A Survivor?
How Many Survivors Are There?
Are Survivors at Risk for Suicide?
Assessing Risk in Survivors
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Definition of a Survivor
Language
Suicide attempters vs. suicide survivors
Suicide survivor vs. bereaved by suicide
Previous Definitions
Exposure
Kin
Psychological proximity
A Broader Definition
“A suicide survivor is someone who experiences a
high level of self-perceived psychological, physical,
and/or social distress for a considerable length of
time as a result of the suicide of another person” Jordan & McIntosh, 2011
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John R. Jordan, Ph.D. - The Family
Loss Project
Cerel, McIntosh, Neimeyer, Maple, &
Marshall (2014) – “A Continuum of
Survivorship“
Bereaved, Long-term
Bereaved, Short-term
Affected by Suicide
Exposed to Suicide
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How Many Survivors Are
There? – Exposure vs.Survivor
Exposure - Crosby & Sacks (2002)
7% of U.S. population exposed in a year (21
million each year)
1.1% have lost a family member (3.3 million
each year)
Of those exposed:
3.2% lost immediate family
13.7% extended family
80.4% friend or acquaintance
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How Many Survivors Are
There? – Exposure vs.Survivor
Cerel, et.al. (2014)
40 % had known someone who
completed
64% had known someone who had
attempted or completed
20% self-identified as a survivor –
“affected by the suicide”
Psychological proximity predicted selfidentified survivorhood
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John R. Jordan, Ph.D. - The Family
Loss Project
Are Survivors at Risk for
Suicide?
Important Studies: Crosby & Sacks (2002); Qin, Agerbo, &
Mortensen (2005); Hedstrom, Liu, & Nordvik (2008); Spiwak,
et.al. (2011); Feigelman, Jordan, McIntosh, & Feigelman
(2012)
Summary
Risk of completion increases 2-3 fold over all kinship categories
Highest risk is a 46 fold increase for male spouses who lose a
spouse to suicide
Childhood loss of parent (particularly Mother) is a 3 - 5 fold
increase
Workplace (< 100) exposure involves a 3.5 fold increase
Parent survivors report of ideation (Feigelman, et.al.):
Almost 49% report ideation during first five years
18% still report ideation ten years or beyond
Mothers bereaved 5 or more years reported ideation at a rate that was
> 6 times the rate for a non-bereaved, demographically equivalent
sample of women
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Are Survivors at Risk for
Suicide?
Conclusions:
Survivors can be at elevated risk for
suicide
Survivors should be more vigilant, but
not terrified
Survivor families need help in
understanding and gaining perspective
on their increased risk for suicide
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Observations on Assessing
Suicidality in Survivors
Suicidality is not uncommon in survivors
Particularly ideation
Suicidality needs to always be
assessed in survivors
Distinction between:
Passive vs. active ideation
Tripartite Model (Sands, et.al. 2011; 2009)
“Walking in the Shoes”/ Identification with the
deceased vs. active suicidality
Assessing suicide risk (AMSR Training)
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John R. Jordan, Ph.D. - The Family
Loss Project
WHAT IS THE IMPACT OF
SUICIDE ON SURVIVORS?
What Are The Prominent Themes for
Survivors?
Are There Positive Effects of
Survivorhood
What Is the Impact On Families?
Post-traumatic Growth After Suicide
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Prominent Themes For Survivors
WHY? - Making Sense of the Death
RESPONSIBILITY - Guilt & Blame
Role of magical thinking
TRAUMA & HELPLESSNESS - Shock &
Horror
ANGER - Rejection & Abandonment
RELIEF - The End Of Suffering
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Prominent Themes For Survivors
SHAME - Stigma
SOCIAL AMBIGUITY – Isolation &
Social Disruption
SUICIDALITY – Why Go On?
SORROW – Grief & Yearning
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John R. Jordan, Ph.D. - The Family
Loss Project
Prominent Themes For Survivors:
Family Impact
Information Management – who and what to tell
Powerful impact of secrets on families
Disruption of family routines, rituals, & role
functions
Changes in role functioning
Changes in emotional availability
Changes in distance and power in relationships
Communication Shut-down
Perceived fragility of members
Anger/ conflict management
Coping Asynchrony - differences in grieving styles
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Prominent Themes For Survivors:
Family Impact
Blame/Scapegoating
Development of cut-offs and estrangement
Struggle to construct a shared narrative
Developmental anxiety about repetition
(esp. for parents)
Hypervigilence
Problems with developmental separations
“Are we cursed?”
Result = Loss of Family Cohesion
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Post-Traumatic Growth After
Suicide
Changed identity
Development of a survivor identity
Resilient & worthy of self-care
Changed relations with others
More priority on relationships
More expression of love/ affection
More compassion for others
Ending dysfunctional relationships
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John R. Jordan, Ph.D. - The Family
Loss Project
Post-Traumatic Growth After
Suicide
Changed outlook on life
Purpose – sometimes a new purpose
Greater appreciation/ gratitude
Deeper spirituality/faith
Hope
End result = psychological/spiritual
growth
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WHAT CAN WE DO TO HELP?
Tasks of Loss Integration & Goals of
Postvention Treatment
Postvention Options
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Tasks of Loss Integration &
Goals of Postvention
Containment of the trauma & restoration of
control
Bio-rhythms
Management of intrusive images, memories
Creation of a “narrative” of the suicide Psychological autopsy & sense-making
activities
To understand the mental state of the deceased
Sort out realistic responsibility for the death and
develop a realistic perspective about the multiple
causes
To learn to live with the “blind spot” – not having all
the information
Note: AAS has a training/certification in Psych. Autopsy
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John R. Jordan, Ph.D. - The Family
Loss Project
Tasks of Loss Integration &
Goals of Postvention
Self-dosing - Cultivating analgesia
and finding psychological sanctuary
For “grief pangs” & traumatic reliving
Dual Process Model of grief – Alternating movement
“towards” the grief and “away from” the grief
Learn social management skills
Eliciting support from helpful social
networks
Avoiding/managing “toxic” people
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Tasks of Loss Integration &
Goals of Postvention
Repair and transformation of the
relationship with deceased
Idea of “continuing bonds” in thanatology
Dis-identification with the deceased
Internalizing positive connection with the
deceased
Develop a “durable biography” of the
deceased
Cultivating memories from others
Honoring the life, not the death
Reinvestment in living – reactivation of the
“exploratory system”
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Postvention Options –
After Client Suicide: Family Contact
“Is contact with the surviving family legal?
Ethical? Can it be therapeutic? We believe that
the answers are yes, yes and yes, given certain
guidelines, clinical acumen, and care.”
McGann, V. L., Gutin, N., & Jordan, J. R. (2011).
Seek consultation for yourself
Notify your malpractice insurer
You may also want to contact an attorney for
yourself
May need to be a legally protected relationship if
concerned about litigation – therapist or attorney
Note: AAS website has Clinician – Survivor
resources
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John R. Jordan, Ph.D. - The Family
Loss Project
Postvention Options –
Family of a Client
Suggestions for a family meeting:
Express condolences
Offer psychoeducation about suicide
& grief (see resource list)
Help with “Why” questions (explain
limits on confidentiality)
Offer general observations on factors
related to client’s suicide
With permission of client’s legal
representative, discuss details of the
treatment that will be helpful in the
healing process
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Postvention Options –
Family of a Client
Assess family functioning and
concerns family members have about
each other
Help with planning for family’s needs,
including for Rx.
Should you treat the survivor family?
Offer to be available to help with
further questions, referrals
Offer to check back in at a later point
in time
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Postvention Options – Services
Survivor outreach programs
Family/Couples counseling
Support groups
Referrals – Online databases:
AFSP - afsp.org
AAS - suicidology.org
Other forms of survivor to survivor
contact
Activism
Individual therapy (see next slides)
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John R. Jordan, Ph.D. - The Family
Loss Project
GRIEF THERAPY WITH
SURVIVORS
Foundations – Attachment & Grief
Therapy
Roles of the Therapist
Use of Focused Techniques
Summary: Guidelines for Clinical
Work with Survivors
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Foundations of Grief Therapy
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An Orientation to Grief Therapy
Head & heart work
Medical vs. companioning models
Symptom focused vs. person focused
Technique vs. relationship
Diagnosis vs. relationship building
“Rules” of Therapy
Goal = Integration, not resolution
“Boulder” metaphor
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John R. Jordan, Ph.D. - The Family
Loss Project
Therapist as an Attachment Figure
Recall the Attachment Paradigm
Attachment figures serve as “Safe Harbor” &
“Secure Base”
Caregiver & child as attuned, resonating
system
Repair of empathic failures
Secure attachment results in internalization of
and allows separation from attachment figure
Child grows able to self-regulate, tolerate distress &
“self-soothe”
Insecure attachment results in one of three
attachment “styles”
Anxious (hyper-activation of attachment system)
Avoidant (deactivation of attachment system)
Disorganized
Observations on Attachment &
Grief Therapy
The literature on attachment informed
psychotherapy – (Schore, 2011; Obegi & Berant,
2009; Wallin, 2007)
Therapist serves as transitional attachment figure – a “reparenting” experience
The skill of the therapist at empathically attuning to client
(including non-verbal communication) is crucial
Ability to match the client’s attachment style
Empathy forms the core of what is healing – empathic
accuracy vs. empathic failure
Re-working of internal attachment models - relearning
what connection is about
Mostly presumes therapy for people who have had maladaptive early attachment relationships
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Grief Therapist as Attachment
Figure
“Grief counseling is a concentrated
form of empathically attuned and
skillfully applied social support from a
clinician who serves as a transitional
attachment figure and helps the
mourner to integrate the loss” - JRJ
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John R. Jordan, Ph.D. - The Family
Loss Project
Overview of the
Grief Therapy Process
ReactionDysregulation
Reflection
Crisis Therapy
Grief
Therapy
Reregulation Integration
Psychotherapy
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Overarching Questions/
Themes of Grief Therapy
How are you doing now?
Death Narrative?
Life Narrative (back story)
What have you lost?
What do you need to let go of?
What do you need to hold on to?
What have you learned? How have
you been changed? What is your
future?
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Use Of Focused Techniques
A Word About Technique In Grief
Counseling
Psychotropic Medication
Trauma Reduction Techniques
Restorative Retelling & Meaning
Reconstruction Techniques
Relational Repair Techniques
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John R. Jordan, Ph.D. - The Family
Loss Project
The Use of Technique in Grief
Therapy
Without Wisdom Technique Is:
At best useless
At worst dangerous
Wisely Used Technique Is:
Invaluable
The right technique
At the right time
With the right skillfulness
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Psychotropic Medication
The Controversy
A Guiding Criterion:
“Will the medication be in the service of
the griefwork?”
Some Examples
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Trauma Reduction Techniques
Underlying Principles
Establishment of safety, control, & self-soothing
skills
Controlled re-exposure to traumatic images,
memories, sensory data
Perspective taking about the trauma
EMDR - Eye Movement Desensitization and
Reprocessing - (Shapiro, 2004)
Background
Protocol
Retelling the Narrative of the Death
Shear’s Complicated Grief Therapy (2205,
2006)
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John R. Jordan, Ph.D. - The Family
Loss Project
Meaning Reconstruction
Psychological Autopsy
The procedure
The possible benefits
Note: AAS training in Psych. Autopsy
Pennebaker Writing Protocol
Background
Protocol
Uses of the technique
Other Uses of Writing
Neimeyer's Life Imprint Technique
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The Life Imprint Exercise –
Neimeyer (2012)
Decide About Whom You Wish to
Journal
This person has had the following
impact on:
My mannerisms or gestures:
My ways of speaking/communicating:
My work and pastimes:
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The Life Imprint Exercise –
Neimeyer (2012)
My feelings about myself & others:
My basic personality:
My values and beliefs:
The imprints I would most like to affirm
and develop are:
The imprints I would most like to
relinquish or change are:
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John R. Jordan, Ph.D. - The Family
Loss Project
Restorative Retelling –
Rynearson (2001, 2006)
Rynearson Protocol
Background
Protocol – 10 Sessions
1 & 2 - Introductions & Identifying sources of support
3 & 4 - Prevailing (how do you cope) & Co-morbidity
(distress, disorders, plan for 5)
5 & 6 - Commemorative presentations
7 & 8 - Death Imagery Presentations - self in a
different, more empowered role.
9 & 10 - Family & Friends & Ceremonial Goodbye
Underlying principle – revising the
death narrative
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Restorative Retelling
& Trauma Reduction
Goal = Cultivation of “pacified”
imagery of the deceased
“In Heaven” technique
Guided imagery of deceased in a healed
setting or condition
Drawn from past images, or present
imagination
Examples
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Relational Repair Techniques
Letter writing
Empty Chair
Imaginal (guided imagery)
Enactment
Ritual (e.g., graveside)
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John R. Jordan, Ph.D. - The Family
Loss Project
Relational Repair Technique –
Guided Imaginal Conversation
Guided imaginal conversation with the
deceased – (Jordan, 2012)
Background
Procedures
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Summary: Guidelines For
Working With Suicide Survivors
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Guidelines
Revise your assumptions about the grieving
process & clinician role
Goal = Integration not resolution of the loss
Duration & intensity of the grief response
Expert companioning vs. “treatment”
Overall goal = provide a safe & sheltered
context for doing griefwork & expanding
repertoire of coping skills
Educate the survivor
About suicide, trauma, grief, & recovery
Encourage self-education
Emphasize self-care; trial and error, and
empowerment through skill acquisition
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John R. Jordan, Ph.D. - The Family
Loss Project
Guidelines
Attend to traumatization
Combine therapies for PTSD & grief
Facilitate confronting and reworking of the
death narrative
Dosed re-exposure to avoided triggers
Imaginal & in-vivo
Personal psychological autopsy/inquest
“Walk in the shoes of the deceased” – Sands
Differentiate the self from the deceased
Go slowly with guilt
Gently help with reality testing
Consider “atonement”
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Guidelines
Support transformation of attachment
to the deceased
Development of continuing bonds
Reparative work on the ruptured
relationship
Facilitate restoration of positive imagery,
memories & connection
Encourage memorialization of the
deceased
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Guidelines
Address family & social network
issues
Facilitate contact with other survivors
Groups
Internet
Reading personal narratives
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John R. Jordan, Ph.D. - The Family
Loss Project
Guidelines
Facilitate meaning making (Sense-making &
benefit finding)
Redemption - “Don’t Waste Your Grief”
Bearing witness
Spiritual search
Honoring the life, not the death/ suicide
Activism - Preventing reoccurrence & assisting other
survivors
Encourage Reinvestment in Life & Exploration
Ritualize transitions
New activities, goals
Seek Growth In Your Clients
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Two Final Thoughts
Postvention is Prevention
It Takes a Village to Journey with
a Survivor
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WRAP-UP
Questions?
Comments?
What will you take with you?
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John R. Jordan, Ph.D. - The Family
Loss Project
Video: Threads/Themes of
Therapy
Suicidality – why go on, can I have a future?
Estrangement from work – phony vs. real?
Continuing bonds and transformation of her world-view
Continuing bond with David possible?
Additional Losses
Loss of her Father, his legacy of authenticity, and can
she call on his internalized voice?
Loss of family home
Loss of marriage
Loss of beloved dog
Loss of safety at work
Two “techniques”
EMDR
“In Heaven”
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American Association of Suicidology
American Foundation for Suicide Prevention
SUICIDE BEREAVEMENT CLINICIAN TRAINING PROGRAM
Case Study
Presenting Problems:
This married mother of three children entered treatment seeking help with her grief after
the death of her young adult son to suicide more than three years earlier. The woman
found her son, who lived at home, hanging in the basement of their home. She
immediately called for her daughter (also at home), and then 911. She got her son down
and attempted to revive him, but knew from his appearance that he was already dead. It
took six hours for the medical examiner to arrive, and her memories of the entire day
day, including the appearance of his face and body, the process of trying to revive him,
dealing with the police and medical examiner, and the removal of her son’s body in a
body bag remain a horrifying nightmare for her.
Since his death, the client has suffered from many of the problems that a suicide loss
survivor may experience. These include flashbacks of the events that morning, strong
feelings of guilt for not preventing the suicide (“I killed my son”), disrupted sleep and
appetite, significant anhedonia and suicidal ideation, and intense yearning for her son.
She questions whether she can ever recover, and finds the prospect of living the rest of
her life without her son and with the intense emotional pain to be very bleak. The client
reports that the only place she can talk about the death and her grief is in a once a
month survivor support group, which she finds moderately helpful, and with two of her
sisters. The suicide has strained the relationship with her husband of many years, who
is often reluctant to discuss his own feelings about the death, and frequently angry with
her for her inability to recover. Her husband has recently asked for a divorce. Her two
surviving children have been mostly supportive and protective of their mother, but she
has significant concerns about her other son, who has been using drugs and ignoring
the rules of the household. The client feels very estranged from her job and work
colleagues as a teacher – she finds her work to be meaningless now. Lastly, the client
presents with self-criticism about why she continues to be so distraught and why she is
not further along in her healing.
Background:
The client was raised in a large, closely knit and unusual family. Both of her parents
were highly educated and devoutly religious. In some ways, the family lived a life that
blended religious fervor with a love of learning. “Self-sufficiency” was highly valued, as
was skepticism of the larger society’s values, so the family lived in a rural area, raised
most of their own food, and kept themselves relatively isolated from the larger society.
The client had a very close relationship with her father, who died a difficult death of
cancer a few years before her son’s death. The client’s mother died a year after the
death of her son, also of cancer. The client’s son had also been very close to his
grandparents, and the loss of his grandfather may have been an important contributor to
his own depression and suicidality.
Treatment Highlights:
The treatment (about 8 months/20 sessions at the time of writing this case study) has
included many elements. They include: discussion of the details of the morning the
client found her son, and a single session of EMDR focused around that morning; work
on developing a “pacified” imagery of her son; discussion of the “culture” of her family of
origin, and the profound impact of the death of her father and impending loss of the
family homestead (which is for sale); her conflicting beliefs about an afterlife and
whether she will ever be with her son again; her concerns about her other children’s
well-being; her dissatisfaction with her job and work environment, the felt need to
“pretend” that everything is okay for her while at work, and whether she can take the
risk of changing her career path; and her waves of suicidality and sense of despair at
living a life without her son. This latter has intensified after the decision by her husband
to seek a divorce.
Suicide Bereavement Clinician Training Program
Professional Reading List
1. American Foundation for Suicide Prevention (2011) After a suicide: A toolkit for
schools. Available at: www.afsp.org/files/Surviving/toolkit.pdf.
2. Berman, A. (2011). Estimating the Population of Survivors of Suicide: Seeking an
Evidence Base. Suicide and Life-Threatening Behavior, 41(1), 110-116.
3. Berman, A., & Pompili, M. (Eds.). (2011). Medical Conditions Associated with
Suicide Risk. Washington, D.C.: American Association of Suicidology.
4. Berman, A., & Silverman, M. M. (2014). Suicide Risk Assessment and Risk
Formulation Part II: Suicide Risk Formulation and the Determination of Levels of
Risk. Suicide and Life-Threatening Behavior, 44(4), 432 - 443. doi:
10.1111/sltb.12067
5. Bolton Jm, A. W. L. W. D., & et al. (2012). Parents bereaved by offspring suicide:
A population-based longitudinal case-control study. Archives of General
Psychiatry, 1-10. doi: 10.1001/jamapsychiatry.2013.275
6. Burke, L. A., & Neimeyer, R. A. (2013). Prospective risk factors for complicated
grief: A review of the empirical literature. In M. Stroebe, H. Schut & J. v. d. Bout
(Eds.), Complicated grief: Scientific foundations for health care professionals (pp.
145-161). New York, NY, US: Routledge/Taylor & Francis Group.
7. Campbell, F. R., Simon, R. I., & Hales, R. E. (2006). Aftermath of suicide: The
clinician's role The American Psychiatric Publishing textbook of suicide
assessment and management (1st ed.). (pp. 459-476): American Psychiatric
Publishing.
8. Campbell FR, Cataldie L, McIntosh J, & Millet K. (2004) An active postvention
program. Crisis. 25(1):30-32.
9. Cerel J & Campbell FR. (2008) Suicide survivors seeking mental health services:
A preliminary examination of the role of an active postvention model. Suicide and
Life Threatening Behavior 38(1):30-34.
10. Cerel, J., Jordan, J.R., & Duberstein, P.R. (2008) The Impact of Suicide on the
Family. Crisis 29(1): 38-44.
11. Clark, S. (2001). Bereavement after suicide – How far have we come and where
do we go from here? Crisis, 22, 102-108.
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Life-Threatening Behavior, 32, 321-328.
13. Colt, George H. (2006) November of the soul: The enigma of suicide. New York,
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24. Feigelman, W., Jordan, J.R., McIntosh, J, & Feigelman, B. (2012) Devastating
losses: How parents cope with the death of a child to suicide or drugs New York,
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25. Feigelman, W., Jordan, J. R., & Gorman, B. S. (2009) Personal growth after
suicide loss: Cross-sectional findings suggest growth after loss may be
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and Dying, 59(3), 181-202.
26. Feigelman, W., Jordan, J., & Gorman, B. S. (2009) How they died, time since
loss, and bereavement outcomes Omega: Journal of Death and Dying, 58(4),
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27. Feigelman, W., Gorman, B. S., & Jordan, J. R. (2009) Stigmatization and suicide
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32. Joiner, T.E (2005) Why People Die By Suicide Cambridge, MA: Harvard
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Neimeyer (Ed.), Techniques of Grief Therapy: Creative Practices for Counseling
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38. Jordan, J. & McMenamy, J. (2004). Interventions for suicide survivors: A review
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they need? Results of a pilot study. Suicide and Life Threatening Behavior
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Grief and Bereavement in Contemporary Society: Bridging Research and
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Washington, D.C.: American Psychological Association, 2001
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with adults: New York, NY, US: Guilford Press.
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(2014). Treating traumatic bereavement: A practitioner's guide. New York, NY:
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And The Mental Health Crisis Among African-Americans. Boston, MA: Beacon
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61. Rynearson, E.K. (2006) Violent Death: Resilience and Intervention Beyond the
Crisis. New York, NY: Taylor & Francis Group.
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A narrative approach to healing Grief after suicide: Understanding the
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Routledge/Taylor & Francis Group.
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Sareen, J. (2011). Childhood exposure to caregiver suicidal behavior and risk for
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National
Suicide
Prevention
Lifeline.
Available
at
https://sites.google.com/a/personalgriefcoach.com/suicidegriefsupport/.
5
76. U.S. Public Health Service (1999) The Surgeon General’s Call to Action to
Prevent Suicide. Washington, D.C.: Department of Health & Human Services.
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National Action Alliance for Suicide Prevention. (2012). National Strategy for
Suicide Prevention: Goals and Objectives for Action. Washington, D.C.: HHS.
78. Wallin, D. J. (2007). Attachment in Psychotherapy: New York, NY, US: Guilford
Press.
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1(1), 7-25.
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6
JOHN R. JORDAN, Ph.D.
10 Exchange Court – Unit 401
Pawtucket, RI 02860-2261 USA
E-mail: jjordan50@aol.com
Tel. 401-305-3051
SURVIVING AFTER SUICIDE LOSS
Recommended Readings for Survivors
_Baugher, Bob & Jordan, Jack After Suicide Loss: Coping With Your Grief. Available from Bob
Baugher, Ph.D., 7108 127th Place S.E., Newcastle, WA 98056-1325 or
b_kbaugher@yahoo.com, 2002.
_Bolton,Iris My Son...My Son: A Guide to Healing After Death, Loss or Suicide Atlanta.
GA:Bolton Press, 1983.
_Cammarata, Doreen Someone I Love Died by Suicide: A Story for Child Survivors and Those
Who Care for Them. Grief Guidance, Inc., 2001. (www.griefguidance.com).
_Chalifour, Francis After. Tundra, 2005.
_Collins, Judy Sanity and Grace: A Journey of Suicide, Survival, and Strength.
Tarcher/Penguin, 2003.
_Colt, George Howe November of the Soul: The Enigma of Suicide New York: Scribner: Books,
2006.
_Dougy Center for Grieving Children. After Suicide: A Workbook for Grieving Kids. Dougy
Center, 2001 (www.dougy.org/).
_Feigelman, W., Jordan, J.R., McIntosh, J, & Feigelman, B. (2012) Devastating losses: How
parents cope with the death of a child to suicide or drugs. New York, NY: Springer Publishers.
_Fine, Carla No Time to Say Good-Bye: Surviving the Suicide of a Loved One New York:
Doubleday, 1997.
_Goldman, Linda Great Answers to Difficult Questions about Death: What Children Need to
Know about Death Jessica Philadelphia, PA: Jessica Kingsley Publishers, 2009.
_Jamison, Kay Redfield An Unquiet Mind: A Memoir of Moods and Madness. New York, NY:
Knopf, 1995
_Jamison, Kay Redfield Night Falls Fast: Understanding Suicide. New York, NY: Knopf, 1999.
_Joiner, Thomas Myths About Suicide Cambridge, MA: Harvard University Press, 2011.
_Joiner, Thomas Why People Die by Suicide Cambridge, MA: Harvard University Press, 2006.
_Kosminsky, Phyllis Getting Back to Life When Grief Won’t Heal New York, NY: McGraw-Hill,
2007.
_Lester, David Making Sense of Suicide: An In-Depth Look at Why People Kill Themselves
Philadelphia, PA: Charles Press, 1997.
_Linn-Gust, M., & Cerel, J. Seeking Hope: Stories of the Suicide Bereaved (Eds.).
Albuquerque: Chellehead Works (2011).
_Linn-Gust, M., & Peters, J. (2010). A Winding Road: A Handbook for Those Supporting the
Suicide Bereaved. Albuquerque: Chellehead Works, 2010.
7
_Linn-Gust, M. Rocky Roads: The Journeys of Families through Suicide Grief. Albuquerque,
NM: Chellehead Works, 2010.
_Linn-Gust, M. Do they have bad days in heaven? Surviving the suicide loss of a sibling.
Atlanta, GA: Bolton Press, 2001 (Chellehead Works 2002).
_Marcus, Eric Why Suicide? New York, NY: Harper-Collins, 2010.
_Meyers, Michael & Fine, Carla Touched by Suicide: Hope and Healing After Loss New York,
NY: Gotham Books, 2006.
_Rappaport, Nancy In Her Wake: A Child Psychiatrist Explores the Mystery of Her Mother’s
Suicide New York, NY: Basic Books, 2009.
_Requarth, Margo After a Parent’s Suicide: Helping Children Heal. Sebastopol, CA: Healing
Hearts Press, 2006 (www.HealingHeartsPress.com).
_Rubel, Barbara. But I Didn’t Say Goodbye: For Parents and Professionals Helping Child
Suicide Survivors. Griefwork Center, Inc. 2000.
_Slaby, Andrew & Garfinkel, Lili No One Saw My Pain: Why Teens Kill Themselves New York,
NY: W.W. Norton & Co., 1994.
_ Solomon, Andrew The Noonday Demon: An Atlas of Depression New York, NY: Scribner,
2001.
_Styron, William Darkness Visible: A Memoir of Madness. New York, NY: Random House,
1990.
_Wise, Terry L. Waking Up-Climbing Through The Darkness Oxnard, CA: Pathfinder
Publishing, 2004.
_Wrobleski, A. & Reidenberg, D. Suicide: Why? 85 Questions and Answers, 3rd Ed. SAVE
(Suicide Awareness Voices of Education), 2005. (http://www.save.org/)
Book Services:
These book services specialize in a wide range of books related to loss and bereavement, for
children, adolescents, and adults.
_ Compassion Books Burnsville, NC – Telephone - 1-800-970-4220
http://www.compassionbooks.com/store/
_ Centering Corporation – Omaha, NE – Telephone - 866-218-0101 http://www.centering.org/
Organizations and Online Resources:
All of these groups have resources for survivors.
_American Association of Suicidology - 5221 Wisconsin Avenue, NW Washington, DC 20015
Telephone 202-237-2280. www.suicidology.org/
_American Foundation for Suicide Prevention 120 Wall Street – 29th Floor, New York, NY10005 Telephone 888-363-3500. www.afsp.org/
_Center for Suicide Prevention Suite 320, 1202 Centre Street S.E.
Calgary, AB T2G 5A5, Canada – Telephone: 403-245-3900. http://suicideinfo.ca/.
8
_National Action Alliance for Suicide Prevention - 1025 Thomas Jefferson St., NW, Ste 700
Washington, DC 20007. -202-572-3784 - http://actionallianceforsuicideprevention.org/ - A national
public/private partnership dedicated to reducing suicide in the U.S. Includes a number of task
forces on topics related to suicide, including the Survivors of Suicide Loss Task Force.
_ Parents of Suicide and Friends and Families of Suicide - http://www.pos-ffos.com/ - online
web resources for parents bereaved by suicide, and other family members/friends bereaved by
suicide (siblings, children, spouses, friends, etc.).
_ Samaritans Grief Support Services – 41 West St., 4th Floor - Boston, MA 02111 Telephone:
877 870 4673. www.samaritanshope.org/
_Samaritans of Rhode Island – Telephone: 401-272-4044 - www.samaritansri.org/home.htm
_ SAVE (Suicide Awareness Voices of Education) - 8120 Penn Ave. S., Suite 470, Bloomington,
MN – 55431 – Telephone 952- 946-7998.
_Sibling Survivors.com - http://siblingsurvivors.com/sibling-grief/ - for survivors of the death of a
sibling to suicide.
_ Suicide: Finding Hope - http://www.suicidefindinghope.com/
_ Suicide Grief Support: Quick Reference – a comprehensive listing of support resources for
suicide survivors. - https://sites.google.com/a/personalgriefcoach.com/suicidegriefsupport/ or
sg.sg/griefreference
_Suicide Grief Support Forum - http:www.suicidegrief.com
9
SUGGESTIONS FOR GUIDED IMAGERY:
A Conversation with the Deceased
John R. Jordan, Ph.D.
© - 2015 - All Rights Reserved
I.
II.
III.
Preparation
A.
This exercise should be done only in the context of a productive
and secure therapeutic relationship with the client.
B.
The clinician and client should carefully discuss the technique
before participating in it. This discussion should include deciding on
the goals (leave-taking, finishing unfinished business, reestablishing a sense of connection with the deceased, etc.),
possible benefits, and possible risks. Particular fears that the client
might have about doing the technique should be carefully explored,
and should guide the decision about whether to try the technique.
C.
An extended session length (e.g., 90 minutes or more) may be
advisable, given the need to process the material that is brought up
in the technique.
D.
The technique should be used cautiously, if at all, with clients who
are:
1.
Recently bereaved, particularly after traumatic death
2.
Traumatized or who have a history of childhood
traumatization
3.
Likely to find the emotional intensity produced by the
technique more disturbing than helpful
4.
Lacking a trusting relationship with the clinician
5.
Reporting a history of dissociative or psychotic episodes
6.
Actively suicidal
Relaxation
A.
Make clear to the client that they can stop at any point in the
process if they are feeling overwhelmed or find continuing too
psychologically distressing.
B.
Begin with an exercise that helps the client both physically and
mentally relax. The goal is to help the client “go inside” and attend
to their internal physical and emotional state. Asking clients to close
their eyes, take a deep breath and physically relax on the
exhalation, and then focus their attention on diaphragmatic
breathing for a short while is one way to do this.
Setting up the encounter
IV.
V.
A.
When ready, ask the client to imagine coming into a comfortable
room with two comfortable chairs. As they enter, they see that their
loved one is seated in one of the chairs and waiting to meet and
talk with them.
B.
Emphasize that the physical and psychological state of the
deceased is one of being physically healed, psychologically at
peace, and receptive to listening to the client. Regardless of past
conflicts and relational problems between the deceased and the
client, the deceased is now ready and willing to listen carefully and
empathically to whatever the client needs to say. The deceased
has come to the encounter wanting to understand the experience of
the client.
C.
Ask the client to begin the conversation with the deceased. Note
that this can be done completely silently within the client’s mind or it
can be done out loud. If the client has difficulty getting started, the
clinician can suggest a prompt, such as “What do you want them to
know about what the relationship has meant to you? What do you
want them to know about your regrets about the relationship? What
do you want them to know about anger that you feel about the
relationship? What do you wish that you had said to the deceased
before they died? What do you want them to know about what it
has been like for you since they died?”, etc.
D.
The technique can be done for 5 - 20 minutes. Generally, the
clinician should be silent while the client is having the conversation,
interrupting only if the client appears to be very distressed, or
unable to proceed with the experience.
Closing the technique
A.
Clients can be prompted that they will be asked to stop shortly.
They can signal when they are ready to do so. The client should be
asked to do a leave-taking with the deceased, with the explanation
that the client can return for additional visits when needed. In other
words, the conversation should not be framed as a “final farewell”,
but rather as a meaningful visit with the deceased, which can lead
to further visits as needed.
B.
The client can then be asked to go back to attending to their
breathing, followed by opening their eyes and “coming back to the
room” with the clinician, as they are ready to do so.
Debriefing and integrating the experience
A.
It is very important to allow the client sufficient time to process this
experience after closing it down. The goal of the debriefing is to
help the client reduce the emotional intensity before they leave the
session and to begin to integrate what the experience has meant
for them.
VI.
B.
Debriefing can include asking the client to discuss as much (or as
little) of the conversation as they wish to share, discussing what the
conversation means to them, and what steps they think might come
next. Clients should also always be asked about their present
emotional state, any strong physical or emotional reactions they are
experiencing, what they found helpful or disturbing about the
experience, and whether feel it would be helpful to use the
technique in a future session.
C.
If warranted, clients should be asked about any concerns about
their emotional well being after they leave the session, and a plan
should be developed for how they will handle any anticipated
problematic distress, such as inquiries from others about the
session, suicidal feelings, retraumatization, etc.
D.
Clients can also be encouraged to journal about further thoughts
about the experience and to bring those to future sessions with the
clinician.
Variations of the technique
A.
Clients can be encouraged to imagine the deceased responding to
what they have heard from the client, so that more of an interactive
conversation between the client and the deceased takes place
B.
Clients can be asked to not only to communicate their messages
out loud, but to “enact” them by sitting in one chair and speaking to
the deceased, and then in the opposing chair to speak back from
the deceased. This is the classic “empty chair” technique.
C.
Instead of imagining the conversation with the deceased, after the
induction of the encounter with the deceased, clients can be asked
to write the conversation out on paper (both to the deceased and
from the deceased). This can be kept by the client and re-read as
desired.
D.
The session can be tape recorded, and the client asked to listen to
the recording at home. They can also be asked to journal about
their reflections on the conversation after listening to the recording.
This can be discussed in future sessions.
E.
Depending on the dynamics of the family or other relationship and
the issues involved, clients can also show the journaling or play the
recording of the session to a significant other person in their life
with whom they wish to share the experience.
SUICIDE BEREAVEMENT CLINICIAN TRAINING PROGRAM
Optional Clinician Referral Database
A major goal of the Suicide Bereavement Clinician Training Program is to
develop an online database by which people bereaved by suicide can find
a clinician who is knowledgeable about bereavement after suicide and
willing to provide grief therapy for survivors. Participation in this database
does not constitute an endorsement or referral from the American
Association of Suicidology or the American Foundation for Suicide
Prevention. Rather, your name and contact information will be listed in the
database only as mental health clinician who has completed the SBCTP,
and has expressed a willingness to provide grief therapy to people
bereaved by suicide.
1. Name & Degree as you want it to appear in the Database:
_________________________________________________________
2. Address of your Office:
_________________________________________________________
3. Office Phone:
_________________________________________________________
4. Office E-Mail:
_________________________________________________________
5. Years of Experience as a Mental Health Professional:
_________________________________________________________
6. Specializations or Other Information: (Adolescents: Children; Couples
Therapy; Etc.:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
SUICIDE BEREAVEMENT CLINICIAN TRAINING
EVALUATION FORM
Thank you for attending today’s workshop. We would very much appreciate your help in
evaluating the training and in offering suggestions about how we could improve this
workshop. If you could fill out this brief questionnaire, and leave it with Dr. Jordan before
you leave, we would be very appreciative of your time and comments.
Background:
1. Please tell us your professional discipline and work setting (e.g., psychologist in
private practice, social worker in a medical hospital, etc.):
______________________________________________________________________
2. Please tell us briefly why you decided to attend this training:
______________________________________________________________________
3. Please describe how your work is related to bereavement care (whether after
suicide or not):
______________________________________________________________________
Ratings: Please give us a numerical rating from 1 to 5 on each of the questions below –
1 = “Strongly Disagree 5 = Strongly Agree:
1. I have a better understanding of how to be of help to suicide survivors
_____
2. This training will help me directly in my professional capacity
_____
3. This training met or exceeded my expectations
_____
4. This training has increased my confidence in working with survivors
_____
5. I would recommend this training to other clinicians
_____
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General Comments:
Please help us understand your reactions to the specific sections of the training, so that
we can make modifications. For each section listed below, please do two things: first,
give us a numerical rating between 1 and 5 of how valuable to your work (or not) this
section was for you (1 = Not Very Valuable to 5 = Very Valuable). Then, please provide
some elaboration on why the section was valuable (or not) for your professional work,
and what might improve this section.
Section 1 – “Suicide Survivors: Who Are They?”
Rating:_____
Please Elaborate _______________________________________________________
______________________________________________________________________
______________________________________________________________________
Section 2 – “The Impact of Suicide”
Rating:_____
Please Elaborate _______________________________________________________
______________________________________________________________________
______________________________________________________________________
Section 3 – “What Can We Do to Help Survivors?”
Rating: ______
Please Elaborate _______________________________________________________
______________________________________________________________________
______________________________________________________________________
Section 4 - “Grief Therapy with Survivors”
Rating:_____
Please Elaborate _______________________________________________________
______________________________________________________________________
______________________________________________________________________
2
The Video/Case Study
Rating:_____
Please Elaborate _______________________________________________________
______________________________________________________________________
______________________________________________________________________
What additional suggestions do you have for us to improve the training?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Please leave this form with Dr. Jordan before you leave, and thanks so much for your
help!
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