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Healing within families following youth suicide Grant Kalischuk, Ruth 1999

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Family Healing HEALING WITHIN FAMILIES FOLLOWING YOUTH SUICIDE by Ruth Grant Kalischuk RN, Medicine Hat College School of Nursing, 1979 B N , The University of Lethbridge, 1985 MEd, The University of Lethbridge, 1992 A THESIS SUBMITTED IN PARTIAL F U L F I L L M E N T OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN NURSING in THE F A C U L T Y OF G R A D U A T E STUDIES School of Nursing We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH C O L U M B I A 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) Hea l ing W i t h i n Fami l ies i i H E A L I N G W I T H I N F A M I L I E S F O L L O W I N G Y O U T H S U I C I D E A B S T R A C T Despite preventive efforts, youth suicide is identified as a publ ic and mental health problem of epidemic proportion in Western society. The short- and long-term health and human consequences associated wi th youth suicide are enormous, affecting each fami ly survivor , the family , and ultimately, the communi ty and society. Y o u t h suicide has its greatest impact on the family , yet health care responses to these gr ieving families remains inadequate at best. Th is grounded theory study, based on a health promot ion phi losophy that embraces the strengths and resilient nature o f gr ieving individuals , examined how individuals wi th in the context of the family heal in the aftermath of youth suicide. E l even families f rom rural and smal l urban centres were in terviewed for the study during an 18 month period. Individual healing fo l lowing youth suicide is conceptualized as Journeying Toward Wholeness. Th i s journey is characterized by the inter-relationships among three enfolding, f lu id , and iterative themes, w h i c h in themselves, each represent one port ion o f the overal l journey: C o c o o n i n g (Journey of Descent); Center ing (Journey o f Growth) ; and Connec t ing (Journey of Transcendence). W i t h i n each theme, five self-organizing and inter-relating patterns (i.e., relating, thinking, functioning, energizing, and f inding meaning/exploring spirituality) operate in mutual rhythmical interchange wi th the other patterns unbound by time. E a c h pattern describes one facet o f the ind iv idua l ' s experience in response to youth suicide. Journeying toward wholeness (i.e., healing) varies in expression and intensity over time i n response to a variety o f contextual factors inc luding personal history, factors related to the suicide, social considerations, and the health care environment. Importantly, healing emanates, as an act o f vo l i t ion , f rom the surv ivor ' s consciousness (i.e., the heal ing epicentre) as a result o f decis ion m a k i n g . The degree to wh ich healing occurs depends on a number o f intervening variables reflecting the survivor ' s capacity to say yes to l i fe ; step out and speak up; achieve a sense o f peace, harmony, and balance; and expand personal consciousness. A s a major outcome o f the healing process, each survivor creates a love knot, symbol ic o f the heal ing strategies he or she uses to H e a l i n g W i t h i n Fami l ies i i i facilitate healing wi th in both private and publ ic spheres. The love knot represents the creative expression o f love as a healthy and cont inuing bond between the survivor and deceased youth. The love knot is based on the meaning the survivor attributes to his or her experience wi th youth suicide and the relationship between the survivor and deceased youth pr ior to death. Ul t imate ly , ind iv idua l heal ing expands outward inf luencing fami ly , societal, and global spheres. The theory presented in this dissertation w i l l be of particular interest to c l in ica l nurse specialists and mental health care professionals f rom a variety of discipl ines who work closely wi th families in the communi ty . W i t h its focus on health promotion, this theory captures some of the intricacies and complexi t ies 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 C H A P T E R T H R E E - R E S E A R C H DESIGN A N D I M P L E M E N T A T I O N 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 H e a l i n g W i t h i n Fami l ies v i Summary 69 C H A P T E R F O U R - J O U R N E Y I N G T O W A R D W H O L E N E S S : A C O N T E X T U A L I Z E D E X P E R I E N C E 70 Descr ip t ion of Participants (The Sample) 70 Individual Hea l ing Process F o l l o w i n g Y o u t h Suicide: A Prev iew 72 O v e r v i e w of the Grounded Theory 76 The Precipitating Event 78 Hear ing the N e w s 78 Initial Responses 79 H o r r o r or D i s c o v e r y 82 D e a l i n g with Suicide Notes 83 Break ing the N e w s to Others 84 S u m m a r y o f P r e c i p i t a t i n g E v e n t 85 Contextual Factors 86 Personal H i s to ry 86 Relat ionship wi th the Deceased Y o u t h Pr io r to Suic ide 86 Gender 87 Rel ig ious Aff i l i a t ion 88 Cul tura l Practices 89 Previous Exper ience wi th Los s 90 Hea l th Status 91 Factors Related to the Suicide 93 Unexpected, Sudden, and V io l en t Death 93 Suic ide or H o m i c i d e 93 Soc ia l Factors 94 Socia l S t igma 95 Soc ia l Support 95 Health Care Environment 96 S u m m a r y 97 C H A P T E R F I V E - C O C O O N I N G : J O U R N E Y O F D E S C E N T 99 Rela t ing Pattern (Struggling) 100 Struggling W i t h i n Oneself 100 F i n d i n g Psycho log ica l Safety 100 Processing Intense Emot iona l Trauma 101 H e a l i n g W i t h i n Fami l ies v i i Lonel iness : 102 A n x i e t y and Fear 102 Anger 104 Pa in and Suffering 106 Depression 108 Gu i l t : 109 Regret 110 Struggling W i t h Others I l l Wi thd rawing from Others I l l Effect on Relationships 112 Dea l ing wi th Others' Reactions , 112 T h i n k i n g Pattern (Chaotic Th ink ing) 113 Exper ienc ing Cogni t ive Dissonance 114 E x p e r i e n c i n g A l t e r e d T h i n k i n g 115 Contemplat ing O w n Suicide 117 Funct ioning Pattern (Autopi lot ing) 118 Decreased Funct ioning 118 L i v i n g wi th Phys ica l Absence 119 U s i n g Add ic t i ve Substances 120 T a k i n g R i s k s 120 Energy Pattern (Consuming) 121 Su rv iv ing the Trauma 121 A s k i n g W h y 122 F i n d i n g M e a n i n g / E x p l o r i n g Spiri tuali ty Pattern (Awakening) 123 W a k i n g U p to L i f e 123 Doubt ing Oneself and Experience 124 V i s i t i n g the D a r k Side of L i f e 124 S u m m a r y 125 C H A P T E R SIX - C E N T E R I N G : J O U R N E Y OF G R O W T H 127 Rela t ing Pattern (Gett ing a Gr ip ) 128 Confronting Emot iona l Experience 128 Address ing Unf in i shed Business 129 T h i n k i n g Pattern ( M a k i n g Decis ions) 130 M a k i n g Decis ions 130 Val ida t ing O w n Reali ty 130 H e a l i n g W i t h i n Fami l ies v i i i Releas ing Se l f of Responsibi l i ty for the Suic ide 131 A l l o w i n g Hea l ing to Occur 131 Funct ioning Pattern (Re-Engaging) 132 Increasing A c t i v i t y L e v e l 132 Participating i n Hea l ing Act ivi t ies 133 Energ iz ing Pattern (Replenishing) 136 Reso lv ing the W h y Question 137 Releas ing Energy 137 F i n d i n g M e a n i n g / E x p l o r i n g Spiri tuali ty Pattern (Transforming) 138 F o r g i v i n g Se l f and the Deceased Y o u t h 138 F i n d i n g M e a n i n g in Experience 140 S u m m a r y 141 C H A P T E R S E V E N - C O N N E C T I N G : J O U R N E Y O F T R A N S C E N D E N C E . . 143 Relat ing Pattern (Reaching Out) 144 Seeking H e l p 144 L i n k i n g wi th Others ' 146 Faci l i ta t ing Others ' Hea l ing 150 T h i n k i n g Pattern (Learning) 151 T h i n k i n g Differently 151 Deve lop ing Creativity 152 Trust ing Intuition 154 Funct ioning Pattern (Orchestrating L i f e ) 158 Reorder ing L i f e Priorit ies 158 Break ing the Silence 159 Energ iz ing Pattern (Channeling) 160 Redirect ing Energy 160 Focus ing on the Posi t ive Aspect o f Exper ience 161 F i n d i n g M e a n i n g / E x p l o r i n g Spiri tuali ty Pattern (Transcending) 162 Re-bir thing 162 Trust ing Experience 163 S u m m a r y 165 C H A P T E R E I G H T - T O W A R D S A N U N D E R S T A N D I N G O F T H E H E A L I N G P R O C E S S 167 Heal ing Strategies 1 6 7 Hea l ing W i t h i n Fami l ies ix Intervening Variables: Hea l ing Characteristics 170 Saying Y e s to L i f e 170 Stepping Out and Speaking U p 171 A c h i e v i n g a Sense of Peace, Harmony , and Balance 172 E x p a n d i n g Personal Consciousness 173 Outcome of Individual Hea l ing F o l l o w i n g Y o u t h Suicide: Creat ing o f a L o v e K n o t 175 Individual Hea l ing F o l l o w i n g Y o u t h Suicide: A Summary 176 Transi t ion, Transformation, and Transcendence 178 Relat ionship Between Hea l ing and G r i e v i n g 180 D i s c u s s i o n 182 S u m m a r y 189 CHAPTER NINE - HEALING WITHIN FAMILIES FOLLOWING YOUTH SUICIDE: IMPLICATIONS AND CONCLUSIONS 191 Implications for Heal th Promot ion Practice 193 Unders tanding the H e a l i n g Process 193 Creat ing Communi ty-based Partnerships 198 W o r k i n g wi th Rural-based Fami l ies 201 Implications for Future Research 203 C o n c l u s i o n s •••• 205 R E F E R E N C E S 208 APPENDICES Append ix A - 1 : Genogram 227 Append ix A - 2 : E c o m a p 229 Append ix B : F a m i l y M e m b e r Information Letter and Informed Consent 231 Append ix C : M e d i a Invitation 234 Append ix D : Interview Guide l ine 236 Append ix E : Oath o f Confidentiali ty 238 Append ix F : Demographic Questionnaire 241 Hea l ing W i t h i n Fami l ies L i s t of Figures F igure 4-1: Individual Hea l ing Process Represented by a L o v e K n o t 74 Figure 4-2: Individual-Socie ty H e a l i n g Process F o l l o w i n g Y o u t h Suic ide 78 Figure 8-1: Hea l ing Expand ing Over T i m e 176 Figure 8-2: Individual Hea l ing W i t h i n Fami l ies F o l l o w i n g Y o u t h Suic ide 178 Hea l ing W i t h i n Fami l ies x i L i s t o f Tables Table 4-1: Residence o f Sample Populat ion 70 Table 4-2: Sample Populat ion Data ; 72 Table 4-3: Individual Hea l ing Template 75 Table 8-1: Journeying T o w a r d Wholeness: Hea l ing Strategies 169 Table 8-2: Differences Between Hea l ing and G r i e v i n g in Response to Y o u t h Suic ide 182 Hea l ing W i t h i n Fami l ies x i i A C K N O W L E D G E M E N T S I have been inspired by those with w h o m I have journeyed. I extend m y heartfelt thanks to the fourty-one individuals f rom eleven families that, i n a spirit o f generosity, opened their hearts and souls as they shared their stories wi th me. I feel pr iv i leged to have learned so much f rom each of you . Th i s work has been enhanced by m y association wi th many k i n d and car ing people. Warmest thanks are extended to m y brother, R o n a l d Grant, and to m y dear friend, Cor l i s s Burke , both o f w h o m have always been there for me. I adore m y son- in- law, W i l c o Tymenson , and value his contribution to this work. M y grandson, T y s o n B a i l e y K a l i s c h u k , helped me to maintain perspective wh i l e doing this k i n d of work. H i s light, laughter, and love sustained me during the tough times. T o m y friends and colleagues in the School of Heal th Sciences at the Univers i ty of Lethbridge, I offer thanks —to Dean Patr icia W a l l for creating the space and for be l ieving in me; to D r . Ga ry N i x o n for his depth and br i l l iance; to H o w a r d and D r . K a t h r y n H i g u c h i for helping me to maintain balance in m y l ife; to D r . Judith K u l i g and D r . V i r g i n i a M c G o w a n for their unwavering support and encouragement, to D r . Brad ley Hagen for sharing the journey, and to D r . Kar ran Thorpe for her support and friendship over many years. I acknowledge and appreciate the expert technical assistance provided by W e n d y Herbers. A special thanks goes to B r a d K e i m , m y research assistant, for his interest in and commitment to this research. Indeed, I am fortunate to have been ski l fu l ly guided in this endeavor by a world-class committee. W i t h gratitude, I thank D r . Bet ty Davies for gu id ing the way. I have been forever changed because o f her passion for excellence and her c a lm and car ing presence along the way. M y sincere thanks is extended to D r . V i r g i n i a Hayes who has taught me much about the essentials required for the journey. D r . Katharyn M a y ' s incredible v i s ion for the b i g picture has inspired me to stay focused—for this I am thankful. M y involvement in this research study has been the highlight o f m y doctoral program. I gratefully acknowledge the financial contributions o f the organizations that provided funding for this research inc luding the Alber ta Assoc ia t ion o f Registered Nurses and the Reg iona l Center for Heal th Promot ion and C o m m u n i t y Studies at the Unive r s i ty o f Lethbr idge, Lethbridge, Alber ta . Healing Within Families xiii !for Victor %alischuk\ My True 'North and for Our Children, Our Stars Andrea, %pcfoj, 9/CeCanie, and Lisa Hea l ing W i t h i n Fami l ies 1 C H A P T E R O N E B A C K G R O U N D T O H E A L I N G W I T H I N F A M I L I E S F O L L O W I N G Y O U T H S U I C I D E Death is one o f l i fe 's few certainties. Despite its inevitabil i ty, w ide ly accepted wi th in society is the notion that it is unnatural for chi ldren to predecease their parents; unfortunately, in some instances, reality proves otherwise. The idea of a youth wi l l fu l l y ending his or her life is incomprehensible to most people. Suicide, an unnatural, unanticipated, and psychologica l ly violent death is often v i ewed as an act of aggression that has been commit ted by the v i c t i m 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 o f contemporary society. Indeed, this increasingly c o m m o n mental health care problem challenges some of the strongest and most sacred beliefs and convict ions held by fami ly survivors. Y o u t h suicide is especially tragic for fami ly survivors because it involves not only the death of a young person, but death that is sudden and violent. The ini t ia l b low of hearing the news of a youth suicide is l i ke ly to e l ic i t a disturbing response among fami ly survivors, much l ike the ripple-effect o f an earthquake and its resultant aftershocks. In the midst of tremendous upheaval, survivors are chal lenged i n terms of making sense o f their grievous experience and healing in response to this l ife-altering situation. Th is dissertation is pr imar i ly concerned wi th how family survivors heal i n the aftermath of youth suicide. The Scope of the P rob lem of Y o u t h Suic ide Y o u t h suicide has been identified as a compel l ing global and national publ ic health problem (Leenaars, Wencks te rn , Sak inofsky , D y c k , K r a i , & B l a n d , 1998; L o w & A n d r e w s , 1990), and a mental health concern o f epidemic proportion (Thornton, Whi t temore , & Robertson, 1989). The magnitude o f this problem and its concomitant untoward sequelae cannot be overstated. A t both the national and provinc ia l levels, the increased incidence o f suicide among our youth is alarming. Hea l ing W i t h i n Fami l ies 2 The recent rise i n suicides among young males is a complex and perplexing problem. In Canada, in 1993, male youngsters aged 15 to 19 k i l l e d themselves at a rate of 19.4 per 100,000 ( W i l k i n s , 1996). F r o m 1981 to 1991, Canadian males aged 10 to 14 showed a startling increase of 60 percent in the rate o f completed suicides, the highest percentage increase o f any age group in the country (Whi te , 1993). It is disturbing to note that the highest incidence of suicide occurs wi th in the aboriginal youth population (Roya l C o m m i s s i o n on A b o r i g i n a l Peoples, 1995), i nc lud ing A m e r i c a n Indians (both status and non-status), Inuit, and M e t i s (Isaacs, K e o g h , M e n a r d , & H o c k i n , 1998; Leenaars et a l . , 1998; M a r d i r o s , 1987; M a y , 1990). A c c o r d i n g to Statistics Canada (1994b), dur ing 1987-1991, Canadian and registered Indian males, aged 15 to 19 years, completed suicide at a rate o f 117 per 100,000. N o t surprisingly, Quebec and Alber ta , Canadian provinces wi th the largest aboriginal populations, have the highest incidence of youth suicide. W i t h i n a one-year period in Alber ta , the rate o f suicide among youth aged 15 to 19 showed a substantial increase of almost 39 percent—from 18.8 per 100,000 i n 1990, to 26.0 per 100,000 i n 1991 (Whi te , 1993). Moreove r , the majority o f aboriginal youth l ive i n rural areas. D u r i n g 1996, in Alber ta , the incidence of suicide among rural youth exceeded that of their urban peers (Alber ta Justice Office of the C h i e f M e d i c a l Examiner , 1997). Approx imate ly 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). M o r e male youth suicides occur i n Canada per capita than i n the U n i t e d States (Leenaars & Lester, 1990; Leenaars et a l . , 1998). E v e n s t i l l , in the U n i t e d States, suicides among youths have quadrupled wi th in the last three decades (Gartrel l , Jarvis, & Derksen , 1993). In 1988, a total of 2,059 youths aged 15 to 19, and 243 chi ldren under 15 years o f age, took their l ives in the U n i t e d States (Nat ional Center for Heal th Statistics, 1968-1991). Suic ide is now the second leading cause of death among the youth o f A m e r i c a (Leenaars et a l . , 1998; L o w & A n d r e w s , 1990). E v e n though health and human service professionals are commit ted to p rov id ing youth suicide prevention programs (Blumenthal , 1990; Bo ld t , 1987; Brent , 1995; Brent et a l . , 1993; Gar l and & Z ig le r , 1993; R u d d , D a h m , & Rajab, 1993), each year, more than 300 famil ies in Canada (Statistics Canada, 1994a, 1994b) are confronted wi th youth suicide. T h i s statistic is Hea l ing W i t h i n Fami l ies 3 insignificant in comparison to the devastation that youth suicide casts in its wake, especially for fami ly survivors. Moreove r , this fact is a conservative estimate o f the problem; it under-represents reality (Garland & Zig le r , 1993) and this under-representation may be l i nked to the inherent difficulties associated wi th reporting self-inflicted deaths. These problems center on concern for the fami ly ' s wel l -be ing, rel igious implicat ions, and financial considerations regarding insurance payment restrictions (Gar land & Zig le r , 1993). Add i t i ona l ly , many sudden deaths are probably suicides, but without direct evidence such as a suicide note, the cause o f death may be reported as accidental or undetermined. A d d i n g to the enormity of the problem, it has been suggested that a m i n i m u m of 50 people, many o f w h o m are family members, are affected by each incidence of youth suicide ( B . Shawanda, personal communica t ion , M a y , 28, 1998). Further, it is estimated that 50 to 100 attempts occur for every completed youth suicide (Smi th & Crawford , 1986), and this begins to give some indicat ion o f the true magnitude of the problem. The Heal th and H u m a n Consequences Associa ted wi th Y o u t h Suic ide The short- and long-term health and human consequences associated wi th youth suicide are enormous, affecting each fami ly survivor, the fami ly as a unit, and ul t imately, the communi ty and society. F a m i l y survivors o f youth suicide often experience a number o f stressors inc lud ing increased vulnerabi l i ty to illness and disease (Rudestam, 1992), increased incidence o f drug and alcohol abuse (S i lverman, Range, & Overholster, 1994-95), and extensive emotional and personal suffering (Ness & Pfeffer, 1990; Parkes & B r o w n , 1972; Solursh , 1990; V a n D o n g e n , 1990). A l t h o u g h sometimes over looked, grandparents (Ponzetti & Johnson, 1991) and s ib l ing survivors may also experience adverse health consequences (e.g., B a l k 1983, 1990a, 1990b, 1991a, 1991b; Fanos & N i c k e r m a n , 1991; Grogan , 1990; H i l g a r d , 1969; H o g a n & B a l k , 1990; H o g a n & DeSant is , 1994; K r e l l & R a b k i n , 1979; Mar t inson , Dav ies , & M c C l o w r y , 1987; P o l l o c k , 1986; Zelauskas, 1981). The situation is further complicated in that famil ies who have endured such trauma are often confronted wi th subtle, yet powerful , forms o f s t igma ( B r o w n , 1994; Thornton, Whit temore, & Robertson, 1989; V a n Dongen , 1993; Schlump-Urquhar t , 1990; S o l o m o n 1982-1983; Somme-Rotenberg , 1998); social isolat ion (Ness & Pfeffer, 1990; Rudestam, 1992; V a n Hea l ing W i t h i n Fami l ies 4 Dongen , 1991); role uncertainty ( V a n Dongen , 1993); and strained relationships wh ich often lead to mari tal d i scord (Ness & Pfeffer, 1990; Parkes & B r o w n , 1972; V a n D o n g e n , 1993). Moreove r , the deleterious effects of multi-generational loss, especially c o m m o n among Canadian A b o r i g i n a l famil ies, place heavy demands on exis t ing health care services ( B . Shawanda, personal communica t ion , M a y , 28, 1998). Mult i -generat ional loss arises f rom an accumulat ion o f unresolved loss issues inadvertently passed down f rom one generation to the next ( B . Shawanda, personal communica t ion , M a y 28, 1998). Some o f these loss issues include a lack o f integration of the indiv idual wi th in society (Durkhe im, 1951); ego identity crisis , and the resulting trauma that may result f rom grappl ing wi th the question " W h o A m I?" (Er ickson , 1968); and, the loss of one's ethnic identity (Phinney, 1989). F a m i l y survivors o f multi-generational loss often become "famil ies o f trauma" ( B . Shawanda, personal communica t ion , M a y 28, 1998) who access the health care system more frequently than persons who are able to confront their loss soon after it occurs. Ul t imate ly , ind iv idua l and fami ly responses to death i n general, and to youth suicide in particular, are inf luenced by societal responses. The Response of Society to Death In the past, death was recognized as a natural and normal l ife event. Howeve r , wi th in the last century, death has been social ly reconstructed as a 'medica l event. ' W i t h i n our death-denying and death-defying society, the medical izat ion and bureaucratization of death has led to its depersonalization. Thus , for many, death has become an enigma. The social aspects o f death have been removed from the home and fami ly and have been transplanted wi th in institutions. " W i t h the growth o f the secular and rational outlook, hegemony i n the affairs o f death has been transferred from the church to science and its representatives, the medica l profession and the rationally organized hospi ta l" (Blauner, 1966, p. 385). B launer ' s message st i l l applies 30 years after he wrote it. Today , i n Canada, about 7 0 % of a l l deaths occur wi th in hospitals (Locka rd , 1989). W i t h a pr ime focus on efficiency, hospitals continue to manage the crisis of dy ing . W i t h i n the hospital environment, death becomes the arena for experts rather than famil ies and friends. The high-tech Hea l ing W i t h i n Fami l ies 5 hospital environment is often sterile, efficient, and depersonalized. M a c h i n e s , not people, are the c o m m o n features of the death room. F a m i l y members often become visitors and chi ldren are shielded f rom death. The separation of death from the fami ly min imizes the average person's exposure to death wi th its disruption o f social processes (Blauner, 1966). The ever present avoidance o f death-related issues wi th in society is even more pronounced wi th respect to youth suicide. The Response o f Society to Y o u t h Suic ide Y o u t h suicide is a stark and powerful reminder that a l l is not w e l l wi th in society. A number o f forces have had an impact on society 's response to youth suicide, inc lud ing : the sociogenic v i ew of youth suicide, changing views of death and suicide, the social value accorded to our youth i n society, the stigmatization surrounding youth suicide, and educational deficiencies. The alarming increase in the incidence of youth suicide wi th in contemporary society is indeed difficult to comprehend. In spite of g rowing concern about this p rob lem wi th in the health care sector, as yet, we do not understand the mul t ip l ic i ty of forces that underlie this complex health problem. A c c o r d i n g to Shneidman (1993b), suicide occurs when an ind iv idua l experiences intolerable psychologica l pain or "psychache" (p. 145). E m i l e D u r k h e i m (1951), a renowned French sociologist , v iews suicide not as a voluntary act, but as an ind iv idua l phenomenon et iological ly explained wi th in the parameters of our Western social structure. Espous ing a s imilar v iew, B o l d t (1987) maintains that "Suic ide is vir tually always a forced act to resolve what are perceived as overwhe lming problems" (p. 4). Further, he argues that the idea of moral culpabi l i ty needs to be reintroduced wi th the responsibil i ty for suicide shifted f rom the ind iv idua l to society. Several sociological phenomena have been attributed to the increased incidence of youth suicide inc lud ing: issues related to changing social and economic structures (Farrow, 1993; Shneidman, 1993a ); changing fami ly and communi ty dynamics (Boldt , 1987; B u s h y , 1994c; Leenaars et a l . , 1998); decl in ing religious affil iation; an increased prevalence o f depression among youth (Sakinofsky, 1998); and the influence o f popular media (B ib l a rz , B r o w n , N o o n a n B i b l a r z , P i l g r i m , & Baldree , 1991; Stack, 1992). Cul tura l change, increased personal freedom, uncertainty Hea l ing W i t h i n Fami l ies 6 about the future (Cotton & Range, 1993), and "value heterogeneity" are also considered to be factors (Boldt , 1987, p. 6). Moreove r , social and economic structures often impose barriers to youth attempting to seek professional help, especially for concerns that have moral overtones— such as suic idal th inking , intense emotional responses to stress, symptoms o f mental i l lness, or problems wi th addict ion, pregnancy, sexuality issues or infractions o f the l aw (Bushy , 1994c). Proponents of the sociogenic v iew emphasize the need to focus on t rying to change environmental realities that cause psychological pain and m i n i m i z i n g the moral and social stigmata that act as barriers to surv ivor help seeking (e.g., A t k i n s o n , 1978; B o l d t , 1976; C a l h o u n , Se lby , & Fauls t i ch , 1980, 1982; K l a s s , 1996; Paicheler , 1988; Rudes tam & Imbro l , 1983). W i t h i n societal institutions, v iews about death and suicide are also changing. M a n y social systems (e.g., health care, legal , pol i t ical) wi th in the Western w o r l d are beginning to show, not only tolerance of, but whole-hearted support for ind iv idua l rights to self-autonomy and self-determination. These personal freedoms have been enacted i n a variety o f personal rights, for example, the right to die. These ideas have had a corresponding effect on contemporary and social conceptions o f suicide. Espec ia l ly disturbing, B o l d t (1987) contends that " W e are m o v i n g from predominantly negative conceptions of suicide toward a consensus that there is a time and situation when suicide is acceptable, i f not appropriate" (Boldt , 1987, p.6). B o l d t (1987) notes that a "worr isome reconstruction of the meaning o f suicide has occurred for the y o u n g " (p. 6) in a pro-suicidal direction, i n that suicide is now being interpreted by youth as a viable option to seemingly intolerable life situations. The youth of today frequently speak o f 'rational suic ide ' and 'the right to suicide. ' Th i s trend suggests that youth are influenced by and vulnerable to societal v iews. In the past, the stronghold o f Judeo-Christ ian values and beliefs has l imi ted our understanding o f the experiences of fami ly survivors o f youth suicide. U n t i l recently, both sacred and secular standards defined suicide as a mora l ly abhorrent act. In recent years, secular laws against suicide have been repealed, and the Church has abandoned its moralist ic and punit ive attitude toward suicide (Bold t , 1987). E v e n so, change has been s low and fami ly survivors o f suicide often continue to be the recipients of society 's harsh judgment. Hea l ing W i t h i n Fami l ies 7 The value placed on youth wi th in society is questionable. Society , favoring deeds and accomplishments among its members, bestows high regard and recognit ion on those able to make significant contributions to the welfare o f its c i t izen. W h e n those who die (i.e., youth) have not contributed to the social fabric o f society, they may not be v i ewed as a loss wi th in society (Glaser & Strauss, 1964). Thus , when a youth ends his or her l i fe , it is c o m m o n for members o f society to dismiss the incident along wi th any reminders o f this 'unwarranted act.' Such responses not only negate the life o f the deceased ind iv idua l , they also invalidate, to a great extent, the experiences of f ami ly survivors . Stigmatization surrounding suicide remains pervasive wi th in society. Societal attitudes and related perceptions about bereaved family members contribute to stigmatization. The "no talk rule" becomes the modus operandi wi th in society ( B . Shawanda, personal communica t ion , M a y 28, 1998). W h e n suicide strikes, others are often not there for bereaved fami ly members to the same degree as is the case wi th other kinds o f deaths (Sheskin & Wal l ace , 1976; Thornton, Whit temore, & Robertson, 1989). Further, those who are uncomfortable wi th the topic frequently 'blame the f ami ly ' (Rudestam, 1992) for the suicide. Survivors often feel si lenced. Sensi t ive to others' discomfort about suicide-related matters, they frequently respond by wi thdrawing f rom other people, especially those external to the fami ly unit. Hence, the st igma associated wi th youth suicide often b locks the fami ly f rom seeking needed professional help and social support. The stigmatization surrounding youth suicide isolates and ostracizes fami ly survivors during a time when understanding and compassion are sorely needed (So lomon , 1982-1983; Thornton, Whi t temore , & Rober tson, 1989). Educators generally respond to the expressed needs o f those wi th in society. In keeping wi th society's general disdain of death-related matters, educational programs currently provide min ima l preparation (Morgan , 1990) to assist human service professionals i n car ing for famil ies who have experienced youth suicide. M o r e than 30 years ago, Quin t (1967) indentif ied the need to develop a systematic plan for educating nurses about death and dy ing . Howeve r , wi th in most curr icula , m in ima l emphasis is placed on issues related to death and bereavement generally, and on the health care needs of fami ly survivors of youth suicide specif ical ly. In addit ion, teaching faculty often lack Heal ing W i t h i n Fami l ies 8 adequate preparation specific to youth suicide and its impact on the fami ly . Wi thout sound theoretical understanding and s k i l l acquisit ion, it is unrealistic to expect human service professionals to provide quali ty care (Grant K a l i s c h u k , 1992) to this populat ion. In part, this educational deficit may be attributed to the l ow priority placed on death-related issues wi th in the health care system. The Response of the Heal th Care System to Y o u t h Suic ide It is important to address the shortcomings o f the health care system i n dealing wi th bereaved famil ies, especial ly families who are bereaved due to youth suicide. In the past, the philosophy and organization o f the health care system perpetuated a context i n wh ich the humane side o f care g iv ing was often left to chance (Beno l i e l , 1988; Watson , 1999). T h e shroud o f silence and secrecy surrounding suicide has contributed greatly to mainta ining the status quo posit ion (i.e., silence prevails) wi th in the exist ing health care practice arena. F a m i l y survivors o f youth suicide are sensitive to the "no talk rule" that permeates every level o f discourse wi th in the health care system. In an effort to reach out to others in s imi lar circumstances, suicide survivors have often initiated the organization of informal suicide support groups. W h i l e these groups provide much needed support to individuals and families, they fail to address concerns related to youth suicide wi th in the broader communi ty and society. The Canadian health care system remains heavily influenced by the medica l model and as a result spends a disproportionate amount of the health care budget on institutional care (Minis ter of Pub l i c W o r k s & Government Services Canada, 1998). In Canada, the port ion of the provinc ia l mental health care budget that is spent on communi ty support services averages 13%, ranging from 3 .1% in M a n i t o b a to 4 6 % i n N e w B r u n s w i c k (Nasir , 1994). In regard to youth suicide, most of these community-targeted funds are spent on preventive measures. W h i l e such efforts are commendable, families that have been traumatized by youth suicide are often overlooked. Ul t imate ly , this ever-growing segment of the population is often left to manage and cope on its o w n wi th in a deficiency-based health care system that provides m i n i m a l support and assistance. The b iomedica l mode l has had a strong influence wi th in the health care system. Heal ing W i t h i n Fami l ies 9 Influence of the B iomed ica l M o d e l W i t h i n the Western wor ld , the problem-focused, deficiency-based b iomedica l model has adversely influenced health care research and practice in three distinct ways. First , w i th in the last century, the medical iza t ion o f death has had a corresponding effect on the care provided to bereaved families in that medical treatment and cure have been given priori ty over psychosocial and spiritual care. It appears as i f there are social rules about what to ignore wi th in health care, and death-related matters seem to engender the ultimate i n denial (Rudestam, 1992). Se ldom is a suicide survivor ' s suffering recognized as a psychosocia l and spiritual crisis worthy of attention and care by health care professionals. W h e n such a crisis is identified, medica l personnel often prescribe medication rather than sitting wi th and listening to fami ly survivors share their stories about loss. Second, much o f the research literature publ ished to date focuses on the difficulties and problems confronted by families i n the aftermath o f youth suicide (Adams , Overholser , & Spir i to , 1994; Brent , 1995; Brent et a l , 1993; Pataki & Car l son , 1995; Re i fman & W i n d l e , 1995; R u d d , D a h m & Rajab, 1993). Correspondingly , this problem-focused approach to research has led t o ' problem-based practice wh ich often fails to address ind iv idua l and fami ly strengths. General ly , suicide survivors only enter the health care system when gr ieving becomes unmanageable. Bereaved individuals and families are often identified by health care professionals as an extremely vulnerable populat ion (Thompson & Range, 1992-93), and because they are labeled i n this way, they are treated accordingly—as individuals and families i n need o f help f rom external sources. Patterson (1995) contends that individuals and families often are unaware o f their o w n strengths because professionals tend to focus on deficiencies and problems rather than on indiv idual and family strengths and competencies. Hence, one of the major barriers to family-centered health care del ivery has been the failure of health care professionals to assist individuals and families i n the discovery and development o f their o w n capabilities. T o a great extent, problem-oriented research has unintentionally impeded health-focused practice. T h i r d , the b iomedica l model with its emphasis on parts rather than wholes has influenced researchers and c l in ic ians to focus on individuals rather than famil ies . H o w e v e r , individuals do not Hea l ing W i t h i n Fami l ies 10 exist in isolat ion; rather, they l ive in families wi th in a mosaic o f social interaction. F a m i l y members derive meaning i n life f rom their interactions wi th others. The practice o f exclus ively focusing on the indiv idual fails to take into account the many important aspects that are c o m m o n to both individuals and famil ies (e.g., relationships and communicat ion) . A c c o r d i n g to Kissane and B l o c h (1994), "the fami ly vir tual ly always constitutes the most significant social group in wh ich gr ieving is experienced" (p. 728). Since gr ieving occurs wi th in the context o f the fami ly , it is important to consider the influence o f the indiv idual on the family , and the influence o f the fami ly on the indiv idual . The fami ly , wi th its r ich , dynamic , and complex characteristics is a major social agency for human growth. In effect, the reductionistic b iomedica l mode l fails to take into account the inherent complexi ty and vastness of human existence and, therefore, it has been ineffective i n terms o f p rov id ing a v is ion for holist ic health care practice. H o w e v e r , wi th in the last three decades, the b iomedica l mode l ' s stronghold on both health care research and practice has been waning. The shortcomings o f the past have provided the impetus for the future transformation o f the health care system. D u r i n g the past two decades, unprecedented changes have been occurr ing wi th in the health care system. Beset by economic, performance, and credibi l i ty crises, the health care system is currently undergoing a massive overhaul (Ferguson, 1980; Laurence & Weinhouse , 1994; Rach l i s & Kushner , 1989). Increasingly, health care consumers are beginning to withdraw legi t imacy f rom 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 o f health for both themselves and their families. N o w more than ever before, consumers are ho ld ing the health care system accountable for high quality, patient- and family-centered health care del ivery. Increasingly, the influence o f the " N e w Parad igm of Hea l th" (Ferguson, 1980, p. 246) is catching the attention of researchers and cl inicians alike because of its fit wi th the a i m of promot ing holist ic health care practice. The O l d Paradigm of M e d i c i n e — T h e N e w Parad igm of Heal th A l m o s t two decades ago, Ferguson (1980) la id the groundwork descr ibing the transformation that is now occurr ing wi th in the health care system. A c c o r d i n g to Ferguson (1980), Hea l ing W i t h i n Fami l ies 11 " W e have oversold the benefits o f technology and external manipulations; we have undersold the importance o f human relationships and the complexi ty o f nature" (p. 246). T h e " o l d paradigm of medic ine" (Ferguson, 1980, p. 246) wi th its focus on disease and i l lness is s l o w l y being replaced by the "new paradigm of health" (Ferguson, 1980, p. 246) w h i c h stresses the importance o f health and wel l -be ing . Congruent wi th the b iomedica l model , the " o l d paradigm of medic ine" was based on the fo l l owing assumptions: a mechanistic approach to disease; separation o f the m i n d and body; treatment of symptoms rather than cause; an emphasis on quantitative data; primary intervention wi th 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 o f the "new paradigm of health" embraces ideas such as: an integrated concern for the whole patient and an emphasis on achieving m a x i m u m wellness or "metahealth;" the body being v i ewed as a dynamic system, context, and f ie ld of energy wi th in other fields; the min ima l use o f 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 unvei l the human perspective; and prevention that is synonymous wi th wholeness, work , relat ionships, goals, and the body-mind-sp i r i t (Ferguson, 1980, p. 247). Th is latter perspective underscores the inherent value of holistic professional nursing practice based on health-oriented research. Health-Oriented Research W i t h i n the Western wor ld , health care has been significantly influenced by the adoption of pr imary health care as a means o f achieving "health for a l l " (Lalonde, 1974). W i d e l y 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 communi ty by means acceptable to them, through their ful l participation, and at a cost that the communi ty and country can afford" ( W o r l d Heal th Organizat ion, 1978). Specif ical ly , pr imary health care promotes m a x i m u m indiv idual and communi ty involvement meaning that "a l l persons have the right and duty to participate Heal ing W i t h i n Fami l ies 12 indiv idual ly and col lect ively i n the planning and implementation of their health care" (Canadian Nurses Assoc i a t i on , 1988, p. 5). P r imary health care serves as the forerunner o f a newer concept, that o f health promotion, w h i c h is the process o f enabling people to increase control over, and to improve their health (Raeburn & Rootman , 1998; W H O , 1984). W h i l e this reconceptualization o f health care has been espoused i n theory, a corresponding emphasis in research is st i l l i n the neophyte stage. In order for individuals and families to increase control over their health, and to participate i n their o w n health care, it is imperative that they be inc luded i n 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 o f individuals and families is pivotal to the development o f healthy communit ies . Eng l i sh and H i c k s (1992) note that in order to promote the health of famil ies and communit ies , that it is important to identify and b u i l d on human strengths. A n t o n o v s k y (1996) suggests that "the persistence o f the disease orientation and the l imits of r isk factor approaches for conceptual izing and conduct ing research on health" (p. 11) poses a serious threat to the concept o f health promotion. H e goes on to c l a i m that it is mora l ly " impermissible to identify a r ich , complex human being wi th a particular pathology, disabil i ty or characteristic" (p. 14). Instead, A n t o n o v s k y (1996) proposes that the "Salutogenic M o d e l " (p. 14) wi th its focus on health promot ing factors, cou ld w e l l serve as a viable , useful, and powerful guide for both practitioners and researchers. Th is approach is opposed to a dichotomous classification of persons who are either healthy or diseased, characteristic o f the b iomedica l mode l (Antonovsky, 1996). Rather, this mode l directs both research and practice efforts to encompass a l l persons, wherever they are on the health-disease cont inuum (Antonovsky , 1996; Jensen & A l l e n , 1993). Through the use of this mode l , health-promoting questions such as " H o w can this person be helped to move toward greater health?" have significant relevance. In terms o f facilitating a movement toward health, A n t o n o v s k y , (1996) suggests that one 's "sense o f coherence" (p. 15), or abi l i ty to f ind meaning i n , and make sense o f one's wor ld , is essential. Further, he c la ims that it is the combinat ion of cognit ive (a belief that the challenge is understood), behavioral (a belief that the resources to cope are available), and motivational (the wi sh to cope) factors that determine the Hea l ing W i t h i n Fami l ies 13 strength o f one 's sense o f coherence, and thus one's movement toward health. T h i s health-oriented, yet h igh ly ind iv idua l ized model is congruent with nursing's holist ic approach to health care delivery, and thus influenced the approach taken during the early conceptualization of this dissertation study. The Response of N u r s i n g to Y o u t h Suic ide A l i g n e d wi th medicine by necessity, nursing has also contributed to the shortfalls wi th in the health care system. In the past, nursing has also been negatively inf luenced by the b iomedica l model . Howeve r , posi t ive and exci t ing changes wi th in the nursing profession are emerging wi th increasing frequency. The proliferation of research-based nursing knowledge in recent years has validated and fortified the scientific basis o f nursing practice. A s the scientific knowledge base of nursing expands, and as the level of education among nurses increases, nurses are further able to define, c l a i m , and take responsibil i ty for their legitimate scope o f practice. Nur s ing , charged with the responsibil i ty o f provid ing holistic health care to individuals and famil ies in a variety of settings (Alber ta Assoc ia t ion of Registered Nurses, 1993), has the potential to make a significant contribution i n terms o f assisting bereaved families. A s Rogers and V a c h o n (1975) c l a im: "Nurses, by virtue of their personal caring roles and their positions wi th in institutions and in the communi ty at large, are uniquely suited to carry more responsibil i ty i n p rov id ing service to the bereaved" (p. 16). Nurses are members of the health care team who have the most contact wi th bereaved families; they are often i n contact wi th individuals and families on a 24-hour basis. Th i s increased contact time facilitates nurses establishing therapeutic relationships (Quinn , 1989; Watson , 1999) wi th individuals and families. In addition, nurses are strategically posi t ioned wi th in the communi ty and prepared to coordinate the activities of the mult idiscipl inary health care team. "Nurses are at the vanguard of the quickening o f the transpersonal currents o f heal ing" (Dossey & Dossey , 1999, p. x) . Q u i n n (1989) asserts that heal ing is a major goal o f nursing and that nurses may be the midwives who facilitate healing in others, whi le Wel l s -Fe lderman (1996) purports that it is time for nurses to take the initiative by introducing healing nursing interventions that acknowledge compassionate and knowledge-based caregiving. S i m i l a r l y , Le f tw ich (1993) Hea l ing W i t h i n Fami l ies 14 contends that "Nur s ing has a heritage of healing that was h ighly valued i n the past" (p. 13), and maintains that nurses need not be t imid about insisting that healing is an inherent element of nursing practice. In order to c l a i m that healing is a major goal o f nursing practice, nurses need scientif ical ly-based nursing knowledge (i.e., theory) that explicates the process o f heal ing. The Study: A Focus on H e a l i n g Th i s purpose o f this research was to develop a substantive theory that explains how indiv idua l fami ly members heal in the aftermath of youth suicide. T h i s study adopted a health-focused, health promotion perspective that embraced the strengths and resilient nature of gr ieving individuals and families. Assumpt ions Underp inn ing the Study Th i s research was based on the fo l l owing assumptions: 1. Individual fami ly members possess innate healing capabilit ies w h i c h they can draw upon during times o f hardship (e.g., youth suicide). 2. The process of heal ing can be studied. Further, it was assumed that f ami ly survivors are the best sources of data to describe and, hence, promote an understanding o f the ind iv idua l healing process f o l l o w i n g youth suicide. 3. The perceptions and ideas of all family members are relevant and therefore contribute to the development o f theory about healing in indiv idual fami ly members fo l l owing youth suicide. Conceptual Issues A s I approached this study, two issues soon became apparent. Firs t , dur ing the conceptualization of this research study, I intended to study the concept o f ' f ami ly healing. ' However , the study was w e l l underway when I discovered that although fami ly survivors were attuned to the thoughts and feelings o f other family members, they were only able to reflect on their personal experiences. A s I ind iv idua l ly interviewed several survivors f rom the same family , I began to understand that each person had a personal and unique story to tell that sometimes Hea l ing W i t h i n Fami l ies 15 differed f rom the stories shared by other fami ly members. E v e n during fami ly interviews, the ind iv idua l perspective, albeit shared f rom several vantage points, was s t i l l evident. I therefore considered that each story represented a unique understanding that contributed to a comprehensive understanding o f the whole . Since this approach offered much insight pertinent to the research questions, and because l imi ted scientific research specific to heal ing wi th in this population has been conducted to date, I decided, i n consultation wi th m y dissertation committee, to focus this research on the experience o f the ind iv idua l wi th in the context of the fami ly . Second, I wondered how to best portray an understanding o f surv ivors ' accounts o f healing as a complete process, in and of itself, and at the same t ime, provide an understanding o f the intricacies inherent i n the parts compris ing the whole . A s data col lec t ion and analysis proceeded, I discovered that the indiv idual experience was also compr ised of many parts, each part adding to an understanding of the embodied whole . R a n s o m et a l . (1990) maintains that there is a mutual recursive relationship between ind iv idua l fami ly members and the fami ly unit that results i n the co-evolut ion o f both over t ime. Thus , "we cannot understand wholes without understanding parts and their relationships and vice versa" (Robinson , 1995b, p. 11). S i m i l a r l y , understanding the ind iv idua l experience also involves gaining insight about the various facets o f one's experience. Because we k n o w little about how the healing process occurs, the theory presented herein focuses on the ind iv idua l ' s experience w h i c h is also comprised o f many parts. W i t h i n this dissertation, the ind iv idua l ' s experience o f healing is presented i n its parts only for the purpose of understanding. In reality, the parts compr i s ing the whole are enmeshed i n a dynamic , recursive, and seamless process. It is anticipated that such knowledge w i l l increase our understanding about how individuals wi th in families heal wh ich , i n turn, may provide some insight about healing wi th in the communi ty and ultimately wi th in society. Research Questions The fo l l owing four research questions were used to guide this scientific inquiry: 1. Wha t is the meaning o f youth suicide to ind iv idua l fami ly survivors? W h a t sense, or meaning, can be made of the suicide from their perspectives? Hea l ing W i t h i n Famil ies 16 2. F o l l o w i n g youth suicide, how do fami ly survivors grieve? 3. H o w do these same individuals engage in the healing process f o l l o w i n g youth suicide? Specif ica l ly , what factors promote healing and what factors inhibi t healing? 4. W h a t is the relationship between gr ieving and healing? Def in i t ion of Terms Three concepts are central to the study. They are defined as fo l lows: • Y o u t h Suic ide . Y o u t h suicide is the " w i l l i n g and w i l l f u l self-termination" (Boldt , 1988, p. 93) o f a youth aged 10-19. • F a m i l y Surv ivors . Individuals f rom the deceased's fami ly o f or ig in i n addit ion to those identif ied by this group as being part o f the fami ly . • G r i e v i n g . G r i e v i n g refers to "the ful l range o f our cop ing responses to loss through death, inc lud ing , but not conf ined to, social ly defined mourn ing practices, or what we do wi th in ourselves to redefine our relationship wi th the deceased" (At t ig , 1996, p. 9). Summary The health care system has been s low to respond to the health care needs of fami ly survivors o f youth suicide for a number of reasons, some of w h i c h have not been ful ly explored as yet. F o r the past few decades, health care professionals have laudably focused their efforts on youth suicide prevention programs. E v e n so, the incidence o f suicide among youths continues to soar, s ignifying a portentous global and national mental and publ ic health problem. In the aftermath of youth suicide, fami ly survivors continue to be deeply affected throughout l ife. F a m i l y survivors sustain both short- and long-term health and human consequences as a result of such trauma. W i t h i n the Western wor ld , the strong influence of the b iomedica l mode l has resulted in health care delivery that often emphasizes treatment and cure over humane and compassionate care. Unfortunately, youth suicide fami ly survivors often have been left to manage on their o w n wi th in a health care system that provides m i n i m a l support and assistance. Hea l ing W i t h i n Fami l ies 17 Nurs ing , wi th its mandate of p rov id ing holistic health care to indiv iduals and families, can assist i n extending comprehensive health care to bereaved families, inc lud ing families bereft by youth suicide. T o this end, in order to facilitate healing, it is important for nurses and other health care professionals to have a theoretical understanding o f how ind iv idua l healing occurs. Th i s research was concerned with the development of theory that explains how the ind iv idua l wi th in the context o f the fami ly moves toward healing fo l lowing youth suicide. Th i s dissertation is presented in nine chapters. In Chapter One, the background related to healing wi th in families fo l l owing youth suicide was established. Chapter T w o provides an overview of the empir ica l evidence specific to gr ieving and healing wi th in families. Chapter Three is devoted to the methodological forestructure, inc lud ing the phi losophical , theoretical, and personal perspectives o f the researcher, as w e l l as the. method, analytic approach, and ethical considerations that underpin this work. In Chapter Four , an overv iew o f the grounded theory is provided in addition to the contextual factors that influence the healing process. Chapters F i v e to Seven are concerned with the presentation of the theory that was developed as a result o f data analysis. Chapter F i v e portrays the first theme of the healing process, Cocooning, wh i ch embraces the survivor ' s journey o f descent wi th in self. Chapter S i x explicates the second theme, Centering, w h i c h i l luminates the survivor ' s journey of growth. Chapter Seven elucidates the third theme, Connecting, w h i c h captures the survivor ' s journey of transcendence. Chapter E igh t addresses the relationship between healing and gr ieving and enriches the description of the content through a discussion o f selected elements o f the constructed theory. C o n c l u d i n g this dissertation, Chapter N i n e outlines implicat ions of the research. Hea l ing W i t h i n Fami l ies 18 C H A P T E R T W O E M P I R I C A L E V I D E N C E S P E C I F I C T O G R I E V I N G A N D H E A L I N G W I T H I N F A M I L I E S F a m i l y survivors of youth suicide are often left to carry on wi th day-to-day life at a time when they may feel that their wor ld , as they once knew it, has been turned inside out and upside down. The death o f a fami ly youth due to suicide may represent many things to fami ly surv ivors— the loss o f a c h i l d , the loss o f one's hopes and dreams, the loss o f a shared future, and the loss o f part o f oneself. In the face o f catastrophic loss, it is inevitable that fami ly members undergo an extensive per iod o f gr ieving as they journey toward healing. A thorough examination of the literature provided min ima l scientific evidence specific to healing wi th in families fo l l owing youth suicide. However , gr ieving, an important aspect o f healing, has been studied extensively. Since this study is located wi th in the domain o f gr ieving families, this chapter highlights current knowledge related to gr ieving wi th in the context of the family . It also identifies a gap wi th in the current literature. The fo l l owing topics are discussed: the concept of gr ieving, traditional and contemporary theories o f gr ieving, gr ieving wi th in families, research and practice issues, gr ieving fo l l owing suicide, the meaning o f suicide, and also a brief description o f the empir ical ly-based literature that addresses the concept o f healing. The Concept o f G r i e v i n g The study o f gr ieving is relatively new. F reud began the analysis of the concept when he compared the subjective experience of grief to the experience of melanchol ia (Burnel l & Burne l l , 1989; H a i g , 1990; W o r d e n , 1982). H e proposed that the pr imary difference between the two was that one experiences an extreme loss of self-esteem and a persistent sense o f self-denigration only in melanchol ia (Ha ig , 1990). Later, in a classic study o f survivor reactions to a fire in the Coconut G r o v e nightclub in Bos ton , L indemann (1944) described gr ieving according to a predictable pattern accompanied by certain identifiable reactions to loss (Burne l l & B u r n e l l , 1989). These early conceptualizations o f the concept o f gr ieving provided the basis for further study. Var ious definitions of grief appear i n the literature. G r i e f is defined as: an adaptation to loss ( B o w l b y , 1973; H a y l o r , 1987); an i l lness (Engle , 1961; V o l k a n , 1970); an acute crisis or series o f Hea l ing W i t h i n Fami l ies 19 crises (Caplan , 1974; L i n d e m a n n , 1944); an indirect pathogen (Sanders, 1982-1983); a syndrome (Lindemann, 1944; Parkes, 1972); and as an active learning process (At t ig , 1991, 1996; Fe ldman , 1989). Parkes (1970) described gr ieving as "a complex and t ime-consuming process in wh ich a person gradually changes his v i e w o f the wor ld . . . . It is a process o f real izat ion, o f mak ing psychologica l ly real an external event wh ich is not desired and for w h i c h cop ing plans do not exist" (p. 465). Based on a comprehensive and systematic review of both current and classic literature, C o w l e s and Rodgers (1991) further expanded previous definitions o f grief. These authors defined grief as "a dynamic , pervasive, h ighly ind iv idua l i zed process wi th a strong normative component" (p. 121). A c c o r d i n g to M a r t i n and E l d e r (1993), " G r i e f arises f rom an awareness that the w o r l d that is and the w o r l d that ' should be' are different" (p. 73). Moreover , our understanding o f this universal phenomenon has been influenced by both traditional and contemporary v iews o f gr ieving. Tradi t ional Theories o f G r i e v i n g : Stages/Phases o f G r i e v i n g In her classic work , O n Death and D y i n g . Kub le r -Ross (1969) categorized the experience of dy ing into f ive stages—denial and isolat ion, anger, bargaining, depression, and acceptance. This ground-breaking book spurred scholars and cl inicians to begin a dialogue about death-related topics that continues today. Because of perceived similarit ies between dy ing and gr ieving, interested indiv iduals extrapolated from K u b l e r - R o s s ' s work other descriptions o f gr ieving. F o r instance, Mar tocch io (1985) described five phases of gr ieving: shock and disbelief; yearning and protest; anguish, disorganization, and despair; identification i n bereavement; and reorganization and restitution (pp. 328-331). A v e r i l l (1968) specified three stages o f gr iev ing: shock, despair, and recovery, whi le Parkes (1970) identif ied four stages o f gr ieving: numbness, p in ing (searching behavior) , depression, and recovery (Burne l l & B u r n e l l , 1989, p. 34). A number o f authors identified the tasks related to gr ieving, specifically: acceptance o f the loss; acceptance o f pain associated wi th gr ieving; adjustment to life without the beloved; and investment o f energy into a new life or relationship (Burne l l & B u r n e l l , 1989; H a i g , 1990; Steen, 1998; W o r d e n , 1982). W a l s h and M c G o l d r i c k (1991) incorporated two additional tasks designed to promote grief Hea l ing W i t h i n Fami l ies 20 adaptation wi th in families. These tasks inc luded acknowledgment o f the reality o f the death and sharing o f the experience o f loss, as we l l as reorganization o f the fami ly system and reinvestment in other relationships and life pursuits. Weiss (1988, c i ted in H a i g , 1990) proposed three steps in the adaptation to loss: cognit ive acceptance, emotional acceptance, and identity change. M o s t of the literature describes gr ieving as a mult i-phased process based on c o m m o n assumptions. Tradi t ional theorists recognized the phys ica l , emotional , behavioral , and psychologica l aspects of the gr ieving process. They, responded by specifying several parameters of the gr ieving experience. These theorists envis ioned gr ieving as a l inear and progressive phenomenon i n w h i c h the bereaved ind iv idua l passively moves through a series o f stages or phases that begins at the t ime o f loss and ends at some definit ive point in the future. G r i e v i n g was v i ewed "as yet another thing that happens to bereaved persons, a process into w h i c h they are thrust against their w i l l , wh i ch they undergo or endure, and w h i c h they must somehow survive" (At t ig , 1991, p. 386). Tradi t ional theories often labeled aberrant manifestations o f grief as pathological . Such label ing has not always been helpful in terms of securing needed help for gr ieving individuals and families. U n d e r l y i n g Assumpt ions It has been suggested that conceptualizations of gr ieving are most l i ke ly related to assumptions that underpin the development of knowledge (Wambach , 1986). H o g a n and DeSant is (1992) contend that the major assumptions underpinning the traditional v iews o f gr ieving and bereavement are der ived from mult iple perspectives. Understanding the assumptions upon wh ich theories o f gr ieving are based is essential to determining their efficacy in the practice setting. Based on Western tradition, f ive assumptions prominent wi th in the literature on gr ieving are: 1. distress or depression is inevitable; 2. distress is necessary, and failure to experience distress is indicative of pathology; 3. w o r k i n g through loss is not only important, but necessary; 4. recovery f rom loss w i l l occur; and 5. resolution of grief w i l l be attained ( W o r m i a n & Si lver , 1989). Howeve r , these authors c l a im that empir ical evidence suggests that harm may result i f we practice according to these mistaken assumptions. Hea l ing W i t h i n Fami l ies 21 The majority of traditional theories o f grief are, in fact, based on these assumptions ( B o w l b y - W e s t , 1980; E l i o t , 1932; Freud , 1915; K u b l e r - R o s s , 1969; L i n d e m a n n , 1944; Parkes & Wei s s , 1983). H o w e v e r , these theories do not account for a l l cases o f grief. A s indicated by W o r t m a n and S i lve r (1989), "Tradi t ional theories o f grief and loss are able to account for those who move from high to l ow distress and resolve their grief over t ime. B u t these theories offer little explanation of why some people might consistently respond wi th less distress than expected and others fai l to recover or resolve their loss over t ime" (p. 353). Contemporary Theories o f G r i e v i n g : G r i e v i n g as a D y n a m i c Process Contemporary theorists question traditional interpretations o f gr iev ing ( A r n o l d , 1996; C o p p , 1998; C o w l e s & Rogers , 1991; D o y l e , 1994; K l a s s , S i l ve rman , & N i c k m a n , 1996; Rando , 1988; Stroebe, 1992-1993; Stroebe, V a n D e n Bout , & Schut, 1994). These authors maintain that gr ieving is a dynamic rather than linear process (Cowles & Rogers , 1991) w h i c h is "oscil latory in nature rather than purely sequential" (Trunnel l , Caserta, & Whi t e , 1992, p. 279). Instead o f fo l lowing clearly demarcated steps as proposed in the stage and phase models o f linear and cyc l i ca l gr ieving (Worthington, 1994), reactions to loss may ebb and f low over an unspecif ied per iod of time. Th i s impl ies a certain chronici ty of the gr ieving process (Haylor , 1987) or, as stated by Parkes (1970), " in some senses it [grieving] never ends" (p. 464) . H o w e v e r , even though some authors suggest that the impact o f gr ieving may be long-lasting, there is surprisingly little empir ica l data to support this c l a i m (Lehman, Wor tman , & W i l l i a m s , 1987). A t t i g ' s mode l o f gr ieving (1996), i n contrast to traditional models , describes gr ieving as an active cop ing process o f how to be and act i n a w o r l d where loss disrupts the ind iv idua l ' s biography. A s a multifaceted transitional process, gr ieving involves invest ing ourselves as whole persons i n a process o f relearning our w o r l d i n the absence o f our l oved one. A t t i g suggests that grief is not something we get over, but learn to integrate wi th in our l ives . H e contends that we do not cease lov ing those who die. Rather, A t t i g (1996) maintains that "one of the most important aspects of gr iev ing is f inding ways to make a transition f rom car ing about others who are present to caring about them when they are absent" (p. 39). Based on current research, a number o f other Hea l ing W i t h i n Fami l ies 22 contemporary theorists support this v i ew o f gr iev ing (Klass , S i lve rman , & N i c k m a n , 1996; Rosenblatt , 1996; S i lve rman & N i c k m a n , 1996a, 1996b; Stroebe, Gergen , Gergen , & Stroebe, 1996). A l though representing the v iews of a minor i ty at present, the romanticist notion that values bonding wi th the deceased person is being revived. Th i s v iew presents a case for the healthy presence of the deceased person i n the ongoing l ives o f survivors (Klass , S i lve rman , & N i c k m a n , 1996; M a r w i t & K l a s s , 1996). M a n y authors maintain that the expectation that people should get over their grief is unrealistic and based on a misunderstanding of the gr iev ing process (Klass , S i lve rman , & N i c k m a n , 1996; Rosenblatt , 1996; S i lve rman & N i c k m a n , 1996a; Stroebe, Gergen, Gergen, & Stroebe, 1996). A g rowing number o f researchers and c l in ic ians now contend that gr ieving a major loss extends throughout the life o f the bereaved ind iv idua l (Hogan & DeSantis , 1996; Rosenblatt , 1996; S i lve rman & N i c k m a n , 1996a; K laus s , S i l ve rman , & N i c k m a n , 1996). S i lve rman and N i c k m a n (1996b) assert that survivors maintain a "cont inuing bond" (p. 349) with the deceased; they profess that "survivors ho ld the deceased in l o v i n g memory for long periods, often forever, and that maintaining an inner representation o f the deceased is normal rather than abnormal" (p. 349). Based on contemporary ideas of gr ieving, M a r t i n and E l d e r ' s (1993) Pathways Through G r i e f M o d e l provides an explanation of ind iv idua l gr ieving. T h i s mode l is based on the work of B o w l b y (1973) who maintains that attachment precedes grief. Several assumptions underpin this model , specif ical ly: gr ieving is triggered by los ing someone important; gr ieving affects the total person wi th in the context o f the present and past; gr ieving occurs throughout life and thus is a process rather than an event; and gr ieving changes over time wi th no end point (Mar t in & Elder , 1993). M a r t i n and E lde r ' s model portrays the unending nature of gr iev ing in addition to the contextual influences that affect ind iv idua l gr ieving. M o s t theories of gr ieving to date focus on the indiv idual perspective. Individual gr ieving is influenced by a number o f factors. Hea l ing W i t h i n Fami l ies 23 Influencing Factors M a n y contemporary theorists contend that indiv idual gr ieving is inf luenced by a number of contextual factors. Worden (1982) identified several factors that affect how one grieves. One factor is the identity o f the deceased person in relation to the gr ieving ind iv idua l . I f the deceased ind iv idua l was a c h i l d or spouse, the grief response is stronger than it is for a distant relative. The strength and security of the relationship between the deceased ind iv idua l and the bereaved person is an important factor as w e l l . I f there was ambivalence i n the relationship, gr ieving is often difficult. Whether the death is expected or unexpected, prolonged or sudden, homic ida l or suicidal also determines how the survivor grieves. Death that is sudden and/or unexpected, or that occurs as a result o f suicide, provokes prolonged, diff icult grief (Steen, 1998). The health history o f the gr ieving person also plays a role in the gr ieving experience. A diagnosis o f c l in i ca l depression or mental i l lness may complicate gr ieving for survivors. The nature o f previous losses and the way in w h i c h these losses were dealt wi th modifies subsequent grief experiences. I f the bereaved ind iv idua l was unable to grieve for previous losses, then a new loss may el ic i t a previous grief response and, therefore, compound the present grief experience. T h e personal characteristics of the bereaved are important as w e l l . The bereaved person's age, sex, cop ing sk i l l s , level o f anxiety, and whether he or she is an introvert or extrovert affect the grief experience. O lde r people often have an advantage because they have developed coping ski l ls that assist them in gr ieving. Younger people do not expect to be faced wi th the death o f a loved one and, hence, may lack w e l l developed cop ing sk i l l s . Besides those determinants identified by W o r d e n (1982), social support has also been identified as an important factor that influences gr ieving (Gass & Chang , 1989; M a r t i n & Elder , 1993). A supportive social network and adequate f inancial support aids the gr iev ing person. H ighe r education also may impact the course of grief. Those wi th higher levels o f education tend to uti l ize more problem-focused coping strategies (Gass & Chang , 1989) w h i c h facilitate healthy psychosocial functioning. In addition, having someone available to participate i n appropriate death rituals posi t ively influences the gr ieving person's adjustment to the death o f a l oved one ( M y s s , 1996, 1997; Rosen , 1990). I f the gr ieving person believes that he/she is totally or even partially Hea l ing W i t h i n Famil ies 24 responsible for the death o f a loved one, then gr ieving may be more difficult . The existence o f other major crises in the gr ieving person's l ife may also compound gr ieving. Contextual factors such as ethnic, cultural, and rel igious beliefs are cri t ical determinants of the gr iev ing experience (Cowles , 1996; Rosen , 1990; Stroebe, 1992-1993). These beliefs are based on certain assumptions. F o r example, Stroebe (1992-1993) contends that the grief work hypothesis, w h i c h stresses the importance o f bereaved persons comple t ing their grief work, has been neither conf i rmed nor refuted as a result of empir ica l studies. Rather than assuming that a l l people grieve i n the same way, Stroebe (1992-1993) maintains that there are societal and cultural factors, and preferred styles o f cop ing wi th loss that need to be taken into account. Stroebe (1992-1993) asserts that "not on ly do beliefs i n some societies fai l to show any equivalent o f the grief work hypothesis, but an absence of grief w o r k i n some cultures does not seem to be associated wi th [a] h igh [incidence of] depression, i l lness , or pathology" (p. 28). R o s e n (1990) suggests that when families do not observe the appropriate ethnic/cultural rituals o f mourning , their gr ieving may be affected by deep-seated beliefs based on their ethnic background. A reaction that appears to be denial or an absence o f grief may, i n reality, be a cul tural ly-mediated grief response (e.g., the Irish wake or the N e w Orleans up-beat j azz march during the return f rom the interment). Current theoretical perspectives recognize gr ieving as an ind iv idua l ly unique experience; hence, g r iev ing unfolds according to each individual ' s way o f being i n the wor ld . Recent conceptualizations also acknowledge both the inner and outer work that are required of the gr ieving indiv idua l , the continuity and f luidi ty o f the grief experience over t ime, and especially, the importance of creating new meaning in response to the suffering associated wi th the loss (At t ig , 1991, 1996; K l a s s , S i l ve rman , & N i c k m a n , 1996; M a r t i n & E l d e r , 1993). Gr i ev ing W i t h i n Fami l ies W h i l e a substantial amount of conceptual and empir ical research has been conducted on indiv idual gr ieving, the literature that addresses gr ieving f rom the perspective of the family remains scarce i n both quantity and scope (Kissane & B l o c h , 1994). A majority o f this literature focuses on maladaptation and pathology. However , whi le this literature is not specific to gr ieving associated Heal ing W i t h i n Famil ies 25 wi th youth suicide, it does provide the necessary background needed to understand gr ieving, and hence, gr ieving famil ies as the context for indiv iduals ' experiences o f gr ieving. W i t h i n the structure o f the family unit, fami ly members occupy certain "roles." The death (i.e., suicide) of a fami ly member calls for the reorganization o f the fami ly unit. A c c o r d i n g to V o l l m a n , Ganzert , Pincher, and W i l l i a m s (1971), "the single most important factor in the reorganization o f a fami ly as a continuing social system fo l lowing a death is the role the decedent had been assigned and w h i c h he [or she] assumed wi th in the fami ly system" (p. 104). S imi l a r l y , B o w e n (1976) and W o r d e n (1982) maintain that the loss o f a f ami ly member whose role was "emotionally" or "materially" cr i t ical is fo l lowed by greater fami ly disruption than the loss of a comparatively neutral fami ly member. Hence, it fo l lows that youth suicide is exceedingly disruptive to famil ies, both ind iv idua l ly and col lect ively . Notable contributions to the literature related to gr ieving wi th in the context o f the family have been made by B o w l b y - W e s t (1980), L iebe rman and B l a c k (1982), and Raphae l (1984). B o w l b y - W e s t (1980) identifies six maladaptive responses that famil ies resort to in order to cope wi th the death o f a fami ly member. Raphael (1984) describes seven patterns o f fami ly responses to loss that are often subtle in presentation and may be either constructive or destructive. L ieberman and B l a c k (1982) address the interplay between ind iv idua l and fami ly responses to loss. They identify three categories o f pathological fami ly gr ieving, specif ical ly: avoidance, ideal izat ion, and prolongation. These authors suggest that these response patterns parallel , and indeed amplify , those encountered in ind iv idua l gr ieving. Further, K i s sane and B l o c h (1994) maintain that unresolved grief cannot be dealt wi th until issues related to fami ly dysfunction are addressed. In addit ion, multi-generational loss issues may further compound gr iev ing wi th in famil ies ( B . Shawanda, personal communica t ion , M a y 28, 1998). T h i s refers to unresolved loss issues inadvertently passed down f rom one generation to the next. In a very real sense then, gr ieving needs to be understood from a fami ly perspective, especial ly i n cases where dysfunction is present. These explanations of fami ly grief response patterns in fo rm us that powerful and pervasive ways of coping wi th loss may be quite we l l established wi th in the fami ly unit at the time of youth H e a l i n g W i t h i n Fami l ies 26 suicide. Moreove r , fami ly responses to death are often predicated on previous learning, c o m m o n l y handed down from previous generations. N o t surprisingly, A i n s w o r t h and E i chbe rg (1991) suggest that a significant correlation exists between patterns o f parental attachment behavior (e.g., secure-autonomous, insecure-avoidant) and the quality of attachment found i n chi ldren. Moreover , the concept o f fami ly script ( B y n g - H a l l , 1988, 1991) incorporates the beliefs, values, and rules wi th in the fami ly unit that encode the family 's behavior for future situations. Such cross-generational influences suggest that families adopt styles of gr ieving that are readily transmitted to subsequent generations, either overtly or covert ly. A number o f research and practice issues influence our understanding o f this complex phenomenon. Research and Practice Issues A m b i g u i t y and confusion surrounding the concept o f grief contributes to problems related to both research and practice. In part, this ambiguity is related to the plethora o f definitions of grief-related terms found wi thin the literature, as we l l as the lack o f clari ty regarding operational definitions. In addition, research efforts to i l luminate the mul t id imensional aspects o f grief and the issue o f researchers w o r k i n g in isolation contribute to this confusion. A n awareness of the complex nature of gr ieving is essential to research that endeavors to understand how fami ly survivors grieve and move toward healing fo l l owing youth suicide. E v e n among experts, there is a conspicuous lack o f consensus regarding the definit ion o f grief (Burnett et a l . , 1994). In spite of being a "universal human response" (Cowles and Rodger , 1991, p. 119), the concept o f grief remains plagued by vagueness and ambigui ty . In addition to a lack of consensus regarding definitional clarity, terms l ike grief, bereavement, and mourning are often used interchangeably, and without explanation o f operational definitions (Middle ton , M o y l a n , Raphael , Burnett, & Mar t inek , 1993). Th i s deficiency makes it very diff icult to understand and compare, the research that has been done because of uncertainty about whether the studies are actually look ing at the same things. Such variation among definitions most l ike ly depicts the diverse discipl inary background of the many professionals i nvo lved i n bereavement care. Furthermore, these definitions appear to reflect an evo lv ing understanding of the concept of Hea l ing W i t h i n Fami l ies 27 grief w h i c h is not yet fu l ly developed. In an attempt to address this deficiency, Jacob (1993) offers an operational definit ion of grief as "a normal , dynamic , ind iv idua l i zed process w h i c h pervades each aspect (physical , emotional , social , spiritual) o f persons experiencing the loss o f a significant other" (p. 1789). Clar i f ica t ion o f this type is definitely helpful and serves as a first step toward the resolution o f concerns associated wi th definit ional clarity. Def in i t ional fuzziness or ambiguity may also be related to efforts intended to capture the mul t id imensional quality o f the grief experience. A c c o r d i n g to Jacob (1993), "the mul t i -dimensional i ty of the grief process makes an accurate assessment o f the concept difficult . . . . Th i s difficulty is largely due to the indiv idual and dynamic nature o f grief wh ich varies f rom person to. person and f rom situation to situation" (p. 1791). E v e n research measurement instruments such as the G r i e f Exper ience Inventory (Sanders, Mauger , & Strong, 1985), developed to objectively measure the mul t id imensional aspect of grief, have limitations i n that they have been developed i n reference to specific populations and according to certain assumptions that do not, and cannot, address a l l possible variations i n relation to a h igh ly complex concept such as grief. In addition, a lack o f cultural sensitivity is evident i n a majority o f the instruments currently i n use. In effect, this leads to an under-representation o f the cultural aspect o f grief. Another factor that contributes to the ambiguity surrounding grief is that researchers and cl inic ians often w o r k i n isolat ion and, as a result, rely on their o w n famil iar terminology when communicat ing research findings. This may be particularly problematic i n written communicat ion where assumptions may not be clearly identified. Further compl ica t ing this situation, research consumers frequently interpret written information according to their o w n set o f assumptions w h i c h may, or may not, be congruent wi th those intended by the author. T o enhance knowledge development, assumptions need to be clearly stated and definitions need to be clar if ied at the onset o f a study i f efforts to develop a comprehensive data base regarding grief are to be realized. The generation o f knowledge related to the topic o f grief is dependent on researchers and cl inicians being able to effectively communicate the assumptions upon w h i c h their research is based. H e a l i n g W i t h i n Fami l ies 28 G r i e v i n g F o l l o w i n g Suic ide Sudden and unexpected death has a dramatic effect on gr ieving. Mar tocch io (1985) asserts that "Death is always difficult but premature death disrupts the normal cyc le of events" (p. 334). Based on a research study that examined the long-term adjustment to sudden, traumatic loss o f a loved one (spouse or ch i ld) , the results suggest that "sudden, unexpected loss o f a spouse or c h i l d is associated wi th long-term distress" (Lehman et a l . , 1987, p. 227). Vargas (1991) found four prominent factors i n fami ly survivors o f sudden and unexpected death, specif ical ly: 1. depressive symptoms (most common) ; 2. preservation of the deceased person; 3. su ic idal ideation; and 4. anger directed toward the deceased (p. 36). Death by suicide is a traumatic event. Judith Herman (1992) describes the impact o f traumatic events this way: Traumatic events overwhe lm the ordinary systems o f care that g ive people a sense of control , connection, and meaning. Traumatic events are extraordinary, not because they occur rarely, but because they ove rwhe lm the ordinary human adaptations to l ife. . . . They confront human beings wi th the extremities o f helplessness and terror and evoke the responses o f catastrophe, (p. 33) Sel f - inf l ic ted death poses specific problems for f ami ly survivors. S i lve rman , Range, and Overholster (1994-95) suggest that suicide survivors experience unique gr ief responses and, in some cases, may be unable to ful ly resolve their grief. A c c o r d i n g to these authors, gr ieving fo l l owing suicide is more intense than from other causes o f death (e.g., homic ide , accidental death, natural anticipated death, natural unanticipated death). In addit ion, survivors face the difficulty o f constantly feeling the need to explain the reason(s) for their loved one's tragic demise (Range & Ca lhoun , 1990). Unfortunately, survivors o f suicide are more l i k e l y to assume responsibi l i ty for a loved one's death and they frequently experience an increased fear o f their o w n self-destructive impulses (Worden , 1982). Ul t imate ly , the suicide of a fami ly youth may draw the entire fami ly into distress. Moreove r , the joint experience of suffering may render fami ly members unable to provide much needed support to one another (Vachon & Styl ianos, 1988). Heal ing W i t h i n Fami l ies 29 In comparison to al l other types o f death, suicide survivors receive the least amount of communi ty support (Range & Ca lhoun , 1990; Thompson & Range, 1992-93). Because having a supportive network makes a posit ive difference i n terms o f cop ing wi th loss, a lack o f social support leaves gr ieving families in a compromised posit ion. Societal attitudes toward suicide and related perceptions o f bereaved family members suggest that friends w i l l not 'be there' to the same degree and in the same ways that they w o u l d fo l l owing other types o f deaths (Thornton, Whi t temore , & Robertson, 1989). In the apt words o f Dav ie s (1991), " W o r k i n g through grief does require the encouragement, empathy, support and caring gained through relationships with significant others" (p. 94). A lack o f social support may also have far-reaching consequences, not only for individuals and families but, ultimately, for communit ies and society. The M e a n i n g o f Suicide The ful l impact o f youth suicide occurs wi th in the context o f the gr ieving family . M a k i n g sense out o f the experience o f youth suicide is , indeed, a major challenge faced by fami ly survivors. Surv ivors o f suicide suffer more than those bereaved by other causes o f death in that they are often unable to f ind meaning i n their suffering (Si lverman et a l . , 1994-95). A n important component of gr ieving is the construction of meaning related to the loss at both the indiv idual and family levels. A t the ind iv idua l level , this construction o f 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 o f the events surrounding the death" (Carter, 1989, p. 357). A t the fami ly l eve l , the construction o f meaning may involve c o m i n g to terms wi th the physical absence o f the deceased person on a day-to-day basis; the reorganization o f the family unit; understanding the meaning o f the loss and its impact on the fami ly unit; and continuing wi th fami ly life without the presence o f the deceased person. A c c o r d i n g to Patterson (1995), families construct and share meaning on three levels: 1. meaning related to the stress-inducing situation; 2. meaning related to fami ly identity; and 3. meaning related to the family member 's v iew o f the family . F a m i l y identity emerges i n response to values, beliefs, and relationships shared among fami ly members. Stressful situations (e.g., youth Heal ing W i t h i n Fami l ies 30 suicide) ho ld cognit ive and subjective meaning for fami ly members. Often fami ly members cope wi th stressful situations by changing their perceptions i n regard to their circumstances. F a m i l y identity may be threatened during stressful situations. Hence , f ami ly members may purposefully focus on the inherent opportunities for growth rather than the difficulties they encounter in such situations. The fami ly member 's w o r l d v iew, or Weltanschauung, is the most enduring characteristic of the fami ly , but it too can change i n response to a non-normative cris is . T h i s aspect o f meaning encompasses the fami ly member 's perception of reality: it is based on existential beliefs (e.g., the purpose of the fami ly as a unit), assumptions about the environment, i n addit ion to cultural and religious beliefs. W h e n both the w o r l d v iew o f fami ly members and the identity o f the fami ly as a unit are chal lenged or altered, the fami ly is especial ly vulnerable (Patterson, 1995). I f a resolution does not occur i n such situations, the fami ly may even dissolve. Several authors maintain that any attempt to understand the impact o f suicide on the ind iv idua l and fami ly must take into account the socio-cultural meaning o f suicide (Balk , 1994; Bo ld t , 1988; Gar t re l l , Jarvais, & Derksen , 1993; K r a i , 1994; V a n D o n g e n , 1993). G i v e n that the meaning o f suicide is influenced by socio-cultural values and beliefs, these aspects need to be explored with individuals and families i n an attempt to understand the meaning they ascribe to their experiences ( M . Bo ld t , personal communica t ion , M a r c h 16, 1997). I n o w turn to address the concept of healing. The Concept o f Hea l ing D u r i n g the last decade, the concept of "heal ing" has been mentioned i n the health care literature (e.g., B r o o k e , 1995; Dossey , 1995; F r i s c h & K e l l e y , 1996; Her ruck , 1992; K a h n & Saulo, 1994; M c D o n a l d & M c D o n a l d , 1997; M a n n i n o , 1997; M o n t g o m e r y , 1993), and studied wi th increasing frequency. Th i s "heal ing consciousness" (Achterberg, 1990, p. 187) was born out o f the perceived limitations o f the biomedical model and an emphasis on current models of health care that emphasize human potential (Achterberg, 1990, Ferguson, 1980) and heal ing ( M y s s , 1996, 1997; Watson , 1999). Th i s interest was also the result o f scientific f indings that validate the Heal ing W i t h i n Fami l ies 31 necessity o f addressing the triune nature of humankind (i.e., body-mind-spir i t ) i n the promot ion of health and we l l -be ing (Achterberg, 1990; M y s s , 1996, 1997; Peirce , 1997; Pennington, 1988; Stokes, 1998; Wa t son , 1999). A c c o r d i n g to Webster (1989), "heal ' is defined as "to make whole or sound; restore to health" (p. 653). H e a l i n g , synonymous wi th restoring and op t imiz ing health, is the a i m of a l l health care del ivery. In the past, the concept o f heal ing was associated wi th quacks, evangelists, and others who d i d not understand standard allopathic treatment. P r imary interventions wi th drugs and surgery were used extensively as a means of treating and cur ing i l lness. Hence , the pathophysiology of i l lness and disease was better understood than health and heal ing ( M y s s , 1997). In fact, heal ing i n response to personal loss, was often understood f rom a pathophysiological perspective. E n g e l (1961) l ikened gr ieving to heal ing f rom an il lness or wound, as a passive happening. In general, w o u n d heal ing was seen as a mode l for heal ing ( W e i l , 1983). W e i l (1983) maintained that this v iew can be extended to include the psychic analog o f wound healing, for example, i n relation to the death o f a l oved one: There is the same ini t ia l shock and intense pain that c laims a l l attention and totally shatters one's equ i l ib r ium. There is a f lood o f emotion, perhaps the psychic analog o f bleeding, and wi th time and normal gr ieving the gradual but steady development of scab and scar [evidence o f trauma], the regeneration of posit ive feelings, and adaptation to the loss. The w o u n d may ache on occasion, even years later, but it is then an o l d wound , a healed one, no longer a threat to equi l ib r ium, (p. 68) W e i l (1983) v i ewed healing as a universal property o f a l l creation composed of three distinct components or phases inc luding reaction, regeneration, and adaptation. H e maintained that healing depends on the secret w i s d o m of the body and that medicine can only facilitate healing. W h i l e remnants o f W e i l ' s v iew persist today, most o f our knowledge about the concept of healing has been gained as a result o f empir ica l evidence, that is , evidence based on experience or experiment (Webster, 1989). Achterberg (1989, 1990) maintains that our understanding o f the term "heal ing" requires a redefinition wi th in the Western health care system. Eastern physicians have been aware o f the Hea l ing W i t h i n Fami l ies 32 mind ' s healing capacity for more than two thousand years (Goleman, 1997). Recent collaboration between Eastern and Western thinkers has resulted i n an unprecedented exchange of ideas about ancient w i s d o m and the modern quest for wholeness (Goleman , 1997). A n evo lv ing understanding of the heal ing process is currently underway. D o m b e c k (1995) defines healing as the process o f re-establishing health and wel l -being f o l l o w i n g some type o f trauma. Hea l ing , she purports, is an active and internal process that includes investigating attitudes, memories, and beliefs wi th the desire to release oneself of al l negative patterns that prevent ful l emotional and spiritual recovery. Th is internal review inevitably leads the person to recreate his or her life i n a way that serves to activate the w i l l — t h e w i l l to see and accept life truths, and the w i l l to begin to use energy for the creation o f love, self-esteem, and health. A c c o r d i n g to D o m b e c k (1995), "Whatever the degree of trauma, the pathways to healing involve a symbol ic awakening, a receptivity or hospitality to new learnings, and a commitment to intentionally tend to the practical activities o f healing (Dombeck, 1995, p. 60). Other aspects o f healing include "being restored to health or wholeness, being aware o f one 's connectedness, and f ind ing a sense o f hope, purpose, and direct ion i n one's l i f e " (Dombeck , 1995, p. 40). H e a l i n g is accompl ished by releasing inner pain, establishing new meanings, restoring integration, and emerging into a sense of renewed wholeness (Dombeck , 1995). F r a n k l (1984) contends that healing involves f inding meaning i n suffering. Moreover , heal ing, according to K a t z & St. Denis (1991), is v i e w e d as a "transition toward meaning, wholeness, connectedness, and balance" (p. 24) . Jeanne Achterberg (1990), author o f W o m a n A s Healer, contends that a balanced v iew of healing includes the f o l l o w i n g ideas: 1. Hea l ing is a l i fe long journey toward wholeness; 2. Hea l ing is remembering what has been forgotten about connection, and unity and independence among al l things l i v i n g and non- l iv ing ; 3. H e a l i n g is embracing what is most feared; 4. H e a l i n g is opening what has been closed, softening what has hardened into obstruction; 5. H e a l i n g is entering into the transcendent, timeless moment when one experiences the d iv ine; 6. H e a l i n g is creativity and passion and love; 7. H e a l i n g is seeking and expressing self i n its fullness, its l ight and shadow, its male and female; and 8. H e a l i n g is learning to trust l ife (p. 194). T h i s understanding portends that Hea l ing W i t h i n Fami l ies 33 healing is pr imari ly concerned with the internal aspect of the ind iv idua l ' s experience o f achieving health and wholeness. The concept o f healing has been mentioned in popular literature, pr imar i ly i n the form of anecdotal accounts (Achterberg, 1989, 1990; Dossey , 1991; G o l e m a n , 1997; H o v e r - K r a m e r , 1989; M i n k o w s k i , 1992; M o y e r , 1993; Otto & K n i g h t , 1979; Q u i n n , 1989; Su lmasy , 1997; Swif t , 1994; Vargas , 1991). W i t h i n the last decade, the concept o f healing has been found i n the research literature wi th increasing frequency ( D e m i & H o w e l l , 1991; Frank, 1995; M y s s , 1996, 1997). M o s t of these authors make the assumption that readers understand the meaning of the term "heal ing." Se ldom is a definit ion of the term provided in the literature. Hence , confusion st i l l exists about the meaning of the concept. C o m m o n l y held beliefs also have an impact on our understanding o f the healing process. M y s s (1997) identifies five central myths about healing that can interfere with the person's capacity to move toward healing. These myths include: 1. M y life is defined by m y wound ; 2. B e i n g healthy means being alone; 3. Fee l ing pain means being destroyed by pain; 4. A l l i l lness is the result o f negativity, and we are damaged at our core; and 5. True change is imposs ib le (pp. 31-53). These myths have power over the ind iv idua l because "hopeful, optimist ic beliefs are about the future, about possibi l i t ies , whereas i l lness is a reality and the myths that support it are i n the present t ime. H e a l i n g is intangible, but y o u can feel and see your i l lness" ( M y s s , 1997, p. 30). Indeed, these myths about healing often keep people f rom understanding and experiencing healing. H e a l i n g has been studied wi th respect to adult male survivors o f ch i ldhood sexual abuse (Burke Draucke r & Pet rovic , 1996), breast cancer survivors (Predeger, 1996), survivors of parent or s ib l ing suicide ( D e m i & H o w e l l , 1991), survivors of suicide (Robinson , 1989; S m o l i n & G u i n a n , 1993), and adult female survivors o f incest (Trucker , 1992). H o w e v e r , the literature revealed no family-based research studies that focus on healing f o l l o w i n g youth suicide. Moreover , few research studies that focus on gr ieving families are based on a health promotion phi losophy (Anderson & Y u h o s , 1993), and even fewer studies are a imed at uncover ing the resilient capabilit ies and innate strengths possessed by ind iv idua l gr iev ing fami ly survivors. Th i s 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. Hea l ing W i t h i n Fami l ies 35 C H A P T E R T H R E E R E S E A R C H D E S I G N A N D I M P L E M E N T A T I O N M a n y families are confronted with the suicide of a fami ly youth each year in Canada, and the numbers are increasing (Leenaars et al . , 1998). Understandably, the major emphasis i n the past has been on preventive measures, and whi le such efforts have been somewhat successful, many families are sti l l confronted wi th this publ ic health problem (Leenaars et a l . , 1998; L o w & Andrews , 1990). W h i l e research shows that fami ly members who experience youth suicide often experience prolonged gr ieving i n addition to short- and long-term health consequences (Ness & Pfeffer, 1990; Parkes & B r o w n , 1972; Rudestam, 1992), little emphasis has been focused on the strengths and resilient capacities o f these gr ieving persons. Surpr is ingly little is k n o w n about how fami ly members engage in the healing process in response to youth suicide. Hence , in i t ia l ly the goal of this study was to generate a substantive theory that explicates how individuals wi th in the context o f the gr ieving family heal fo l lowing teen suicide. A qualitative approach, specifically grounded theory, was used to develop such a theory. Th i s chapter focuses on the phi losophical , theoretical, and personal orientations that guided the methods. Three theoretical perspectives integral to this work are discussed, specif ical ly, symbol ic interactionism, systems theory/family research perspectives, as w e l l as gestalt psychology/humanism. These perspectives inf luenced the development o f the research questions, the methodology used to generate theory, and the approach used in the interpretation o f the findings. Second, an overv iew of the method is p rov ided along wi th the rationale for its use. The study is described i n terms of the sample population, and procedures used for data col lect ion and analysis. Strategies for establishing scientific r igor are provided. T h i s chapter concludes wi th an explanation o f the ethical considerations applied during the study. Methodology C u s h i n g (1994), i n discussing research about issues connected wi th nurs ing, defines methodology as "the phi losophical approach adopted for a nursing science question," and the Hea l ing W i t h i n Fami l ies 36 method as "the technique used to gather data" (p. 406). G u b a and L i n c o l n (1994) contend that questions and issues related to the method are o f secondary importance to those of the phi losophical perspective o f the researcher. That is , the researcher a lways approaches a study wi th a particular phi losophy or set of beliefs. General ly , the subject matter o f phi losophy is concerned wi th the "search for meaning in the universe" (Gortner, 1990, p. 101). T h e researcher's phi losophy is situated wi th in a particular paradigm or w o r l d v i e w (Guba & L i n c o l n , 1994). E a c h paradigm perspective embraces a certain set of beliefs that determine the "what" and " h o w " of scientific inquiry . A phi losophy 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. Essent ial ly , the way in wh ich knowledge is gained is directly related to the paradigm perspective adopted by the researcher and the corresponding ontological and epistemological c la ims. The ontological component is concerned wi th the nature of reality, that is , whether a "real" w o r l d exists that can be k n o w n (a realist phi losophical v iewpoint) ; or whether reality is assumed to be relative, and thus, constructed by the indiv idual (a relativist ph i losophica l position) (Guba & L i n c o l n , 1994; Salsberry, 1994). The epis temological constituent addresses how we know and learn about phenomena that are deemed to be the focus o f study. Spec i f ica l ly , epistemology is concerned wi th the relationship between the knower and what can be k n o w n (Guba & L i n c o l n , 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 & L i n c o l n , 1994). It is especially important that the methodological c la ims and research method be congruent wi th the state of exist ing 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. F o r this reason, m y phi losophical orientation w i l l be addressed next, fo l lowed by the theoretical and personal forestructures that I br ing to this study. Hea l ing W i t h i n Fami l ies 37 Phi losophica l Stance Onto logy addresses one's beliefs about reality and what can be k n o w n . A s a researcher, m y ontological views are congruent with the relativist paradigm. A relativist posits that facts and principles are inextricably embedded wi thin in a particular historical and cultural setting (Tinkle & Beaton , 1992, p. 654). Further, this posi t ion subscribes to the not ion that "realities are apprehendable in the form of mult iple , mental constructions, socia l ly and experientially based, loca l and specific in nature . . . and dependent for their fo rm and content on the ind iv idua l persons or groups ho ld ing the constructions" (Guba & L i n c o l n , 1994, pp. 110-111). T h i s ph i losophica l stance views meaning as multifaceted and multi-layered. W i t h i n the relativist paradigm, I identify myse l f as a constructivist. That is, I ho ld the v iew that reality is constructed and re-constructed by the ind iv idua l dur ing the course of his or her life. Moreover , I believe that reality can only be k n o w n by understanding the constructions o f those i n v o l v e d (e.g., g r i ev ing fami ly members) through dialectic discourse. Congruent wi th a relativist ontology, epistemological ly m y approach to knowledge acquisit ion is based on transactions wh ich emphasize the importance o f interaction, context, interpretation, and subjectivity (Ch inn , 1985; S i l v a & Rothbart, 1984). Consequent ly , the data of particular interest in this inquiry inc luded participants' stories, observations o f study participants, non-technical information sources such as diaries and poetry, as w e l l as m y intuit ive grasp of a l l these data sources. M y approach to this study is c losely al igned wi th const ruct iv ism wh ich adopts a relativist ontology, a transactional epistemology, and an interpretive methodology (Guba & L i n c o l n , 1994). In addition to stating m y phi losophical stance, it is important that I, as researcher, disclose the theoretical and personal forestructures I br ing to the dissertation process. Theoretical and Personal Forestructures The theoretical frameworks underpinning the methods used i n this study inc luded symbol ic interactionism, systems theory/family research perspectives, and gestalt psychology/humanism. S y m b o l i c interactionism served as a framework for approaching the ind iv idua l , whi le systems theory provided the basis for examining fami ly context. A humanistic approach provided the lenses Hea l ing W i t h i n Fami l ies 38 for m a k i n g sense o f participants ' stories. H u m a n i s m , an outgrowth o f gestalt psychology, emphasizes the importance o f understanding the personal perspective, validates the worth and uniqueness of each ind iv idua l , and embraces the development o f human potential (Babcock & M i l l e r , 1994). T h i s approach was deemed to be appropriate in m y attempt to understand how individuals and families heal i n response to youth suicide. Perspectives on S y m b o l i c Interactionism Symbo l i c interactionism refers to a distinctive approach to the study of human social l ife (Schellenberg, 1990). Based on the ph i losophica l wri t ings o f James, C o o l e y , D e w e y , M e a d , and B lumer , symbol ic interactionism focuses on the meaning o f events to people i n natural and everyday settings. L i k e phenomenology, it is concerned wi th the study o f the inner or experiential aspects o f human behavior. S y m b o l i c interactionists are concerned wi th understanding one's values and beliefs; they are interested i n how people define events or reality and how they act in relation to their perceptions of reality. Th i s v i ew purports that humans act on the basis o f meaning (Blumer , 1969; Chen i t z & Swanson, 1986; Spradley, 1979). H o w e v e r , a stage o f deliberation or definition o f the situation precedes action. A c t i o n is influenced by several antecedent variables such as feedback f rom significant others, perceptions o f the social environment, and contextual variables such as economic , cultural , and religious factors. The reality or meaning o f a situation is created through interaction wi th in a particular environment. People act based on their perception of reality and, in turn, face the consequences of such action. B l u m e r (1969) cites three premises as constituting the foundation of symbol ic interactionism. First , "that human beings act toward things on the basis o f meanings that the things have for them" (p. 2). These things may be objects, other human beings, institutions, others' activities and situations, or a combinat ion of these. The meaning attached to things governs the actions o f people; hence, behavior is comprehensible only when one understands the meaning of something f rom the perspective of the indiv idual . The second premise states that "the meaning o f such things is der ived from, or arises out of, the social interaction that one has wi th one 's f e l lows" (Blumer , 1969, p. 2). S y m b o l i c Hea l ing W i t h i n Fami l ies 39 interactionists contend that social behavior and culture are inextricably intertwined. A c c o r d i n g to Spradley (1979), culture refers to "the acquired knowledge that people use to interpret experience and generate social behavior" (p. 5). Cul ture , or a shared system of meaning, is developed and modif ied wi th in the context o f interaction among people (Spradley, 1979). S y m b o l i c interactionists do not assume that culture is composed of c o m m o n l y 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 ho ld for the ind iv idua l . H o w 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 i n , and modi f ied through, an interpretive process used by the person i n dealing wi th the things he encounters" (Blumer , 1969, p. 2). In addition to cultural influence, the interpretive process is mediated through a number of variables wh ich include: past experience, educational level , language, and phys ica l and cognit ive abilities (Cheni tz & Swanson, 1986). Essent ia l ly , meaning is "co-created" through a process of social interaction. These premises are based on the assumption that human beings are in constant interaction wi th the environment and are largely able to choose the psycho-social s t imuli to wh ich they respond. Spradley (1979) suggests that the interpretive component can be l ikened to a cognit ive map. In turn, interpretation is culturally determined and best thought o f as: A set o f pr inciples for creating dramas, for wr i t ing scripts, and, o f course, for recruit ing players and a u d i e n c e s . . . . Cul ture is not s imply a cogni t ive map that people acquire, i n 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, cont inual ly shifting seas of everyday life. M a p p i n g them out is a constant process resulting not in an ind iv idua l cogni t ive map, but in a whole chart case of rough, improvised , cont inual ly revised sketch maps. Cul ture does not provide a cognit ive map, but rather a set of principles for map mak ing and navigation. Different cultures are l ike Hea l ing W i t h i n Fami l ies 40 different schools o f navigation designed to cope wi th different terrains and seas. (Frake, 1977, pp. 6-7) M e a n i n g is negotiated through the use o f symbols (e.g., language, artifacts). Communica t ion is symbol ic because we communicate v i a languages and other symbols; through communica t ion we create or produce significant symbols . Through an interpretive process, meanings are established. Spec i f ica l ly , "The actor selects, checks, suspends, regroups, and transforms the meanings in light of the situation in wh ich he is placed and the direction o f his action. . . . Mean ings are used and revised as instruments for the guidance and formation o f [future] act ion" (Blumer , 1969, p. 5). These meanings are products o f col lec t ive situations; that is , meanings arise out of interaction wi th others. Through the interactive process as'it is mediated by language, one acquires a self. A c c o r d i n g to B l u m e r (1969), ind iv idua l behavior, group conduct, and even culture are a l l matters i n v o l v i n g meaning and interpretation. Consequently, i f one wishes to understand an ind iv idua l ' s behavior or a co l lec t iv i ty ' s actions, one must 'get at' the meanings being assigned and the interpretations being made. B l u m e r reduces al l social processes, however complex , to meaningful interpersonal behavior. Grounded theory, based on symbol ic interactionism, aims to discover under lying social processes; consequently, grounded theory methods were selected for this study. Informed by symbol ic interactionism, wi th in this study, I needed to be h ighly 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 ind iv idua l ly and col lect ively constructed in response to their experiences wi th the suicide of a fami ly youth. Add i t i ona l ly , I assumed that each survivor might ho ld different v iews, resulting i n different meaning being subscribed to each ind iv idua l ' s experience. Hence, it was important for me to el ici t the precise meaning related to experience, both indiv idual ly and col lect ively . In part, this entailed 'getting at' (via questioning) the meaning embedded wi thin the language being used by participants. Since meanings are in people rather than words, it was important that I l istened carefully and sought Hea l ing W i t h i n Fami l ies 41 clarif ication frequently i n m y attempt to capture the richness (i.e., thick description) wi th in participants' stories. In this study, symbol ic interactionism guided the selection o f the grounded theory procedures used to explore the process of ind iv idua l healing f o l l o w i n g youth suicide. A s previously mentioned, individuals l ive their l ives wi th in the context o f their families. Therefore, m y perspective on families must also be articulated. Perspectives on Fami l i es M y perspective on families is guided by fami ly systems theory, von Bertalanffy (1968; 1975) recognized l i v i n g systems as complex organizations composed o f many parts in constant interaction wi th other systems. A c c o r d i n g to systems theory, the fami ly is conceptualized as an open system that interacts wi th in a broader socio logica l and historical context ( W h a l l , 1986). Specif ic concepts inherent wi th in this perspective include: 1. A fami ly system is part o f a larger suprasystem and as w e l l is composed o f many subsystems; 2. The fami ly as a whole is greater than the sum of its parts; 3. A change in one family member affects a l l fami ly members; 4. The fami ly is able to create a balance between change and stability; and 5. F a m i l y members ' behaviors are best understood f rom the v i ew of circular rather than linear causality (Wright & Leahey, 1984). O f particular significance, these concepts validate the v iew that families possess inherent strengths and cop ing capabilit ies that can be drawn upon during times of great need. In addition, these concepts allude to the powerful influence that fami ly members have on one another. Perspectives on F a m i l y Research Increasingly, the fami ly has become an important focus for the provis ion o f nursing care. W i t h i n this section, two issues that are central to this study are addressed, the definit ion o f fami ly and the decision regarding who should be inc luded as informants. Hea l ing W i t h i n Fami l ies 42 The first issue pertains to the definit ion of fami ly used i n this inquiry . Numerous definitions o f fami ly are found wi th in the nursing literature. Tradi t ional ly , the fami ly has been defined i n terms o f structure and/or function (Wright & Leahey , 1984). F o r instance, Kris t janson (1992) defined the fami ly as ' " i nd iv idua l s ' bonded by a b io log ica l or legal relationship . . . as those persons having a functional relationship to one another" (p. 39). F a m i l y members may or may not cohabitate, and the fami ly may be described as nuclear, inter-generational, or extended. Other definitions o f fami ly are broad-based, inclusive, and f lexible , and thus reflect the constant state o f change readily apparent wi th in society today. F o r example, G i l l i s s (1991) defined fami ly as "a complex unit wi th distinct attributes of its o w n but containing component parts that are significant as ind iv idua l units, both independently and co l l ec t ive ly" (p. 198). W i t h i n current nursing research, the definition of fami ly is often externally imposed by the researcher, for example, a fami ly consist ing o f a mother, father, and at least one ch i ld . Externa l ly imposed definitions may inadvertently introduce bias (Patterson, 1995) (e.g., socia l , cul tural , or gender) wi th in a research study. Further, the artificial delineation created by an externally imposed definition may not accurately represent boundaries that the fami ly w o u l d v iew as meaningful (Kris t janson, 1992). W i t h i n this inquiry , and congruent wi th the Alber ta Heal th (1993) document, Palliative Care In Alber ta , f ami ly was understood in its broadest sense to include not only next-of-kin fami ly members, but also significant others identified by fami ly members as being part o f the family (Stuart, 1991). A n inclus ive rather than exclusive definition of fami ly was adopted: "a complex unit wi th unique attributes of its o w n " (G i l l i s s , 1991, p. 198). The decis ion regarding " w h o " to include as fami ly was col lect ively determined by the fami ly members themselves. Th is definition was used because it preserves participants' voices and validates the dynamic nature of families, as we l l as the powerful influence that fami ly members have on one another (e.g., Alber ta Associa t ion o f Regis tered Nurses , 1992, 1993). The second issue centered on the use of a single ind iv idua l versus mul t ip le family members as informants about the family . U p h o l d and St r ick land (1989) maintain that the "choice of who should be the source o f data col lect ion must be based on the purpose o f the study, the research Hea l ing W i t h i n Famil ies 43 question, the theoretical basis of the study, and the specific unit about w h o m the researcher intends to generalize" (p. 415). The emphasis in this study was on the ind iv idua l wi th in the context o f the fami ly system, hence, a "un i fy ing conceptual izat ion" (Robinson , 1995b, p. 8) o f f ami ly was used in wh ich data were col lected from both indiv idual fami ly members and subgroups wi th in the fami ly , and whenever possible, the fami ly as a unit. Th i s approach addressed the art if icial separation between the ind iv idua l and fami ly (Davies , 1995; Hayes , 1993; Rob inson , 1995a; Rob inson , 1995b) c o m m o n l y encountered i n fami ly research. The ind iv idua l perspective is not less than the fami ly v iew; it is different from the family viewpoint . E v e n though a single informant can provide family- level data, it must be remembered that restricting fami ly data to a single family member or subset has the potential to present a biased v iew o f the fami ly . Nei ther the ind iv idua l nor the fami ly v iew is complete in and o f itself. Thus, because both the ind iv idua l and fami ly are a part o f the conceptual picture (Davies , 1995; Rob inson , 1995a; R o b i n s o n , 1995b),. the v iews of both were considered important and contributed to a greater understanding o f the phenomenon under study (Davies , 1995b, Rob inson , 1995a; R o b i n s o n , 1995b). In addi t ion, s imultaneously focusing on indiv idual and family systems captured the dynamic and complex nature o f families (Robinson, 1995a; Rob inson 1995b), an important element in understanding ind iv idua l healing wi thin the context of the family . A c o m m o n challenge confronted by researchers is that of obtaining accurate family data. In this study, data were gathered f rom both ind iv idua l fami ly members and the fami ly as a unit. Th is schema focused on the parts compris ing the whole by inc lud ing the ind iv idua l perspective, or that part of the person wh ich is separate f rom the family . In addit ion, v iews about the fami ly as a col lect ive were also of interest in this study. This conceptualization of fami ly recognized the influence of the fami ly on the person, and vice versa (Mangham, R e i d , M c G r a t h , & Stewart, 1995; Rob inson , 1995a; Rob inson , 1995b). The single-informant approach was used to a l low freedom of expression ( U p h o l d & Str ickland, 1989) whi le the mult iple-informant approach was used to gather transactional-level data about individual and family systems. Transactional-level data are concerned wi th interaction and reciprocity on both the personal and fami ly levels (Robinson, Hea l ing W i t h i n Famil ies 44 1995a: Rob inson , 1995b). These data simultaneously focused on the person as both an ind iv idua l and as a member o f a fami ly system. There is agreement in the literature regarding the effect o f context on fami ly data (Krist janson, 1992). It is recognized that an ind iv idua l may respond differently to the same question when posed ind iv idua l ly , and when other fami ly members are present. Thus , context becomes an important variable in the conceptualization o f the research questions. The research questions in this study were written to 'get at' the v iews of the ind iv idua l wi th in the context of the fami ly . Th i s was accompl ished by interviewing each person ind iv idua l ly , and then interviewing the fami ly as a unit whenever possible. T w o sets o f interview questions were prepared—one set directed toward the indiv idual and the other set specific to the fami ly as a unit. It was recognized that there may be a lack o f consensus amongst family members i n response to the research questions. In some cases, data obtained f rom one fami ly member were congruent wi th that obtained f rom another fami ly member; i n other cases, these data were inconsistent. Inconsistent data were therefore reported to reflect the inconsistencies so often apparent wi th in families. Inconsistent data provided information about the family that otherwise might have been unavailable. Schless and Mende l s (1978) c l a i m that in terviewing as many informants as possible provides significantly more data about the family by capturing the density and complexi ty o f the fami ly system. Therefore, a l l sources of data were valued and v i e w e d as contributing to a broader, al l-encompassing perspective on the family context for ind iv idua l gr ieving and healing. S y m b o l i c interactionism and systems theory provided the theoretical foundation for the analysis o f ind iv idua l and fami ly level data. Based on Gestalt psychology, a humanistic approach guided data col lect ion and analysis and the overall approach to the conceptualization o f the theory presented in subsequent chapters. Perspectives on Gestalt P s y c h o l o g y / H u m a n i s m A s pioneers in the f ie ld of Gestalt psychology, Wertheimer , Koeh le r , K o f f k a , and L e w i n insisted that psychologic phenomenon need be studied by introspection and observation. Gestalt is a German word that means "the whole or totality" (Babcock & M i l l e r , 1994, p. 38). W i t h i n the Hea l ing W i t h i n Fami l ies 45 f ie ld o f 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 w h i c h cannot be understood s imply by analyzing their perceptions o f events (Babcock & M i l l e r , 1994; Perls , Heffer l ine, & G o o d m a n , 1951; Schif fman, 1971). Percept ion refers to the port ion o f the w o r l d that is grasped mental ly through sight, hearing, touch, taste, and smel l (Neufeldt, 1991). Gestaltists see perception as contextually-based, as an active process inf luenced by a myr i ad o f factors inc lud ing history, genetics, and environment. Hence , contextually situating this work was cr i t ical and is addressed i n Chapter Four . A s an outgrowth o f Gestalt psychology, humanism is the name g iven to a cultural and intellectual movement that developed during the Renaissance. Deve loped by theorists such Rogers , Golds te in , A n g a l , M a s l o w , M u r r a y , and C o m b s , humanism has h is tor ica l ly been concerned wi th human worth, indiv idual i ty , humanity, and the ind iv idua l ' s right to determine personal action (Babcock & M i l l e r , 1994; Lefrancois , 1988; Rogers , 1951, 1961, 1969). W h i l e acknowledging the importance o f the ind iv idua l ' s developmental history, humanists focus on contemporary experiences and conscious awareness i n the present. H u m a n i s m is concerned wi th the uniqueness of each ind iv idua l ; one's uniqueness is one's self. The development o f self results f rom interactions wi th in one's w o r l d (direct experience) and f rom beliefs and values about one's self learned through interactions wi th others (indirect experience). Humanis ts bel ieve in human potential. Based on the assumption that the indiv idual is s tr iving toward healthy and creative functioning, the pr ime motivat ing force is self-actualization, a continuous effort to achieve the m a x i m u m development o f one's potentiality. Th i s v iew was selected as a basis for this study because it is congruent wi th the concept of health promot ion discussed i n Chapter One. The humanists ' v i s ion for the human experience is closer to the frameworks o f Eastern theorists and their understanding of the higher levels of consciousness. H u m a n i s m is an holist ic approach to understanding people concerned wi th topics inc lud ing: love, creativity, self-growth, becoming ful ly human, j o y , transcendence, play, humor, affection, naturalness, autonomy, responsibil i ty, extrasensory perception, and peak experience (Babcock & M i l l e r , 1994). Hea l ing W i t h i n Famil ies 46 M y analytic approach in this study, al igned wi th that o f humanism, is based on Frank ' s (1995) idea of " th inking w i t h " rather than " th inking about" stories. A c c o r d i n g to Frank (1995): T o think about a story is to reduce it to content and then analyze that content. T h i n k i n g wi th stories takes the story as already complete; there is no go ing beyond it. T o think wi th a story is to experience it affecting one's o w n life and to f ind in that effect a certain truth o f one 's l i fe . (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, wi th the actual play and interplays o f l ife, wi th al l its diff iculty and ambiguity, unredeemed or, better, not i n need of redemption but only thoughtful savoring, reflection, conversation and understanding" (Jardine, 1990, p. 224). The grand narrative is used as a way of avoid ing over-analysis o f the content, o f avoiding too much dissection (Neufeldt, 1991), and as a means o f remain ing close to the truths embedded wi th in these stories (e.g., C la rke , 1995; Coh le r , 1991; L e w i s , 1961). Bes t to ld by the participants themselves, these stories restore life to its "or ig ina l d i f f icu l ty" (Caputo, 1987, p. 1). Cons ider ing the h ighly 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. Unequ ivoca l ly , participants proc la imed that they wanted their stories presented with as much detail as possible. These stories, therefore, are not presented to support m y views; rather, they are the source f rom wh ich the grounded theory was developed H o w e v e r , I do place these stories wi th in the theoretical framework that emerged f rom the analysis o f the data, wh ich I believe is only a means o f i l luminat ing the richness and truths embedded wi th in each and every story in singular or combined presentations. M y approach to this research was influenced not only by these theoretical forestructures, but also by m y personal situatedness. Personal Situatedness W h e n conduct ing highly personal and emotion-laden research such as this, despite al l efforts to represent the views of participants adequately, the researcher becomes impl icated Hea l ing W i t h i n Fami l ies 47 ( L i n c o l n & G u b a , 1985). The researcher's phi losophica l posi t ion a lways has an impact on the research process in terms of both content and process. Hence , the researcher must acknowledge that his or her values w i l l influence the inquiry, make expl ic i t a l l relevant personal values, and account for these ( L i n c o l n & Guba . 1985). Here , I br ief ly describe pertinent aspects o f m y biography that I br ing to this work. I am a white, middle-class, middle-aged wife and mother o f four adult chi ldren, and grandmother of one. Over the past thirty years I combined the traditional female role o f primary care provider and homemaker wi th that of counselor, publ ic health nurse, nurse educator, researcher, and nursing leader i n m y communi ty . I see myse l f as a car ing and commit ted person and as one who approaches life and l i v i n g wi th great enthusiasm. M y professional interest i n work ing i n the area of pall iat ive care stems f rom m y personal experience i n v o l v i n g the death o f m y mother i n 1971. A s a young woman , I knew the pain associated wi th loss long before I understood the gr ieving process. F o l l o w i n g the death o f m y 50-year o l d mother i n the impersonal environment of a b ig ci ty hospital , wi th m y husband and brother at m y side, we made our way to a nearby elevator. W e left the hospital alone, without guidance or support f rom any staff person. I real ized how vulnerable and powerless I felt and how little I knew about death. I real ized how I longed for support and guidance f rom the nurses who were wi th m y mother at the end o f her life. I made a promise to myse l f to pursue this area o f study as a basis for helping nurses and others to assist gr ieving famil ies . M y doctoral program presented me wi th the opportunity to contribute to this f ie ld. W h i l e w o r k i n g as a research assistant during m y doctoral program, I had the posi t ive experience of being invo lved i n a s ib l ing bereavement study w o r k i n g under the supervision o f m y dissertation supervisor. I was i nvo l ve d in a pi lot study i n v o l v i n g families where a c h i l d had d ied due to either short- or long-term causes o f death. Eighteen families volunteered to participate i n this study. W i t h i n those 18 families, five youngsters had d ied as a result of suicide. The incidence o f this occurrence had an impact on me. A s I listened to the stories shared by fami ly members, I was "grabbed" by their honesty and forthrightness. M y curiosi ty was p iqued as I l istened to how some individuals consistently spoke of "heal ing" i n relation to their experiences wi th horrific death. I Hea l ing W i t h i n Fami l ies 48 wondered about how such healing occurred, and w h y some ind iv idua ls spoke o f heal ing and others d i d not. M y professional background includes experience i n the areas o f ind iv idua l and fami ly counsel ing, psychiatr ic nursing, publ ic health nursing, pal l ia t ive care nurs ing, and nursing education. M y counsel ing education provided me wi th an opportunity to hone and refine m y interpersonal sk i l l s . F r o m m y experience as a counselor, I learned about the powerful influence that fami ly members have on one another and how such influence affects the health of each ind iv idua l . F r o m m y experience as a professional nurse I suspected that loss issues may often be related to poor health and dis-ease. B y work ing closely wi th famil ies for more than two decades, I developed an appreciation for the strengths and resilient capacities o f individuals and the synergy that becomes possible when families become empowered to take responsibil i ty for their own health. In response to these counsel ing and nursing experiences, I developed a bel ief that individuals and families often have the answers to their problems. I also believe that it is the responsibili ty o f health care professionals to facilitate health promoting interventions among individuals , famil ies, communit ies , and ult imately wi th in society. T h i s background provided fertile ground for the seeds o f interest in 'heal ing ' that were sown by the famil ies in the aforementioned research study. D u r i n g the process o f conducting this dissertation research, several experiences reinforced the relevance o f this work. I was invi ted to present the pre l iminary findings o f m y research on several occasions wi th in both academic and communi ty settings. F o r example, I was invi ted to be a member o f a panel presentation during Suicide Prevention W e e k i n Lethbridge, Alber ta . D u r i n g the same week I spoke about the findings o f m y research during a M e m o r i a l Service for suicide survivors. A month later ( A p r i l 21 , 1999), I was interviewed by a reporter at a loca l television station regarding the increased use of violence among youth in response to the s laying o f several teens and the suicides of the two teenage gunmen at a high school i n Li t t le ton , Colorado . Then one week later, in the rural communi ty o f Taber, Alber ta , a young h igh school gunman opened fire fatally injuring an innocent youth. Once again I was asked to talk about m y research from the Heal ing W i t h i n Fami l ies 49 perspective of helping families heal in the aftermath of horrific death. Th i s communi ty involvement renewed and reaffirmed m y commitment to and enthusiasm for this work . Grounded Theory Research M e t h o d Firs t developed by Glaser and Strauss in 1967, grounded theory is a h igh ly systematic research approach for the col lect ion and analysis of qualitative data for the purpose o f generating explanatory theory that furthers the understanding o f social and psychologica l phenomenon (Cheni tz and Swanson 1986; Strauss & C o r b i n , 1990, 1994; 1998). In essence, grounded theory research is a imed at understanding how a group of people define their reality v i a social interactions (Hutchinson, 1986). Essent ia l ly , "The grounded theory method results i n concepts and constructs grounded in data that reflect theoretical sensitivity and have imagery and "grab" for those invo lved in the experience. G o o d grounded theory is holist ic , parsimonious, dense, and modi f iab le" ( W i l s o n & Hu tch inson , 1991, p. 274). Grounded theory is an appropriate method when an area to be researched is characterized by a l o w level of conceptualization. Since theoretical explanations related to healing within families fo l lowing youth suicide have not been found wi th in the literature, it was important to use a 'ground u p ' — f r o m practice to theory method for theory generation (Hutchinson, 1986). Moreover , grounded theory methods are appropriate when attempting to gather data o f a unique and highly personal nature that describes experiences and perceptions with contextual meaning. F ina l ly , since social processes are fundamental to families, it fo l lows that the grounded theory method is appropriate for the study o f indiv idual healing wi th in families. E l ig ib i l i t y Cri teria The population of interest in this study were individuals who identif ied themselves as having had experience wi th healing fo l lowing the suicide o f a be loved fami ly youth. Participants were required to meet the fo l lowing el igibi l i ty criteria: 1. A t the time the study began, participants needed to have experienced a youth (10-19 years of age) suicide pr ior to the study, and be able to speak about the concept o f healing (either pro or Hea l ing W i t h i n Fami l ies 50 con) i n response to their experience. However , as the study proceeded, theoretical sampl ing indicated the value o f inc luding two older adults and their famil ies in the study. 2. Informants were required to be able to read, write, speak, and comprehend E n g l i s h . 3. Participants were members of a fami ly . Var ious fami ly constellations were inc luded (e.g., two parent famil ies , single parent families, blended families, gay and/or lesbian families) . 4. Individuals and families from al l socio-economic, racial , cultural , and rel igious groups were invi ted to participate i n this study. 5. Volun ta ry participation in the study was a basic requirement. Da ta Col lec t ion and Procedures In accordance wi th grounded theory methodology, the main methods o f data col lect ion were interviews wi th ind iv idua l fami ly survivors and fami ly units whenever possible, supplemented by participant observation (Lof land & L o f l a n d , 1984; Spradley, 1979). In this study, data inc luded textual data, observational data, and non-technical data. In addition, genograms and ecomaps ( M c G o l d r i c k , 1982; Wr igh t & Leahey , 1984) were completed for each • fami ly as part o f the data base (see Appendices A - l and A - 2 ) . These tools p rov ided a means of gathering family-related information and were especially helpful in terms o f understanding family dynamics . The genogram is a three generational diagram depict ing historical , structural, functional, and relational aspects of the fami ly system ( M c G o l d r i c k , 1982; Wr igh t & Leahey , 1984). The ecomap is a diagram representing the quantity and quality of each fami ly member 's connections wi th external resources ( M c G o l d r i c k , 1982; Wr igh t & Leahey , 1984). Informed Consent Pr io r to col lect ing data for the study, informants were provided wi th a complete description of the study, inc lud ing: an explanation o f the purpose o f the research; a description o f the procedures to be used (e.g., use o f interview and observation) and t ime commitment invo lved ; an explanation of the voluntary nature of the research; and an assurance o f confidentiality related to al l aspects o f the research. Participants were informed o f their right to wi thdraw from the study at any Hea l ing W i t h i n Fami l ies 51 t ime without reason. Further, they were provided wi th an opportunity to ask questions and to discuss any aspect of the research. E a c h participant was provided wi th an information letter and an appended consent form containing the names and phone numbers of appropriate contact people (see A p p e n d i x B ) . F o l l o w i n g this information session, I obtained written informed consent f rom all informants. I retained one copy of the signed consent fo rm for m y fi le and provided a personal copy for each participant. Because children cannot legally provide consent, parents were requested to sign a consent fo rm ( included i n A p p e n d i x B ) for minor chi ldren (less than 10 years of age). However , chi ldren also gave assent for participation. Assent impl ies that the c h i l d understands the purpose of the research study and his/her participation i n it, and agrees to participate i n the study. In an effort to be sensitive to the needs o f each participant, informed consent was continual ly negotiated during the research process (Germain , 1986). T h i s negotiation process entailed constantly educating the participants about the research process, and mak ing sure that informants felt free to act in their o w n best interests, regardless of what that may have meant in terms of the research study. F o r example, in one instance I was invi ted by a mother to interview a fami ly i n their home. W h e n I arrived at the fami ly home, I was wa rmly greeted by the mother in the front yard. The father, who was w o r k i n g in the yard at the t ime, acknowledged m y presence by a brief nod o f his head. The mother invi ted me into the house where we sat at the kitchen table. I began to set up the tape recorder. Moments later, the father appeared i n the ki tchen. H e began to make comments about m y research, and as he spoke it was apparent that he was angry. I listened to h i m and d id not interrupt. W h e n he f inished expressing his v iews , I once again provided a detailed explanation o f the purpose on m y study. I emphasized that voluntary participation was a basic requirement. I assured h i m that the health and wel l -be ing of his fami ly was o f prime importance, far above the importance o f the study. I suggested that i f he was uncomfortable wi th any aspect o f being i nvo l ve d 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 fami ly . W h e n I turned the tape-recorder on (with permission), he spoke for 45 minutes non-stop about his experience related to his son's suicide. Th i s interview took place three years post-suicide. Apparent ly , he and his wife had not discussed the suicide o f their son pr ior to the interview. W h e n Hea l ing W i t h i n Fami l ies 52 I left the fami ly home, both husband and wife wa lked me to m y car. T h e husband thanked me for inc lud ing h i m and his fami ly in the study and both he and his wife gave me a hug. Theoretical Sampl ing Theoretical sampling, or "sampl ing on the basis o f concepts that have proven theoretical relevance to the evo lv ing theory" (Strauss & C o r b i n , 1990, p. 176) was used dur ing the data col lect ion process. A s the study progressed, participants were deliberately selected according to the theoretical needs and direction of the data analysis. Th is approach helped to ensure that the evo lv ing theory was representative o f the concept under investigation. Moreove r , it a l lowed for examinat ion o f a fu l l range o f variation of the phenomenon under study (i.e., heal ing fo l l owing youth suicide) . Firs t , at the onset o f the study, " informat ion-r ich cases" (Patton, 1990, p. 169) were identified. T w o famil ies , who had participated i n a previous research study, and who were k n o w n by myse l f to be r ich sources of relevant data, indicated an interest and wil l ingness to participate in this study when contacted to fo l low-up on their expressed interest. Second, potential participants were sometimes located v i a "network sampl ing" (Burns & G r o v e , 1993), or snowbal l ing as it is sometimes cal led . Th i s technique takes advantage o f previously established informal social networks that often exist among those who have shared a c o m m o n experience. Individuals wi th in the first two families interviewed referred other potential participants to this study. Th i s strategy was, in fact, an extremely valuable recruitment strategy, especial ly during selective sampling that occurred as the study progressed. Th i rd , I recruited families through contact wi th palliative care personnel in health care institutions and communi ty health agencies i n southern Alber ta (e.g., Lethbr idge, M e d i c i n e Hat, Taber, B r o o k s , C la re sho lm, B o w Island). These were ind iv idua ls w i th w h o m I already have established w o r k i n g relationships. I met informal ly with these individuals at times convenient to them. D u r i n g these meetings, I described the purpose o f m y study, out l ined e l ig ib i l i ty criteria, required time commitments, and other pertinent information. Heal ing W i t h i n Fami l ies 53 F i n a l l y , I accepted an invitat ion to be interviewed by the loca l media (e.g., newspaper and television) for the purpose o f recruitment. D u r i n g an interview wi th the loca l newspaper, I provided a description of the study, the e l ig ib i l i ty criteria, and an invitat ion for loca l individuals to participate in the study (see Append ix C ) . Th i s strategy extended the invitat ion for participation to individuals and famil ies who may not have had access by other means. In addit ion, this strategy raised the profile o f the study wi th in the communi ty and led to ne tworking wi th other interested professionals f rom a variety of disciplines who were then able to also recruit potential participants. W h e n potential participants were identified through personnel i n institutions or agencies, or by other participants (via network sampling), those individuals obtained verbal consent f rom the potential participants for me to contact them. I then fo l lowed up by telephoning potential participants to describe the project in greater detail and to arrange to meet wi th them at a convenient time and place. Once an indiv idual indicated a wil l ingness to participate in the study, I informed the participant about m y interest i n understanding the indiv idual healing process. I invi ted the participant to encourage other family members to participate in the project. I requested that the participant obtain verbal consent from other potential participants, a l lowing me to initiate contact wi th them. I then contacted these potential participants v ia telephone or in-person during a scheduled home visit wi th a previously identif ied participant. In each case, I then described the study i n greater detail, determined their wil l ingness to meet wi th me, and arranged a mutually convenient time and place to meet. Theoretical sampling guided data col lect ion. A s categories emerged, cases wh ich further explicated the category and cases where the category was nonexistent, were sought and examined. In order to further enrich and expand the evo lv ing theory, cases that offered a different perspective were also purposefully included. F o r example, the healing processes o f f ami ly survivors who had experienced the suicide of an adult were purposefully inc luded to enrich and expand the evo lv ing theory. N i n e families who experienced the suicide o f a family youth and two families who dealt wi th the suicide o f 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 i n terms of Hea l ing W i t h i n Fami l ies 54 representativeness o f the concept (Strauss & C o r b i n , 1990), and thus were inc luded to further expand the phenomenon o f interest (i.e., healing) i n this inqui ry . In this sense, diversi ty was explained and integrated to enrich rather than disprove the emerging theory, consistent wi th Glaser and Strauss's (1967) idea o f seeking conceptual density and theoretical sensitivity. The number of interviews per ind iv idua l and fami ly was dependent upon ongoing data analysis. A s stated by Sandelowski (1995), "Determining adequate sample size i n qualitative research is ultimately a matter o f judgment and experience i n evaluating the quality of the information collected against the uses to wh ich it w i l l be put, the particular research method and purposeful sampl ing strategy employed, and the research product intended" (p. 179). Theoret ical sampling continued unti l : 1. no new or relevant data seemed to be emerging regarding a category; 2. category development was r ich and dense, meaning that a l l paradigm elements were accounted for, a long wi th variation and process; and 3. the relationships between categories were w e l l established and validated by the participants (Glaser, 1978; Glaser & Strauss, 1967; Strauss & C o r b i n , 1990). I judged that theoretical saturation had occurred f o l l o w i n g 18 months o f f ie ldwork wi th forty-one individuals in eleven families. Interviews Interviews were conducted most often i n participants' homes or other preferred locations such as in m y work office or, i n one instance, i n a restaurant. T h i s study i n v o l v e d at least one two-hour in-depth interview wi th each ind iv idua l fami ly member and the fami ly unit whenever possible. Indiv idual fami ly members were interviewed separately, and then in dyads and/or as fami ly units. T h i s strategy was designed to engage participants i n a discussion of their experiences to the greatest extent possible. In some instances, I in terviewed participants a second or third time to clarify and expand upon ideas that were shared during the in i t ia l interview. The interviews were tape recorded and verbatim transcripts were prepared by a transcriptionist. For ty-four in formal , semi-structured, in-depth interviews (Fontana & Frey , 1994) were conducted during an 18-month per iod during 1996 through 1998. A l t h o u g h 41 individuals participated in the study, 12 persons (7 chi ldren, 3 adults, and 2 grandparents) were present only Heal ing W i t h i n Fami l ies 55 during the fami ly interviews. These individuals preferred not to be ind iv idua l ly interviewed. A n interview guide was used to in i t ia l ly focus the interviews (see A p p e n d i x D ) . D u r i n g ind iv idua l interviews, participants were encouraged to reflect on their experiences related to healing fo l lowing youth suicide. B r o a d open-ended questions and comments were presented at the beginning of the interviews. F o r example, I generally began ind iv idua l conversations wi th something such as: " T e l l me about your life since X took his l i f e . " or, "Wha t has this experience been l ike for y o u ? " A s the interviews progressed, more focused questions were asked, for example , " W h a t does heal ing mean to y o u ? " and, " H o w d i d y o u heal f o l l owing X ' s suic ide?" Spec i f ica l ly , I wanted to understand the ind iv idua l ' s v iews about healing, as w e l l as what helped and hindered this process. D u r i n g fami ly interviews, questions were framed to include the perspectives of others wi th in the fami ly unit. F o r example, family interviews often began wi th questions such as: " T e l l me about life i n your fami ly since X took his l i f e . " and, "Wha t has this experience been l ike for your f a m i l y ? " A s fami ly interviews progressed, I used specific questions to focus the conversation. F o r instance, I asked a father the fo l l owing questions: " C a n y o u describe the effect of X ' s suicide on your chi ldren?" and, "What helped them to heal?" F l e x i b i l i t y dur ing the interview process was vital to a l low for further exploration o f leads and cues p rov ided by participants. S imi la r ly , it was important to remember that neither the content o f the interviews nor the needs of participants cou ld be predetermined. Interview data were supplemented by other non-technical literature (e.g., diaries, photographs, letters, newspaper c l ippings , art work , and poetry) shared by participants. Informants were invi ted 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. D u r i n g the research project I hired a transcriptionist and a research assistant. The transcriptionist prepared the verbatim transcripts of a l l participants' interviews. W o r k i n g under m y direct supervision, the research assistant helped during certain phases o f the project. Ini t ia l ly , he gathered relevant literature and helped with data management. Later, after he gained an in-depth understanding o f the study, he assisted wi th data analysis. F o r example , both the research assistant Hea l ing W i t h i n Fami l ies 56 and I separately coded several interviews and then compared our f indings. T h i s process helped to validate the emerging theory. B o t h the transcriptionist and the research assistant were requested to sign an oath o f confidentiali ty (Appendix E ) prior to being invo lved i n this research. Participant Observation Data were also collected through the use of participant observation. Observations generally occurred during home visits and lasted the duration o f the interview (i.e., approximately two hours). Since meaning creates behavior and behavior is constructed through interaction, it fo l lows that it was necessary to examine participants' interactions i n natural settings whenever possible. If family members have a choice regarding the location of the interviews and observations, they are more l ike ly be more relaxed and comfortable whi le sharing personal and intimate details about their l ives . Participant observation usually occurred once or twice for each participant and once for most families. I was interested i n gaining insight about alterations i n day-to-day fami ly life and learning about the meaning that individuals and families attributed to their experiences i n relation to youth suicide. F a m i l y dynamics (e.g., communica t ion patterns and interactions) that further i l luminated an understanding o f ind iv idua l healing were of particular interest. I observed for symbols used i n communica t ion (e.g., use o f artifacts, language—verbal and nonverbal) , for ind iv idua l behaviors (e.g., readiness and/or wi l l ingness to participate), and for patterns o f interaction amongst f ami ly members (e.g., who speaks to w h o m ? who speaks, and who does not?). I checked m y perceptions about m y observations with informants immediate ly fo l lowing an interaction to clarify informants ' self-definitions and shared meanings. Based on the symbol ic interactionist perspective, the researcher is v i ewed as necessarily both an observer and a participant in the research project. It is only as the researcher enters the w o r l d of the participant that he or she is able to understand the complexi ty of that w o r l d (Atk inson & Hammers l ey , 1994; Chen i t z & Swanson, 1986; Schatzman & Strauss, 1973). In order to capture this complexi ty to the best extent possible, I became an instrument for data col lect ion (L inco ln & Guba , 1985) by immers ing myse l f i n the l ives of these famil ies to the extent that such Hea l ing W i t h i n Famil ies 57 involvement was agreeable to a l l concerned. In an attempt to get to k n o w these families, I readily accepted invitations to spend time with them. F o r example, I was invi ted to j o i n families for meals, v iew mementos and treasured fami ly photo albums, and, i n one instance, to partake i n a memor ia l service. Often this exposure to participants' private l ives p rov ided sensory data and insights that enabled me to formulate immediate comments, probes, and prompts, in addition to relevant questions for future interviews. Fieldnotes depict ing observations, social processes, and reflections were prepared immediately fo l lowing contact wi th 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 l i fe circumstances. A s previously mentioned, I was interested i n understanding the participants' communi ty and home environment. F o r instance, I was invi ted to interview a fami ly of six who l i v e d on a farm. The large farm was located on prime farmland about thirty kilometers f rom a smal l town. I arrived at the farm at the pre-arranged time o f 1600 hours. A s I turned into the dr iveway I noted two houses i n the farmyard. I made m y way to the larger of the two houses as previously instructed. W h e n I stopped m y car, a b ig dog came running toward the car. Soon the owner came to m y rescue. I was greeted by Jan (a pseudonym for the mother o f a deceased youth) who had forgotten about the interview. She soon recalled that we had agreed to meet and invi ted me into the house. W e wa lked through a huge laundry room and I observed that the washing machine and dryer were in use. W e then entered a spacious country kitchen wi th lots o f light, and many oak cupboards with a huge matching oak table in the center o f the room. The furnishings and decor were of fine quality. I immediately sensed the aroma of fresh garden vegetables ming led wi th the pleasant smell of home cook ing . Th i s added to the characteristic w a r m atmosphere I readily sensed. I soon noted that another female adult was present. Jan informed me that her sister f rom the east coast was vis i t ing for the summer. A s I began to set up for the interview, I noted that the two youngest chi ldren (both daughters aged 11 and 9) settled themselves at the far end of the large table. They began to occupy themselves wi th paper and pencil activities. The interview took place at the kitchen table wi th Jan Hea l ing W i t h i n Fami l ies 58 and her husband, M a r t i n , and their two daughters present. The third su rv iv ing c h i l d i n this fami ly , a 16-year o ld male youth, was not at home during the time o f the interview. The mother 's v is i t ing sister continued to work in the kitchen during the interview. The whole fami ly seemed relaxed and the mother 's sister even participated every now and then i n the interview process. Coffee was served as we conversed. I was invi ted to stay for dinner—I accepted. A wel l -balanced meal was served (roast beef, potatoes, vegetables, salad, home-made bread, and beverage). W h i l e the girls d i d not participate during the interview, they were both the center of attention during the meal . There was much light talk and laughter shared among fami ly members during the meal . B o t h parents spoke very posi t ively about the girls in their presence, and it was evident that they appreciated the attention. After dinner, M a r t i n invi ted me into their tastefully furnished l i v i n g r o o m to look at a photo a lbum and other cherished mementos. I noted that there were no pictures o f the deceased youth in the house. M a r t i n commented that he cou ld not br ing himsel f to display photos. H e commented that his parents, who l ive in the other house i n the same yard, have a b ig picture o f Pau l (deceased son) on the w a l l of their l i v i n g room. In a second case, I was invi ted to conduct an interview wi th a su rv iv ing sister, Clare , who was diagnosed wi th schizophrenia. She was l i v i n g on social assistance at the t ime o f the interview. Clare l i v e d i n a basement suite in a low-income, mult iple fami ly dwe l l ing i n a smal l urban center. A s I entered her suite, I noted that it was dark because a l l the bl inds were drawn. She turned on a l ight as I stood i n the entrance. She then guided me to the l i v i n g room. O n the way, I noted that her place was generally unkempt wi th dishes p i l ed on a l l the available counter space. A l s o , there were items of c lothing strewn along the narrow hal lway. The doors to the other rooms i n the suite were closed. W h e n we entered the smal l l i v i n g room, Clare turned on an overhead lamp. She then p icked the cat up off the sofa and cleared a smal l space for me to sit. She cheerfully offered me a cup of coffee. Cla re informed me that she was getting marr ied soon. She said that she wanted to show me something. She disappeared down the hal l and returned wi th a jacket that she had made. P roud of her accomplishment, she pointed to the cross-stitch w o r k on the back o f the jacket. She seemed pleased that I commented posi t ively about her work. She then sat down on a w e l l worn Hea l ing W i t h i n Fami l ies 59 recliner rocker and began talking about her experience related to her brother's suicide. A s we carried on our conversation, I observed some figurines l ined up along the opposite w a l l o f the l i v i n g room. I inquired about them. Clare said that she had made them as a way o f dealing wi th her brother's death. E a c h figurine represented one facet o f her grief. In a third situation, I was invi ted to visit L i z , a single mother of two chi ldren, in her mobi le home in a smal l urban center. L i z was very warm and most receptive to being interviewed. It had been over a year since her husband had taken his l ife. She had made a decis ion to return to school and was i n the process o f m o v i n g to another country at the t ime o f data col lec t ion. O n the day of the interview, the youngest c h i l d was i n kindergarten and the older c h i l d was in school . Because the movers had just removed the furniture f rom her home, we sat on the l i v i n g r o o m floor wi th our ' legs crossed in front o f us. A s we sat there, L i z pointed out many features o f her home, and I cou ld see that she took a great deal of pride i n her surroundings. A s we cont inued our conversation, L i z folded a b i g basket of chi ldren 's c lothing. She talked easi ly and effortlessly. After about an hour and a half, the telephone rang. Apparent ly , L i z had forgotten to p ick up the youngest c h i l d f rom kindergarten. The caller suggested an alternative c h i l d care arrangement and we continued our conversation. I concluded the interview shortly thereafter. A s part of the f ie ldwork experience, I kept a two-part "ref lexive jou rna l " ( L i n c o l n & Guba , 1985, p. 327) i n w h i c h I documented m y thoughts, ideas, and reflections about the study. These authors recommend inc luding the fo l lowing 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 l og documenting the decision mak ing process used during theory development. The first part o f m y journal contained a calendar that served as a chronological log of the progression o f events throughout the study. Here, I recorded the interview schedule along wi th technical information related to the study. In the second part o f the journal , I documented m y thoughts and ideas about the study inc lud ing: emotional reactions to participants' stories, ideas gleaned f rom conversations wi th other grounded theorists, and methodological decisions along wi th supporting rationale. T h i s journal was invaluable because, in it, I was able to write detailed notes describing m y views about what was Hea l ing W i t h i n Fami l ies 60 happening in the study, draw conceptual diagrams representing the data, and experiment with m y ideas about the meaning of the data. F o r instance, I was able to reflect on the d ichotomy (e.g., experiences o f great pain and great j oy ) I often sensed during m y encounters wi th families and its relevance to the study. A t other times, I s imply wrote about m y feelings related to hearing participants' stories. Journaling also facilitated the conceptualization phase o f theory development. F o r example, one particular incident stands out i n m y mind . I had just attended the funeral o f m y brother-in-law and the fo l l owing day embarked on the long dr ive home (a 13-hour journey). A s m y husband was d r iv ing , I was th inking about m y research when I experienced a strong urge to attempt to represent the data through drawing. W i t h i n moments our vehicle was transformed into a suitable work space. Da ta were spread out along the dashboard and on the floorboard; some even f lowed into the back seat. A l m o s t l ike magic , responding to m y felt sense, I drew a diagram of m y conceptualization of the data. Th is diagram has since become an integral component o f the theory presented in this dissertation. M a y (1986) supports this method for s tudying abstract concepts such as healing. The creation o f this diagram represented an important methodological decision because it captured m y interpretation o f the healing process as experienced by fami ly survivors of youth suicide, and served to further m y conceptualization o f this process. Data Management Ini t ia l ly , each fami ly was assigned an identif ication number (e.g., f ami ly 001 , 002, etc.). E a c h individual family member was also identified by a letter fo l lowing the fami ly identification number (e.g., fami ly member 0 0 1 - A , 0 0 1 - B , etc.). A fami ly file was then created wi th transcripts chronological ly organized according to the date of each interview. F i e l d notes were handled in a .s imilar manner. A s categories emerged from the data, other files were created. F o r example, a file name specific to a category was created and a second copy o f pertinent data f rom al l families was then stored in that fi le. B o t h hard and computerized copies o f the data were prepared. A back-up disc containing the data was stored in a locked f i l i ng cabinet. A s the theory developed, other files were created and handled i n a s imilar fashion. Organ iz ing data i n this way a l lowed me to analyze it Hea l ing W i t h i n Fami l ies 61 f rom many perspectives. Th is method of data management permitted easy access to a large volume of data and worked w e l l during the process o f manual analysis. Data Analys i s Da ta col lect ion and data analysis occurred simultaneously wi th analysis guiding subsequent data col lec t ion (Strauss & C o r b i n , 1990). The constant comparative method (Glaser, 1978) was ut i l ized to a l low for modif icat ion according to the advancing theory. U s i n g the constant comparative method, I compared newly collected data wi th previously obtained data in an on-going fashion to further refine theoretically relevant data (Poli t & Hungler , 1999). Subsequently, data were categorized (Swanson, 1986a) and named. I sought participants' input regarding the naming of categories. A s stated earlier, at the onset of the study I had or ig inal ly planned to study ' fami ly healing. ' It was only as I began to listen to the stories shared by fami ly members that I real ized their stories focused on ly on their personal experiences related to healing. Consequently, the pr ime focus o f the study was modi f ied to reflect an emphasis on the experience o f individuals wi th in the context of the family . Th i s modif icat ion was negotiated wi th m y dissertation committee and just if ied on the basis of what the research f ie ld w o u l d a l low. Because l imi ted scientific knowledge is currently available specific to healing f o l l o w i n g youth suicide, a focus on the ind iv idua l experience o f healing was deemed appropriate for the purposes of this study. The N U D * I S T (Non-numerica l , Unstructured, Da ta Indexing, Searching and Theor iz ing ; Richards & Richards , 1991, 1995) software package for qualitative data management was investigated. Th i s program w o u l d have required considerable time for me to learn to use it efficiently. G i v e n m y unfamiliari ty with computer technology at the t ime I began this project, and given the l imi ted time available to devote to this research whi le resuming m y regular teaching responsibili t ies, I chose to use manual methods o f managing the data. M o r e importantly, I perceived that the famil iar "hands-on" methods a l lowed a sense o f greater immers ion in the data. Th i s , i n fact, turned out to be true. Heal ing W i t h i n Fami l ies 62 D u r i n g the process o f data analysis, I sol ici ted input from several "experts." A s data col lec t ion and analysis progressed, I communicated wi th m y dissertation supervisor on a regular basis v ia telephone and electronic mai l . D u r i n g the early stages o f data col lec t ion and analysis, I met first wi th m y supervisor to discuss and compare some o f the early interviews and to review the code lists as they evolved. Later as the theory evolved, I met wi th m y entire committee to discuss a matrix that represented m y early conceptualization of the emerging theory and the original version of the diagram presented i n Chapter F i v e . A s the study evolved, communica t ion wi th m y supervisor and committee continued. This ongoing dialogue definitely enhanced m y first research experience focusing on theory development. A s mentioned previously, taped interviews and f ie ld notes were typed by a transcriptionist using Mic roso f t W o r d 6.0.1 ( G o o k i n , 1994). H a r d copies were transcribed on the left half o f the page only , leaving the right half of the page blank for hand analysis. The right half o f each page was then d iv ided into three sections, one for each level o f coding . C o d i n g A s soon as the verbatim transcripts were prepared, the data were read two or three times to become famil iar w i th them (J. Anderson , personal communica t ion , September 20, 1996). C o d i n g , the l ink between data and theory (Glaser, 1978), began wi th open coding . T h e open coding technique was used as the first level of data analysis. Open cod ing entailed breaking down, examining, compar ing, conceptual izing, and categorizing data for the purpose o f theory generation (Strauss & C o r b i n , 1990). Th i s process yields codes w h i c h have been labeled descriptive (Charmaz, 1983; Swanson , 1986b), objective (Seidel , 1995), or substantive (Carpenter, 1995; Glaser, 1978) because they represent the uninterpreted facts wi th in the data. Th i s procedure often involves cod ing each event or happening, usually in a l ine-by- l ine fashion, to get at the ideas wi th in the data. In consideration o f the subject matter, I departed f rom Strauss and Corb in ' s (1990) idea o f open coding . In keeping wi th m y analytic approach o f " th ink ing wi th stories" (Frank, 1995), discussed earlier i n this chapter, I opted to code textual data by us ing 'meaning units. ' M e a n i n g units were words, phrases, or paragraphs representing some meaningful idea expressed Hea l ing W i t h i n Famil ies 63 by a participant or group of participants. I reasoned that this unit o f analysis w o u l d more accurately reflect the informants ' v iews. M e a n i n g units were der ived by asking questions o f the data (Glaser, 1978) such as: "Wha t is being communicated here?" and, "Wha t does this mean i n terms of heal ing?" I speculated that by analyzing data i n this manner, I w o u l d be able to honor the w i s d o m wi th in 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 " i n v i v o codes" (Carpenter, 1995; Cha rmaz , 1983; Glaser , 1978, p. 70; Strauss, 1987, p. 33). In addi t ion, selected participants were also invi ted to provide input related to the naming o f categories. Ini t ial ly, three major categories were developed from the data through the process of cod ing meaning units. U s i n g " i n v i v o codes" (Carpenter, 1995; Charmaz , 1983; Glaser , 1978, p. 70; Strauss, 1987, p. 33), these major categories were in i t ia l ly named: H o l d i n g O n T o Le t t ing G o ; Let t ing G o ; and Let t ing G o and M o v i n g B e y o n d . A l though each major category explained one aspect o f the topic under study (i.e., ind iv idua l heal ing fo l l owing youth suicide), each major category had meaning only in relationship to the other two major categories. Moreover , wi th in each o f the three major categories, five elements were developed from the data, each element further defining the parameters wi th in each major category. S imi la r ly , wi th in each element, a number o f ideas emerged from the data. These ideas further defined each element. A x i a l cod ing was used during the second level o f data analysis. D u r i n g axia l coding, I put the data back together again by mak ing connections between the major categories (i.e., concepts) and its elements (Strauss & C o r b i n , 1990). The three in i t ia l categories (i.e., concepts) were labeled as Healing Themes and renamed: Cocooning, Centering, and Connecting. These major concepts reflected a higher degree o f abstraction than the ini t ia l ones. S imi l a r ly , the elements were further refined and sometimes renamed and/or combined wi th former elements. The third level of analysis, selective coding , i nvo lved the synthesis o f previously identified concepts and elements to formulate a "core" concept (Strauss & C o r b i n , 1990). The core concept emerged as a result of using constant comparison to analyze for relationship patterns between and Hea l ing W i t h i n Fami l ies 64 among substantive codes (Cheni tz & Swanson , 1986; Glaser , 1978). Select ive cod ing , 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 & C o r b i n , 1990). The core concept represented the basic social psychologica l processes ( B S P s ) (Carpenter, 1995; Fagerhaugh, 1986) that expla ined the story as portrayed in the data. M e m o i n g Throughout the analysis, memos were kept documenting m y th inking processes whi le coding the data, identifying and l i nk ing the data, and naming the core phenomenon (Glaser & Strauss, 1967). A "condi t iona l mat r ix" (Corb in & Strauss, 1988; Strauss & C o r b i n , 1990) representing the interrelationships among the categories was designed. F i e l d notes documenting observations and m y intuit ive grasp o f the participants' stories were prepared. O n numerous occasions I referred back to these notes. F o r example, I or ig inal ly separated "Intuitive V i s i o n i n g " from " F i n d i n g M e a n i n g / E x p l o r i n g Spir i tual i ty ." A s I reviewed m y notes about m y thinking processes regarding this decis ion, I was able to determine that the second element should be col lapsed wi th in the first. Establ ishing Scientific R i g o r W h i l e the worth o f quantitative research is determined pr imar i ly by assessing its rel iabil i ty and val id i ty , the worth of a qualitative study is ascertained by assessing its trustworthiness (Elder & M i l l e r , 1995; Kre f t ing , 1991; Le in inger , 1994; L i n c o l n and G u b a , 1985; Streubert, 1995). In qualitative research, rel iabi l i ty and val idi ty are often explained in terms o f credibi l i ty , fittingness of the data, auditabili ty, and conf i rmabi l i ty (Sandelowski , 1986). S i m i l a r l y , L i n c o l n and G u b a (1985) stipulate four criteria that can be used to determine the trustworthiness o f qualitative inquiry, specif ical ly: credibi l i ty , transferability, dependability, and confi rmabi l i ty . F ind ings are credible to the extent they represent the ind iv idua l truths expressed by each participant i nvo lved i n the study. Transferabili ty is addressed by ascertaining the extent to wh ich the researcher has provided adequate descriptive data to enable others to apply or transfer the findings to other contexts or Hea l ing W i t h i n Fami l ies 65 respondents. Because the naturalistic inquirer expects variabil i ty in every aspect of the research project, inc lud ing changes in the informants, the setting, or the researcher, the concern regarding repl icabi l i ty or consistency o f the study focuses on determining dependabili ty, or the extent to wh ich the researcher can account for the variabil i ty wi th in the data. F i n a l l y , because it is understood that qualitative research is not value-free, the emphasis regarding the research findings being neutral or free from the biases o f the researcher is shifted to a detennination o f the extent to wh ich the data are neutral, or can be confirmed. I elected to establish scientific r igor by determining trustworthiness according to the criteria set forth by L i n c o l n and G u b a (1985). Credibi l i ty I used a number of strategies to establish credibi l i ty . Firs t , tr iangulation, or the use o f a number of different data col lec t ion methods, sources of data, investigators, or compet ing theories was used (Kref t ing, 1991; L i n c o l n & Guba , 1985). I triangulated a variety o f data col lect ion methods (e.g., interviews, participant observations; use o f non-technical data sources, and m y reflexive journal) to secure m a x i m u m variation wi th in the data and to ensure accurate representation of the participants' experiences i n developing the theory. The second strategy i nvo l ved the careful framing of questions. A c c o r d i n g to Kref t ing (1991), "the reframing o f questions, repetition o f questions, or expansion o f questions on different occasions are ways in w h i c h to increase c red ib i l i ty" (p. 220). In m y effort to understand the views of each participant, I proceeded by asking questions clearly and concise ly . In addit ion, I used paraphrasing to ensure that I received the participant 's intended message. A third strategy used to increase credibi l i ty was prolonged engagement wi th participants, defined by L i n c o l n and G u b a (1985) as, "the investment of sufficient t ime to achieve certain purposes" (p. 301). T o achieve m y purpose o f understanding participants ' stories, I spent a m i n i m u m of several hours with each participant. M u c h attention and time were spent bui ld ing rapport and trust wi th participants i n addition to focusing on the research questions. Pro longed engagement wi th participants accentuates one o f the dangers inherent in naturalistic inquiry—the potential for the researcher to "go native" by becoming over-identified Hea l ing W i t h i n Fami l ies 66 wi th respondents (Cheni tz & Swanson, 1986; Kre f t ing , 1991). I used two strategies to prevent this and thus maintain credibi l i ty: peer examination (Kreft ing, 1991) or peer debriefing (L inco ln & G u b a , 1985), and journa l ing (Cheni tz & Swanson, 1986). Peer debrief ing, defined as "expos ing oneself to a disinterested peer. . . . for the purpose o f exp lor ing aspects o f inqui ry that might otherwise remain on ly imp l i c i t wi th the inquirer 's m i n d " ( L i n c o l n & G u b a , 1985, p. 308), was accommodated by sharing this work with professional colleagues and inv i t ing their feedback. Another helpful strategy was m y routine participation in debriefing sessions wi th a trusted professional colleague. In addition, I felt free to contact m y dissertation supervisor about any concerns during the course of m y involvement in this study. Journal ing, the second strategy, was discussed above in the section dealing wi th participant observation and f ie ldwork. Cred ib i l i ty was also achieved through member checking. A c c o r d i n g to L i n c o l n and G u b a (1985), "the member check, whereby data, analytic categories, interpretations, and conclusions are tested wi th members of those stakeholding groups from w h o m the data were or ig inal ly collected, is the most crucia l technique for establishing credib i l i ty" (p. 314). O n g o i n g member checking ( L i n c o l n & G u b a , 1985) wi th selected participants was carried out as the research study progressed. M i n o r modifications to the theory were made based on participant feedback. Add i t i ona l l y , 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 fo l l owing youth suicide. Negat ive case analysis was the final strategy I used to enhance credibi l i ty . The goal of negative case analysis is to refine the theory until it accurately reflects a l l those w h o m it intends to represent ( L i n c o l n & G u b a , 1985). One example of negative case analysis in m y study was the need to account for two individuals who, in contrast to the other participants, d i d not consider themselves to be m o v i n g toward healing. In sharing the developing theory wi th them, they identif ied wi th the theory even though they were not yet ready to heal. Thus , even these two individuals validated the theory and the cri t ical aspect o f vol i t ion in healing. Hea l ing W i t h i n Fami l ies 67 Transferability T o augment transferability of the study, I used two techniques. The first o f these was the use of " th ick descr ipt ion" ( L i n c o l n & Guba , 1985, p. 316) or "dense background informat ion" (Kref t ing, 1991, p. 220) gathered during the data co l lec t ion process (Cheni tz and Swanson, 1986). Second, I engaged in theoretical sampl ing, discussed previous ly , to ensure both depth and breadth wi th in the thick descriptions and to accommodate saturation of the data ( L i n c o l n & Guba , 1985). Dependabili ty Measures that enhanced the credibi l i ty of this research endeavor also helped to increase its dependability. I took three additional measures to establish the dependabili ty o f this work. The first o f these recommended by Kref t ing (1991) was the "code-recode procedure" (p. 221) wh ich involves cod ing the data, wai t ing a per iod o f two weeks, and then recoding. T h i s technique was used during the in i t ia l phase of the project, whi le w o r k i n g wi th the research assistant, to ensure that we were thoroughly coding the data and arr iving at categories that accurately reflected the data. The second step taken to enhance dependability was to provide, i n this chapter, "dense descriptions of [the] methods" (Kref t ing , 1991, p. 221) used dur ing the entire research undertaking. The final measure used to increase the dependability o f this study was to provide an " inqui ry audit" ( L i n c o l n & G u b a , 1985, p. 317). Th i s i nvo lved examin ing the process of the study recorded as an "audit t ra i l " ( L i n c o l n & Guba , 1985, p. 319). Streubert (1995) defines the audit trail as "a recording of activities over time w h i c h can be fo l lowed by another i n d i v i d u a l . . . [the] objective [of which] is to, as clearly as possible, illustrate the evidence and thought processes which led to the conclus ions" (p. 26). A study is dependable to the extent that the audit trail documents the sources of variabil i ty in the study. The audit trail I left inc luded the thesis proposal documenting the research plan, the raw data (e.g., interview data and f i e ld notes), the chronological l og o f research events, m y reflexive journal , a portfolio containing an assortment of non-technical information shared by participants, and documentation related to data analysis and synthesis contained i n this dissertation. Hea l ing W i t h i n Fami l ies 68 Conf i rmabi l i ty Conf i rmabi l i ty is synonymous wi th 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 i n the study. A s the study evolved , selected participants were invo lved i n identifying and naming key concepts and categories. Th i s approach kept data analysis and synthesis grounded i n participants' stories. In addit ion, the evo lv ing theory was presented to suicide survivors at a research conference; these individuals further validated the research findings. T o further ensure confirmabi l i ty , an audit trail was kept documenting the decision making process used during the theory development process. Th i s strategy enhanced conf i rmabi l i ty in that it a l lows others to trace the research findings to their or iginal data sources. E th ica l Considerations Pr io r to beginning the research project, approval was granted by the Univers i ty o f Br i t i sh C o l u m b i a Behaviora l Sciences Screening Commit tee for Research Invo lv ing H u m a n Subjects (November 6, 1996). W i t h i n 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 i n this chapter wi th in the data col lect ion section. In addition, other steps were taken to ensure confidentiali ty during the research process. Pseudonyms were assigned by the researcher during the data col lec t ion process as one way of securing anonymity for participants. In one case, a participant indicated that she preferred being identif ied by her ful l name. Since the participant was f lexible in this regard, it was jo in t ly decided that a pseudonym w o u l d be used i n this study. Participants were advised that identifying information w o u l d not be revealed i n any publications or at any conferences related to this research study. D u r i n g analysis, participants' names were coded so that no ident ifying information was recorded on the transcripts. Code sheets were stored separately from the data. Da ta were secured in locked f i l ing cabinets i n m y home. Data were accessible only to al l dissertation committee members, the research assistant, and myself . Participants were advised that Hea l ing W i t h i n Famil ies 69 audio tapes w o u l d be erased and transcripts appropriately disposed o f three years after the complet ion o f the study. G i v e n the sensitive nature of the topic o f this research, interviews were also conducted wi th 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 tel l ing often evokes i n research participants ( A l t y & R o d h a m , 1998; Banks -Wal l ace , 1998; D e m i & War ren , 1995; Hutch inson , W i l s o n , & S k o d o l W i l s o n , 1994). H o w e v e r , it was also recognized that the interviews might induce intense emotional reactions for some participants. A l though not needed, arrangements were in place for an appropriate referral for individuals and families i n the event they required such assistance. Moreover , participants were advised that upon complet ion o f the study, a summary o f the key findings of the research project w o u l d be shared wi th them. Summary The research was designed as a grounded theory focusing on ind iv idua l fami ly members ' experiences of healing fo l lowing youth suicide. Congruent wi th a relativist phi losophical posit ion, a symbol ic interactionism perspective guided the methods used in this inquiry . The study was conducted in a natural setting—the homes o f ind iv idua l or fami ly members who consented to participate. Theoretical sampling guided data col lect ion 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 fami ly members ' healing experiences. E l even families participated i n the study during an 18-month period o f t ime. Th i s study generated a detailed, contextually-grounded description and theoretical explanation o f ind iv idua l healing within famil ies f o l l o w i n g youth suicide. Grounded theory was an effective method for addressing the research questions. A n overv iew of grounded theory that was developed f rom the data, and the contextual variables that influence the healing process, are described i n the next chapter; a more specific description o f the heal ing process is presented i n Chapters F i v e , S i x , and Seven. Hea l ing W i t h i n Fami l ies 70 C H A P T E R F O U R J O U R N E Y I N G T O W A R D W H O L E N E S S : A C O N T E X T U A L I Z E D E X P E R I E N C E 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 descript ion o f the participants. Second, it presents a preview and an overv iew of the grounded theory that emerged as a result of this study wh ich w i l l be further developed in the chapters that fo l l ow. B e g i n n i n g wi th the precipitating event, this chapter also addresses several important contextual factors that influence the heal ing process. Descr ipt ion o f Participants (The Sample) E leven families from rural communit ies (8 families) and smal l urban centers (3 families) in three Western Canadian provinces participated in the study (see Table 4-1). These families ranged i n size from 3 to 12 individuals . A total o f 41 fami ly 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 i n the form of a chart in Table 4-2. The information in these charts was gleaned f rom data p rov ided i n response to the Hea l ing W i t h i n Fami l ies 71 Demographic Questionnaire (see Append ix F ) and information obtained during ind iv idua l and family interviews. A l l potential participants wi th w h o m I spoke and expla ined the study agreed to participate. A l though some chose to participate only during the fami ly interview, a l l o f those who became invo lved in the study fo l lowed it through to its complet ion. In total, 44 interviews, inc lud ing 33 ind iv idua l and 11 fami ly interviews, were conducted. A little more than one half o f the participants were female (n=26). The participants inc luded mothers (n=9), fathers (n=8), sisters (n=8), brothers (n=3), grandparents (n=2), significant others (n=7), wives (n=2), and chi ldren of the deceased (n=2). Participants ranged i n age f rom 6 to 80 years wi th a mean age of 38 years. The average length of t ime since the suicide was 3.1 years, ranging from 6 months to 12 years. T w o survivors f rom two different famil ies had previous experience wi th the suicide o f a significant other. Soc ioeconomic diversity among families was evident wi th four famil ies reporting an annual fami ly income of less than $30,000; three families reporting an annual income o f $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 fami ly reporting an annual income exceeding $150,000. The occupational status o f adult fami ly members inc luded currently unemployed, students, homemakers, blue and white co l la r workers , semi-professionals, professionals, and retired persons. Educa t iona l status ranged f rom those without high school complet ion to those ho ld ing graduate degrees. A l l participants were fluent i n E n g l i s h ; al l interviews were conducted i n E n g l i s h . Three-quarters of participants described their health status as "excellent" or "very good" whi le one-quarter rated their health status as "fair" or "poor." T e n individuals were diagnosed wi th health problems. N i n e participants had mental i l lness diagnoses inc lud ing depression (n=5), and schizophrenia (n=4). One participant had experienced the death of a four month o ld infant and had received a diagnosis of cancer a week pr ior to being interviewed. W h i l e most participants (33 o f the 41) identified wi th the dominant Eng l i sh Canadian culture of Western Canada, eight individuals c l a imed l inks with one o f the fo l lowing ethnic minorit ies: Canadian A b o r i g i n a l , Dan i sh , Ge rman Canadian, or French Canadian. Just over half o f the participants (n=24) specified a particular rel igious affil iation as Protestant, R o m a n Ca tho l i c , Buddhis t , M o r m o n , or Jehovah 's Witness . Hea l ing W i t h i n Fami l ies 72 A l l 11 persons who ended their l ives were males. They took their o w n l ives by hanging (n=5), shooting (n=5), and d rowning (n=l ) . Su ic ide notes were left by s ix ind iv idua ls . N i n e youths ranging in age f rom 14 to 19 years ended their l ives; two others were older (29 and 24 years of age). F i v e individuals who took their l ives were single, three were married, and three were l i v i n g in c o m m o n law relationships at the time of their deaths. N i n e individuals who ended their l ives came f rom families wi th married parents whi le two came f rom families where the parents were separated at the t ime of the suicide. M o s t (n=9) suicides occurred wi th in the four years just prior to the t ime o f data col lect ion. T w o of the self-inflicted deaths occurred on Ha l loween and one occurred on the deceased youth 's mother 's birthday. T A B L E 4-2: SAMPLE POPULATION DATA Fami ly Number of Persons in Fami ly ( including deceased) Individual Inter-views Fami ly Inter-views Total Inter-views Gender & Age of Suicide V i c t i m Length of Time Since Suicide (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 - 2 0 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 Hea l ing Process F o l l o w i n g Y o u t h Suic ide: A Prev iew In this study, ind iv idua l healing fo l lowing youth suicide is conceptual ized as a dynamic , ongoing, recursive, and seamless process that I have labeled Journeying Toward Wholeness. Heal ing W i t h i n Fami l ies 73 Survivors consistently described their healing experience as "a journey." T h e y also spoke repeatedly about being "fragmented" and feeling "torn apart ins ide" by the tragedy. Survivors expressed the wi sh to regain a sense o f "wholeness." T h e y perceived this cou ld be accompl ished by embarking on a personal journey. The w o r d toward, in the phrase Journeying Toward Wholeness is not used to indicate linear direction. W i t h i n this study, this terminology is used in its broadest sense to indicate a direction rather than a destination. S imi l a r l y , this w o r d has been used in expressions such as " toward an understanding." Understanding, l i ke heal ing, se ldom occurs as a solely linear activity. The journey toward healing is graphical ly 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. Th i s bond of love between the survivor and deceased youth was emphasized several times over the course o f the study. In addit ion, during m y "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 m y attention through reading that 'the knot ' is a preserver o f the l ife force, and a symbol of attachment and unity (Petzl , 1998). Based on this background information and m y 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. Col lec t ive ly , I have labeled these three major concepts as healing themes. Based on survivors ' stories about heal ing, I have also labeled each o f the three healing themes (i.e., major concepts) in m y theory as Cocooning, Centering, and Connecting. The love knot is depicted as three endless ovals exist ing i n separate realms at slightly different angles to one another and converging at the healing epicenter. The healing epicenter is the place where heal ing manifests itself, synonymous wi th the surv ivor ' s consciousness. A l though each healing theme (represented by an oval) explains one aspect o f the overal l journey of healing, each one has meaning only in relationship to the other two healing themes (see F igure 4-1). The three healing themes of the indiv idual healing process are: H e a l i n g W i t h i n Famil ies 74 • Cocooning - T u r n i n g inward as a means o f survival f o l l o w i n g youth suicide. • Centering - Exper ienc ing personal growth as a result o f mak ing key decisions in the aftermath of youth suicide. • Connecting - U n i t i n g wi th self, others, God/h igher power , and the environment; m o v i n g beyond mediocr i ty as a self-chosen response to youth suicide. F I G U R E 4-1: INDIVIDUAL H E A L I N G P R O C E S S R E P R E S E N T E D B Y A L O V E K N O T COCOONING J ourney of Descent Journey of Transcendence Journey of Growth W i t h i n each theme in the healing process, five elements or healing patterns were developed from the data. A l though represented here as discrete entities, these healing patterns are ind iv idua l ly identified only for the purpose of understanding the theory presented in this dissertation. In effect, each healing pattern remains inextricably intertwined wi th al l the other healing patterns. The five healing patterns that portray the survivor ' s healing journey include: • Relating - Interaction and communicat ion ( including the expression o f emotion) wi th self, others, and G o d or a higher power, embedded wi th in a broader social context, in the aftermath of youth suicide. Hea l ing W i t h i n Fami l ies 75 • Thinking - Cogn i t i ve processes such as reminisc ing , remember ing, be l i ev ing , learning, decis ion mak ing , and using intuition in response to youth suicide. • Functioning - Behav io r associated wi th activities of dai ly l i v i n g in response to the suicide o f a beloved fami ly youth. • Energizing - Capaci ty for physical exertion, vigorous act ivi ty, and a felt sense of personal or authentic power f o l l o w i n g youth suicide. • Finding Meaning/Exploring Spirituality - Higher power source and/or information indicating that meaning is beginning to emerge in relation to youth suicide. W i t h i n each o f the three healing themes, the five healing patterns are manifested somewhat differently. The fo l lowing template illustrates the relationship between the healing themes and the healing patterns (see Figure 4-3). T A B L E 4-3: INDIVIDUAL HEALING T E M P L A T E * HEALING PATTERNS H E A L I N G T H E M E S COCOONING CENTERING CONNECTING RELATING STRUGGLING GETTING A GRIP REACHING OUT THINKING CHAOTIC THINKING M A K I N G DECISIONS LEARNING FUNCTIONING AUTOPILOTING RE-ENGAGING ORCHESTRATING LIFE ENERGIZING CONSUMING REPLENISHING CHANNELING FINDING MEANING/ EXPLORING SPIRITUALITY AWAKENING TRANSFORMING TRANSCENDING * Th i s template is provided for the purpose o f orienting the reader to the theory presented i n this dissertation study. In a practical sense, the healing themes and healing patterns are enmeshed in a three-dimensional , recursive, and seamless process. Heal ing W i t h i n Fami l ies 76 B e g i n n i n g i n this chapter, and cont inuing in subsequent chapters, the stories of 41 individuals wi th in 11 families are woven into a theory that explains their experiences o f healing fo l l owing youth suicide. Th i s presentation format is used to provide an effective means of honoring participants' voices and capturing the truths embedded wi th in their stories. Ove rv i ew of the Grounded Theory Y o u t h suicide was the precipitating event that created a crisis wi th in each of the 11 families that participated in this study. Wi thout mercy, this single, irreversible event catapulted suicide survivors on a perilous and uncertain journey. Surv ivors ' l ives were drastically altered when they received the news about the tragedy. W i t h i n this instant, survivors were left alone, left l i v i n g , and left l ov ing the one who had just taken his l ife. D r a w i n g on inner strength and courage, survivors began the frequently scary and always demanding process of reconstructing their l ives. The theory described i n this dissertation study does not conceptualize healing in terms of discrete stages or phases, nor does it explain healing in terms o f achieving some final predetermined outcome. Rather, this theory represents the dynamic and uniquely ind iv idua l nature of the healing process wh ich varies in expression and intensity over the course o f each survivor ' s l ife. W i t h i n this study, ind iv idua l healing fo l l owing youth suicide is conceptual ized as Journeying Toward Wholeness. Individual healing is a personal and unique journey experienced by most, but not a l l , f ami ly survivors o f youth suicide. Th i s journey is characterized by the inter-relationships among three enfolding, dynamic , f lu id , and iterative healing themes entitled: Cocooning; Centering; and Connecting. E a c h healing theme represents one portion of the overal l healing journey. Speci f ica l ly , Cocooning focuses on the survivor ' s journey o f descent into self; Centering deals wi th the survivor ' s journey of personal growth; and Connecting addresses the survivor ' s journey o f transcendence. W i t h i n each healing theme, f ive self-organizing and inter-relating healing patterns (i.e., relating, thinking, functioning, energizing, and finding meaning/exploring spirituality) operate in mutual rhythmical interchange wi th each other. Each of the five healing patterns describes one facet of the survivor ' s overal l experience o f healing Hea l ing W i t h i n Fami l ies 77 fo l lowing youth suicide. W i t h i n this dissertation, the healing patterns are presented as distinct entities, only for the purpose of understanding the various facets o f the whole process. The ongoing healing journey varies in expression and intensity over t ime in response to a variety o f contextual factors inc luding 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 f rom the survivor ' s consciousness (i.e., the heal ing epicentre) i n response to three key decisions made by each survivor o f youth suicide. The degree to wh ich healing occurs depends on a number o f intervening variables (i.e., healing characteristics) reflecting the survivor ' s capacity to say yes to l i fe ; step out and speak up; achieve a sense of peace, harmony, and balance; and expand personal consciousness. A s a major outcome o f the heal ing process, each survivor creates a love knot w h i c h represents a healthy and cont inuing bond o f love between the survivor and deceased youth enacted through the use o f healing strategies. These healing strategies are based on the meaning the survivor attributes to his or her experience wi th youth suicide, and the relationship between the surv ivor and youth prior to his death. Individual healing is both a solo and shared experience that is created and re-created during the course o f each survivor ' s life. Further, it is hypothesized that ind iv idua l healing ultimately expands outward inf luencing fami ly , societal, and global spheres (see F igure 4-2). Conceptual ized as a whole , the healing process is represented by the grounded theory developed i n this research study. H e a l i n g W i t h i n Fami l ies 78 H E A L I N G AS JOURNEYING TOWARD WHOLENESS The Precipitating Event The precipitating event that launched survivors on "a journey o f no return" was that of hearing the news about the suicide of a young family member. Understandably, the psychologica l trauma associated wi th youth suicide ini t ia l ly evoked an ove rwhe lming sense o f terror and helplessness among fami ly survivors. Hear ing the N e w s Hearing the news was an "earth shattering" and "emotional ly traumatic" experience for all fami ly suicide survivors. Sue, a bereaved mother, commented, "nothing i n life even comes close to preparing one for that k i n d o f news—sometimes I can' t bel ieve I ' m s t i l l here." The harsh news evoked wi th in survivors a sense of being mercilessly launched on a treacherous journey without time for preparation. Characterist ically, survivors described their in i t ia l reactions to their unfortunate circumstances wi th phrases such as being "lost without a compass ," and having "a map without a destination." Hearing the news was comprised o f five concepts inc lud ing: 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^ Hea l ing W i t h i n Fami l ies 80 to h i m . W e began to hear some of the detai ls—basical ly R y a n had entered their bedroom, taken dad's gun and shot himself. F o r the participants in eight families, news o f the suicide came as "a complete surprise;" most survivors maintained that the suicide occurred "out of the blue." Th i s was especially hard to cope wi th because survivors often recalled that life, pr ior to the suicide, was satisfying and that everything seemed to be going "pretty much as usual ." Consequently, the sheer shock o f hearing the news was ove rwhe lming for most survivors as indicated by J i m , a father and husband: It's overwhelming and you are dealing wi th al l o f it at the same time and not seeing beyond it because i t ' s just come out o f the blue. . . . Y o u w o u l d think that somebody who commit ted suicide w o u l d be depressed and on the edge. Th i s wasn ' t the case. It just comes out of basical ly nowhere, and that's what y o u have to deal wi th . Survivors i n three families recalled not being surprised that the youth had ended his life. In one fami ly , a survivor knew that "something wasn' t quite right" but was unable to identify exactly what it was that was troublesome. In another fami ly , Ca rmen recounted how her boyfr iend had been dealing wi th a number of problems prior to the suicide: W h e n K e v i n was g rowing up he had a real ly horrible l i fe . H i s m o m and dad were never married but they had three kids and they separated. A n d then h e ' d always told me that his real m o m was dead. A n d so that's what I bel ieved for years, l ike the whole time that we were dating unt i l our son was six months o ld . She showed up at our doorstep, and then I d idn ' t real ly ever understand w h y he to ld me his m o m was dead. So when he died, we were f ight ing and we were t rying to move to [new town] and get our l ives on the road. A s I look back and look at the note he left me, and I got to k n o w his m o m very we l l after he died, and m y question was, " W h y didn ' t he do it sooner?" L i z l i v e d for years in a situation o f not k n o w i n g when, and if, the suicide w o u l d take place. She recalled the "tragic r e l i e f she ini t ia l ly experienced: " A n d 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 Hea l ing W i t h i n Fami l ies 81 U p o n hearing the news, a few survivors reported intense phys i ca l responses. Chr i s recalled her ini t ial 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 k i c k i n g and screaming and y e l l i n g . " Three mothers indicated their physical experiences were 'guttural responses' to the pain associated wi th loss. L i z remarked, " O h yes, there were times when I moaned so m u c h pain, f rom the depths of m y soul , it wasn ' t even a cry . . . when y o u are g iv ing birth y o u don ' t even go there." M a r i e , a mother, writes about her experience this way: The screams that erupted from m y 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 h o w l . I have never heard sounds l ike that before, and I too, was scared. I later came to compare that sound to the wa i l i ng o f a pain f i l l ed animal . H o w true that I was wounded . Sara, a mother, was brought to her knees when she found out that her 16-year o l d son had taken his life. She v i v i d l y described her bodi ly experience of "grief at the cel lular l eve l . " She recalled fa l l ing to her knees, i m m o b i l i z e d by intense pain resembling that o f labor pains. Involuntar i ly , she felt the need to "bear d o w n , " as i f g iv ing bir th. T h i s spontaneous, intense, and total bodi ly experience was accompanied by deep wa i l ing and c ry ing out i n agony for her deceased son. Sara felt a connection to her son through this experience. Surv ivors ' responses to youth suicide, to a great extent, mi r rored society 's avoidance of and discomfort wi th the topic of suicide. Survivors were sensitive to the discomfort o f 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. L i n d a , a mother commented, "Th i s [suicide] is a loss that we don ' t talk about." Th i s 'conspiracy o f si lence ' further compounded the isolation felt by many survivors. In the midst of tremendous upheaval, many survivors demonstrated remarkable insight. Immediately upon discovering the suicide o f her son, Rose real ized the potentially devastating impact of such tragedy on her fami ly . J i m , Rose ' s husband, recal led his wi fe ' s in i t ia l response to the hearing the news: Hea l ing W i t h i n Fami l ies 82 That morn ing we were al l down i n the basement wi th Jason [deceased son] and we were al l so emotional ly distraught. She [Rose, J i m ' s wife] turned to me and the first thing she said was, "Whatever happens, i f I forget, remember, we don ' t b lame one another for this. W e can' t b lame one another for this." H e r strength has been what has brought us together. Th i s is something that we have experienced together. It 's l ike y o u ' v e seen the worst together and that makes y o u stronger. The Hor ro r o f D i scove ry The "horror of d iscovery" was catastrophic for survivors w h o reported the experience: " F i n d i n g the body is the worst possible experience that anyone cou ld ever have to face in l i fe . " The horrific discovery often haunted these survivors. A s w e l l , even the imagined discovery sometimes haunted those who were not present at the scene o f discovery. Haun t ing thoughts frequently centered on the family survivor 's imagined emotional state o f the youth i n the moments preceding the suicide: "I a l lowed mysel f to think about the actual process o f what T i m might have gone through, and what he might have been th inking or feel ing." In several cases, it appeared that the youth had given considerable thought to staging the suicide. In three cases, fami ly survivors perceived that the suicide was staged by the youth so that a particular fami ly member (e.g., the father) w o u l d discover the body. It was suggested that the motive for staging the suicide was to protect certain other fami ly members (e.g., the mother) f rom the trauma o f discovery. The 'scene o f d iscovery ' evoked a variety o f responses among survivors . Some wanted to be present at the scene o f discovery whi le others preferred to avo id the setting. H u m a n service providers at the scene o f discovery frequently took control o f the situation by either inc luding or exc luding survivors i n caring for the deceased. H a v i n g someone take charge o f the situation w o r k e d w e l l for most survivors as often they were i n a state o f shock. H o w e v e r , a few survivors preferred to take charge of the situation and requested involvement i n the post-mortem care provided to their beloved fami ly member. M a r t i n , the father o f a youth who ended his l ife, became assertive regarding his right to be invo lved at the scene o f discovery. H e remarked that it was Hea l ing W i t h i n Fami l ies 83 better for h i m to be present and see for himself, rather than let his imaginat ion "run w i l d wi th what might have been the case." H e insisted on being i n v o l v e d i n car ing for his son's body as a way o f showing respect to his deceased son. H e needed to be assured that "things were done right," meaning that his son's body was cared for i n 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 wi th the scene of discovery haunted survivors over the long term. Retr ieval o f the loved one's body for the purpose of burial or cremation was important to al l fami ly members. In one case, a youth ended his life by j u m p i n g off a bridge. F a m i l y survivors suffered immensely i n the weeks and months that fo l lowed. A t one point, the parents launched a canoe trip on the r iver where their son drowned as a way of c o m i n g to terms wi th the possibi l i ty that his body might never be located. Despite search efforts, the body was not discovered for six months. Sara, the mother, expla ined that it was only after she had released a l l hope o f recovering his body that it was f inal ly 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 o f their experience wi th suicide. Dea l ing W i t h Suic ide Notes Survivors had diff iculty dealing wi th suicide notes because they conf i rmed what survivors were struggling to believe—that a be loved fami ly youth had ended his o w n l ife . However , in situations where suicide notes were left, survivors found them to be valuable sources of information. Suic ide notes sometimes contained information that released survivors of the responsibil i ty for the death, often gave clues as to the motive for the suicide, and always conf i rmed the intentions o f the youth who took his l i fe . Su ic ide notes were left by six indiv iduals . 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. Suic ide notes confi rmed the l oved one's decis ion to commi t suicide, as illustrated in the fo l lowing suicide note, written by a 14-year o l d male: Hea l ing W i t h i n Fami l ies 84 I feel m y time is over and m y life is l i v e d to its fullest i n m y o w n way. M y life may seem short to some by ending it today but i n m y life I found out the meaning o f m y life wh ich I was unable to succeed in fu l f i l l ing , yet on m y journey to m y conclus ion , I was able to f ind what true friends are, what enemies are and how a heartbreak feels. A l t h o u g h some might feel it is wrong to take one's l ife I v i ew it as G o d ' s way o f saying that your life is ful f i l led and it is your choice on continuing it or j o i n i n g me i n heaven, and I hope I ' m right but i f I ' m not, " G o d I hope you can forgive me." B y e ! Y o u r s truly Steve Break ing the N e w s to Others Break ing the news to others, both wi th in and outside the fami ly , was diff icult for at least two reasons. Firs t , survivors were reluctant to break the news to others because o f the traumatic nature of what they had to tell . Survivors real ized that such news w o u l d forever change the l ives o f fami ly members, and inst inct ively, they wanted to protect their l oved ones. Second, survivors understood society 's general "no talk rule" and sensed the discomfort and perturbation that breaking the news w o u l d el ici t in others. Break ing the news to those closest to the deceased was a heart wrenching experience. T e l l i n g people external to the fami ly was almost as difficult . The task was a lways dreaded and sometimes postponed. Clare , a s ib l ing , recal led, "dropping this bombshel l i n the neighborhood was something else . . . the si lence says so m u c h . " U p o n hearing the news, several survivors spoke o f their perceived need to be strong for the sake o f others, although at a costly price to themselves. M a y recal led her response: D a d shared scant details wi th us in i t ia l ly and we began to consider what had to happen next, who needed to be notified, etc. A t one point, I observed dad beginning to crumble before m y eyes as his knees gave out and he began to s ink to the floor. I went to his side and guided h i m to m y bed, where he col lapsed i n m y arms and we sobbed together. I somehow determined at that point and in m y o w n m i n d that I needed to be strong for everyone else's sake. I don' t think I was totally conscious o f that decision at the t ime, but years later I recognized that I had chosen to set aside some o f m y o w n grief. Hea l ing W i t h i n Fami l ies 85 W i t h great sensitivity, most parents immediately informed their surv iv ing chi ldren about the suicide. Howeve r , an exception was noted; in one situation, the parents were so distraught that they were unable to speak to their surviv ing children about the suicide for an entire day. A s might be expected, the chi ldren sensed that something was dreadfully wrong . A l t h o u g h shaken and saddened by the news, they were rel ieved when their parents f inal ly spoke to them about their brother 's suicide. Summary o f Precipitating Event W i t h i n this study, youth suicide precipitated a major crisis for f ami ly survivors. U p o n hearing the news o f the suicide of a fami ly youth, each survivors began his or her heal ing journey wi th in the Cocooning theme. Soon after hearing the news, most survivors needed to f ind a sanctuary where they cou ld begin to sift and sort through the remains of their "never to be the same again" wor ld . Init ial reactions to the tragedy were as var ied as survivors. Indeed, processing the trauma was demanding and difficult work. W i t h dignity and courage, survivors faced many challenges such as confronting the horror o f discovery, dealing wi th suicide notes, and breaking the news to others. The suffering induced by dealing wi th these unpleasant but necessary aspects of suicide was an important element of the healing process. F o r most survivors , suffering entailed re l iv ing the horror again and again. R e l i v i n g the time surrounding the suicide enabled survivors to grasp the reality o f their drastically altered lives. It was as i f this per iod o f acute suffering provided the seeds for future growth. The st igma surrounding suicide and the silence and secrecy that persist wi th in society often isolated and si lenced fami ly survivors o f youth suicide. T h i s aspect of dealing wi th youth suicide intensified survivors ' suffering. In response to their experiences w i th youth suicide, most survivors embarked on a l i fe- long journey a imed at mak ing sense o f the grievous experience, and l i v i n g a meaningful l ife despite horrific loss. A number o f contextual variables influenced how this process occurred. Hea l ing W i t h i n Fami l ies 86 Contextual Factors Y o u t h suicide is not an isolated event. It always occurs wi th in the context o f the family . S imi la r ly , families l ive wi th in communit ies embedded wi th in a broader social structure. Consequently, survivors ' healing experiences need to be understood wi th in the context in wh ich they occur. The fo l lowing 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 His to ry S i x personal history variables were identified as having an impact on the survivors ' healing experiences: the survivor ' s relationship wi th the youth prior to suicide, gender, rel igious affi l iation, cultural practices, previous experience wi th loss, and health status. Personal history variables that d i d not appear to influence how the survivor m o v e d toward healing included age, occupational status, income level , and marital status. Relationship W i t h the Deceased Y o u t h Pr ior to Suicide T h e survivors ' posit ive appraisal o f their relationships wi th the deceased youth prior to suicide was the ma in variable that determined the survivors ' propensity to move toward healing. . Survivors w h o perceived they had a special and lov ing relationship wi th the youth and those who felt emotional ly and spiri tually close the youth prior to his death were more l i ke ly to embark on a healing journey sooner than those unable to make this c l a im. Rae described her relationship with her brother this way: T w o weeks prior to his death he had phoned me and asked me i f he cou ld move out f rom [town] to [town] to l ive wi th me. A n d I was thri l led. I was real ly exci ted about it because we were really close as kids g rowing up because he was m y next s ib l ing . A n d when the fami ly had m o v e d to the farm we were the only two not i n school . M y younger sister hadn't been b o m yet. The rest of the kids were a l l in school , I was f ive and he was three, and so we became the best o f friends and we grew up that way . Hea l ing W i t h i n Fami l ies 87 A l t h o u g h often overlooked, youth suicide had a tremendous impact on extended family members. In particular, grandparents had to contend wi th a "double-edged sword . " They simultaneously gr ieved for the loss o f a grandchi ld and witnessed the suffering endured by their o w n ch i ld . Consequently, youth suicide intensified the gr iev ing process for grandparents. Indelible on J i m ' s m i n d was the enormous sense o f devastation experienced by his father at the loss o f his grandson. J i m recalled his father's absolute adoration o f his grandson: M y dad w o u l d sit in the coffee shop in town and he's getting up there—he just turned 80. H e w o u l d sit i n the coffee shop i n town and he w o u l d look out the w i n d o w and Jason w o u l d be w o r k i n g at the gas pumps. H e was so efficient and such a di l igent worker , and so commit ted and dedicated, and h e ' d say to his friends, his coffee buddies, h e ' d say "That ' s m y grandson out there." In part, the extra demands required to deal wi th this double exposure to loss, in addition to the life-threatening medica l diagnosis of a granddaughter, may have accounted for the fact that these grandparents experienced tremendous diff iculty fo l l owing the suicide of their grandson. Gender Gender inf luenced the survivors ' journey towards wholeness. A l t h o u g h more women (n=26) than men (n=15) participated i n the study, both men and women v i ewed themselves as m o v i n g toward healing. N o t surprisingly, women were able to speak about their healing experiences wi th greater ease than men. A l though based on a smal l sample size, this f inding is most l ike ly attributed to the fact that psychosocial support is generally more readily available to women than men. In addition, i n this study, congruent wi th the traditional male role in society, adult male survivors often deferred their gr ieving and healing in favor o f "watching over" or "shadowing" other fami ly members. They needed to be sure that others i n the fami ly were coping wi th the suicide before they were able to deal wi th their o w n issues related to the loss. Hea l ing W i t h i n Famil ies 88 Rel ig ious Aff i l i a t ion Re l ig ious practices affected the survivors ' experiences wi th healing. Re l ig ious values and beliefs generally influenced survivors ' ideas about death and suicide. Just over half o f the participants specified a particular religious affiliation and the majority felt comforted by their rel igious practices. A few individuals questioned their faith, and some even felt abandoned by G o d . Survivors who were able to understand youth suicide wi th in the f ramework of their religious values and beliefs m o v e d toward healing wi th less tension and turmoi l than those unable to f ind this k i n d o f peace. The survivor ' s rel igious values and beliefs were occasional ly questioned. Fundamental assumptions that formerly gave life value and meaning were sometimes challenged. A few survivors questioned former rel igious beliefs, whi le others turned either toward or away from re l ig ion after the suicide. L i n d a , a mother, gained a sense of strength and peace through practicing her faith: "The first three days [ fol lowing the suicide] I felt compel led to be on m y knees praying and f ight ing for A l l a n i n prayer. . . . I gained such a sense of peace." In contrast, M a r t i n , a husband and father, remarked, " W h e n a suicide c la ims someone who y o u have loved so very much , your re l ig ion is chal lenged." Jan, another mother, expressed a s imi la r v i ew, " F o r a long t ime I d idn ' t go to church. I just couldn ' t . I cou ld not understand how G o d c o u l d let this happen to our son and to us." A few survivors were angry and felt betrayed by G o d . Chr i s , an only surv iv ing s ib l ing , angri ly contorted, " I ' d go out i n the c o l d . . . I ' d sit and I ' d have a cigarette and I ' d y e l l , or I ' d scream, or I ' d cry and I ' d ba l l , and I ' d ye l l at G o d . " Western society has been strongly influenced by Judeo-Chris t ian values and beliefs, w h i c h above al l else, enshrine the sanctity of l ife. A c c o r d i n g to this bel ief system, only G o d determines w h o dies and when death occurs. Hence , youth suicide is v i ewed as a sinful act. In some cases, survivors felt judged by others. Y o u t h suicide sometimes triggered a tension between fami ly survivors and others wi th in the broader communi ty who , through subtle and sometimes subversive means, he ld the fami ly responsible for the suicide. Da l e , the father o f a teen who ended his life described his experience this way: Hea l ing W i t h i n Fami l ies 89 Y o u think that something l ike this w i l l never happen to you . That ' s what I used to think. A n d then one day it happened. W h e n it happens, y o u begin to understand things differently . . . you ' re treated differently after it happens . . . you ' r e judged by others according to their re l igion. Cul tura l Practices M o s t families were Caucasian (predominantly of European descent); one fami ly was Canadian A b o r i g i n a l . F a m i l y survivors who honored their cultural practices m o v e d toward healing wi th a degree o f peace. These individuals were helped by the use o f death-related cultural practices such as the use o f ceremony and ritual. Canadian A b o r i g i n a l fami ly members found much comfort and support by acting according to their cultural values and beliefs. Th is fami ly held certain cultural v iews that afforded survivors some sense o f solidarity and support i n deal ing wi th the suicide o f a 14-year-old family member. W i t h i n the Canadian A b o r i g i n a l culture, death is v i ewed as part o f l ife, and the afterworld is a w o r l d o f peace, regardless o f the cause of death. Nei ther the ind iv idua l nor fami ly is b lamed for the death. Death, inc luding death by suicide, signifies that the deceased indiv idual has departed on "a spiri tual quest." F o l l o w i n g a death, there is usual ly a four-day wake during wh ich t ime the fami ly may v iew the body. F a m i l y , friends, and food are a l l h igh ly valued and very much part o f the immediate post-death experience. D u r i n g this time o f mourning, fami ly survivors usually receive much help and support f rom others wi th in their communi ty . Survivors gather informal ly to pray, share stories, and provide comfort to one another. D u r i n g these gatherings, fami ly members often seek the w i s d o m of their elders. Funeral services and burial are fo l lowed by a pipe ceremony performed or supervised by an elder who has earned and been given that responsibi l i ty by recognized others (B . Shawanda, personal communica t ion , M a y , 28, 1998). Moreover , "the presence" of the beloved continues to be part o f the survivor ' s experience, wi th messages often being communicated from beyond the grave. E d spoke about a cultural practice that supported his heal ing fo l l owing his son's suicide: Hea l ing W i t h i n Fami l ies 90 W e s t i l l talk about it every once i n a whi le , l ike when I feel his spirit in the house. . . . H e ' s w i th me every day. H e ' s part o f m y existence. . . . T o me, the suicide is part o f me. A n d I go back to our traditional ways to get help. Remember , I was ta lking to you about a little rock we found inside his pocket. The rock, they use it for heal ing sweats. There ' s different kinds of sweats where y o u go and pray o f whatever. That ' s what helped me. Previous Exper ience W i t h L o s s Previous experience in dealing wi th loss also had an impact on survivors ' healing experiences. In seven out o f eleven families, other major losses i n life had occurred pr ior to the suicide; for example, the death o f another ch i ld , marital breakdown, life-threatening il lness, and job loss. D e a l i n g wi th these previous losses enabled survivors to draw on their earlier experiences. Howeve r , they also felt that death due to suicide posed a different set o f challenges. F o r example, lack o f support f rom others external to the fami ly , and decreased opportunity for conversations about their experiences, added stress to an already diff icult situation. In a few instances, other losses fo l lowed the suicide and compounded the challenges faced by survivors. In addition to dealing wi th the suicide o f their oldest grandson, J i m ' s parents also had to contend wi th the life-threatening illness of their oldest granddaughter: " Y e s , 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 fo l l owing the death o f a l oved one recalled that every subsequent death evoked memories o f previous experiences wi th death. Survivors who felt supported during their earlier gr ieving experiences were able to move toward healing sooner than those without such support. Carmen , a significant other, experienced the previous suicide of a former boyfr iend. W h e n she was confronted wi th the second suicide, that of her fiancee, she recalled that the experience o f surviving the first suicide enabled her to access needed help immediately. In another case, M e g , the mother of four chi ldren, experienced the death o f her six-year-o ld daughter due to accidental electrocution twelve years prior to the suicide of her oldest teenage Hea l ing W i t h i n Fami l ies 91 son. She c la imed that even though both deaths occurred suddenly, self- infl icted death was much more difficult to comprehend than accidental death. M e g ' s previous experience wi th gr ieving provided her w i th much insight i n terms of dealing wi th her son's suicide. H o w e v e r , she felt that her husband d i d not experience the same advantage. M e g spoke o f the heavy personal and fami ly to l l l ev ied by her chi ldrens ' deaths. F o l l o w i n g the death o f their young daughter, M e g ' s husband, Terry, started dr ink ing heavi ly . H i s d r ink ing continued over many years and dramatical ly increased f o l l o w i n g their son's suicide. F o u r years post-suicide, M e g was s t i l l i n v o l v e d i n therapy. She was just beginning to seek help and support f rom others and was contemplating separation at the t ime o f the interview. M a n y survivors who had not previously experienced loss read vorac ious ly t rying to understand what was happening to them. In particular, Carmen commented that many o f the books currently on the market over-s impli fy the "craziness" felt by suicide survivors wh ich is so much a part of their experience. She mentioned that suicide survivors, especial ly those without previous experience i n deal ing wi th loss, cou ld be helped by a frank discussion about this aspect of dealing wi th suic idal death. Heal th Status F i n a l l y , survivors ' health status influenced their movement toward heal ing. Survivors who, over the long term, rated their health as "excellent'-' or "very good" were more l i ke ly to move toward heal ing sooner than survivors who identif ied health concerns and/or medica l diagnoses. Ini t ia l ly , many survivors experienced a variety o f short-term'somatic symptoms. Repeatedly, survivors spoke of the intense "pressure" they experienced immedia te ly fo l lowing the suicide. M a r i e , a mother, said, "I wished I cou ld have cut a hole i n m y head to release the pressure." Surv ivors found ways to alleviate the pressure. F o r some ind iv idua ls , conf id ing wi th a trusted other was helpful; for others, an increase i n phys ica l activity helped. A i r hunger and feelings of suffocation were also common. M a r i e recalled her experience: " A l l o f a sudden it w o u l d feel l ike the wal l s were cav ing i n on m e . . . . Sometimes I ' d have to go to a w i n d o w and just gulp air." Sleep disruptions sometimes deprived survivors o f m u c h needed rest and Hea l ing W i t h i n Fami l ies 92 relaxation. "Flashbacks" and "nightmares" i n the first few weeks f o l l o w i n g the suicide were prevalent: "I d i d have some terrible nightmares. . . . I think that I was t ry ing to solve the ' w h y ques t ion . ' " Survivors rarely neglected their health. O n the contrary, most survivors maintained their former state o f health and wel l -being. In one instance, Gar ry and his wife experienced improved health status: "I can hardly believe i t—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 o f exercise, and sufficient rest and relaxation. O n l y one participant neglected his health: "I d idn ' t know where I was going or what to do. I d idn ' t give a damn about mysel f ." Other survivors succumbed to illnesses that, i n some cases, required hospital izat ion. A n n , unable to express her emotions in other ways at the time recalled: "I k n o w that I stored all that emot ion. I d i d not let it out o f m y body . . . m y body was storing it somewhere . . . it came out as pneumonia ." L o m a , a mother and wife , spent two months in a psychiatr ic unit f o l l owing her son's suicide, and upon discharge from hospital took a year off w o r k to re-establish her priorities in l ife. L o m a found that she needed time to pamper herself as an important aspect o f her healing. Fami l ies i n wh ich at least one member had a mental health diagnosis faced additional stress. Three individuals wi th in one fami ly ( including the father and two surv iv ing children) had been diagnosed wi th schizophrenia prior to the suicide o f a schizophrenic fami ly youth. Suzanne, the mother and only fami ly survivor without a mental i l lness diagnosis, chose to l ive alone because she needed respite f rom the pressure o f fami ly demands. Suzanne maintained that al l she cou ld do was "manage one day at a t ime." A t the time data col lec t ion, Suzanne was separated from her spouse, p lanning her future, and attending classes at a nearby universi ty. In the another fami ly , C la re , the youngest o f f ive surv iv ing sibl ings, was also diagnosed wi th schizophrenia. In an effort to make sense o f her brother's suicide, she wi thdrew f rom others and dealt wi th her loss i n ways that made sense to her. Preferring solitary activity, Cla re expressed her grief by sculpting a set o f figurines, each depict ing a unique facet o f her experience wi th loss. Hea l ing W i t h i n Fami l ies 93 Factors Related to Y o u t h Suic ide Y o u t h suicide was a traumatic event for a l l family members. T w o factors had an impact on survivors ' healing experiences: the nature o f the death and questions regarding whether the death was caused by suicide or homic ide . Surv ivors who were able to identify, grapple wi th , and eventually resolve these aspects of suicidal death were more l i ke ly 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 V io l en t Death D e a l i n g wi th youth suicide raised seemingly irreconcilable issues for some fami ly members w h i c h centered on the unexpected, sudden, and violent nature o f the death. Some survivors struggled wi th the fact that there was no possibi l i ty o f direct ly resolv ing past differences, nor was there an opportunity to say good-bye to the deceased loved one prior to death. R e a l i z i n g the finality o f death was also difficult . Rose struggled wi th the realization of her son's suicide: " I ' m never going to see h i m again. . . . that's m y struggle—to realize that." F a m i l y members also struggled wi th the violence associated wi th self- infl icted death. Understandably, these violent deaths caused horrendous anguish and suffering for survivors . D e a l i n g wi th the imagined state of the youth in the moments preceding suicide, and dealing wi th the painful memories associated wi th the scene of discovery were especial ly diff icult for survivors. Suicide or H o m i c i d e The uncertainty about the cause of death was t roubling for some survivors. Survivors in four families c la imed that the death may have been the result of homicide rather than suicide: "I don ' t k n o w w h i c h it was [murder or suicide] and I can ' t cope. . . . so I put it away." A n n , a s ib l ing , commented, " l i k e maybe he d id , and maybe he d idn ' t [take his o w n l i fe ] . " In these situations, survivors felt that a romantic partner of the deceased youth may have been responsible for the death. Rae , another s ib l ing , expressed her thoughts: "Part o f m y confusion was related to the cause o f death. . . . A n d I think that part o f it was that there was a question as to whether T y l e r 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. Hea l ing W i t h i n Fami l ies 95 Societal St igma The stigma surrounding suicide commonly manifested itself i n what some fami ly members cal led the "no talk rule," that is , the unchallenged silence that surrounds suicide wi th in Western society. Th i s nonverbal fo rm of communica t ion was powerful . Despi te feel ing supported and validated by those wi th s imi lar beliefs, even Canadian A b o r i g i n a l survivors felt judged by others wi th in society. E d , a Canadian A b o r i g i n a l father, explained: There 's this st igma especially felt i n the native communi ty . Y o u go f rom one extreme to the other extreme, l ike re l ig ion. . . . They say the person w h o commit ted suicide goes to he l l or they end up i n purgatory or whatever. . . . It 's k i n d o f embarrassing for me that m y son comrnitted suicide because it is always interpreted according to European standards. In two families, the stigma felt by fami ly members was compounded when mental illness was also present. In one fami ly , the youth who took his l i fe was diagnosed wi th schizophrenia. B o t h parents recal led that prior to his suicide, they had advised h i m not to reveal his i l lness to others. These parents intended to protect their c h i l d f rom being humil ia ted by his peers. Unfortunately, the silence regarding his health status also l imi ted possibil i t ies for init iating dialogue about his medica l condit ion. L i n d a , the deceased youth 's mother commented: " W e experienced a double w h a m m y . . . . There is s t igma related to suicide, but there is also stigma associated wi th mental i l lness." Surv ivors ' responses to stigma influenced their healing experiences. Individuals who felt empowered to change this societal st igma m o v e d toward healing sooner than those who d id not think they cou ld "make a difference." T a k i n g action aimed at helping others understand more about suicide and its impact on the fami ly often became an integral aspect of the survivor 's miss ion i n l i fe . Soc ia l Support N o t surpris ingly, survivors who felt supported and understood by at least one other person were able to face the reality o f their situation more readily than those l ack ing social Heal ing W i t h i n Fami l ies 96 support. Individuals who m o v e d toward healing typica l ly developed a coterie o f friends wi th w h o m they cou ld 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 k n o w beyond a shadow of a doubt that I w o u l d not have made it without the support o f m y husband. There were times when I was so wobb ly that I c o u l d hardly stand on m y o w n two feet. H e [husband] just seemed to k n o w what I needed and when I needed it. H e ' s such a good listener. H e listened to me talk about the same thing over and over, and that's what helped me the most. M y friends were there for me too, and that really helped, especial ly later on. Heal th Care Environment Survivors perceived the health care environment to be i n a state o f transition and, therefore, not a lways responsive to their needs. Survivors who were able to reach beyond the confines o f the health care environment by drawing upon inner strength and w i s d o m , as w e l l as previously established coping capabilit ies, m o v e d toward healing sooner than those who rel ied solely on exis t ing health care services. In addition, survivors who took the ini t iat ive i n creating their o w n healing environments moved toward healing more expediently than those who d id not take such action. F o r example, Da le , the father of a 17-year o l d youth who ended his l ife, took it upon h imsel f to develop a web page in the hope of communica t ing wi th other suicide survivors. W i t h i n six months after the suicide of his son, he began attending death education conferences. A t the time o f the interview, D a l e was also investigating possibil i t ies for changing his current employment so that he cou ld devote more time to educating others about youth suicide and its impact on the family . H e took the initiative to improve life for both h imsel f and others; Da le said, " I f it is to be then i t ' 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. Healing is conceptualized as Journeying Toward Wholeness. Influenced by several contextual factors, the healing journey is characterized by three ongoing, dynamic, and recursive themes, specifically: Cocooning, Centering, and Connecting. Each theme contains five patterns (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 Hea l ing W i t h i n Fami l ies 98 close to the youth pr ior to his suicide. A l though fami ly survivors o f both genders m o v e d toward healing, adult males needed to ensure that other fami ly members were cop ing wi th the unfortunate situation before they felt free to tend to their o w n psycholog ica l needs. In addit ion, survivors who were able to understand youth suicide from the perspective o f their rel igious beliefs and cultural values experienced an advantage in terms o f m o v i n g toward healing. S imi l a r l y , those who rated their health as "excellent" or "very good," and those who felt supported dur ing their previous experiences wi th loss also moved toward healing more expediently than others unable to make these c la ims. Certain issues related to suicidal death were particularly troublesome for family survivors inc lud ing death by unexpected, sudden, and violent means, as w e l l as questions about whether the death was the result o f suicide or homicide . Survivors who were able to identify and work through their particular issues regarding youth suicide m o v e d toward heal ing sooner than those who avoided or chose not to confront these aspects o f their experiences. Soc ia l factors inc luding social support and societal s t igma influenced survivors ' healing experiences. N o t supris ingly, survivors who felt supported by at least one other person experienced an advantage i n terms of dealing with youth suicide. Surv ivors who felt empowered to take action a imed at changing the societal stigma surrounding youth suicide moved toward healing sooner than those who d id not think they cou ld make a difference. Moreove r , survivors v iewed the health care environment as in a state of f lux and not particularly responsive to their needs. Those who m o v e d toward healing were not deterred because o f this perceived unresponsiveness. Rather, these indiv iduals assumed responsibi l i ty for their o w n health by drawing on their innate strengths and coping capabilities. In the next chapter, I turn to a description o f Cocooning, the first healing theme o f 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 Hea l ing W i t h i n Fami l ies 101 that others wi th in the fami ly were "watching over each other" provided a sense of security for many survivors . Some individuals identified themselves as the emotional stronghold i n their families and postponed their o w n gr ieving i n favor of "being there" for other fami ly members. These individuals put their o w n struggle on hold whi le becoming alert, hypervigi lant , and responsive to the psychologica l needs of other fami ly members. M i k e , a husband and father, explained: I had a sense o f t rying to keep an eye on what was go ing on. I knew that I st i l l had to be strong and everything because I s t i l l had m y fami ly and m y wife and everything. . . . It was extremely important to concentrate on m y wife , almost shadowing her in terms o f mak ing sure that m y whole life wasn ' t going to fal l apart. . . . I had to k i n d o f 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 go ing before I cou ld actually start gr ieving in m y o w n way. F o r many survivors, " f inding a safe place" for processing their emotional trauma was of major importance. However , survivors qu ick ly sensed that they needed to exercise discretion in terms o f f inding a safe place for sharing their struggle. Places deemed to be safe var ied among survivors and inc luded the fami ly residence, wi th or without the presence o f others; counselors ' offices; loca l grief support groups; and natural habitats such as gardens and forests. A n n , a s ibl ing, remarked: I needed to f ind a place to express m y emotions. . . . So . I j o i n e d a w o m e n ' s group, found a group o f friends . . . and began expressing m y emotions on a da i ly basis. . . . A s soon as I was able to express myse l f without feeling that I was going to be cr i t ic ized for the emotions that I was feeling . . . I found uncondit ional love and acceptance, and I began to heal. Processing Intense Emot iona l Trauma F o r most survivors, struggling with emotional trauma was l ike being on an "emotional roller coaster." They experienced a myr iad of intense emotions ranging f rom apathy at certain Heal ing W i t h i n Fami l ies 102 times, to "explosiveness" at other times. M i k e sought counsel ing as a way o f 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. A n d so she [counselor] was able to break d o w n the barriers that were keeping me f rom breaking down , w h i c h was what I needed to do so that I cou ld release m y emotional turmoil . M o s t survivors struggled as they endeavored to address their loneliness, anxiety and fear, anger, pain and suffering, depression, guilt , and regret. Lonel iness . Feel ings o f "intense loneliness" and a "gnawing feeling i n the pit o f one's s tomach" were common . Whether alone or in the presence o f others, the intensity of the loneliness was new to those who experienced it. N o t surprisingly, fami ly survivors were sometimes astounded by the intensity o f their loneliness: "I realize now how alone I am. . . . I 've never felt this way before." F o r the most part, survivors ' loneliness was related to the phys ica l absence of the deceased youth. Sometimes this vehement loneliness served to expand the survivor ' s capacity for emotional expression. M a n y survivors experienced intense emotions, often for the first t ime. A n x i e t y and Fear. F a m i l y survivors often felt h ighly anxious and fearful f o l l owing the suicide. Strong emotions were l i nked to the place where the suicide occurred, the fear o f another family member commit t ing suicide, and the fear of forgetting the deceased. Traumatized by the suicide, a few survivors developed phobias. M a n y survivors feared the location where the suicide occurred. Ini t ia l ly , they avoided this place. Howeve r , as t ime passed, survivors confronted their fears in various ways . M a r t i n developed his o w n unique way o f dealing wi th his son's suicide. M a r t i n ' s son ended his l i fe in the bodyshop where both he and his son worked prior to the suicide. S ince M a r t i n cou ld not avoid the place of death, he tried facing the memory: "I don ' t know, I ' d go i n there and I w o u l d even say, ' G o o d morn ing P a u l . ' A n d I w o u l d go and stand where he hanged h imse l f and talk to h i m even." M a r t i n found it difficult to work i n the place where the suicide occurred. T w o years post-Hea l ing W i t h i n Fami l ies 103 suicide, M a r t i n and his wife realized a dream and moved to an acreage (i.e., a smal l piece o f land in the country) i n the hope o f f inding a new beginning. In new surroundings, M a r t i n felt the burden had been lifted. In four cases, the suicide occurred in the fami ly residence. Consequent ly , for some survivors the home environment was disturbing, whereas for others, it was a place o f comfort. W i t h i n the first year fo l lowing the suicide, two families moved whi le two other families remained in their homes. Consistently, fami ly survivors feared that another fami ly member w o u l d also end his or her l ife. The "who ' s next?" fear loomed larger than life for some survivors . Rose and J i m were concerned that their only surv iv ing son w o u l d j o i n his deceased brother, his closest friend. A w a r e of this situation, they sought help for h i m from a counselor. E v e n though felt by most survivors, this fear was se ldom discussed wi th in the fami ly unit. Because this fear was wi thheld , survivors frequently became hypervigilant, carefully watching for unusual behaviors i n other family members. M a n y survivors were afraid of forgetting their loved ones. Surv ivors were reluctant to address the emotional impact of the suicide because they feared forgetting the deceased youth: " I ' m almost afraid to deal wi th it because I ' m afraid I ' l l lose the memories o f h i m . I ' m afraid of forgetting h i m . " F r o m a family perspective, the fear of forgetting was even more difficult to acknowledge. Rose commented: "The fami ly as a whole is deal ing wi th Jason's suicide . . . i t ' s the fear o f forgetting and letting go wi th in the whole fami ly . . . his place i n the fami ly is now v o i d . " A few survivors described phobias that began during the t ime surrounding the suicide. Characteristically, survivors were able to recal l , in great detail, the setting and other details related to the suicide. In a few cases, certain st imuli triggered phobias that continued for a long time. M a r i e spoke o f her fear that began soon after the suicide: "The sirens became terrors for me . . . i f I ever heard a siren f rom an ambulance or fire truck . . . m y heart was beating so fast that I felt l ike I was having a heart attack." In another case, whi le J i m was getting ready to go to work, his son shot h imsel f i n the basement of the fami ly home. J i m was st i l l 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. Hea l ing W i t h i n Fami l ies 105 Sometimes, anger was directed toward the deceased youth. Surv ivors frequently expressed anger because they felt rejected and betrayed by their deceased loved one. M a n y survivors v i ewed suicide as the "ultimate form of rejection." Responding to such rejection, a father stated, " H e made this decis ion, this choice, and i f we ' re go ing to be angry at anybody, we should be directing our anger at h i m . " In an effort to deal wi th her anger, in a letter to her deceased son, M a r i e wrote: There has been so much anger in me because o f your decis ion to commi t suicide. Some o f it surfaced in ways that I d idn ' t recognize. S i x weeks after your death, I began to feel as i f I had Park inson ' s disease. I remember teaching and having to stand wi th m y arms hugging myse l f as i f I were co ld . People l ook ing at me w o u l d never have guessed the real reason that I held myse l f l ike that—it was to l i terally ho ld m y body parts together. Chr i s , M a r i e ' s only surv iv ing ch i ld , expressed anger toward her brother because he took his life on their mother 's birthday: " H e [committed suicide] on m y m o m ' s birthday . . . and that's why I ' m a litt le bit upset. I A M A N G R Y . . . . I s t i l l have a lot o f anger bo i l ed up inside . . . I keep everything boi led up inside unti l it breaks." Some survivors felt uncomfortable overtly expressing anger. H o w e v e r , beneath a c a lm exterior, these survivors struggled to contain a quiet but unrelenting rage. The i r anger was often revealed in the fo rm of somatic symptoms and atypical behavior. Jane, for example, withdrew from others and became totally incapacitated fo l lowing the suicide of her son and eventually sought professional help. Surv ivors ' anger was often related to the shame associated wi th suic idal death. Fee l ing strong enough to put words to her anger, Ca rmen raised her voice and said, " I ' m ashamed . . . he wrecked m y l i fe , he wrecked his o w n l i fe , he wrecked his son's l i fe . . . . I ' l l never get over it. I w i l l never change the way I feel. N E V E R E V E R , N E V E R . " Some survivors vented anger privately whi le others expressed it openly. S imi l a r l y , some sought help whi le others d i d not. Rose , a mother, recognized the importance o f addressing anger as she searched for a way to help her only surv iv ing teenage son deal wi th his anger. She c la imed Hea l ing W i t h i n Fami l ies 106 that the culpri t was "the anger wi th in h im . A n d that's what we had to deal w i t h . . . . Once you get on wi th that, then y o u can get on wi th other things." Y o u t h suicide not only triggered anger and frustration i n relationship to the death, it prompted survivors to review other aspects o f their l ives as w e l l . M i k e described it this way: The sources o f the angers and frustrations weren' t just the death o f m y son. I k i n d o f l ikened it to—as y o u go through life, you p i ck up little packages o f complexi ty that you carry wi th you . F o r boys, i t ' s a little red wagon and for girls i t ' s a lit t le blue baby carriage. They a l l have their little packages wrapped up in them and the complexi t ies go with you . Y o u r keep dragging the packages, and i f you are the type o f ind iv idua l who has a complex life, y o u are dragging a pretty heavy load. A l l o f these packages become a pretty heavy bundle by the t ime that you have a major crisis. Then y o u have to go back and re-touch and re-c la im every one o f those complexi t ies and work your way through them ind iv idua l ly . It 's almost l ike starting on a regressive basis and c o m i n g back to the reality o f what is current. Pa in and Suffering. Surv ivors ' healing experiences were characterized by both physical pain and emotional suffering. Ye t , the pain of suffering was an al l -encompassing experience and a crucia l rite of passage i n terms o f the survivors ' movement toward heal ing. F o r a l l survivors, the trauma of youth suicide left i n its wake, a pain that was "always there under the surface." E d , a father, c l a imed that the pain lingers long after the assault: " Y o u heal the w o u n d but carry the scar." C o m m o n l y , survivors expressed their pain wi th words such as "feel ing hard" or "heavy:" "It's a lot o f weight that each person carries." One survivor felt as i f she had become "encased i n a hard shel l , " whi le another spoke o f being " so l id as a rock." These emot ional ly numbing reactions protected survivors and a l lowed them time to process the impact o f the suicide. A s a survival strategy, many survivors compartmentalized or shelved their feelings for a short per iod of time fo l lowing the suicide: "I think I shelved it. I put it on the backburner and decided that I w o u l d deal wi th m y emotions later." Emot iona l numbness sometimes a l lowed survivors to l ive up to the self-imposed expectation of being in control: "I just became so l id as a rock. Something inside me said, Hea l ing W i t h i n Fami l ies 107 y o u have to be stronger than anyone else i n this because you are the strongest person i n this fami ly . I d idn ' t c ry . " E v e n the most composed survivors eventually began a l l owing reality to surface by emotional ly " w o r k i n g through" the trauma. Th i s i n v o l v e d suffering. Moreove r , the joint experience of suffering sometimes rendered fami ly members unable to support one another. A l though family members watched over each other, they needed to process the trauma ind iv idua l ly . Wi thout exception, survivors commented on the need to privately revisit memories of the deceased wi th in their own space and time. Eventua l ly they were able to a l low their feelings to surface: " A t first I d idn ' t feel anything. A n d then later, as I lay awake in m y bed at night, I w o u l d start th inking about everything." Though painful , many survivors reported the need to rel ive, i n their m ind , every emotion that the loved one may have felt prior to ending his l ife. Rae, a s ib l ing , questioned, "I kept th inking, what was he thinking? . . . It must have looked totally black, l ike there was no help for h i m . . . . D i d he not k n o w how much he was loved?" J i m , the father o f a 16-year-old who ended his l ife, recal led spending hours 'staring into space' as a way o f processing the horror: It 's a lways on your m i n d , i t ' s a lways there behind y o u when y o u stare, and I stare now more than I ever d id . Y o u k n o w , y o u k i n d o f look into space, and t ime stands s t i l l . . . . The pain is always there as I ' m staring. It's l ike a mot ion picture right up there i n the corner of m y m i n d . That whole week plays through m y m i n d , i t ' s a lways there. T h e loss o f relationship, and consequently, the loss o f a future together, also caused a great deal o f pain and suffering for survivors. M a r i e shared her pain in a letter to her deceased son: H o w things cou ld have been different, i f only y o u ' d g iven yourself time to reflect on your decis ion. W h e n y o u made the choice to end your l ife, K e v i n , I wonder i f y o u ever comprehended how much pain w o u l d be left behind for your fami ly , your classmates, your friends, and your teachers. Y o u never gave yoursel f the precious gift o f t ime, K e v i n . T i m e to look at whatever it was that became so humongous, i n your m i n d , that you felt that this was your only choice. T i m e to see i f someone c o u l d help you . T i m e to share your pain wi th people who loved you deeply. T i m e to get the pain out o f y o u in a healthier way. Hea l ing W i t h i n Fami l ies 108 T i m e to realize that you d id have other choices. T i m e also for your fami ly to see you grow, t ime to see y o u graduate, t ime to see what career y o u w o u l d choose. T i m e to laugh and cry at your wedding and time to celebrate the births o f your chi ldren. Depression. Several survivors became depressed in response to the suicide characterized by " fa l l ing apart emotional ly ." E v e n whi le recognizing that they were spiral ing downward , they remained cognizant o f their famil ia l responsibilities. Dave , a father, remarked: H o w much lower can you really go actually because y o u feel l ike what 's the use o f l iv ing? . . . but i t ' s not just you . Y o u have a fami ly and y o u have a wife , y o u have two other kids and they are going to need you . A l t h o u g h several survivors commented that "hitt ing rock bot tom" was a jo l t ing experience, they learned things about themselves they cou ld not have k n o w n by gentler means. Carmen elaborated: W h e n y o u hit rock bottom y o u say, "I don' t l ike this. I 've got to get up there." Y o u hit rock bot tom and y o u f ind your goal . . . . Y o u make a goal to a i m up. . . . I found a reason to stay al ive . . . i f you can make it through the first year . . . i t ' s amazing what you can do wi th your l ife. F o r 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 t ime i n her life: Sometimes when y o u are in a depression, then i t ' s even hard to get help. Y o u r m i n d just doesn't w o r k the same. L i k e I 've explained it to other people, i t ' s l ike something else takes over, and y o u have no control over yourself, or very lit t le. It 's ho r r ib l e— depression. F o r other survivors, the depression developed much later. S i x years after the suicide o f her brother, Rae recognized her depression: It was a combinat ion o f problems. . . . That ' s when I hit the bot tom and it wasn ' t a matter o f right after . . . it was a few years later. S i x 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: A l l 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 ' l l 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 « m y s t i c k n o t » 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 i t . . . . 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 ' l l 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 w i l l . . . 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]. A l l 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. A l l 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: A l l 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. A l l 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. A l l 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: A l l 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 A N UNDERSTANDING OF THE H E A L I N G 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. T A B L E 8-1: JOURNEYING TOWARD WHOLENESS: HEALING STRATEGIES Cocooning (focus on survival) Centering (focus on personal growth) Connecting (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 environment meditation, and imagery • 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 a