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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 R N , Medicine Hat College School of Nursing, 1979 B N , The University of Lethbridge, 1985 MEd, The University of Lethbridge, 1992 A THESIS SUBMITTED IN P A R T I A L F U L F I L L M E N T OF T H E REQUIREMENTS FOR THE D E G R E E 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  degree  this  at the  thesis  in  University  of  partial fulfilment of British Columbia,  freely available for reference and copying  of  department publication  this or of  thesis by  this  for  his thesis  or  scholarly her  The University of British C o l u m b i a Vancouver, Canada ,  (2/88)  requirements  I agree  that the  I further agree  purposes  may  representatives.  be  It  for financial gain shall not  permission.  DE-6  study.  the  is  an  advanced  Library shall make  that permission  for  granted  head  by  understood be  for  the that  it  extensive of  my  copying  or  allowed without my written  Healing Within Families  ii  H E A L I N G WITHIN FAMILIES F O L L O W I N G Y O U T H SUICIDE ABSTRACT D e s p i t e preventive efforts, youth suicide is identified as a p u b l i c and mental health p r o b l e m of e p i d e m i c proportion i n W e s t e r n society. T h e short- and l o n g - t e r m health and h u m a n consequences associated w i t h youth suicide are enormous, affecting each f a m i l y s u r v i v o r , the f a m i l y , and ultimately, the c o m m u n i t y and society. Y o u t h suicide has its greatest i m p a c t on the f a m i l y , yet health care responses to these g r i e v i n g families remains inadequate at best. T h i s grounded theory study, based on a health p r o m o t i o n p h i l o s o p h y that embraces the strengths and resilient nature o f g r i e v i n g i n d i v i d u a l s , e x a m i n e d h o w i n d i v i d u a l s w i t h i n the context o f the f a m i l y heal i n the aftermath o f youth suicide. E l e v e n families f r o m rural and s m a l l urban centres were i n t e r v i e w e d for the study d u r i n g an 18 m o n t h p e r i o d . I n d i v i d u a l healing f o l l o w i n g youth suicide is c o n c e p t u a l i z e d as  Journeying Toward  Wholeness. T h i s j o u r n e y is characterized by the inter-relationships a m o n g three e n f o l d i n g , f l u i d , and iterative themes, w h i c h i n themselves, each represent one p o r t i o n o f the o v e r a l l journey: C o c o o n i n g (Journey o f Descent); C e n t e r i n g (Journey o f G r o w t h ) ; and C o n n e c t i n g (Journey o f Transcendence). W i t h i n each theme, five self-organizing and inter-relating patterns (i.e., relating, t h i n k i n g , f u n c t i o n i n g , e n e r g i z i n g , and f i n d i n g m e a n i n g / e x p l o r i n g spirituality) operate i n mutual r h y t h m i c a l interchange w i t h the other patterns u n b o u n d b y time. E a c h pattern describes one facet o f the i n d i v i d u a l ' s experience i n response to y o u t h s u i c i d e .  Journeying toward wholeness (i.e.,  healing) varies i n expression and intensity over time i n response to a variety o f contextual factors i n c l u d i n g personal history, factors related to the suicide, social considerations, and the health care environment. Importantly, h e a l i n g emanates, as an act o f v o l i t i o n , f r o m the s u r v i v o r ' s consciousness (i.e., the h e a l i n g epicentre) as a result o f d e c i s i o n m a k i n g . T h e degree to w h i c h healing occurs depends o n a n u m b e r o f intervening variables reflecting the s u r v i v o r ' s capacity to say yes to life; step out and speak up; achieve a sense o f peace, h a r m o n y , and balance; and e x p a n d personal consciousness. A s a major outcome o f the healing process, each s u r v i v o r creates a  love knot, s y m b o l i c o f the h e a l i n g strategies he or she uses to  Healing Within Families  facilitate healing w i t h i n both private and p u b l i c spheres. T h e  iii  love knot represents the creative  expression o f l o v e as a healthy and c o n t i n u i n g b o n d between the s u r v i v o r and deceased youth. T h e  love knot is based on the m e a n i n g the s u r v i v o r attributes to his or her experience w i t h youth suicide and the relationship between the s u r v i v o r and deceased youth p r i o r to death. U l t i m a t e l y , i n d i v i d u a l h e a l i n g expands o u t w a r d i n f l u e n c i n g f a m i l y , societal, and g l o b a l spheres. T h e theory presented i n this dissertation w i l l be o f particular interest to c l i n i c a l nurse specialists and mental health care professionals f r o m a variety o f d i s c i p l i n e s w h o w o r k c l o s e l y w i t h families i n the c o m m u n i t y . W i t h its focus on health p r o m o t i o n , this theory captures some o f the intricacies and c o m p l e x i t i e s o f 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 Contemporary Theories of Grieving: Grieving as a Dynamic Process Influencing Factors  20 21 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 AND 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  Healing Within Families  Summary  vi  69  CHAPTER FOUR - JOURNEYING TOWARD WHOLENESS: A CONTEXTUALIZED EXPERIENCE  70  D e s c r i p t i o n o f Participants (The S a m p l e )  70  I n d i v i d u a l H e a l i n g Process F o l l o w i n g Y o u t h S u i c i d e : A P r e v i e w  72  O v e r v i e w o f the G r o u n d e d T h e o r y  76  T h e Precipitating E v e n t  78  H e a r i n g the N e w s  Summary  78  Initial Responses  79  H o r r o r or D i s c o v e r y  82  Dealing with Suicide Notes  83  B r e a k i n g the N e w s to Others  84  of Precipitating  Event  C o n t e x t u a l Factors  85 86  Personal History  86  R e l a t i o n s h i p w i t h the Deceased Y o u t h P r i o r to S u i c i d e  86  Gender  87  Religious Affiliation  88  C u l t u r a l Practices  89  Previous Experience with Loss  90  H e a l t h Status  91  Factors R e l a t e d to the S u i c i d e  93  U n e x p e c t e d , Sudden, and V i o l e n t D e a t h  93  S u i c i d e or H o m i c i d e  93  S o c i a l Factors  94  Social Stigma  95  S o c i a l Support  95  Health Care Environment  96  Summary  97  CHAPTER FIVE - COCOONING: JOURNEY OF DESCENT  99  R e l a t i n g Pattern (Struggling) Struggling W i t h i n Oneself  100 100  F i n d i n g P s y c h o l o g i c a l Safety  100  P r o c e s s i n g Intense E m o t i o n a l T r a u m a  101  Healing W i t h i n Families  Loneliness  :  vii  102  A n x i e t y and Fear  102  Anger  104  P a i n and Suffering  106  Depression  108  Guilt  :  109  Regret  110  Struggling W i t h Others  Ill  W i t h d r a w i n g f r o m Others  Ill  Effect on Relationships  112  D e a l i n g w i t h Others' Reactions  ,  T h i n k i n g Pattern (Chaotic T h i n k i n g )  112 113  E x p e r i e n c i n g C o g n i t i v e Dissonance  114  Experiencing  115  AlteredThinking  Contemplating O w n Suicide F u n c t i o n i n g Pattern ( A u t o p i l o t i n g )  117 118  Decreased Functioning  118  L i v i n g with Physical Absence  119  U s i n g A d d i c t i v e Substances  120  Taking Risks  120  E n e r g y Pattern ( C o n s u m i n g )  121  S u r v i v i n g the T r a u m a  121  Asking Why  122  F i n d i n g M e a n i n g / E x p l o r i n g Spirituality Pattern ( A w a k e n i n g )  123  W a k i n g U p to L i f e  123  D o u b t i n g O n e s e l f and Experience  124  V i s i t i n g the D a r k S i d e o f L i f e  124  Summary  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 R e l a t i n g Pattern (Getting a G r i p )  127 128  Confronting E m o t i o n a l E x p e r i e n c e  128  Addressing Unfinished Business  129  T h i n k i n g Pattern ( M a k i n g D e c i s i o n s ) M a k i n g Decisions V a l i d a t i n g O w n Reality  130 130 130  Healing Within Families  viii  R e l e a s i n g S e l f o f R e s p o n s i b i l i t y for the S u i c i d e  131  A l l o w i n g H e a l i n g to O c c u r  131  F u n c t i o n i n g Pattern ( R e - E n g a g i n g )  132  Increasing A c t i v i t y L e v e l  132  Participating i n H e a l i n g A c t i v i t i e s  133  E n e r g i z i n g Pattern (Replenishing)  136  R e s o l v i n g the W h y Question  137  Releasing 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 Spirituality Pattern (Transforming)  138  F o r g i v i n g S e l f and the D e c e a s e d Y o u t h  138  F i n d i n g M e a n i n g i n Experience  140  Summary  141  CHAPTER SEVEN - CONNECTING: JOURNEY OF TRANSCENDENCE.. R e l a t i n g Pattern (Reaching Out)  143 144  Seeking Help  144  L i n k i n g w i t h Others  '  Facilitating Others' H e a l i n g  146 150  T h i n k i n g Pattern (Learning)  151  T h i n k i n g Differently  151  D e v e l o p i n g Creativity  152  T r u s t i n g Intuition  154  F u n c t i o n i n g Pattern (Orchestrating L i f e )  158  R e o r d e r i n g L i f e Priorities  158  B r e a k i n g the Silence  159  E n e r g i z i n g Pattern (Channeling)  160  Redirecting Energy  160  F o c u s i n g on the P o s i t i v e A s p e c t o f E x p e r i e n c e  161  F i n d i n g M e a n i n g / E x p l o r i n g Spirituality Pattern (Transcending)  162  Re-birthing  162  Trusting Experience  163  Summary  CHAPTER EIGHT - TOWARDS  165  A N UNDERSTANDING OF T H E HEALING  PROCESS  167  H e a l i n g Strategies  167  Healing Within Families  Intervening V a r i a b l e s : H e a l i n g Characteristics  ix  170  S a y i n g Y e s to L i f e  170  S t e p p i n g O u t and S p e a k i n g U p  171  A c h i e v i n g a Sense o f Peace, H a r m o n y , and B a l a n c e  172  E x p a n d i n g Personal Consciousness  173  Outcome of Individual Healing F o l l o w i n g Youth Suicide: Creating of a L o v e K n o t  175  Individual Healing F o l l o w i n g Youth Suicide: A Summary  176  T r a n s i t i o n , T r a n s f o r m a t i o n , and Transcendence  178  R e l a t i o n s h i p B e t w e e n H e a l i n g and G r i e v i n g  180  Discussion  182  Summary  189  CHAPTER NINE - HEALING WITHIN FAMILIES F O L L O W I N G Y O U T H SUICIDE: IMPLICATIONS AND CONCLUSIONS  191  Implications for H e a l t h P r o m o t i o n Practice  193  U n d e r s t a n d i n g the H e a l i n g Process  193  C r e a t i n g C o m m u n i t y - b a s e d Partnerships  198  W o r k i n g with Rural-based Families  201  Implications for Future Research Conclusions  REFERENCES  203 ••••  205  208  APPENDICES Appendix A - 1 : Genogram  227  Appendix A - 2 : Ecomap  229  A p p e n d i x B : F a m i l y M e m b e r Information Letter and Informed C o n s e n t  231  A p p e n d i x C : M e d i a Invitation  234  A p p e n d i x D : Interview G u i d e l i n e  236  A p p e n d i x E : Oath o f Confidentiality  238  A p p e n d i x F : D e m o g r a p h i c Questionnaire  241  Healing W i t h i n Families  List of Figures F i g u r e 4 - 1 : I n d i v i d u a l H e a l i n g Process Represented b y a L o v e K n o t  74  F i g u r e 4-2: I n d i v i d u a l - S o c i e t y H e a l i n g Process F o l l o w i n g Y o u t h S u i c i d e  78  F i g u r e 8-1: H e a l i n g E x p a n d i n g O v e r T i m e  176  F i g u r e 8-2: I n d i v i d u a l 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  178  Healing Within Families  xi  L i s t o f Tables Table 4-1: Residence of Sample Population T a b l e 4-2: S a m p l e P o p u l a t i o n D a t a  70 ;  T a b l e 4-3: I n d i v i d u a l H e a l i n g Template  72 75  T a b l e 8-1: 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 : H e a l i n g Strategies  169  T a b l e 8-2: Differences B e t w e e n H e a l i n g and G r i e v i n g i n R e s p o n s e to Y o u t h S u i c i d e  182  Healing Within Families  xii  ACKNOWLEDGEMENTS  I have been i n s p i r e d b y those w i t h w h o m I have j o u r n e y e d . I extend m y heartfelt thanks to the fourty-one i n d i v i d u a l s f r o m eleven families that, i n a spirit o f generosity, opened their hearts and souls as they shared their stories w i t h me. I feel p r i v i l e g e d to have learned so m u c h f r o m each of you. T h i s w o r k has been enhanced by m y association w i t h m a n y k i n d and c a r i n g people. W a r m e s t thanks are extended to m y brother, R o n a l d Grant, and to m y dear friend, C o r l i s s B u r k e , both o f w h o m have a l w a y s been there for me. I adore m y s o n - i n - l a w , W i l c o T y m e n s o n , and value his contribution to this w o r k . M y grandson, T y s o n B a i l e y K a l i s c h u k , h e l p e d m e to m a i n t a i n perspective w h i l e d o i n g this k i n d o f w o r k . H i s light, laughter, and l o v e sustained me d u r i n g the tough times. T o m y friends and colleagues i n the S c h o o l o f H e a l t h Sciences at the U n i v e r s i t y o f Lethbridge, I offer thanks — t o D e a n P a t r i c i a W a l l for creating the space and for b e l i e v i n g i n me; to D r . G a r y N i x o n for his depth and b r i l l i a n c e ; 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 h e l p i n g m e to maintain balance i n m y life; 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 u n w a v e r i n g support and encouragement, to D r . B r a d l e y H a g e n for sharing the j o u r n e y , and to D r . K a r r a n T h o r p e for her support and friendship over m a n y years. I a c k n o w l e d g e and appreciate the expert technical assistance p r o v i d e d b y 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 i n and c o m m i t m e n t to this research. Indeed, I a m fortunate to have been s k i l f u l l y g u i d e d i n this endeavor b y a w o r l d - c l a s s committee. W i t h gratitude, I thank D r . B e t t y D a v i e s for g u i d i n g the w a y . I have been forever changed because o f her passion for excellence and her c a l m and c a r i n g presence along the w a y . M y sincere thanks is extended to D r . V i r g i n i a H a y e s w h o has taught me m u c h about the essentials required for the j o u r n e y . D r . K a t h a r y n M a y ' s incredible v i s i o n for the b i g picture has i n s p i r e d me to stay f o c u s e d — f o r this I a m thankful. M y i n v o l v e m e n t i n this research study has been the h i g h l i g h t o f m y doctoral program. I gratefully a c k n o w l e d g e the financial contributions o f the organizations that p r o v i d e d funding for this research i n c l u d i n g the A l b e r t a A s s o c i a t i o n o f R e g i s t e r e d N u r s e s and the R e g i o n a l Center for H e a l t h P r o m o t i o n and C o m m u n i t y Studies at the U n i v e r s i t y o f L e t h b r i d g e , L e t h b r i d g e , Alberta.  Healing Within Families  !for Victor %alischuk\ My True  'North  and for Our Children, Our Stars Andrea,  %pcfoj,  9/CeCanie, and Lisa  xiii  Healing Within Families  1  CHAPTER ONE B A C K G R O U N D TO H E A L I N G WITHIN FAMILIES F O L L O W I N G Y O U T H SUICIDE  D e a t h is one o f l i f e ' s few certainties. Despite its i n e v i t a b i l i t y , w i d e l y accepted w i t h i n society is the n o t i o n that it is unnatural for c h i l d r e n to predecease their parents; unfortunately, i n some instances, reality proves otherwise. T h e idea o f a youth w i l l f u l l y ending his or her life is i n c o m p r e h e n s i b l e to most people. S u i c i d e , an unnatural, unanticipated, and p s y c h o l o g i c a l l y violent death is often v i e w e d as an act o f aggression that has been c o m m i t t e d b y the v i c t i m against both self and s u r v i v o r s ( N o r t o n , 1994). T h e staggering increase i n the incidence o f youth suicide i n recent years is a c o m p l e x and disturbing fact o f contemporary society. Indeed, this increasingly c o m m o n mental health care p r o b l e m challenges some o f the strongest and most sacred beliefs and c o n v i c t i o n s h e l d by f a m i l y survivors. Y o u t h suicide is especially tragic for f a m i l y survivors because it i n v o l v e s not o n l y the death o f a y o u n g person, but death that is sudden and violent. T h e initial b l o w o f hearing the news o f a youth suicide is l i k e l y to e l i c i t a disturbing response a m o n g f a m i l y survivors, m u c h l i k e the ripple-effect o f an earthquake and its resultant aftershocks. In the midst o f tremendous upheaval, survivors are c h a l l e n g e d i n terms o f m a k i n g sense o f their grievous experience and healing i n response to this life-altering situation. T h i s dissertation is p r i m a r i l y concerned w i t h h o w f a m i l y survivors heal i n the aftermath o f youth suicide.  T h e Scope o f the P r o b l e m o f Y o u t h S u i c i d e Y o u t h suicide has been identified as a c o m p e l l i n g global and national p u b l i c health p r o b l e m (Leenaars, W e n c k s t e r n , S a k i n o f s k y , 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 e p i d e m i c proportion (Thornton, W h i t t e m o r e , & R o b e r t s o n , 1989). T h e magnitude o f this p r o b l e m and its concomitant u n t o w a r d sequelae cannot be overstated. A t both the national and p r o v i n c i a l levels, the increased incidence o f suicide a m o n g our youth is alarming.  Healing Within Families  2  T h e recent rise i n suicides a m o n g y o u n g males is a c o m p l e x and p e r p l e x i n g p r o b l e m . In C a n a d a , i n 1993, m a l e youngsters aged 15 to 19 k i l l e d themselves at a rate o f 19.4 per 100,000 ( W i l k i n s , 1996). F r o m 1981 to 1991, C a n a d i a n males aged 10 to 14 s h o w e d a startling increase o f 60 percent i n the rate o f c o m p l e t e d suicides, the highest percentage increase o f any age group i n the country ( W h i t e , 1993). It is disturbing to note that the highest incidence o f suicide occurs w i t h i n the aboriginal youth population ( R o y a 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 n c l u d i n g 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 C a n a d a (1994b), d u r i n g 19871991, C a n a d i a n and registered Indian males, aged 15 to 19 years, c o m p l e t e d s u i c i d e at a rate o f 117 per 100,000. N o t s u r p r i s i n g l y , Quebec and A l b e r t a , C a n a d i a n p r o v i n c e s w i t h the largest aboriginal populations, have the highest incidence o f youth suicide. W i t h i n a one-year p e r i o d i n A l b e r t a , the rate o f suicide a m o n g youth aged 15 to 19 s h o w e d a substantial increase o f almost 39 p e r c e n t — f r o m 18.8 per 100,000 i n 1990, to 26.0 per 100,000 i n 1991 ( W h i t e , 1993). M o r e o v e r , the majority o f a b o r i g i n a l youth l i v e i n rural areas. D u r i n g 1996, i n A l b e r t a , the incidence o f suicide a m o n g rural youth exceeded that o f their urban peers ( A l b e r t a Justice Office o f the C h i e f M e d i c a l E x a m i n e r , 1997). A p p r o x i m a t e l y 5 0 0 0 C a n a d i a n aboriginals under the age o f 25 die f r o m suicide each year, a rate six times higher than that for non-aboriginals (Regnier, 1994). M o r e m a l e youth suicides occur i n C a n a d a per capita than i n the U n i t e d States (Leenaars & Lester, 1990; L e e n a a r s et a l . , 1998). E v e n s t i l l , i n the U n i t e d States, suicides a m o n g youths have q u a d r u p l e d w i t h i n the last three decades ( G a r t r e l l , Jarvis, & D e r k s e n , 1993). I n 1988, a total o f 2,059 youths aged 15 to 19, and 243 c h i l d r e n under 15 years o f age, t o o k their l i v e s i n the U n i t e d States ( N a t i o n a l Center for H e a l t h Statistics, 1968-1991). S u i c i d e is n o w the s e c o n d l e a d i n g cause of death a m o n g the y o u t h 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 h u m a n service professionals are c o m m i t t e d to p r o v i d i n g youth s u i c i d e prevention programs ( B l u m e n t h a l , 1990; B o l d t , 1987; B r e n t , 1995; B r e n t et a l . , 1993; G a r l a n d & Z i g l e r , 1993; R u d d , D a h m , & Rajab, 1993), each year, m o r e than 300 f a m i l i e s i n C a n a d a (Statistics C a n a d a , 1994a, 1994b) are confronted w i t h y o u t h s u i c i d e . T h i s statistic is  Healing Within Families  3  insignificant i n c o m p a r i s o n to the devastation that youth suicide casts i n its w a k e , especially for f a m i l y survivors. M o r e o v e r , this fact is a conservative estimate o f the p r o b l e m ; it under-represents reality ( G a r l a n d & Z i g l e r , 1993) and this under-representation m a y be l i n k e d to the inherent difficulties associated w i t h reporting self-inflicted deaths. These p r o b l e m s center o n c o n c e r n for the f a m i l y ' s w e l l - b e i n g , r e l i g i o u s i m p l i c a t i o n s , and financial considerations regarding insurance payment restrictions ( G a r l a n d & Z i g l e r , 1993). A d d i t i o n a l l y , m a n y sudden deaths are p r o b a b l y suicides, but w i t h o u t direct evidence such as a suicide note, the cause o f death m a y be reported as accidental or undetermined. A d d i n g to the enormity o f the p r o b l e m , it has been suggested that a m i n i m u m o f 50 people, m a n y o f w h o m are f a m i l y members, are affected b y each incidence o f y o u t h s u i c i d e ( B . S h a w a n d a , personal c o m m u n i c a t i o n , M a y , 28, 1998). F u r t h e r , it is estimated that 50 to 100 attempts o c c u r for every c o m p l e t e d youth s u i c i d e ( S m i t h & C r a w f o r d , 1986), and this begins to g i v e some i n d i c a t i o n o f the true magnitude o f the p r o b l e m .  T h e H e a l t h and H u m a n Consequences A s s o c i a t e d w i t h Y o u t h S u i c i d e T h e short- and l o n g - t e r m health and h u m a n consequences associated w i t h youth suicide are enormous, affecting each f a m i l y s u r v i v o r , the f a m i l y as a unit, and u l t i m a t e l y , the c o m m u n i t y and society. F a m i l y s u r v i v o r s o f youth suicide often experience a n u m b e r o f stressors i n c l u d i n g increased v u l n e r a b i l i t y to illness and disease (Rudestam, 1992), increased i n c i d e n c e o f drug and a l c o h o l abuse ( S i l v e r m a n , R a n g e , & Overholster, 1994-95), and extensive e m o t i o n a l and personal suffering (Ness & Pfeffer, 1990; Parkes & B r o w n , 1972; S o l u r s h , 1 9 9 0 ; V a n D o n g e n , 1990). A l t h o u g h sometimes o v e r l o o k e d , grandparents (Ponzetti & J o h n s o n , 1991) and s i b l i n g survivors m a y also experience adverse health consequences (e.g., B a l k 1983, 1990a, 1990b, 1991a, 1991b; F a n o s & N i c k e r m a n , 1 9 9 1 ; G r o g a n , 1990; H i l g a r d , 1969; H o g a n & B a l k , 1990; H o g a n & D e S a n t i s , 1994; K r e l l & R a b k i n , 1979; M a r t i n s o n , D a v i e s , & M c C l o w r y , 1987; P o l l o c k , 1986; Zelauskas, 1981). T h e situation is further c o m p l i c a t e d i n that f a m i l i e s w h o have endured such trauma are often confronted w i t h subtle, yet p o w e r f u l , forms o f s t i g m a ( B r o w n , 1994; T h o r n t o n , W h i t t e m o r e , & R o b e r t s o n , 1989; V a n D o n g e n , 1993; S c h l u m p - U r q u h a r t , 1990; S o l o m o n 19821983; S o m m e - R o t e n b e r g , 1998); s o c i a l i s o l a t i o n (Ness & Pfeffer, 1990; R u d e s t a m , 1992; V a n  Healing Within Families  4  D o n g e n , 1991); role uncertainty ( V a n D o n g e n , 1993); and strained relationships w h i c h often lead to m a r i t a l d i s c o r d (Ness & Pfeffer, 1990; Parkes & B r o w n , 1972; V a n D o n g e n , 1993). M o r e o v e r , the deleterious effects o f multi-generational loss, especially c o m m o n a m o n g C a n a d i a n A b o r i g i n a l families, place heavy demands on e x i s t i n g health care services ( B . S h a w a n d a , personal c o m m u n i c a t i o n , M a y , 28, 1998). M u l t i - g e n e r a t i o n a l loss arises f r o m an a c c u m u l a t i o n o f u n r e s o l v e d loss issues inadvertently passed d o w n f r o m one generation to the next ( B . S h a w a n d a , personal c o m m u n i c a t i o n , M a y 28, 1998). S o m e o f these loss issues i n c l u d e a l a c k o f integration o f the i n d i v i d u a l w i t h i n society ( D u r k h e i m , 1951); ego identity crisis, and the resulting trauma that m a y result f r o m g r a p p l i n g w i t h the question " W h o A m I ? " ( E r i c k s o n , 1968); and, the loss o f one's ethnic identity ( P h i n n e y , 1989). F a m i l y survivors o f multi-generational loss often b e c o m e " f a m i l i e s o f t r a u m a " ( B . S h a w a n d a , personal c o m m u n i c a t i o n , M a y 28, 1998) w h o access the health care system more frequently than persons w h o are able to confront their loss soon after it occurs. U l t i m a t e l y , i n d i v i d u a l and f a m i l y responses to death i n general, and to youth suicide i n particular, are i n f l u e n c e d by societal responses.  T h e Response o f S o c i e t y to D e a t h In the past, death was r e c o g n i z e d as a natural and n o r m a l life event. H o w e v e r , w i t h i n the last century, death has been socially reconstructed as a ' m e d i c a l event.' W i t h i n our death-denying and death-defying society, the m e d i c a l i z a t i o n and bureaucratization o f death has l e d to its depersonalization. T h u s , for m a n y , death has b e c o m e an e n i g m a . T h e s o c i a l aspects o f death have been r e m o v e d f r o m the home and f a m i l y and have been transplanted w i t h i n 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 f r o m the c h u r c h to science and its representatives, the m e d i c a l profession and the rationally o r g a n i z e d h o s p i t a l " ( B l a u n e r , 1966, p. 385). B l a u n e r ' s message still applies 30 years after he wrote it. T o d a y , i n C a n a d a , about 7 0 % o f a l l deaths o c c u r w i t h i n hospitals ( L o c k a r d , 1989). W i t h a p r i m e focus on efficiency, hospitals continue to manage the crisis o f d y i n g . W i t h i n the hospital environment, death becomes the arena for experts rather than f a m i l i e s and friends. T h e high-tech  Healing Within Families  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 o f the death r o o m . F a m i l y members often become visitors and c h i l d r e n are shielded f r o m death. T h e separation o f death f r o m the f a m i l y m i n i m i z e s the average person's exposure to death w i t h its disruption o f s o c i a l processes ( B l a u n e r , 1966). T h e ever present avoidance o f death-related issues w i t h i n society is even m o r e p r o n o u n c e d w i t h respect to youth suicide.  T h e Response o f S o c i e t y to Y o u t h S u i c i d e Y o u t h suicide is a stark and p o w e r f u l reminder that a l l is not w e l l w i t h i n society. A n u m b e r o f forces have had an impact on society's response to youth suicide, i n c l u d i n g : the sociogenic v i e w of youth suicide, c h a n g i n g v i e w s o f death and suicide, the s o c i a l value a c c o r d e d to our youth i n society, the stigmatization surrounding youth suicide, and educational deficiencies. T h e a l a r m i n g increase i n the incidence o f youth suicide w i t h i n contemporary society is indeed difficult to comprehend. In spite o f g r o w i n g concern about this p r o b l e m w i t h i n the health care sector, as yet, w e do not understand the m u l t i p l i c i t y o f forces that underlie this c o m p l e x health p r o b l e m . A c c o r d i n g to S h n e i d m a n (1993b), suicide occurs w h e n an i n d i v i d u a l experiences intolerable p s y c h o l o g i c a l pain or " p s y c h a c h e " (p. 145). E m i l e D u r k h e i m (1951), a r e n o w n e d F r e n c h sociologist, v i e w s suicide not as a voluntary act, but as an i n d i v i d u a l p h e n o m e n o n e t i o l o g i c a l l y e x p l a i n e d w i t h i n the parameters o f our Western social structure. E s p o u s i n g a s i m i l a r v i e w , B o l d t (1987) maintains that " S u i c i d e is v i r t u a l l y always a f o r c e d act to resolve what are perceived as o v e r w h e l m i n g p r o b l e m s " (p. 4). Further, he argues that the i d e a o f m o r a l c u l p a b i l i t y needs to be reintroduced w i t h the responsibility for suicide shifted f r o m the i n d i v i d u a l to society. Several s o c i o l o g i c a l phenomena have been attributed to the increased incidence o f youth suicide i n c l u d i n g : issues related to c h a n g i n g s o c i a l and e c o n o m i c structures ( F a r r o w , 1993; S h n e i d m a n , 1993a ); c h a n g i n g f a m i l y and c o m m u n i t y d y n a m i c s ( B o l d t , 1987; B u s h y , 1994c; Leenaars et a l . , 1998); d e c l i n i n g religious affiliation; an increased prevalence o f depression a m o n g y o u t h ( S a k i n o f s k y , 1998); and the influence o f p o p u l a r m e d i a ( B i b l a r z , 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 , & B a l d r e e , 1 9 9 1 ; Stack, 1992). C u l t u r a l change, increased personal freedom, uncertainty  Healing Within Families  6  about the future ( C o t t o n & R a n g e , 1993), and "value heterogeneity" are also considered to be factors ( B o l d t , 1987, p. 6). M o r e o v e r , social and e c o n o m i c structures often i m p o s e barriers to youth attempting to seek professional help, especially for concerns that have m o r a l overtones— such as s u i c i d a l t h i n k i n g , intense e m o t i o n a l responses to stress, s y m p t o m s o f mental illness, or p r o b l e m s w i t h a d d i c t i o n , pregnancy, sexuality issues or infractions o f the l a w ( B u s h y , 1994c). Proponents o f the sociogenic v i e w emphasize the need to focus o n t r y i n g to change environmental realities that cause p s y c h o l o g i c a l pain and m i n i m i z i n g the m o r a l and social stigmata that act as barriers to s u r v i v o r help s e e k i n g (e.g., A t k i n s o n , 1978; B o l d t , 1976; C a l h o u n , S e l b y , & F a u l s t i c h , 1980, 1982; K l a s s , 1996; P a i c h e l e r , 1988; R u d e s t a m & I m b r o l , 1983). W i t h i n societal institutions, v i e w s about death and suicide are also c h a n g i n g . M a n y social systems (e.g., health care, l e g a l , p o l i t i c a l ) w i t h i n the W e s t e r n w o r l d are b e g i n n i n g to show, not o n l y tolerance of, but whole-hearted support for i n d i v i d u a l rights to self-autonomy and selfdetermination. These personal freedoms have been enacted i n a variety o f personal rights, for e x a m p l e , the right to die. These ideas have had a corresponding effect on contemporary and social conceptions o f s u i c i d e . E s p e c i a l l y disturbing, B o l d t (1987) contends that " W e are m o v i n g f r o m predominantly negative conceptions o f suicide t o w a r d a consensus that there is a time and situation when suicide is acceptable, i f not appropriate" ( B o l d t , 1987, p.6). B o l d t (1987) notes that a " w o r r i s o m e reconstruction o f the m e a n i n g o f suicide has o c c u r r e d for the y o u n g " (p. 6) i n a prosuicidal direction, i n that suicide is n o w b e i n g interpreted b y y o u t h as a v i a b l e option to seemingly intolerable life situations. T h e youth o f today frequently speak o f 'rational s u i c i d e ' and 'the right to s u i c i d e . ' T h i s trend suggests that youth are i n f l u e n c e d b y and vulnerable to societal v i e w s . In the past, the stronghold o f J u d e o - C h r i s t i a n values and beliefs has l i m i t e d our understanding o f the experiences o f f a m i l y s u r v i v o r s o f y o u t h s u i c i d e . U n t i l recently, both sacred and secular standards defined suicide as a m o r a l l y abhorrent act. In recent years, secular l a w s against suicide have been repealed, and the C h u r c h has abandoned its m o r a l i s t i c and punitive attitude t o w a r d s u i c i d e ( B o l d t , 1987). E v e n so, change has been s l o w and f a m i l y s u r v i v o r s o f suicide often continue to be the recipients o f s o c i e t y ' s harsh j u d g m e n t .  Healing Within Families  7  T h e value p l a c e d o n youth w i t h i n society is questionable. S o c i e t y , f a v o r i n g deeds and accomplishments a m o n g its members, bestows high regard and r e c o g n i t i o n on those able to make significant contributions to the welfare o f its c i t i z e n . W h e n those w h o die (i.e., youth) have not contributed to the social fabric o f society, they m a y not be v i e w e d as a loss w i t h i n society (Glaser & Strauss, 1964). T h u s , w h e n a y o u t h ends his or her life, it is c o m m o n for m e m b e r s o f society to dismiss the incident a l o n g w i t h any reminders o f this 'unwarranted act.' S u c h responses not o n l y negate the life o f the deceased i n d i v i d u a l , they also invalidate, to a great extent, the experiences o f family survivors. Stigmatization surrounding suicide remains pervasive w i t h i n society. S o c i e t a l attitudes and related perceptions about bereaved f a m i l y members contribute to stigmatization. T h e "no talk rule" becomes the m o d u s operandi w i t h i n society ( B . S h a w a n d a , personal c o m m u n i c a t i o n , M a y 28, 1998). W h e n suicide strikes, others are often not there for bereaved f a m i l y m e m b e r s to the same degree as is the case w i t h other k i n d s o f deaths ( S h e s k i n & W a l l a c e , 1976; T h o r n t o n , W h i t t e m o r e , & R o b e r t s o n , 1989). Further, those w h o are uncomfortable w i t h the topic frequently ' b l a m e the f a m i l y ' (Rudestam, 1992) for the suicide. S u r v i v o r s often feel silenced. S e n s i t i v e to others' discomfort about suicide-related matters, they frequently r e s p o n d b y w i t h d r a w i n g f r o m other people, especially those external to the f a m i l y unit. H e n c e , the stigma associated w i t h youth suicide often b l o c k s the f a m i l y f r o m seeking needed professional help and s o c i a l support. T h e stigmatization surrounding youth suicide isolates and ostracizes f a m i l y survivors d u r i n g a time w h e n understanding and c o m p a s s i o n are sorely needed ( S o l o m o n , 1 9 8 2 - 1 9 8 3 ; T h o r n t o n , W h i t t e m o r e , & R o b e r t s o n , 1989). E d u c a t o r s generally respond to the expressed needs o f those w i t h i n society. In k e e p i n g w i t h society's general disdain o f death-related matters, educational programs currently p r o v i d e m i n i m a l preparation ( M o r g a n , 1990) to assist h u m a n service professionals i n c a r i n g for f a m i l i e s w h o have experienced youth suicide. M o r e than 30 years ago, Q u i n t (1967) indentified the need to develop a systematic plan for educating nurses about death and d y i n g . H o w e v e r , w i t h i n most c u r r i c u l a , m i n i m a l emphasis is p l a c e d on issues related to death and bereavement generally, and on the health care needs o f f a m i l y survivors o f youth suicide s p e c i f i c a l l y . In addition, teaching faculty often l a c k  Healing Within Families  8  adequate preparation specific to youth suicide and its i m p a c t on the f a m i l y . W i t h o u t sound theoretical understanding and s k i l l acquisition, it is unrealistic to expect h u m a n service professionals to p r o v i d e quality care (Grant K a l i s c h u k , 1992) to this p o p u l a t i o n . I n part, this educational deficit m a y be attributed to the l o w priority placed on death-related issues w i t h i n the health care system.  T h e Response o f the H e a l t h C a r e S y s t e m to Y o u t h S u i c i d e It is important to address the shortcomings o f the health care system i n d e a l i n g w i t h bereaved f a m i l i e s , e s p e c i a l l y families w h o are bereaved due to y o u t h s u i c i d e . I n the past, the p h i l o s o p h y and organization o f the health care system perpetuated a context i n w h i c h the humane side o f care g i v i n g was often left to chance ( B e n o l i e l , 1988; W a t s o n , 1999). T h e shroud o f silence and secrecy surrounding suicide has contributed greatly to m a i n t a i n i n g the status q u o p o s i t i o n (i.e., silence prevails) w i t h i n the existing health care practice arena. F a m i l y s u r v i v o r s o f youth suicide are sensitive to the "no talk r u l e " that permeates every l e v e l o f discourse w i t h i n the health care system. In an effort to reach out to others i n s i m i l a r circumstances, s u i c i d e s u r v i v o r s have often initiated the organization o f i n f o r m a l suicide support groups. W h i l e these groups p r o v i d e m u c h needed support to i n d i v i d u a l s and families, they fail to address concerns related to youth suicide w i t h i n the broader c o m m u n i t y and society. T h e C a n a d i a n health care system remains h e a v i l y influenced b y the m e d i c a l m o d e l and as a result spends a disproportionate amount o f the health care budget on institutional care ( M i n i s t e r o f P u b l i c W o r k s & G o v e r n m e n t Services C a n a d a , 1998). In C a n a d a , the p o r t i o n o f the p r o v i n c i a l mental health care budget that is spent on c o m m u n i t y support services averages 1 3 % , r a n g i n g f r o m 3 . 1 % i n 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 ( N a s i r , 1994). I n regard to y o u t h s u i c i d e , most o f these community-targeted funds are spent on preventive measures. W h i l e such efforts are c o m m e n d a b l e , families that have been traumatized by youth suicide are often o v e r l o o k e d . U l t i m a t e l y , this e v e r - g r o w i n g segment o f the population is often left to manage and cope on its o w n w i t h i n a deficiency-based health care system that provides m i n i m a l support and assistance. T h e b i o m e d i c a l m o d e l has had a strong influence w i t h i n the health care system.  Healing Within Families  9  Influence o f the B i o m e d i c a l M o d e l W i t h i n the W e s t e r n w o r l d , the problem-focused, deficiency-based b i o m e d i c a l m o d e l has adversely i n f l u e n c e d health care research and practice i n three distinct w a y s . First, w i t h i n the last century, the m e d i c a l i z a t i o n o f death has had a corresponding effect on the care p r o v i d e d to bereaved families i n that m e d i c a l treatment and cure have been g i v e n priority over p s y c h o s o c i a l and spiritual care. It appears as i f there are social rules about what to ignore w i t h i n health care, and death-related matters seem to engender the ultimate i n denial (Rudestam, 1992). S e l d o m is a suicide s u r v i v o r ' s suffering r e c o g n i z e d as a p s y c h o s o c i a l a n d spiritual crisis w o r t h y o f attention and care b y health care professionals. W h e n such a crisis is identified, m e d i c a l personnel often prescribe m e d i c a t i o n rather than sitting w i t h and listening to f a m i l y survivors share their stories about loss. S e c o n d , m u c h o f the research literature p u b l i s h e d to date focuses on the difficulties and problems confronted b y families i n the aftermath o f y o u t h suicide ( A d a m s , O v e r h o l s e r , & S p i r i t o , 1994; B r e n t , 1995; B r e n t et a l , 1993; P a t a k i & C a r l s o n , 1995; R e i f m a n & W i n d l e , 1995; R u d d , D a h m & Rajab, 1993). C o r r e s p o n d i n g l y , this p r o b l e m - f o c u s e d approach to research has l e d t o ' problem-based practice w h i c h often fails to address i n d i v i d u a l and f a m i l y strengths. G e n e r a l l y , suicide survivors o n l y enter the health care system w h e n g r i e v i n g becomes unmanageable. B e r e a v e d i n d i v i d u a l s and families are often identified b y health care professionals as an extremely vulnerable p o p u l a t i o n ( T h o m p s o n & R a n g e , 1992-93), and because they are l a b e l e d i n this w a y , they are treated a c c o r d i n g l y — a s i n d i v i d u a l s and families i n need o f help f r o m external sources. Patterson (1995) contends that i n d i v i d u a l s and families often are unaware o f their o w n strengths because professionals tend to focus on deficiencies and problems rather than on i n d i v i d u a l and f a m i l y strengths and competencies. H e n c e , one o f the major barriers to family-centered health care delivery has been the failure o f health care professionals to assist i n d i v i d u a l s and families i n the d i s c o v e r y and development o f their o w n capabilities. T o a great extent, problem-oriented research has unintentionally i m p e d e d health-focused practice. T h i r d , the b i o m e d i c a l m o d e l w i t h its emphasis on parts rather than w h o l e s has influenced researchers and c l i n i c i a n s to focus o n i n d i v i d u a l s rather than f a m i l i e s . H o w e v e r , i n d i v i d u a l s do not  Healing Within Families  10  exist i n i s o l a t i o n ; rather, they l i v e i n families w i t h i n a mosaic o f social interaction. F a m i l y members derive m e a n i n g i n life f r o m their interactions w i t h others. T h e practice o f e x c l u s i v e l y f o c u s i n g o n the i n d i v i d u a l fails to take into account the m a n y important aspects that are c o m m o n to both i n d i v i d u a l s and f a m i l i e s (e.g., relationships and c o m m u n i c a t i o n ) . A c c o r d i n g to K i s s a n e and B l o c h (1994), "the f a m i l y virtually a l w a y s constitutes the most significant social group i n w h i c h g r i e v i n g is e x p e r i e n c e d " (p. 728). S i n c e g r i e v i n g occurs w i t h i n the context o f the f a m i l y , it is important to consider the influence o f the i n d i v i d u a l o n the f a m i l y , and the influence o f the f a m i l y on the i n d i v i d u a l . T h e f a m i l y , w i t h its r i c h , d y n a m i c , and c o m p l e x characteristics is a major social agency for h u m a n g r o w t h . In effect, the reductionistic b i o m e d i c a l m o d e l fails to take into account the inherent c o m p l e x i t y and vastness o f h u m a n existence and, therefore, it has been ineffective i n terms o f p r o v i d i n g a v i s i o n for holistic health care practice. H o w e v e r , w i t h i n the last three decades, the b i o m e d i c a l m o d e l ' s stronghold on both health care research and practice has been w a n i n g . T h e shortcomings o f the past have p r o v i d e d the impetus for the future transformation o f the health care system. D u r i n g the past t w o decades, unprecedented changes have been o c c u r r i n g w i t h i n the health care system. Beset b y e c o n o m i c , performance, and c r e d i b i l i t y crises, the health care system is currently undergoing a massive overhaul (Ferguson, 1980; L a u r e n c e & W e i n h o u s e , 1994; R a c h l i s & K u s h n e r , 1989). Increasingly, health care consumers are b e g i n n i n g to w i t h d r a w l e g i t i m a c y f r o m the m e d i c a l establishment, l o n g the bastion o f barren efficiency. C o n s u m e r s are b e g i n n i n g to assert their right to be i n c l u d e d as equal partners i n the co-creation o f health for both themselves and their f a m i l i e s . N o w more than ever before, consumers are h o l d i n g the health care system accountable for h i g h quality, patient- and family-centered health care d e l i v e r y . Increasingly, the influence o f the " N e w P a r a d i g m o f H e a l t h " (Ferguson, 1980, p. 246) is c a t c h i n g the attention of researchers and c l i n i c i a n s alike because o f its fit w i t h the a i m o f p r o m o t i n g holistic health care practice.  The O l d Paradigm of Medicine—The N e w Paradigm of Health A l m o s t t w o decades ago, F e r g u s o n (1980) l a i d the g r o u n d w o r k d e s c r i b i n g the transformation that is n o w o c c u r r i n g w i t h i n the health care system. A c c o r d i n g to F e r g u s o n (1980),  Healing Within Families  11  " W e have o v e r s o l d the benefits o f technology and external manipulations; w e have undersold the importance o f h u m a n relationships and the c o m p l e x i t y o f nature" (p. 246). T h e " o l d p a r a d i g m o f m e d i c i n e " ( F e r g u s o n , 1980, p. 246) w i t h its focus on disease and illness is s l o w l y b e i n g replaced b y the " n e w p a r a d i g m o f health" (Ferguson, 1980, p. 246) w h i c h stresses the i m p o r t a n c e o f health and w e l l - b e i n g . Congruent w i t h the b i o m e d i c a l m o d e l , the " o l d p a r a d i g m o f m e d i c i n e " was based on the f o l l o w i n g assumptions: a mechanistic approach to disease; separation o f the m i n d and b o d y ; treatment o f s y m p t o m s rather than cause; an emphasis on quantitative data; p r i m a r y intervention w i t h drugs and surgery; the patient as dependent upon the authoritarian health care professional; and p r e v e n t i o n l a r g e l y determined b y e n v i r o n m e n t a l factors ( F e r g u s o n , 1980, p. 247). In contrast, the emergence o f the " n e w p a r a d i g m o f health" embraces ideas such as: an integrated concern for the w h o l e patient and an emphasis on a c h i e v i n g m a x i m u m wellness or "metahealth;" the b o d y b e i n g v i e w e d as a d y n a m i c system, context, and f i e l d o f energy w i t h i n other fields; the m i n i m a l use o f t e c h n o l o g i c a l intervention c o m p l e m e n t e d by a vast armamentarium o f n o n - i n v a s i v e techniques; the patient b e i n g seen as autonomous and the professional as a therapeutic partner; an emphasis on qualitative data to u n v e i l the human perspective; and prevention that is s y n o n y m o u s w i t h w h o l e n e s s , w o r k , relationships, goals, and the b o d y - m i n d - s p i r i t ( F e r g u s o n , 1980, p. 247). T h i s latter perspective underscores the inherent value o f holistic professional n u r s i n g practice based on health-oriented research.  Health-Oriented Research W i t h i n the W e s t e r n w o r l d , health care has been significantly i n f l u e n c e d by the adoption o f p r i m a r y health care as a means o f a c h i e v i n g "health for a l l " ( L a l o n d e , 1974). W i d e l y purported as the h a l l m a r k o f the C a n a d i a n health care system, " p r i m a r y health care is essential health care made universally accessible to i n d i v i d u a l s and families i n the c o m m u n i t y by means acceptable to them, through their full participation, and at a cost that the c o m m u n i t y and country can afford" ( W o r l d H e a l t h O r g a n i z a t i o n , 1978). S p e c i f i c a l l y , p r i m a r y health care promotes m a x i m u m i n d i v i d u a l and c o m m u n i t y i n v o l v e m e n t m e a n i n g that " a l l persons have the right and duty to participate  Healing Within Families  12  i n d i v i d u a l l y and c o l l e c t i v e l y i n the p l a n n i n g and implementation o f their health care" (Canadian N u r s e s A s s o c i a t i o n , 1988, p. 5). P r i m a r y health care serves as the forerunner o f a n e w e r concept, that o f health p r o m o t i o n , w h i c h is the process o f e n a b l i n g people to increase c o n t r o l over, and to i m p r o v e their health (Raeburn & R o o t m a n , 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 i n research is still i n the neophyte stage. In order for i n d i v i d u a l s and families to increase c o n t r o l o v e r their health, and to participate i n their o w n health care, it is imperative that they be i n c l u d e d i n research that is designed to offer t h e m a v o i c e i n the redirection o f existing health care delivery. Health-oriented research that investigates the tremendous strengths and capabilities o f i n d i v i d u a l s and f a m i l i e s is p i v o t a l to the development o f healthy c o m m u n i t i e s . E n g l i s h and H i c k s (1992) note that i n order to promote the health o f f a m i l i e s and c o m m u n i t i e s , that it is important to identify and b u i l d o n h u m a n strengths. A n t o n o v s k y (1996) suggests that "the persistence o f the disease orientation and the l i m i t s of r i s k factor approaches for c o n c e p t u a l i z i n g and c o n d u c t i n g research on health" (p. 11) poses a serious threat to the concept o f health p r o m o t i o n . H e goes on to c l a i m that it is m o r a l l y " i m p e r m i s s i b l e to identify a r i c h , c o m p l e x human being w i t h a particular pathology, disability or characteristic" (p. 14). Instead, A n t o n o v s k y (1996) proposes that the " S a l u t o g e n i c M o d e l " (p. 14) w i t h its focus o n health p r o m o t i n g factors, c o u l d w e l l serve as a v i a b l e , useful, a n d p o w e r f u l guide for both practitioners and researchers. T h i s approach is o p p o s e d to a d i c h o t o m o u s classification o f persons w h o are either healthy or diseased, characteristic o f the b i o m e d i c a l m o d e l ( A n t o n o v s k y , 1996). Rather, this m o d e l directs both research and practice efforts to encompass a l l persons, wherever they are o n the health-disease c o n t i n u u m ( A n t o n o v s k y , 1996; Jensen & A l l e n , 1993). T h r o u g h the use o f this m o d e l , health-promoting questions such as " H o w can this person be helped to m o v e t o w a r d greater health?" have significant relevance. In terms o f facilitating a m o v e m e n t t o w a r d health, A n t o n o v s k y , (1996) suggests that o n e ' s "sense o f c o h e r e n c e " (p. 15), or ability to f i n d m e a n i n g i n , and m a k e sense o f one's w o r l d , is essential. Further, he c l a i m s that it is the c o m b i n a t i o n o f c o g n i t i v e (a belief that the challenge is understood), behavioral (a belief that the resources to cope are available), and motivational (the w i s h to cope) factors that determine the  Healing Within Families  13  strength o f o n e ' s sense o f coherence, and thus o n e ' s m o v e m e n t t o w a r d health. T h i s healthoriented, yet h i g h l y i n d i v i d u a l i z e d m o d e l is congruent w i t h n u r s i n g ' s h o l i s t i c approach to health care d e l i v e r y , and thus influenced the approach taken during the early conceptualization o f this dissertation study.  T h e R e s p o n s e o f N u r s i n g to Y o u t h S u i c i d e A l i g n e d w i t h m e d i c i n e b y necessity, n u r s i n g has also contributed to the shortfalls w i t h i n the health care system. In the past, nursing has also been negatively i n f l u e n c e d b y the b i o m e d i c a l m o d e l . H o w e v e r , p o s i t i v e and e x c i t i n g changes w i t h i n the n u r s i n g profession are e m e r g i n g w i t h increasing frequency. T h e proliferation o f research-based n u r s i n g k n o w l e d g e i n recent years has validated and fortified the scientific basis o f n u r s i n g practice. A s the scientific k n o w l e d g e base o f n u r s i n g expands, and as the l e v e l o f education a m o n g nurses increases, nurses are further able to define, c l a i m , and take responsibility for their legitimate scope o f practice. N u r s i n g , charged w i t h the responsibility o f p r o v i d i n g holistic health care to i n d i v i d u a l s and f a m i l i e s i n a variety o f settings ( A l b e r t a A s s o c i a t i o n o f Registered Nurses, 1993), has the potential to m a k e a significant contribution i n terms o f assisting bereaved f a m i l i e s . A s R o g e r s and V a c h o n (1975) c l a i m : " N u r s e s , by virtue o f their personal c a r i n g roles and their positions w i t h i n institutions and i n the c o m m u n i t y at large, are u n i q u e l y suited to carry m o r e responsibility i n p r o v i d i n g service to the bereaved" (p. 16). Nurses are members o f the health care team w h o have the most contact w i t h bereaved families; they are often i n contact w i t h i n d i v i d u a l s and families on a 24-hour basis. T h i s increased contact time facilitates nurses establishing therapeutic relationships ( Q u i n n , 1989; W a t s o n , 1999) w i t h i n d i v i d u a l s and f a m i l i e s . In addition, nurses are strategically p o s i t i o n e d w i t h i n the c o m m u n i t y and prepared to coordinate the activities o f the m u l t i d i s c i p l i n a r y health care team. " N u r s e s are at the vanguard o f the q u i c k e n i n g o f the transpersonal currents o f h e a l i n g " ( D o s s e y & D o s s e y , 1999, p. x ) . Q u i n n (1989) asserts that h e a l i n g is a major g o a l o f n u r s i n g and that nurses m a y be the m i d w i v e s w h o facilitate healing i n others, w h i l e W e l l s - F e l d e r m a n (1996) purports that it is time for nurses to take the initiative b y i n t r o d u c i n g h e a l i n g n u r s i n g interventions that a c k n o w l e d g e compassionate and k n o w l e d g e - b a s e d c a r e g i v i n g . S i m i l a r l y , L e f t w i c h (1993)  Healing Within Families  14  contends that " N u r s i n g has a heritage o f h e a l i n g that was h i g h l y v a l u e d i n the past" (p. 13), and maintains that nurses need not be t i m i d about insisting that h e a l i n g is an inherent element o f nursing practice. In order to c l a i m that healing is a major g o a l o f n u r s i n g practice, nurses need scientifically-based n u r s i n g k n o w l e d g e (i.e., theory) that explicates the process o f h e a l i n g .  T h e Study: A F o c u s on H e a l i n g T h i s purpose o f this research was to d e v e l o p a substantive theory that explains h o w i n d i v i d u a l f a m i l y members heal i n the aftermath o f youth suicide. T h i s study adopted a healthfocused, health p r o m o t i o n perspective that embraced the strengths and resilient nature o f g r i e v i n g i n d i v i d u a l s and families.  A s s u m p t i o n s U n d e r p i n n i n g the S t u d y T h i s research was based on the f o l l o w i n g assumptions: 1. I n d i v i d u a l f a m i l y members possess innate healing capabilities w h i c h they c a n draw u p o n d u r i n g times o f hardship (e.g., y o u t h s u i c i d e ) . 2. T h e process o f h e a l i n g can be studied. Further, it was assumed that f a m i l y s u r v i v o r s are the best sources o f data to describe and, hence, promote an understanding o f the i n d i v i d u a l h e a l i n g process following youth suicide. 3. T h e perceptions and ideas o f all f a m i l y members are relevant and therefore contribute to the development o f theory about healing i n i n d i v i d u a l f a m i l y members f o l l o w i n g y o u t h suicide.  C o n c e p t u a l Issues A s I a p p r o a c h e d this study, t w o issues soon became apparent. F i r s t , d u r i n g the conceptualization o f this research study, I intended to study the concept o f ' f a m i l y h e a l i n g . ' H o w e v e r , the study was w e l l underway w h e n I d i s c o v e r e d that although f a m i l y s u r v i v o r s were attuned to the thoughts and feelings o f other f a m i l y members, they were o n l y able to reflect on their personal experiences. A s I i n d i v i d u a l l y i n t e r v i e w e d several s u r v i v o r s f r o m the same f a m i l y , I began to understand that each person had a personal and unique story to tell that sometimes  Healing Within Families  15  differed f r o m the stories shared b y other f a m i l y members. E v e n d u r i n g f a m i l y i n t e r v i e w s , the i n d i v i d u a l perspective, albeit shared f r o m several vantage points, was still evident. I therefore considered that each story represented a unique understanding that contributed to a comprehensive understanding o f the w h o l e . S i n c e this approach offered m u c h insight pertinent to the research questions, and because l i m i t e d scientific research specific to h e a l i n g w i t h i n this p o p u l a t i o n has been c o n d u c t e d to date, I decided, i n consultation w i t h m y dissertation committee, to focus this research o n the experience o f the i n d i v i d u a l w i t h i n the context o f the f a m i l y . S e c o n d , I w o n d e r e d h o w to best portray an understanding o f s u r v i v o r s ' accounts o f h e a l i n g as a c o m p l e t e process, i n and o f itself, and at the same t i m e , p r o v i d e an understanding o f the intricacies inherent i n the parts c o m p r i s i n g the w h o l e . A s data c o l l e c t i o n and analysis proceeded, I d i s c o v e r e d that the i n d i v i d u a l experience was also c o m p r i s e d o f m a n y parts, each part adding to an understanding o f the e m b o d i e d w h o l e . R a n s o m et a l . (1990) maintains that there is a mutual recursive relationship between i n d i v i d u a l f a m i l y members and the f a m i l y unit that results i n the c o - e v o l u t i o n o f both o v e r time. T h u s , " w e cannot understand w h o l e s w i t h o u t understanding parts and their relationships and v i c e v e r s a " ( R o b i n s o n , 1995b, p. 11). S i m i l a r l y , understanding the i n d i v i d u a l experience also i n v o l v e s g a i n i n g insight about the various facets o f one's experience. B e c a u s e w e k n o w little about h o w the h e a l i n g process occurs, the theory presented herein focuses on the i n d i v i d u a l ' s experience w h i c h is also c o m p r i s e d o f m a n y parts. W i t h i n this dissertation, the i n d i v i d u a l ' s experience o f h e a l i n g is presented i n its parts o n l y for the purpose o f understanding. In reality, the parts c o m p r i s i n g the w h o l e are enmeshed i n a d y n a m i c , recursive, and seamless process. It is anticipated that such k n o w l e d g e w i l l increase our understanding about h o w i n d i v i d u a l s w i t h i n f a m i l i e s heal w h i c h , i n turn, m a y p r o v i d e some insight about h e a l i n g w i t h i n the c o m m u n i t y and ultimately w i t h i n society.  Research Questions T h e f o l l o w i n g four research questions were used to guide this scientific i n q u i r y : 1. W h a t is the m e a n i n g o f y o u t h suicide to i n d i v i d u a l f a m i l y s u r v i v o r s ? W h a t sense, or m e a n i n g , can be made o f the suicide f r o m their perspectives?  Healing Within Families  16  2. F o l l o w i n g youth s u i c i d e , h o w do f a m i l y s u r v i v o r s g r i e v e ? 3. H o w do these same i n d i v i d u a l s engage i n the h e a l i n g process f o l l o w i n g y o u t h s u i c i d e ? S p e c i f i c a l l y , what factors promote healing and what factors i n h i b i t healing? 4. W h a t is the relationship between g r i e v i n g and healing?  Definition of Terms Three concepts are central to the study. T h e y are defined as f o l l o w s : •  Y o u t h S u i c i d e . 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" ( B o l d t , 1988, p. 93) o f a y o u t h aged 10-19.  •  F a m i l y S u r v i v o r s . I n d i v i d u a l s f r o m the deceased's f a m i l y o f o r i g i n i n addition to those identified b y this group as b e i n g part o f the f a m i l y .  •  G r i e v i n g . G r i e v i n g refers to "the full range o f o u r c o p i n g responses to loss through death, i n c l u d i n g , but not c o n f i n e d to, s o c i a l l y defined m o u r n i n g practices, or what w e do w i t h i n ourselves to redefine our relationship w i t h the deceased" ( A t t i g , 1996, p. 9).  Summary T h e health care system has been s l o w to respond to the health care needs o f f a m i l y survivors o f youth s u i c i d e for a n u m b e r o f reasons, some o f w h i c h have not been fully e x p l o r e d as yet. F o r the past few decades, health care professionals have l a u d a b l y f o c u s e d their efforts on youth suicide prevention programs. E v e n so, the i n c i d e n c e o f suicide a m o n g youths continues to soar, s i g n i f y i n g a portentous g l o b a l and national mental and p u b l i c health p r o b l e m . In the aftermath of youth suicide, f a m i l y survivors continue to be deeply affected throughout life. F a m i l y survivors sustain both short- and l o n g - t e r m health and h u m a n consequences as a result o f such trauma. W i t h i n the W e s t e r n w o r l d , the strong influence o f the b i o m e d i c a l m o d e l has resulted i n health care delivery that often emphasizes treatment and cure over humane and compassionate care. Unfortunately, youth suicide f a m i l y survivors often have been left to manage on their o w n w i t h i n a health care system that provides m i n i m a l support and assistance.  Healing Within Families  17  N u r s i n g , w i t h its mandate o f p r o v i d i n g holistic health care to i n d i v i d u a l s and families, can assist i n extending comprehensive health care to bereaved families, i n c l u d i n g families bereft b y youth suicide. T o this end, i n order to facilitate h e a l i n g , it i s important for nurses and other health care professionals to have a theoretical understanding o f h o w i n d i v i d u a l healing occurs. T h i s research was c o n c e r n e d w i t h the development o f theory that explains h o w the i n d i v i d u a l w i t h i n the context o f the f a m i l y m o v e s t o w a r d healing f o l l o w i n g youth suicide. T h i s dissertation is presented i n nine chapters. In C h a p t e r O n e , the b a c k g r o u n d related to 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 youth suicide was established. C h a p t e r T w o provides an o v e r v i e w o f the e m p i r i c a l evidence specific to g r i e v i n g and healing w i t h i n families. Chapter Three is devoted to the m e t h o d o l o g i c a l forestructure, i n c l u d i n g the p h i l o s o p h i c a l , theoretical, a n d personal perspectives o f the researcher, as w e l l as the. method, analytic approach, and ethical considerations that u n d e r p i n this w o r k . I n C h a p t e r F o u r , an o v e r v i e w o f the g r o u n d e d theory is p r o v i d e d i n addition to the contextual factors that influence the healing process. Chapters F i v e to S e v e n are c o n c e r n e d w i t h the presentation o f the theory that was d e v e l o p e d as a result o f data analysis. C h a p t e r F i v e portrays the first theme o f the h e a l i n g process,  Cocooning, w h i c h embraces  the s u r v i v o r ' s j o u r n e y o f descent w i t h i n self. Chapter S i x explicates the s e c o n d theme,  Centering,  w h i c h i l l u m i n a t e s the s u r v i v o r ' s j o u r n e y o f g r o w t h . Chapter S e v e n elucidates the t h i r d theme, Connecting, w h i c h captures the s u r v i v o r ' s j o u r n e y o f transcendence. C h a p t e r E i g h t addresses the relationship between h e a l i n g and g r i e v i n g and enriches the description o f 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 i m p l i c a t i o n s o f the research.  Healing Within Families  18  CHAPTER TWO E M P I R I C A L E V I D E N C E SPECIFIC T O GRIEVING A N D H E A L I N G WITHIN FAMILIES F a m i l y survivors o f youth suicide are often left to carry on w i t h day-to-day life at a time w h e n they m a y feel that their w o r l d , as they once k n e w it, has been turned i n s i d e out and upside d o w n . T h e death o f a f a m i l y youth due to suicide m a y represent m a n y things to f a m i l y s u r v i v o r s — the loss o f a c h i l d , the loss o f o n e ' 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 f a m i l y members undergo an extensive p e r i o d o f g r i e v i n g as they j o u r n e y t o w a r d healing. A thorough examination o f the literature p r o v i d e d m i n i m a l scientific evidence specific to h e a l i n g w i t h i n families f o l l o w i n g y o u t h suicide. H o w e v e r , g r i e v i n g , an important aspect o f healing, has been studied extensively. S i n c e this study is located w i t h i n the d o m a i n o f g r i e v i n g families, this chapter highlights current k n o w l e d g e related to g r i e v i n g w i t h i n the context o f the f a m i l y . It also identifies a gap w i t h i n the current literature. T h e f o l l o w i n g topics are discussed: the concept o f g r i e v i n g , traditional and contemporary theories o f g r i e v i n g , g r i e v i n g w i t h i n families, research and practice issues, g r i e v i n g f o l l o w i n g suicide, the m e a n i n g o f s u i c i d e , and also a b r i e f description o f the e m p i r i c a l l y - b a s e d literature that addresses the concept o f healing.  The Concept of Grieving T h e study o f g r i e v i n g is relatively n e w . F r e u d began the analysis o f the concept w h e n he c o m p a r e d the subjective experience o f grief to the experience o f m e l a n c h o l i a ( B u r n e l l & B u r n e l l , 1989; H a i g , 1990; W o r d e n , 1982). H e proposed that the p r i m a r y difference between the t w o was that one experiences an extreme loss o f self-esteem and a persistent sense o f self-denigration o n l y i n m e l a n c h o l i a ( H a i g , 1990). Later, i n a classic study o f s u r v i v o r reactions to a fire i n the C o c o n u t G r o v e nightclub i n B o s t o n , L i n d e m a n n (1944) described g r i e v i n g a c c o r d i n g to a predictable pattern a c c o m p a n i e d b y certain identifiable reactions to loss ( B u r n e l l & B u r n e l l , 1989). These early conceptualizations o f the concept o f g r i e v i n g p r o v i d e d the basis for further study. V a r i o u s definitions o f 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 l n e s s ( E n g l e , 1961; V o l k a n , 1970); an acute crisis or series o f  Healing Within Families  19  crises ( C a p l a n , 1974; L i n d e m a n n , 1944); an indirect pathogen (Sanders, 1982-1983); a s y n d r o m e ( L i n d e m a n n , 1944; P a r k e s , 1972); and as an active l e a r n i n g process ( A t t i g , 1991, 1996; F e l d m a n , 1989). Parkes (1970) described g r i e v i n g as "a c o m p l e x and t i m e - c o n s u m i n g process i n w h i c h a person g r a d u a l l y changes his v i e w o f the w o r l d . . . . It is a process o f r e a l i z a t i o n , o f m a k i n g p s y c h o l o g i c a l l y real an external event w h i c h is not desired and for w h i c h c o p i n g plans do not exist" (p. 4 6 5 ) . B a s e d o n a c o m p r e h e n s i v e and systematic r e v i e w o f both current and classic literature, C o w l e s and R o d g e r s (1991) further e x p a n d e d p r e v i o u s definitions o f grief. These authors defined grief as "a d y n a m i c , pervasive, h i g h l y i n d i v i d u a l i z e d process w i t h a strong normative c o m p o n e n t " (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 r o m an awareness that the w o r l d that is and the w o r l d that ' s h o u l d be' are different" (p. 73). M o r e o v e r , our understanding o f this universal p h e n o m e n o n has been i n f l u e n c e d b y both traditional and contemporary v i e w s o f g r i e v i n g .  T r a d i t i o n a l 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 c l a s s i c w o r k , O n Death and D y i n g . K u b l e r - R o s s (1969) categorized the experience of d y i n g into f i v e stages—denial and i s o l a t i o n , anger, b a r g a i n i n g , depression, and acceptance. T h i s ground-breaking b o o k spurred scholars and c l i n i c i a n s to b e g i n a dialogue about death-related topics that continues today. B e c a u s e o f p e r c e i v e d similarities between d y i n g and g r i e v i n g , interested i n d i v i d u a l s extrapolated f r o m K u b l e r - R o s s ' s w o r k other descriptions o f g r i e v i n g . F o r instance, M a r t o c c h i o (1985) described five phases o f g r i e v i n g : shock and disbelief; yearning and protest; anguish, disorganization, and despair; identification i n bereavement; and reorganization and restitution (pp. 3 2 8 - 3 3 1 ) . A v e r i l l (1968) specified three stages o f g r i e v i n g : shock, despair, and recovery, w h i l e Parkes (1970) identified four stages o f g r i e v i n g : n u m b n e s s , p i n i n g (searching b e h a v i o r ) , depression, and r e c o v e r y ( B u r n e l l & B u r n e l l , 1989, p. 34). A n u m b e r o f authors identified the tasks related to g r i e v i n g , specifically: acceptance o f the loss; acceptance o f pain associated w i t h g r i e v i n g ; adjustment to life without the b e l o v e d ; and investment o f energy into a n e w life or relationship ( B u r n e 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 t w o additional tasks designed to promote grief  Healing Within Families  20  adaptation w i t h i n families. These tasks i n c l u d e d a c k n o w l e d g m e n t o f the reality o f the death and sharing o f the experience o f loss, as w e l l as reorganization o f the f a m i l y system and reinvestment in other relationships and life pursuits. W e i s s (1988, c i t e d i n H a i g , 1990) p r o p o s e d three steps i n the adaptation to loss: cognitive acceptance, emotional acceptance, and identity change. M o s t o f the literature describes g r i e v i n g as a m u l t i - p h a s e d process based o n c o m m o n assumptions. T r a d i t i o n a l theorists r e c o g n i z e d the p h y s i c a l , e m o t i o n a l , b e h a v i o r a l , and p s y c h o l o g i c a l aspects o f the g r i e v i n g process. They, responded b y s p e c i f y i n g several parameters o f the g r i e v i n g experience. These theorists e n v i s i o n e d g r i e v i n g as a linear and progressive p h e n o m e n o n i n w h i c h the bereaved i n d i v i d u a l passively m o v e s through a series o f stages or phases that begins at the time o f loss and ends at some definitive point i n the future. G r i e v i n g was v i e w e d "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 , w h i c h they undergo or endure, and w h i c h they must s o m e h o w s u r v i v e " ( A t t i g , 1991, p. 386). T r a d i t i o n a l theories often labeled aberrant manifestations o f grief as p a t h o l o g i c a l . S u c h l a b e l i n g has not a l w a y s been helpful i n terms o f securing needed help for g r i e v i n g i n d i v i d u a l s and f a m i l i e s .  Underlying Assumptions It has been suggested that conceptualizations o f g r i e v i n g are most l i k e l y related to assumptions that underpin the development o f k n o w l e d g e ( W a m b a c h , 1986). H o g a n and D e S a n t i s (1992) contend that the major assumptions underpinning the traditional v i e w s o f g r i e v i n g and bereavement are d e r i v e d f r o m m u l t i p l e perspectives. U n d e r s t a n d i n g the assumptions u p o n w h i c h theories o f g r i e v i n g are based is essential to determining their efficacy i n the practice setting. B a s e d on W e s t e r n tradition, five assumptions prominent w i t h i n the literature o n g r i e v i n g are: 1. distress or depression is inevitable; 2. distress is necessary, and failure to experience distress is i n d i c a t i v e of p a t h o l o g y ; 3. w o r k i n g through loss is not o n l y important, but necessary; 4. r e c o v e r y f r o m loss w i l l occur; and 5. resolution o f grief w i l l be attained ( W o r m i a n & S i l v e r , 1989). H o w e v e r , these authors c l a i m that e m p i r i c a l evidence suggests that h a r m m a y result i f w e practice according to these m i s t a k e n assumptions.  Healing Within Families  21  T h e majority o f traditional theories o f g r i e f are, i n fact, based o n these assumptions ( B o w l b y - W e s t , 1980; E l i o t , 1932; F r e u d , 1915; K u b l e r - R o s s , 1969; L i n d e m a n n , 1944; Parkes & W e i 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 i n d i c a t e d b y W o r t m a n and S i l v e r (1989), " T r a d i t i o n a l theories o f grief and loss are able to account for those w h o m o v e f r o m h i g h to l o w distress and resolve their grief over time. B u t these theories offer little explanation o f w h y some people m i g h t consistently respond w i t h less distress than expected and others fail to recover or resolve their loss over time" (p. 353).  C o n t e m p o r a r y 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 C o n t e m p o r a r y theorists question traditional interpretations o f g r i e v i n g ( A r n o l d , 1996; C o p p , 1998; C o w l e s & R o g e r s , 1 9 9 1 ; D o y l e , 1994; K l a s s , S i l v e r m a n , & N i c k m a n , 1996; R a n d o , 1988; Stroebe, 1 9 9 2 - 1 9 9 3 ; Stroebe, V a n D e n B o u t , & Schut, 1994). T h e s e authors m a i n t a i n that g r i e v i n g is a d y n a m i c rather than linear process ( C o w l e s & R o g e r s , 1991) w h i c h is "oscillatory i n nature rather than p u r e l y sequential" ( T r u n n e l l , Caserta, & W h i t e , 1992, p. 279). Instead o f f o l l o w i n g clearly demarcated steps as proposed i n the stage and phase m o d e l s o f linear and c y c l i c a l g r i e v i n g ( W o r t h i n g t o n , 1994), reactions to loss m a y ebb a n d f l o w o v e r an u n s p e c i f i e d p e r i o d o f time. T h i s i m p l i e s a certain c h r o n i c i t y o f the g r i e v i n g process ( H a y l o r , 1987) or, as stated b y Parkes (1970), " i n some senses it [grieving] never ends" (p. 4 6 4 ) . H o w e v e r , e v e n though some authors suggest that the impact o f g r i e v i n g m a y be long-lasting, there is surprisingly little e m p i r i c a l data to support this c l a i m ( L e h m a n , W o r t m a n , & W i l l i a m s , 1987). A t t i g ' s m o d e l o f g r i e v i n g (1996), i n contrast to traditional m o d e l s , describes g r i e v i n g as an active c o p i n g process o f h o w to be and act i n a w o r l d where loss disrupts the i n d i v i d u a l ' s biography. A s a multifaceted transitional process, g r i e v i n g i n v o l v e s i n v e s t i n g ourselves as w h o l e persons i n a process o f relearning our w o r l d i n the absence o f our l o v e d one. A t t i g suggests that grief is not something w e get over, but learn to integrate w i t h i n our l i v e s . H e contends that w e do not cease l o v i n g those w h o die. Rather, A t t i g (1996) maintains that "one o f the most important aspects o f g r i e v i n g is f i n d i n g w a y s to m a k e a transition f r o m c a r i n g about others w h o are present to c a r i n g about t h e m w h e n they are absent" (p. 39). B a s e d on current research, a n u m b e r o f other  Healing Within Families  22  contemporary theorists support this v i e w o f g r i e v i n g ( K l a s s , S i l v e r m a n , & N i c k m a n , 1996; Rosenblatt, 1996; S i l v e r m a n & N i c k m a n , 1996a, 1996b; Stroebe, G e r g e n , G e r g e n , & Stroebe, 1996). A l t h o u g h representing the v i e w s o f a m i n o r i t y at present, the romanticist notion that values b o n d i n g w i t h the deceased person is b e i n g r e v i v e d . T h i s v i e w presents a case for the healthy presence o f the deceased person i n the o n g o i n g l i v e s o f s u r v i v o r s ( K l a s s , S i l v e r m a n , & 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 m a i n t a i n that the expectation that people s h o u l d get o v e r their grief is unrealistic and based on a misunderstanding o f the g r i e v i n g process ( K l a s s , S i l v e r m a n , & N i c k m a n , 1996; Rosenblatt, 1996; S i l v e r m a n & N i c k m a n , 1996a; Stroebe, G e r g e n , G e r g e n , & Stroebe, 1996). A g r o w i n g n u m b e r o f researchers a n d c l i n i c i a n s n o w contend that g r i e v i n g a major loss extends throughout the life o f the bereaved i n d i v i d u a l ( H o g a n & D e S a n t i s , 1996; Rosenblatt, 1996; S i l v e r m a n & N i c k m a n , 1996a; K l a u s s , S i l v e r m a n , & N i c k m a n , 1996). S i l v e r m a n and N i c k m a n (1996b) assert that survivors maintain a " c o n t i n u i n g b o n d " (p. 349) w i t h the deceased; they profess that " s u r v i v o r s h o l d the deceased i n l o v i n g m e m o r y for l o n g periods, often forever, and that m a i n t a i n i n g an inner representation o f the deceased is n o r m a l rather than a b n o r m a l " (p. 349). B a s e d on contemporary ideas o f g r i e v i n g , M a r t i n and E l d e r ' s (1993) P a t h w a y s T h r o u g h G r i e f M o d e l provides an explanation o f i n d i v i d u a l g r i e v i n g . T h i s m o d e l is based o n the w o r k o f B o w l b y (1973) w h o maintains that attachment precedes grief. S e v e r a l assumptions underpin this m o d e l , specifically: g r i e v i n g is triggered b y l o s i n g someone important; g r i e v i n g affects the total person w i t h i n the context o f the present and past; g r i e v i n g occurs throughout life and thus is a process rather than an event; and g r i e v i n g changes over time w i t h n o e n d point ( M a r t i n & E l d e r , 1993). M a r t i n and E l d e r ' s m o d e l portrays the unending nature o f g r i e v i n g i n addition to the contextual influences that affect i n d i v i d u a l g r i e v i n g . M o s t theories o f g r i e v i n g to date focus o n the i n d i v i d u a l perspective. I n d i v i d u a l g r i e v i n g is i n f l u e n c e d b y a n u m b e r o f factors.  Healing Within Families  23  Influencing Factors M a n y contemporary theorists contend that i n d i v i d u a l g r i e v i n g is i n f l u e n c e d b y a number o f contextual factors. W o r d e n (1982) identified several factors that affect h o w one grieves. O n e factor is the identity o f the deceased person i n relation to the g r i e v i n g i n d i v i d u a l . I f the deceased i n d i v i d u a l was a c h i l d or spouse, the grief response is stronger than it is for a distant relative. T h e strength and security o f the relationship between the deceased i n d i v i d u a l and the bereaved person is an important factor as w e l l . I f there was a m b i v a l e n c e i n the relationship, g r i e v i n g is often difficult. W h e t h e r the death is expected or unexpected, p r o l o n g e d or sudden, h o m i c i d a l or s u i c i d a l also determines h o w the s u r v i v o r grieves. D e a t h that is sudden and/or unexpected, or that occurs as a result o f s u i c i d e , p r o v o k e s p r o l o n g e d , difficult grief (Steen, 1998). T h e health history o f the g r i e v i n g person also plays a role i n the g r i e v i n g experience. A diagnosis o f c l i n i c a l depression or mental illness m a y c o m p l i c a t e g r i e v i n g for s u r v i v o r s . T h e nature o f p r e v i o u s losses and the w a y i n w h i c h these losses were dealt w i t h modifies subsequent grief experiences. I f the bereaved i n d i v i d u a l was unable to grieve for previous losses, then a n e w loss m a y e l i c i t a previous grief response and, therefore, c o m p o u n d the present grief experience. T h e personal characteristics o f the bereaved are important as w e l l . T h e bereaved person's age, sex, c o p i n g s k i l l s , l e v e l o f anxiety, and whether he or she is an introvert or extrovert affect the grief experience. O l d e r people often have an advantage because they have d e v e l o p e d c o p i n g skills that assist t h e m i n g r i e v i n g . Y o u n g e r people do not expect to be faced w i t h the death o f a l o v e d one and, hence, m a y l a c k w e l l d e v e l o p e d coping skills. B e s i d e s those determinants identified b y W o r d e n (1982), s o c i a l support has also been identified as an important factor that influences g r i e v i n g (Gass & C h a n g , 1989; M a r t i n & E l d e r , 1993). A supportive social n e t w o r k and adequate financial support aids the g r i e v i n g person. H i g h e r education also m a y impact the course o f grief. T h o s e w i t h higher levels o f education tend to utilize more p r o b l e m - f o c u s e d c o p i n g strategies (Gass & C h a n g , 1989) w h i c h facilitate healthy p s y c h o s o c i a l functioning. In addition, h a v i n g someone available to participate i n appropriate death rituals p o s i t i v e l y influences the g r i e v i n g person's adjustment to the death o f a l o v e d one ( M y s s , 1996, 1997; R o s e n , 1990). I f the g r i e v i n g person believes that he/she is totally or e v e n partially  Healing Within Families  24  responsible for the death o f a l o v e d one, then g r i e v i n g m a y be more difficult. T h e existence o f other major crises i n the g r i e v i n g person's life m a y also c o m p o u n d g r i e v i n g . C o n t e x t u a l factors such as ethnic, cultural, and r e l i g i o u s beliefs are critical determinants o f the g r i e v i n g experience ( C o w l e s , 1996; R o s e n , 1990; Stroebe, 1992-1993). T h e s e beliefs are based o n certain assumptions. F o r e x a m p l e , Stroebe (1992-1993) contends that the grief w o r k hypothesis, w h i c h stresses the importance o f bereaved persons c o m p l e t i n g their grief w o r k , has been neither c o n f i r m e d nor refuted as a result o f e m p i r i c a l studies. Rather than assuming that a l l people grieve i n the same w a y , Stroebe (1992-1993) maintains that there are societal and cultural factors, and preferred styles o f c o p i n g w i t h loss that need to be taken into account. Stroebe (19921993) asserts that "not o n l y do beliefs i n some societies fail to s h o w any equivalent o f the grief w o r k hypothesis, but an absence o f grief w o r k i n some cultures does not seem to be associated w i t h [a] h i g h [incidence of] depression, i l l n e s s , or p a t h o l o g y " (p. 28). R o s e n (1990) suggests that w h e n f a m i l i e s do not observe the appropriate ethnic/cultural rituals o f m o u r n i n g , their g r i e v i n g m a y be affected b y deep-seated beliefs based on their ethnic b a c k g r o u n d . A reaction that appears to be denial or an absence o f grief m a y , i n reality, be a c u l t u r a l l y - m e d i a t e d grief response (e.g., the Irish w a k e or the N e w Orleans up-beat j a z z m a r c h d u r i n g the return f r o m the interment). Current theoretical perspectives recognize g r i e v i n g as an i n d i v i d u a l l y unique experience; hence, g r i e v i n g unfolds a c c o r d i n g to each i n d i v i d u a l ' s w a y o f b e i n g i n the w o r l d . R e c e n t conceptualizations also a c k n o w l e d g e both the inner and outer w o r k that are required o f the g r i e v i n g i n d i v i d u a l , the continuity and fluidity o f the grief experience o v e r time, and especially, the importance o f creating n e w m e a n i n g i n response to the suffering associated w i t h the loss ( A t t i g , 1991, 1996; K l a s s , S i l v e r m a n , & N i c k m a n , 1996; M a r t i n & E l d e r , 1993).  Grieving Within Families W h i l e a substantial amount of conceptual and e m p i r i c a l research has been conducted on i n d i v i d u a l g r i e v i n g , the literature that addresses g r i e v i n g f r o m the perspective o f the f a m i l y remains scarce i n both quantity and scope ( K i s s a n e & B l o c h , 1994). A majority o f this literature focuses on maladaptation and pathology. H o w e v e r , w h i l e this literature is not specific to g r i e v i n g associated  Healing Within Families  25  w i t h y o u t h suicide, it does p r o v i d e the necessary b a c k g r o u n d needed to understand g r i e v i n g , and hence, g r i e v i n g f a m i l i e s as the context for i n d i v i d u a l s ' experiences o f g r i e v i n g . W i t h i n the structure o f the f a m i l y unit, f a m i l y members o c c u p y certain "roles." T h e death (i.e., suicide) o f a f a m i l y m e m b e r calls for the reorganization o f the f a m i l y unit. A c c o r d i n g to V o l l m a n , Ganzert, P i n c h e r , and W i l l i a m s (1971), "the single most important factor i n the reorganization o f a f a m i l y as a c o n t i n u i n g social system f o l l o w i n g a death is the role the decedent had been assigned and w h i c h he [or she] assumed w i t h i n the f a m i l y system" (p. 104). S i m i 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 a m i l y m e m b e r w h o s e role was "emotionally" or "materially" critical is f o l l o w e d b y greater f a m i l y disruption than the loss o f a comparatively neutral f a m i l y member. H e n c e , it f o l l o w s that youth suicide is e x c e e d i n g l y disruptive to f a m i l i e s , both i n d i v i d u a l l y and c o l l e c t i v e l y . N o t a b l e contributions to the literature related to g r i e v i n g w i t h i n the context o f the f a m i l y have been made b y B o w l b y - W e s t (1980), L i e b e r m a n and B l a c k (1982), and R a p h a e l (1984). B o w l b y - W e s t (1980) identifies six maladaptive responses that f a m i l i e s resort to i n order to cope w i t h the death o f a f a m i l y member. R a p h a e l (1984) describes seven patterns o f f a m i l y responses to loss that are often subtle i n presentation and m a y be either constructive or destructive. L i e b e r m a n and B l a c k (1982) address the interplay between i n d i v i d u a l and f a m i l y responses to loss. T h e y identify three categories o f p a t h o l o g i c a l f a m i l y g r i e v i n g , specifically: avoidance, i d e a l i z a t i o n , and p r o l o n g a t i o n . These authors suggest that these response patterns p a r a l l e l , and i n d e e d a m p l i f y , those encountered i n i n d i v i d u a l g r i e v i n g . Further, K i s s a n e and B l o c h (1994) maintain that unresolved grief cannot be dealt w i t h until issues related to f a m i l y dysfunction are addressed. In addition, multi-generational loss issues m a y further c o m p o u n d g r i e v i n g w i t h i n f a m i l i e s ( B . S h a w a n d a , personal c o m m u n i c a t i o n , M a y 2 8 , 1998). T h i s refers to u n r e s o l v e d loss issues inadvertently passed d o w n f r o m one generation to the next. In a v e r y real sense then, g r i e v i n g needs to be understood f r o m a f a m i l y perspective, e s p e c i a l l y i n cases where dysfunction is present. These explanations o f f a m i l y grief response patterns i n f o r m us that p o w e r f u l and pervasive w a y s o f c o p i n g w i t h loss m a y be quite w e l l established w i t h i n the f a m i l y unit at the time o f youth  Healing Within Families  26  suicide. M o r e o v e r , f a m i l y responses to death are often predicated o n previous l e a r n i n g , c o m m o n l y handed d o w n f r o m p r e v i o u s generations. N o t s u r p r i s i n g l y , A i n s w o r t h and E i c h b e r g (1991) suggest that a significant correlation exists between patterns o f parental attachment b e h a v i o r (e.g., secure-autonomous, insecure-avoidant) and the quality o f attachment f o u n d i n c h i l d r e n . M o r e o v e r , the concept o f f a m i l y script ( B y n g - H a l l , 1988, 1991) incorporates the beliefs, values, and rules w i t h i n the f a m i l y unit that encode the family's b e h a v i o r for future situations. S u c h crossgenerational influences suggest that families adopt styles o f g r i e v i n g that are r e a d i l y transmitted to subsequent generations, either overtly or c o v e r t l y . A n u m b e r o f research and practice issues influence our understanding o f this c o m p l e x p h e n o m e n o n .  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 a m b i g u i t y is related to the plethora o f definitions o f grief-related terms f o u n d w i t h i n the literature, as w e l l as the l a c k o f clarity regarding operational definitions. In addition, research efforts to i l l u m i n a t e the m u l t i d i m e n s i o n a l aspects o f grief and the issue o f researchers w o r k i n g i n isolation contribute to this c o n f u s i o n . A n awareness o f the c o m p l e x nature o f g r i e v i n g is essential to research that endeavors to understand h o w f a m i l y survivors grieve and m o v e t o w a r d healing f o l l o w i n g y o u t h s u i c i d e . E v e n a m o n g experts, there is a conspicuous l a c k o f consensus r e g a r d i n g the definition o f grief (Burnett et a l . , 1994). In spite o f b e i n g a " u n i v e r s a l h u m a n response" ( C o w l e s and R o d g e r , 1991, p. 119), the concept o f grief remains p l a g u e d b y vagueness and a m b i g u i t y . In addition to a lack o f consensus regarding definitional clarity, terms l i k e grief, bereavement, and m o u r n i n g are often used interchangeably, and without explanation o f operational definitions ( M i d d l e t o n , M o y l a n , R a p h a e l , Burnett, & M a r t i n e k , 1993). T h i s d e f i c i e n c y makes it very difficult to understand and compare, the research that has been done because o f uncertainty about whether the studies are actually l o o k i n g at the same things. S u c h variation a m o n g definitions most l i k e l y depicts the diverse d i s c i p l i n a r y b a c k g r o u n d o f the m a n y professionals i n v o l v e d i n bereavement care. Furthermore, these definitions appear to reflect an e v o l v i n g understanding o f the concept o f  Healing Within Families  27  grief w h i c h is not yet f u l l y developed. I n an attempt to address this d e f i c i e n c y , J a c o b (1993) offers an operational definition o f grief as "a n o r m a l , d y n a m i c , i n d i v i d u a l i z e d process w h i c h pervades each aspect ( p h y s i c a l , e m o t i o n a l , s o c i a l , spiritual) o f persons e x p e r i e n c i n g the loss o f a significant other" (p. 1789). C l a r i f i c a t i o n o f this type is definitely h e l p f u l and serves as a first step t o w a r d the resolution o f concerns associated w i t h definitional clarity. D e f i n i t i o n a l fuzziness or ambiguity m a y also be related to efforts intended to capture the m u l t i d i m e n s i o n a l quality o f the grief experience. A c c o r d i n g to Jacob (1993), "the m u l t i d i m e n s i o n a l i t y o f the grief process makes an accurate assessment o f the concept difficult. . . . T h i s difficulty is largely due to the i n d i v i d u a l and d y n a m i c nature o f grief w h i c h varies f r o m person to. person and f r o m situation to situation" (p. 1791). E v e n research measurement instruments such as the G r i e f E x p e r i e n c e Inventory (Sanders, M a u g e r , & Strong, 1985), d e v e l o p e d to objectively measure the m u l t i d i m e n s i o n a l aspect o f grief, have limitations i n that they have been developed i n reference to specific populations and a c c o r d i n g to certain assumptions that do not, and cannot, address a l l possible variations i n relation to a h i g h l y c o m p l e x 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. A n o t h e r factor that contributes to the a m b i g u i t y surrounding grief is that researchers and c l i n i c i a n s often w o r k i n i s o l a t i o n and, as a result, r e l y on their o w n f a m i l i a r t e r m i n o l o g y w h e n c o m m u n i c a t i n g research findings. T h i s m a y be particularly problematic i n written c o m m u n i c a t i o n where assumptions m a y not be clearly identified. Further c o m p l i c a t i n g this situation, research consumers frequently interpret written information a c c o r d i n g to their o w n set o f assumptions w h i c h m a y , or m a y not, be congruent w i t h those intended b y the author. T o enhance k n o w l e d g e development, assumptions need to be clearly stated and definitions need to be clarified at the onset o f a study i f efforts to develop a comprehensive data base regarding grief are to be realized. T h e generation o f k n o w l e d g e related to the topic o f grief is dependent o n researchers and c l i n i c i a n s b e i n g able to effectively c o m m u n i c a t e the assumptions u p o n w h i c h their research is based.  Healing Within Families  28  Grieving Following Suicide Sudden and unexpected death has a dramatic effect o n g r i e v i n g . M a r t o c c h i o (1985) asserts that "Death is a l w a y s difficult but premature death disrupts the n o r m a l c y c l e o f events" (p. 334). B a s e d on a research study that e x a m i n e d the long-term adjustment to sudden, traumatic loss o f a l o v e d one (spouse o r c h i l d ) , the results suggest that "sudden, u n e x p e c t e d loss o f a spouse or c h i l d is associated w i t h l o n g - t e r m distress" ( L e h m a n et a l . , 1987, p. 2 2 7 ) . V a r g a s (1991) f o u n d four prominent factors i n f a m i l y s u r v i v o r s o f sudden a n d unexpected death, s p e c i f i c a l l y : 1. depressive s y m p t o m s (most c o m m o n ) ; 2. preservation o f the deceased person; 3. s u i c i d a l ideation; and 4. anger directed t o w a r d the deceased (p. 36). D e a t h b y suicide is a traumatic event. Judith H e r m a n (1992) describes the impact o f traumatic events this w a y : T r a u m a t i c events o v e r w h e l m the ordinary systems o f care that g i v e people a sense o f c o n t r o l , c o n n e c t i o n , and m e a n i n g . T r a u m a t i c events are extraordinary, not because they o c c u r rarely, but because they o v e r w h e l m the ordinary h u m a n adaptations to life. . . . T h e y confront h u m a n beings w i t h the extremities o f helplessness a n d terror a n d e v o k e the responses o f catastrophe, (p. 33) S e l f - i n f l i c t e d death poses specific p r o b l e m s for f a m i l y s u r v i v o r s . S i l v e r m a n , R a n g e , and O v e r h o l s t e r (1994-95) suggest that suicide s u r v i v o r s experience unique g r i e f responses and, i n some cases, m a y be unable to fully resolve their grief. A c c o r d i n g to these authors, g r i e v i n g f o l l o w i n g s u i c i d e is m o r e intense than f r o m other causes o f death (e.g., h o m i c i d e , accidental death, natural anticipated death, natural unanticipated death). In addition, s u r v i v o r s face the difficulty o f constantly feeling the need to e x p l a i n the reason(s) for their l o v e d one's tragic demise (Range & C a l h o u n , 1990). U n f o r t u n a t e l y , s u r v i v o r s o f suicide are m o r e l i k e l y to assume r e s p o n s i b i l i t y for a l o v e d one's death a n d they frequently experience an increased fear o f their o w n self-destructive impulses ( W o r d e n , 1982). U l t i m a t e l y , the suicide o f a f a m i l y y o u t h m a y draw the entire f a m i l y into distress. M o r e o v e r , the j o i n t experience o f suffering m a y render f a m i l y members unable to p r o v i d e m u c h needed support to one another ( V a c h o n & S t y l i a n o s , 1988).  Healing Within Families  29  In c o m p a r i s o n to all other types o f death, suicide survivors receive the least amount o f c o m m u n i t y support (Range & C a l h o u n , 1990; T h o m p s o n & R a n g e , 1992-93). B e c a u s e h a v i n g a supportive n e t w o r k makes a positive difference i n terms o f c o p i n g w i t h loss, a l a c k o f social support leaves g r i e v i n g families i n a c o m p r o m i s e d position. S o c i e t a l attitudes t o w a r d suicide and related perceptions o f bereaved f a m i l y members suggest that friends w i l l not 'be there' to the same degree and i n the same w a y s that they w o u l d f o l l o w i n g other types o f deaths ( T h o r n t o n , W h i t t e m o r e , & R o b e r t s o n , 1989). In the apt w o r d s o f D a v i e s (1991), " W o r k i n g through grief does require the encouragement, empathy, support and c a r i n g g a i n e d through relationships w i t h significant others" (p. 94). A l a c k o f social support m a y also have far-reaching consequences, not o n l y for i n d i v i d u a l s and families but, ultimately, for c o m m u n i t i e s and society.  The Meaning of Suicide T h e full i m p a c t o f youth suicide occurs w i t h i n the context o f the g r i e v i n g f a m i l y . M a k i n g sense out o f the experience o f youth suicide is, indeed, a major challenge faced b y f a m i l y survivors. S u r v i v o r s o f suicide suffer m o r e than those bereaved b y other causes o f death i n that they are often unable to f i n d m e a n i n g i n their suffering ( S i l v e r m a n et a l . , 1994-95). A n important component o f g r i e v i n g is the construction o f m e a n i n g related to the loss at both the i n d i v i d u a l and f a m i l y levels. A t the i n d i v i d u a l l e v e l , this construction o f m e a n i n g m a y entail "understanding the bereaved's history; w h o the l o v e d one was; what that person meant to the s u r v i v o r ; h o w 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 f a m i l y l e v e l , the construction o f m e a n i n g m a y i n v o l v e c o m i n g to terms w i t h the p h y s i c a l absence o f the deceased person on a day-to-day basis; the reorganization o f the f a m i l y unit; understanding the m e a n i n g o f the loss and its impact on the f a m i l y unit; and c o n t i n u i n g w i t h f a m i l y 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 m e a n i n g on three levels: 1. m e a n i n g related to the stress-inducing situation; 2. m e a n i n g related to f a m i l y identity; and 3. m e a n i n g related to the f a m i l y m e m b e r ' s v i e w o f the f a m i l y . F a m i l y identity emerges i n response to values, beliefs, and relationships shared a m o n g f a m i l y m e m b e r s . Stressful situations (e.g., y o u t h  Healing Within Families  30  suicide) h o l d c o g n i t i v e and subjective m e a n i n g for f a m i l y members. Often f a m i l y members cope w i t h stressful situations by c h a n g i n g their perceptions i n regard to their circumstances. F a m i l y identity m a y be threatened d u r i n g stressful situations. H e n c e , f a m i l y m e m b e r s m a y purposefully focus on the inherent opportunities for growth rather than the difficulties they encounter i n such situations. T h e f a m i l y m e m b e r ' s w o r l d v i e w , or W e l t a n s c h a u u n g , is the most e n d u r i n g characteristic of the f a m i l y , but it too can change i n response to a non-normative crisis. T h i s aspect o f m e a n i n g encompasses the f a m i l y m e m b e r ' s perception o f reality: it is based on existential beliefs (e.g., the purpose o f the f a m i l y as a unit), assumptions about the environment, i n addition to cultural and religious beliefs. W h e n both the w o r l d v i e w o f f a m i l y members and the identity o f the f a m i l y as a unit are c h a l l e n g e d or altered, the f a m i l y is e s p e c i a l l y vulnerable (Patterson, 1995). I f a resolution does not o c c u r i n such situations, the f a m i l y m a y even d i s s o l v e . Several authors maintain that any attempt to understand the i m p a c t o f suicide on the i n d i v i d u a l and f a m i l y must take into account the socio-cultural m e a n i n g o f suicide ( B a l k , 1994; B o l d t , 1988; G a r t r e l l , Jarvais, & D e r k s e n , 1993; K r a i , 1994; V a n D o n g e n , 1993). G i v e n that the m e a n i n g o f suicide is i n f l u e n c e d b y socio-cultural values and beliefs, these aspects need to be e x p l o r e d w i t h i n d i v i d u a l s and families i n an attempt to understand the m e a n i n g they ascribe to their experiences ( M . B o l d t , personal c o m m u n i c a t i o n , M a r c h 16, 1997). I n o w turn to address the concept o f healing.  The Concept of Healing D u r i n g the last decade, the concept o f " h e a l i n g " has been m e n t i o n e d i n the health care literature (e.g., B r o o k e , 1995; D o s s e y , 1995; F r i s c h & K e l l e y , 1996; H e r r u c k , 1992; K a h n & S a u l o , 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 w i t h i n c r e a s i n g frequency. T h i s " h e a l i n g c o n s c i o u s n e s s " ( A c h t e r b e r g , 1990, p. 187) was b o r n out o f the perceived limitations o f the b i o m e d i c a l m o d e l and an emphasis o n current models o f health care that e m p h a s i z e h u m a n potential ( A c h t e r b e r g , 1990, F e r g u s o n , 1980) a n d h e a l i n g ( M y s s , 1996, 1997; W a t s o n , 1999). T h i s interest was also the result o f scientific f i n d i n g s that validate the  Healing Within Families  31  necessity o f addressing the triune nature o f h u m a n k i n d (i.e., b o d y - m i n d - s p i r i t ) i n the p r o m o t i o n o f health and w e l l - b e i n g ( A c h t e r b e r g , 1990; M y s s , 1996, 1997; P e i r c e , 1997; P e n n i n g t o n , 1988; Stokes, 1998; W a t s o n , 1999). A c c o r d i n g to W e b s t e r (1989), " h e a l ' is defined as "to m a k e w h o l e or sound; restore to health" (p. 653). H e a l i n g , s y n o n y m o u s w i t h restoring and o p t i m i z i n g health, is the a i m o f a l l health care d e l i v e r y . In the past, the concept o f h e a l i n g was associated w i t h q u a c k s , evangelists, and others w h o d i d not understand standard allopathic treatment. P r i m a r y interventions w i t h drugs and surgery were used extensively as a means o f treating and c u r i n g i l l n e s s . H e n c e , the p a t h o p h y s i o l o g y o f illness and disease was better understood than health and h e a l i n g ( M y s s , 1997). I n fact, h e a l i n g i n response to personal loss, was often understood f r o m a p a t h o p h y s i o l o g i c a l perspective. E n g e l (1961) l i k e n e d g r i e v i n g to h e a l i n g f r o m an illness or w o u n d , as a passive h a p p e n i n g . I n general, w o u n d h e a l i n g was seen as a m o d e l for h e a l i n g ( W e i l , 1983). W e i l (1983) m a i n t a i n e d that this v i e w can be extended to i n c l u d e the p s y c h i c analog o f w o u n d healing, for e x a m p l e , i n relation to the death o f a l o v e d one: There is the same initial shock and intense p a i n that c l a i m s a l l attention and totally shatters o n e ' s e q u i l i b r i u m . T h e r e is a f l o o d o f e m o t i o n , perhaps the p s y c h i c analog o f b l e e d i n g , and w i t h time and n o r m a l g r i e v i n g the gradual but steady development o f scab and scar [evidence o f trauma], the regeneration o f positive feelings, and adaptation to the loss. T h e w o u n d m a y ache o n o c c a s i o n , even years later, but it is then an o l d w o u n d , a healed one, n o longer a threat to e q u i l i b r i u m , (p. 68) W e i l (1983) v i e w e d healing as a universal property o f a l l creation c o m p o s e d o f three distinct components or phases i n c l u d i n g reaction, regeneration, and adaptation. H e maintained that healing depends o n the secret w i s d o m o f the b o d y and that m e d i c i n e can o n l y facilitate healing. W h i l e remnants o f W e i l ' s v i e w persist today, most o f our k n o w l e d g e about the concept o f healing has been gained as a result o f e m p i r i c a l evidence, that is, evidence based o n experience or experiment (Webster, 1989). A c h t e r b e r g (1989, 1990) maintains that our understanding o f the t e r m " h e a l i n g " requires a redefinition w i t h i n the W e s t e r n health care system. Eastern p h y s i c i a n s have been aware o f the  Healing Within Families  32  m i n d ' s h e a l i n g capacity for more than t w o thousand years ( G o l e m a n , 1997). R e c e n t collaboration between Eastern and W e s t e r n thinkers has resulted i n an unprecedented exchange o f ideas about ancient w i s d o m and the m o d e r n quest for wholeness ( G o l e m a n , 1997). A n e v o l v i n g understanding o f the h e a l i n g process is currently underway. D o m b e c k (1995) defines healing as the process o f re-establishing health and w e l l - b e i n g f o l l o w i n g some type o f trauma. H e a l i n g , she purports, is an active and internal process that includes investigating attitudes, memories, and beliefs w i t h the desire to release oneself o f all negative patterns that prevent full emotional and spiritual recovery. T h i s internal r e v i e w inevitably leads the person to recreate his or her life i n a w a y 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 b e g i n to use energy for the creation o f l o v e , self-esteem, and health. A c c o r d i n g to D o m b e c k (1995), " W h a t e v e r the degree o f trauma, the pathways to healing i n v o l v e a s y m b o l i c a w a k e n i n g , a receptivity or hospitality to n e w learnings, and a c o m m i t m e n t to intentionally tend to the practical activities o f healing ( D o m b e c k , 1995, p. 60). O t h e r aspects o f h e a l i n g i n c l u d e " b e i n g restored to health or wholeness, b e i n g aware o f o n e ' s connectedness, and f i n d i n g a sense o f hope, purpose, and d i r e c t i o n i n o n e ' s l i f e " ( D o m b e c k , 1995, p. 40). H e a l i n g is a c c o m p l i s h e d b y releasing inner p a i n , establishing new meanings, restoring integration, and e m e r g i n g into a sense o f r e n e w e d wholeness ( D o m b e c k , 1995). F r a n k l (1984) contends that h e a l i n g i n v o l v e s f i n d i n g m e a n i n g i n suffering. M o r e o v e r , h e a l i n g , a c c o r d i n g to K a t z & St. D e n i s (1991), is v i e w e d as a "transition t o w a r d m e a n i n g , wholeness, connectedness, and balance" (p. 24). Jeanne A c h t e r b e r g (1990), author o f W o m a n A s Healer, contends that a balanced v i e w o f h e a l i n g includes the f o l l o w i n g ideas: 1. H e a l i n g is a l i f e l o n g j o u r n e y t o w a r d wholeness; 2. H e a l i n g is r e m e m b e r i n g what has been forgotten about connection, and unity and independence a m o n g a l l things l i v i n g and n o n - l i v i n g ; 3. H e a l i n g is e m b r a c i n g what is most feared; 4. H e a l i n g is o p e n i n g what has been c l o s e d , softening what has hardened into obstruction; 5. H e a l i n g is entering into the transcendent, timeless m o m e n t w h e n one experiences the d i v i n e ; 6. H e a l i n g is creativity and passion and l o v e ; 7. H e a l i n g is s e e k i n g and expressing self i n its fullness, its l i g h t and shadow, its m a l e and female; and 8. H e a l i n g is learning to trust life (p. 194). T h i s understanding portends that  Healing Within Families  33  healing is p r i m a r i l y concerned w i t h the internal aspect o f the i n d i v i d u a l ' s experience o f a c h i e v i n g health and wholeness. T h e concept o f healing has been mentioned i n popular literature, p r i m a r i l y i n the f o r m o f anecdotal accounts ( A c h t e r b e r g , 1989, 1990; D o s s e y , 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; S u l m a s y , 1997; S w i f t , 1994; V a r g a s , 1991). W i t h i n the last decade, the concept o f h e a l i n g has been f o u n d i n the research literature w i t h i n c r e a s i n g frequency ( D e m i & H o w e l l , 1991; F r a n k , 1995; M y s s , 1996, 1997). M o s t o f these authors m a k e the assumption that readers understand the m e a n i n g o f the term " h e a l i n g . " S e l d o m is a definition o f the term p r o v i d e d i n the literature. H e n c e , confusion still exists about the m e a n i n g o f the concept. C o m m o n l y h e l d beliefs also have an impact on our understanding o f the h e a l i n g process. M y s s (1997) identifies five central myths about healing that can interfere w i t h the person's capacity to m o v e t o w a r d healing. These myths i n c l u d e : 1. M y life is defined b y m y w o u n d ; 2. B e i n g healthy means b e i n g alone; 3. F e e l i n g pain means b e i n g destroyed b y p a i n ; 4. A l l illness is the result o f negativity, and w e are d a m a g e d at our core; and 5. T r u e change is i m p o s s i b l e (pp. 31-53). These m y t h s have p o w e r over the i n d i v i d u a l because "hopeful, o p t i m i s t i c beliefs are about the future, about p o s s i b i l i t i e s , whereas illness is a reality and the m y t h s that support it are i n the present time. H e a l i n g is intangible, but y o u can feel and see y o u r i l l n e s s " ( M y s s , 1997, p. 30). Indeed, these myths about h e a l i n g often keep people f r o m understanding and e x p e r i e n c i n g healing. H e a l i n g has been studied w i t h respect to adult m a l e s u r v i v o r s o f c h i l d h o o d sexual abuse ( B u r k e D r a u c k e r & P e t r o v i c , 1996), breast cancer s u r v i v o r s (Predeger, 1996), s u r v i v o r s o f parent or s i b l i n g s u i c i d e ( D e m i & H o w e l l , 1991), s u r v i v o r s o f suicide ( R o b i n s o n , 1989; S m o l i n & G u i n a n , 1993), and adult female s u r v i v o r s o f incest ( T r u c k e r , 1992). H o w e v e r , the literature revealed no f a m i l y - b a s e d research studies that focus o n h e a l i n g f o l l o w i n g y o u t h suicide. M o r e o v e r , few research studies that focus on g r i e v i n g families are based o n a health p r o m o t i o n p h i l o s o p h y ( A n d e r s o n & Y u h o s , 1993), and even fewer studies are a i m e d at u n c o v e r i n g the resilient capabilities and innate strengths possessed by i n d i v i d u a l g r i e v i n g f a m i l y survivors. T h 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.  Healing Within Families  35  CHAPTER THREE RESEARCH DESIGN AND IMPLEMENTATION  M a n y f a m i l i e s are confronted w i t h the suicide o f a f a m i l y youth each year i n C a n a d a , and the numbers are i n c r e a s i n g (Leenaars et a l . , 1998). U n d e r s t a n d a b l y , the major emphasis i n the past has been on preventive measures, and w h i l e such efforts have been s o m e w h a t successful, m a n y families are still confronted w i t h this p u b l i c health p r o b l e m (Leenaars et a l . , 1998; L o w & A n d r e w s , 1990). W h i l e research shows that f a m i l y members w h o experience y o u t h suicide often experience p r o l o n g e d g r i e v i n g i n addition to short- and long-term health consequences (Ness & Pfeffer, 1990; P a r k e s & B r o w n , 1972; R u d e s t a m , 1992), little emphasis has been f o c u s e d on the strengths and resilient capacities o f these g r i e v i n g persons. S u r p r i s i n g l y little is k n o w n about h o w f a m i l y members engage i n the healing process i n response to youth suicide. H e n c e , i n i t i a l l y the goal o f this study was to generate a substantive theory that explicates h o w i n d i v i d u a l s w i t h i n the context o f the g r i e v i n g f a m i l y heal f o l l o w i n g teen suicide. A qualitative approach, specifically g r o u n d e d theory, was used to d e v e l o p such a theory. T h i s chapter focuses on the p h i l o s o p h i c a l , theoretical, and personal orientations that g u i d e d the methods. T h r e e theoretical perspectives integral to this w o r k are discussed, specifically, s y m b o l i c interactionism, systems theory/family research perspectives, as w e l l as gestalt p s y c h o l o g y / h u m a n i s m . These perspectives i n f l u e n c e d the d e v e l o p m e n t o f the research questions, the m e t h o d o l o g y used to generate theory, and the approach used i n the interpretation o f the findings. S e c o n d , an o v e r v i e w o f the m e t h o d is p r o v i d e d a l o n g w i t h the rationale for its use. T h e study is described i n terms o f the sample p o p u l a t i o n , and procedures used for data c o l l e c t i o n and analysis. Strategies for establishing scientific r i g o r are p r o v i d e d . T h i s chapter concludes w i t h an explanation o f the ethical considerations applied d u r i n g the study.  Methodology C u s h i n g (1994), i n d i s c u s s i n g research about issues c o n n e c t e d w i t h n u r s i n g , defines m e t h o d o l o g y as "the p h i l o s o p h i c a l approach adopted for a n u r s i n g science q u e s t i o n , " and the  Healing Within Families  36  m e t h o d as "the technique used to gather data" (p. 406). G u b a a n d L i n c o l n (1994) contend that questions a n d issues related to the m e t h o d are o f secondary importance to those o f the p h i l o s o p h i c a l perspective o f the researcher. T h a t is, the researcher a l w a y s approaches a study w i t h a particular p h i l o s o p h y o r set o f beliefs. G e n e r a l l y , the subject matter o f p h i l o s o p h y is concerned w i t h the "search for m e a n i n g i n the u n i v e r s e " (Gortner, 1990, p. 101). T h e researcher's p h i l o s o p h y is situated w i t h i n a particular p a r a d i g m or w o r l d v i e w ( G u b a & L i n c o l n , 1994). E a c h p a r a d i g m perspective embraces a certain set o f beliefs that determine the " w h a t " and " h o w " o f scientific i n q u i r y . A p h i l o s o p h y has three components: an o n t o l o g y , an e p i s t e m o l o g y , and an ethic. T h e first t w o components are addressed here, and the third aspect, e t h i c a l considerations, is discussed later i n this chapter. E s s e n t i a l l y , the w a y i n w h i c h k n o w l e d g e is gained is directly related to the p a r a d i g m perspective adopted b y the researcher and the corresponding o n t o l o g i c a l a n d e p i s t e m o l o g i c a l c l a i m s . T h e o n t o l o g i c a l component is concerned w i t h the nature o f reality, that is, whether a " r e a l " w o r l d exists that can be k n o w n (a realist p h i l o s o p h i c a l v i e w p o i n t ) ; or whether reality is assumed to be relative, and thus, constructed by the i n d i v i d u a l (a relativist p h i l o s o p h i c a l position) ( G u b a & L i n c o l n , 1994; S a l s b e r r y , 1994). T h e e p i s t e m o l o g i c a l constituent addresses h o w w e k n o w and learn about p h e n o m e n a that are deemed to be the focus o f study. S p e c i f i c a l l y , e p i s t e m o l o g y is concerned w i t h the relationship between the k n o w e r and what c a n be k n o w n ( G u b a & L i n c o l n , 1994). I n v a r i a b l y , such a relationship is i n f l u e n c e d and/or constrained b y the researcher's o n t o l o g i c a l perspective. R e s e a r c h m e t h o d o l o g y focuses o n h o w an inquirer gains k n o w l e d g e about the research question(s) ( G u b a & L i n c o l n , 1994). It is especially important that the m e t h o d o l o g i c a l c l a i m s and research m e t h o d be congruent w i t h the state o f e x i s t i n g k n o w l e d g e related to the research questions b e i n g asked (Siegel, 1983). T h e m e t h o d can o n l y be determined once the o n t o l o g i c a l and e p i s t e m o l o g i c a l perspectives have been determined. F o r this reason, m y p h i l o s o p h i c a l orientation w i l l be addressed next, f o l l o w e d by the theoretical a n d personal forestructures that I b r i n g to this study.  Healing Within Families  37  P h i l o s o p h i c a l Stance O n t o l o g y addresses o n e ' s beliefs about reality and what can be k n o w n . A s a researcher, m y o n t o l o g i c a l v i e w s are congruent w i t h the relativist p a r a d i g m . A relativist posits that facts and principles are inextricably embedded w i t h i n i n a particular historical and cultural setting ( T i n k l e & B e a t o n , 1992, p. 6 5 4 ) . Further, this p o s i t i o n subscribes to the n o t i o n that "realities are apprehendable i n the f o r m o f m u l t i p l e , mental constructions, s o c i a l l y and experientially based, l o c a l and specific i n nature . . . and dependent for their f o r m and content o n the i n d i v i d u a l persons or groups h o l d i n g the constructions" ( G u b a & L i n c o l n , 1994, p p . 110-111). T h i s p h i l o s o p h i c a l stance v i e w s m e a n i n g as multifaceted and multi-layered. W i t h i n the relativist paradigm, I identify m y s e l f as a constructivist. T h a t is, I h o l d the v i e w that reality is constructed and re-constructed b y the i n d i v i d u a l d u r i n g the course o f his or her life. M o r e o v e r , I b e l i e v e that reality c a n o n l y be k n o w n b y understanding the constructions o f those i n v o l v e d (e.g., g r i e v i n g f a m i l y members) through dialectic discourse. C o n g r u e n t w i t h a relativist ontology, e p i s t e m o l o g i c a l l y m y approach to k n o w l e d g e acquisition is based on transactions w h i c h emphasize the importance o f interaction, context, interpretation, and subjectivity ( C h i n n , 1985; S i l v a & Rothbart, 1984). C o n s e q u e n t l y , the data o f particular interest i n this i n q u i r y i n c l u d e d participants' stories, observations o f study participants, non-technical i n f o r m a t i o n sources such as diaries and poetry, as w e l l as m y intuitive grasp o f a l l these data sources. M y approach to this study is c l o s e l y a l i g n e d w i t h c o n s t r u c t i v i s m w h i c h adopts a relativist o n t o l o g y , a transactional epistemology, and an interpretive m e t h o d o l o g y ( G u b a & L i n c o l n , 1994). In addition to stating m y p h i l o s o p h i c a l stance, it is important that I, as researcher, disclose the theoretical and personal forestructures I b r i n g to the dissertation process.  Theoretical and Personal Forestructures T h e theoretical frameworks underpinning the methods used i n this study i n c l u d e d s y m b o l i c interactionism, systems theory/family research perspectives, and gestalt p s y c h o l o g y / h u m a n i s m . S y m b o l i c interactionism served as a f r a m e w o r k for approaching the i n d i v i d u a l , w h i l e systems theory p r o v i d e d the basis for e x a m i n i n g f a m i l y context. A humanistic approach p r o v i d e d the lenses  Healing Within Families  38  for m a k i n g sense o f participants' stories. H u m a n i s m , an o u t g r o w t h o f gestalt p s y c h o l o g y , emphasizes the importance o f understanding the personal perspective, validates the w o r t h and uniqueness o f each i n d i v i d u a l , and embraces the development o f h u m a n potential ( B a b c o c k & M i l l e r , 1994). T h i s approach was deemed to be appropriate i n m y attempt to understand h o w i n d i v i d u a l s and f a m i l i e s heal i n response to y o u t h suicide.  Perspectives on S y m b o l i c Interactionism S y m b o l i c interactionism refers to a distinctive approach to the study o f h u m a n social life ( S c h e l l e n b e r g , 1990). B a s e d on the p h i l o s o p h i c a l w r i t i n g s o f James, C o o l e y , D e w e y , M e a d , and B l u m e r , s y m b o l i c interactionism focuses on the m e a n i n g o f events to people i n natural and everyday settings. L i k e p h e n o m e n o l o g y , it is c o n c e r n e d w i t h the study o f the inner or experiential aspects o f h u m a n behavior. S y m b o l i c interactionists are c o n c e r n e d w i t h understanding one's values and beliefs; they are interested i n h o w people define events or reality and h o w they act i n relation to their perceptions o f reality. T h i s v i e w purports that humans act o n the basis o f m e a n i n g ( B l u m e r , 1969; C h e n i t z & S w a n s o n , 1986; S p r a d l e y , 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 i n f l u e n c e d b y several antecedent variables such as feedback f r o m significant others, perceptions o f the social environment, and contextual variables such as e c o n o m i c , c u l t u r a l , and religious factors. T h e reality or m e a n i n g o f a situation is created through interaction w i t h i n a particular environment. P e o p l e act based on their perception o f reality and, i n turn, face the consequences o f such action. B l u m e r (1969) cites three premises as constituting the foundation o f s y m b o l i c interactionism. First, "that human beings act t o w a r d things o n the basis o f meanings that the things have for t h e m " (p. 2). These things m a y be objects, other h u m a n beings, institutions, others' activities and situations, or a c o m b i n a t i o n o f these. T h e m e a n i n g attached to things governs the actions o f people; hence, behavior is comprehensible o n l y w h e n one understands the m e a n i n g o f something f r o m the perspective o f the i n d i v i d u a l . T h e second premise states that "the m e a n i n g o f such things is d e r i v e d f r o m , or arises out of, the s o c i a l interaction that one has w i t h o n e ' s f e l l o w s " ( B l u m e r , 1969, p . 2). S y m b o l i c  Healing Within Families  39  interactionists contend that social behavior and culture are i n e x t r i c a b l y intertwined. A c c o r d i n g to Spradley (1979), culture refers to "the acquired k n o w l e d g e that people use to interpret experience and generate social b e h a v i o r " (p. 5). C u l t u r e , or a shared system o f m e a n i n g , is d e v e l o p e d and m o d i f i e d w i t h i n the context o f interaction a m o n g people (Spradley, 1979). S y m b o l i c interactionists do not assume that culture is c o m p o s e d o f c o m m o n l y shared signs and s y m b o l s that are u n i f o r m l y understood. Rather, they believe that to understand social behavior, it is necessary to understand the m e a n i n g various signs and s y m b o l s h o l d for the i n d i v i d u a l . H o w one interprets a situation is i n v a r i a b l y related to the m e a n i n g the situation holds for the person, and the m e a n i n g m a y vary f r o m time to time and f r o m situation to situation. T h e last premise maintains "that these meanings are handled i n , and m o d i f i e d through, an interpretive process used by the person i n d e a l i n g w i t h the things he encounters" ( B l u m e r , 1969, p. 2). In addition to cultural influence, the interpretive process is m e d i a t e d through a number o f variables w h i c h i n c l u d e : past experience, educational l e v e l , language, and p h y s i c a l and c o g n i t i v e abilities ( C h e n i t z & S w a n s o n , 1986). E s s e n t i a l l y , m e a n i n g is "co-created" through a process o f social interaction. These premises are based on the assumption that h u m a n beings are i n constant interaction w i t h the environment and are largely able to choose the p s y c h o - s o c i a l stimuli to w h i c h they respond. Spradley (1979) suggests that the interpretive component c a n be l i k e n e d to a c o g n i t i v e map. In turn, interpretation is culturally determined and best thought o f as: A set o f p r i n c i p l e s for creating dramas, for w r i t i n g scripts, and, o f course, for recruiting players and a u d i e n c e s . . . . C u l t u r e is not s i m p l y a c o g n i t i v e m a p that people acquire, i n w h o l e or. i n part, more or less accurately, and then learn to read. P e o p l e are not just map-readers; they are m a p makers. P e o p l e are cast into imperfectly charted, c o n t i n u a l l y shifting seas o f everyday life. M a p p i n g them out is a constant process resulting not i n an i n d i v i d u a l c o g n i t i v e m a p , but i n a w h o l e chart case o f r o u g h , i m p r o v i s e d , c o n t i n u a l l y r e v i s e d sketch maps. C u l t u r e does not p r o v i d e a c o g n i t i v e map, but rather a set o f principles for map m a k i n g and navigation. Different cultures are l i k e  Healing Within Families  40  different schools o f n a v i g a t i o n designed to cope w i t h different terrains and seas. (Frake, 1977, p p . 6-7) M e a n i n g is negotiated through the use o f s y m b o l s (e.g., language, artifacts). C o m m u n i c a t i o n is s y m b o l i c because w e c o m m u n i c a t e v i a languages and other s y m b o l s ; through c o m m u n i c a t i o n w e create or produce significant s y m b o l s . T h r o u g h an interpretive process, meanings are established. S p e c i f i c a l l y , " T h e actor selects, c h e c k s , suspends, regroups, and transforms the meanings i n light o f the situation i n w h i c h he is p l a c e d and the direction o f his action. . . . M e a n i n g s are used and r e v i s e d as instruments for the g u i d a n c e and f o r m a t i o n o f [future] a c t i o n " ( B l u m e r , 1969, p. 5). These meanings are products o f c o l l e c t i v e situations; that is, meanings arise out o f interaction w i t h others. T h r o u g h the interactive process as'it is mediated b y language, one acquires a self. A c c o r d i n g to B l u m e r (1969), i n d i v i d u a l behavior, group conduct, and e v e n culture are a l l matters i n v o l v i n g m e a n i n g and interpretation. C o n s e q u e n t l y , i f one wishes to understand an i n d i v i d u a l ' s behavior or a c o l l e c t i v i t y ' s actions, one must 'get at' the meanings b e i n g assigned and the interpretations b e i n g made. B l u m e r reduces a l l social processes, h o w e v e r c o m p l e x , to meaningful interpersonal behavior. G r o u n d e d theory, based on s y m b o l i c interactionism, aims to d i s c o v e r u n d e r l y i n g social processes; consequently, g r o u n d e d theory methods were selected for this study. I n f o r m e d b y s y m b o l i c interactionism, w i t h i n this study, I needed to be h i g h l y sensitive to the meaning(s) that i n d i v i d u a l s and f a m i l i e s attached to people, things, and situations. It was important to understand the layered m e a n i n g that survivors i n d i v i d u a l l y and c o l l e c t i v e l y constructed i n response to their experiences w i t h the suicide o f a f a m i l y youth. A d d i t i o n a l l y , I assumed that each s u r v i v o r m i g h t h o l d different v i e w s , resulting i n different m e a n i n g b e i n g subscribed to each i n d i v i d u a l ' s experience. H e n c e , it was important for m e to elicit the precise m e a n i n g related to experience, both i n d i v i d u a l l y and c o l l e c t i v e l y . In part, this entailed 'getting at' (via questioning) the m e a n i n g e m b e d d e d w i t h i n the language b e i n g used b y participants. S i n c e meanings are i n people rather than w o r d s , it was important that I listened carefully and sought  Healing Within Families  41  clarification frequently i n m y attempt to capture the richness (i.e., t h i c k description) w i t h i n participants' stories. In this study, s y m b o l i c interactionism g u i d e d the selection o f the g r o u n d e d theory procedures used to e x p l o r e the process o f i n d i v i d u a l h e a l i n g f o l l o w i n g y o u t h suicide. A s p r e v i o u s l y mentioned, i n d i v i d u a l s l i v e their lives w i t h i n the context o f their families. Therefore, m y perspective on families must also be articulated.  Perspectives on F a m i l i e s M y perspective o n families is g u i d e d b y f a m i l y systems theory, v o n Bertalanffy (1968; 1975) r e c o g n i z e d l i v i n g systems as c o m p l e x organizations c o m p o s e d o f m a n y parts i n constant interaction w i t h other systems. A c c o r d i n g to systems theory, the f a m i l y is c o n c e p t u a l i z e d as an open system that interacts w i t h i n a broader s o c i o l o g i c a l and h i s t o r i c a l context ( W h a l l , 1986). Specific concepts inherent w i t h i n this perspective include: 1. A f a m i l y system is part o f a larger suprasystem and as w e l l is c o m p o s e d o f m a n y subsystems; 2. T h e f a m i l y as a w h o l e is greater than the s u m o f its parts; 3. A change i n one f a m i l y m e m b e r affects a l l f a m i l y members; 4. T h e f a m i l y is able to create a balance between change and stability; and 5. F a m i l y m e m b e r s ' behaviors are best understood f r o m the v i e w o f c i r c u l a r rather than linear causality ( W r i g h t & L e a h e y , 1984). O f particular significance, these concepts validate the v i e w that families possess inherent strengths and c o p i n g capabilities that can be d r a w n u p o n d u r i n g times o f great need. In addition, these concepts allude to the p o w e r f u l influence that f a m i l y members have o n one another.  Perspectives on F a m i l y Research Increasingly, the f a m i l y has become an important focus for the p r o v i s i o n o f n u r s i n g care. W i t h i n this section, t w o issues that are central to this study are addressed, the definition o f f a m i l y and the d e c i s i o n regarding w h o s h o u l d be i n c l u d e d as informants.  Healing Within Families  42  T h e first issue pertains to the definition o f f a m i l y used i n this i n q u i r y . N u m e r o u s definitions o f f a m i l y are f o u n d w i t h i n the nursing literature. T r a d i t i o n a l l y , the f a m i l y has been defined i n terms o f structure and/or function ( W r i g h t & L e a h e y , 1984). F o r instance, K r i s t j a n s o n (1992) defined the f a m i l y as ' " i n d i v i d u a l s ' b o n d e d b y a b i o l o g i c a l or l e g a l relationship . . . as those persons h a v i n g a functional relationship to one another" (p. 39). F a m i l y members m a y or m a y not cohabitate, and the f a m i l y m a y be described as nuclear, inter-generational, or extended. Other definitions o f f a m i l y are broad-based, i n c l u s i v e , and f l e x i b l e , and thus reflect the constant state o f change r e a d i l y apparent w i t h i n society today. F o r e x a m p l e , G i l l i s s (1991) defined f a m i l y as " a c o m p l e x unit w i t h distinct attributes o f its o w n but c o n t a i n i n g c o m p o n e n t parts that are significant as i n d i v i d u a l units, both independently and c o l l e c t i v e l y " (p. 198). W i t h i n current n u r s i n g research, the definition o f f a m i l y is often externally i m p o s e d b y the researcher, for e x a m p l e , a f a m i l y c o n s i s t i n g o f a mother, father, and at least one c h i l d . E x t e r n a l l y i m p o s e d definitions m a y inadvertently introduce bias (Patterson, 1995) (e.g., s o c i a l , c u l t u r a l , or gender) w i t h i n a research study. Further, the artificial delineation created b y an externally i m p o s e d definition m a y not accurately represent boundaries that the f a m i l y w o u l d v i e w as meaningful ( K r i s t j a n s o n , 1992). W i t h i n this i n q u i r y , and congruent w i t h the A l b e r t a H e a l t h (1993) document, Palliative C a r e In A l b e r t a , f a m i l y was understood i n its broadest sense to i n c l u d e not o n l y n e x t - o f - k i n f a m i l y members, but also significant others identified b y f a m i l y members as b e i n g part o f the f a m i l y (Stuart, 1991). A n i n c l u s i v e rather than e x c l u s i v e definition o f f a m i l y was adopted: " a c o m p l e x unit w i t h unique attributes o f its o w n " ( G i l l i s s , 1991, p. 198). T h e d e c i s i o n regarding " w h o " to include as f a m i l y was c o l l e c t i v e l y determined b y the f a m i l y members themselves. T h i s definition was used because it preserves participants' voices and validates the d y n a m i c nature o f families, as w e l l as the p o w e r f u l influence that f a m i l y members have on one another (e.g., A l b e r t a A s s o c i a t i o n o f R e g i s t e r e d N u r s e s , 1992, 1993). T h e second issue centered on the use o f a single i n d i v i d u a l versus m u l t i p l e f a m i l y members as informants about the f a m i l y . U p h o l d and S t r i c k l a n d (1989) m a i n t a i n that the " c h o i c e o f w h o s h o u l d be the source o f data c o l l e c t i o n must be based on the purpose o f the study, the research  Healing Within Families  43  question, the theoretical basis o f the study, and the specific unit about w h o m the researcher intends to generalize" (p. 415). T h e emphasis i n this study was on the i n d i v i d u a l w i t h i n the context o f the f a m i l y system, hence, a " u n i f y i n g c o n c e p t u a l i z a t i o n " ( R o b i n s o n , 1995b, p. 8) o f f a m i l y was used i n w h i c h data were c o l l e c t e d f r o m both i n d i v i d u a l f a m i l y members and subgroups w i t h i n the f a m i l y , and w h e n e v e r possible, the f a m i l y as a unit. T h i s approach addressed the artificial separation between the i n d i v i d u a l and f a m i l y ( D a v i e s , 1995; H a y e s , 1993; R o b i n s o n , 1995a; R o b i n s o n , 1995b) c o m m o n l y encountered i n f a m i l y research. T h e i n d i v i d u a l perspective is not less than the f a m i l y v i e w ; it is different f r o m the f a m i l y v i e w p o i n t . E v e n though a single informant can provide f a m i l y - l e v e l data, it must be remembered that restricting f a m i l y data to a single f a m i l y m e m b e r or subset has the potential to present a biased v i e w o f the f a m i l y . N e i t h e r the i n d i v i d u a l nor the f a m i l y v i e w is complete i n and o f itself. T h u s , because both the i n d i v i d u a l and f a m i l y are a part o f the conceptual picture ( D a v i e s , 1995; R o b i n s o n , 1995a; R o b i n s o n , 1995b),. the v i e w s o f both were considered important and contributed to a greater understanding o f the phenomenon under study ( D a v i e s , 1995b, R o b i n s o n , 1995a; R o b i n s o n , 1995b). I n a d d i t i o n , s i m u l t a n e o u s l y focusing on i n d i v i d u a l and f a m i l y systems captured the d y n a m i c and c o m p l e x nature o f families ( R o b i n s o n , 1995a; R o b i n s o n 1995b), an important element i n understanding i n d i v i d u a l healing w i t h i n the context o f the f a m i l y . A c o m m o n challenge confronted b y researchers is that o f obtaining accurate f a m i l y data. In this study, data were gathered f r o m both i n d i v i d u a l f a m i l y members and the f a m i l y as a unit. T h i s schema focused o n the parts c o m p r i s i n g the w h o l e b y i n c l u d i n g the i n d i v i d u a l perspective, or that part o f the person w h i c h is separate f r o m the f a m i l y . In addition, v i e w s about the f a m i l y as a c o l l e c t i v e were also o f interest i n this study. T h i s conceptualization o f f a m i l y r e c o g n i z e d the influence o f the f a m i l y o n the person, and v i c e versa ( M a n g h a m , R e i d , M c G r a t h , & Stewart, 1995; R o b i n s o n , 1995a; R o b i n s o n , 1995b). T h e single-informant approach was used to a l l o w freedom of expression ( U p h o l d & S t r i c k l a n d , 1989) w h i l e the m u l t i p l e - i n f o r m a n t approach was used to gather transactional-level data about i n d i v i d u a l and f a m i l y systems. Transactional-level data are concerned w i t h interaction and reciprocity o n both the personal and f a m i l y levels ( R o b i n s o n ,  Healing Within Families  44  1995a: R o b i n s o n , 1995b). These data simultaneously focused o n the person as both an i n d i v i d u a l and as a m e m b e r o f a f a m i l y system. There is agreement i n the literature regarding the effect o f context on f a m i l y data (Kristjanson, 1992). It is r e c o g n i z e d that an i n d i v i d u a l m a y respond differently to the same question w h e n p o s e d i n d i v i d u a l l y , and w h e n other f a m i l y members are present. T h u s , context becomes an important variable i n the conceptualization o f the research questions. T h e research questions i n this study were written to 'get at' the v i e w s o f the i n d i v i d u a l w i t h i n the context o f the f a m i l y . T h i s was a c c o m p l i s h e d by i n t e r v i e w i n g each person i n d i v i d u a l l y , and then i n t e r v i e w i n g the f a m i l y as a unit w h e n e v e r possible. T w o sets o f i n t e r v i e w questions were prepared—one set directed t o w a r d the i n d i v i d u a l and the other set specific to the f a m i l y as a unit. It was r e c o g n i z e d that there m a y be a l a c k o f consensus amongst f a m i l y members i n response to the research questions. In some cases, data obtained f r o m one f a m i l y m e m b e r were congruent w i t h that obtained f r o m another f a m i l y member; i n other cases, these data were inconsistent. Inconsistent data were therefore reported to reflect the inconsistencies so often apparent w i t h i n families. Inconsistent data p r o v i d e d information about the f a m i l y that otherwise m i g h t have been unavailable. Schless and M e n d e l s (1978) c l a i m that i n t e r v i e w i n g as m a n y informants as possible provides significantly more data about the f a m i l y b y capturing the density and c o m p l e x i t y o f the f a m i l y system. Therefore, a l l sources o f data were v a l u e d and v i e w e d as contributing to a broader, all-encompassing perspective on the f a m i l y context for i n d i v i d u a l g r i e v i n g and healing. S y m b o l i c interactionism and systems theory p r o v i d e d the theoretical foundation for the analysis o f i n d i v i d u a l and f a m i l y l e v e l data. B a s e d on Gestalt p s y c h o l o g y , a humanistic approach guided data c o l l e c t i o n and analysis and the overall approach to the conceptualization o f the theory presented i n subsequent chapters.  Perspectives o n Gestalt P s y c h o l o g y / H u m a n i s m A s pioneers i n the f i e l d o f Gestalt p s y c h o l o g y , W e r t h e i m e r , K o e h l e r , K o f f k a , and L e w i n insisted that p s y c h o l o g i c p h e n o m e n o n need be studied b y introspection and observation. Gestalt is a G e r m a n w o r d that means "the w h o l e or totality" ( B a b c o c k & M i l l e r , 1994, p. 38). W i t h i n the  Healing Within Families  45  f i e l d o f p s y c h o l o g y , this concept refers to the idea that the w h o l e is m o r e than m e r e l y the s u m o f its parts. Gestalt theorists maintain that h u m a n beings are irreducible w h o l e s w h i c h cannot be understood s i m p l y b y a n a l y z i n g their perceptions o f events ( B a b c o c k & M i l l e r , 1994; Perls, H e f f e r l i n e , & G o o d m a n , 1951; S c h i f f m a n , 1971). P e r c e p t i o n refers to the p o r t i o n o f the w o r l d that is grasped m e n t a l l y through sight, hearing, touch, taste, and s m e l l (Neufeldt, 1991). Gestaltists see perception as contextually-based, as an active process i n f l u e n c e d by a m y r i a d o f factors i n c l u d i n g history, genetics, and environment. H e n c e , c o n t e x t u a l l y situating this w o r k was c r i t i c a l and is addressed i n Chapter F o u r . A s an outgrowth o f Gestalt p s y c h o l o g y , h u m a n i s m is the name g i v e n to a cultural and intellectual m o v e m e n t that developed d u r i n g the Renaissance. D e v e l o p e d b y theorists such R o g e r s , G o l d s t e i n , A n g a l , M a s l o w , M u r r a y , and C o m b s , h u m a n i s m has h i s t o r i c a l l y been c o n c e r n e d w i t h h u m a n w o r t h , i n d i v i d u a l i t y , humanity, and the i n d i v i d u a l ' s right to determine personal action ( B a b c o c k & M i l l e r , 1994; L e f r a n c o i s , 1988; R o g e r s , 1951, 1 9 6 1 , 1969). W h i l e a c k n o w l e d g i n g the importance o f the i n d i v i d u a l ' s developmental history, humanists focus o n contemporary experiences and c o n s c i o u s awareness i n the present. H u m a n i s m is c o n c e r n e d w i t h the uniqueness of each i n d i v i d u a l ; o n e ' s uniqueness is o n e ' s self. T h e development o f self results f r o m interactions w i t h i n o n e ' s w o r l d (direct experience) and f r o m beliefs and values about one's self learned through interactions w i t h others (indirect experience). H u m a n i s t s b e l i e v e i n h u m a n potential. B a s e d o n the assumption that the i n d i v i d u a l is s t r i v i n g t o w a r d healthy and creative functioning, the p r i m e m o t i v a t i n g force is self-actualization, a continuous effort to achieve the m a x i m u m development o f o n e ' s potentiality. T h i s v i e w was selected as a basis for this study because it is congruent w i t h the concept o f health p r o m o t i o n discussed i n C h a p t e r O n e . T h e humanists' v i s i o n for the h u m a n experience is closer to the frameworks o f Eastern theorists and their understanding o f the higher levels o f consciousness. H u m a n i s m is an holistic approach to understanding people concerned w i t h topics i n c l u d i n g : l o v e , creativity, self-growth, b e c o m i n g fully h u m a n , j o y , transcendence, p l a y , h u m o r , affection, naturalness, autonomy, responsibility, extrasensory perception, and peak experience ( B a b c o c k & M i l l e r , 1994).  Healing Within Families  46  M y analytic approach i n this study, a l i g n e d w i t h that o f h u m a n i s m , is based o n F r a n k ' s (1995) idea o f " t h i n k i n g w i t h " rather than " t h i n k i n g about" stories. A c c o r d i n g to F r a n k (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 w i t h stories takes the story as already complete; there is n o g o i n g b e y o n d it. T o think w i t h a story is to experience it affecting one's o w n life and to f i n d i n that effect a certain truth o f o n e ' s life. (p. 23) Participants' stories are thus w o v e n into the theory that begins i n C h a p t e r F o u r . T h e s e stories need to be heard as once t o l d for they leave "us right where w e a l w a y s already were, w i t h the actual p l a y and interplays o f life, w i t h a l l its difficulty and a m b i g u i t y , unredeemed or, better, not i n need o f redemption but o n l y thoughtful s a v o r i n g , reflection, conversation and understanding" (Jardine, 1990, p. 2 2 4 ) . T h e grand narrative is used as a w a y o f a v o i d i n g over-analysis o f the content, o f a v o i d i n g too m u c h dissection (Neufeldt, 1991), and as a means o f r e m a i n i n g close to the truths e m b e d d e d w i t h i n these stories (e.g., C l a r k e , 1995; C o h l e r , 1 9 9 1 ; L e w i s , 1961). B e s t t o l d b y the participants themselves, these stories restore life to its " o r i g i n a l d i f f i c u l t y " ( C a p u t o , 1987, p . 1). C o n s i d e r i n g the h i g h l y personal and sensitive nature o f the topic b e i n g discussed, I w o n d e r e d h o w to best portray the participants' stories; I therefore asked them h o w they preferred to have their stories represented. U n e q u i v o c a l l y , participants p r o c l a i m e d that they w a n t e d their stories presented w i t h as m u c h detail as possible. These stories, therefore, are not presented to support m y v i e w s ; rather, they are the source f r o m w h i c h the grounded theory was d e v e l o p e d H o w e v e r , I do place these stories w i t h i n the theoretical framework that emerged f r o m the analysis o f the data, w h i c h I believe is o n l y a means o f i l l u m i n a t i n g the richness and truths e m b e d d e d w i t h i n each and every story i n singular or c o m b i n e d presentations. M y approach to this research was i n f l u e n c e d not o n l y by these theoretical forestructures, but also b y m y personal situatedness.  Personal Situatedness W h e n c o n d u c t i n g h i g h l y personal and emotion-laden research such as this, despite a l l efforts to represent the v i e w s o f participants adequately, the researcher becomes i m p l i c a t e d  Healing Within Families  47  ( L i n c o l n & G u b a , 1985). T h e researcher's p h i l o s o p h i c a l p o s i t i o n a l w a y s has an i m p a c t o n the research process i n terms o f both content and process. H e n c e , the researcher must a c k n o w l e d g e that his or her values w i l l influence the i n q u i r y , m a k e e x p l i c i t a l l relevant personal values, and account for these ( L i n c o l n & G u b a . 1985). H e r e , I b r i e f l y describe pertinent aspects o f m y b i o g r a p h y that I b r i n g to this w o r k . I a m a white, m i d d l e - c l a s s , m i d d l e - a g e d w i f e and mother o f four adult c h i l d r e n , and grandmother o f one. O v e r the past thirty years I c o m b i n e d the traditional female role o f p r i m a r y care p r o v i d e r and h o m e m a k e r w i t h that o f counselor, p u b l i c health nurse, nurse educator, researcher, and n u r s i n g leader i n m y c o m m u n i t y . I see m y s e l f as a c a r i n g a n d c o m m i t t e d person and as one w h o approaches life and l i v i n g w i t h great enthusiasm. M y professional interest i n w o r k i n g i n the area o f p a l l i a t i v e care stems f r o m 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 y o u n g w o m a n , I k n e w the pain associated w i t h loss l o n g before I understood the g r i e v i n g process. F o l l o w i n g the death o f m y 5 0 year o l d mother i n the i m p e r s o n a l environment o f a b i g c i t y hospital, w i t h m y husband and brother at m y side, w e made our w a y to a nearby elevator. W e left the h o s p i t a l alone, without guidance or support f r o m any staff person. I r e a l i z e d h o w vulnerable and powerless I felt and h o w little I k n e w about death. I r e a l i z e d h o w I l o n g e d for support and guidance f r o m the nurses w h o were w i t h m y mother at the e n d o f her life. I made a p r o m i s e to m y s e l f to pursue this area o f study as a basis for h e l p i n g nurses and others to assist g r i e v i n g f a m i l i e s . M y doctoral p r o g r a m presented m e w i t h the opportunity to contribute to this field. W h i l e w o r k i n g as a research assistant d u r i n g m y doctoral p r o g r a m , I h a d the p o s i t i v e experience o f b e i n g i n v o l v e d i n a s i b l i n g bereavement study w o r k i n g under the s u p e r v i s i o n o f m y dissertation supervisor. I was i n v o l v e d i n a p i l o t study i n v o l v i n g f a m i l i e s where a c h i l d h a d d i e d due to either short- or l o n g - t e r m causes o f death. E i g h t e e n f a m i l i e s volunteered to participate i n this study. W i t h i n those 18 families, five youngsters h a d d i e d as a result o f suicide. T h e i n c i d e n c e o f this occurrence h a d an i m p a c t o n m e . A s I listened to the stories shared b y f a m i l y members, I was " g r a b b e d " b y their honesty and forthrightness. M y c u r i o s i t y was p i q u e d as I listened to h o w some i n d i v i d u a l s consistently spoke o f " h e a l i n g " i n relation to their experiences w i t h horrific death. I  Healing Within Families  48  w o n d e r e d about h o w such h e a l i n g occurred, and w h y some i n d i v i d u a l s spoke o f h e a l i n g and others d i d not. M y professional b a c k g r o u n d includes experience i n the areas o f i n d i v i d u a l and f a m i l y c o u n s e l i n g , p s y c h i a t r i c n u r s i n g , p u b l i c health nursing, p a l l i a t i v e care n u r s i n g , and n u r s i n g education. M y c o u n s e l i n g education p r o v i d e d me w i t h an opportunity to hone and refine m y interpersonal s k i l l s . F r o m m y experience as a counselor, I learned about the p o w e r f u l influence that f a m i l y members have on one another and h o w such influence affects the health o f each i n d i v i d u a l . F r o m m y experience as a professional nurse I suspected that loss issues m a y often be related to p o o r health and dis-ease. B y w o r k i n g c l o s e l y w i t h f a m i l i e s for m o r e than t w o decades, I developed an appreciation for the strengths and resilient capacities o f i n d i v i d u a l s and the synergy that becomes possible w h e n families become e m p o w e r e d to take r e s p o n s i b i l i t y for their o w n health. In response to these c o u n s e l i n g and n u r s i n g experiences, I d e v e l o p e d a belief that i n d i v i d u a l s and families often have the answers to their problems. I also b e l i e v e that it is the responsibility o f health care professionals to facilitate health p r o m o t i n g interventions a m o n g i n d i v i d u a l s , f a m i l i e s , c o m m u n i t i e s , and ultimately w i t h i n society. T h i s b a c k g r o u n d p r o v i d e d fertile g r o u n d for the seeds o f interest i n ' h e a l i n g ' that were s o w n b y the f a m i l i e s i n the aforementioned research study. D u r i n g the process o f c o n d u c t i n g this dissertation research, several experiences reinforced the relevance o f this w o r k . I was i n v i t e d to present the p r e l i m i n a r y findings o f m y research on several occasions w i t h i n both academic and c o m m u n i t y settings. F o r e x a m p l e , I was i n v i t e d to be a m e m b e r o f a panel presentation d u r i n g S u i c i d e Prevention W e e k i n L e t h b r i d g e , A l b e r t a . D u r i n g the same w e e k I spoke about the findings o f m y research d u r i n g a M e m o r i a l S e r v i c e for suicide survivors. A m o n t h later ( A p r i l 2 1 , 1999), I was i n t e r v i e w e d b y a reporter at a l o c a l television station regarding the increased use o f violence a m o n g youth i n response to the s l a y i n g o f several teens and the suicides o f the t w o teenage g u n m e n at a high s c h o o l i n L i t t l e t o n , C o l o r a d o . T h e n one w e e k later, i n the rural c o m m u n i t y o f Taber, A l b e r t a , a y o u n g h i g h s c h o o l g u n m a n opened fire fatally injuring an innocent youth. O n c e again I was asked to talk about m y research f r o m the  Healing Within Families  49  perspective o f h e l p i n g families heal i n the aftermath o f horrific death. T h i s c o m m u n i t y i n v o l v e m e n t renewed and reaffirmed m y c o m m i t m e n t to and enthusiasm for this w o r k .  G r o u n d e d T h e o r y Research M e t h o d F i r s t d e v e l o p e d b y G l a s e r and Strauss i n 1967, g r o u n d e d theory is a h i g h l y systematic research approach for the c o l l e c t i o n and analysis o f qualitative data for the purpose o f generating explanatory theory that furthers the understanding o f social and p s y c h o l o g i c a l p h e n o m e n o n ( C h e n i t z and S w a n s o n 1986; Strauss & C o r b i n , 1990, 1994; 1998). In essence, g r o u n d e d theory research is a i m e d at understanding h o w a group o f people define their reality v i a social interactions ( H u t c h i n s o n , 1986). E s s e n t i a l l y , " T h e grounded theory m e t h o d results i n concepts and constructs grounded i n data that reflect theoretical sensitivity and have i m a g e r y and " g r a b " for those i n v o l v e d i n the experience. G o o d g r o u n d e d theory is holistic, p a r s i m o n i o u s , dense, and m o d i f i a b l e " ( W i l s o n & H u t c h i n s o n , 1 9 9 1 , p. 274). G r o u n d e d theory is an appropriate m e t h o d w h e n an area to be researched is characterized b y a l o w l e v e l o f conceptualization. S i n c e theoretical explanations related to healing w i t h i n families f o l l o w i n g y o u t h suicide have not been found w i t h i n the literature, it was important to use a ' g r o u n d u p ' — f r o m practice to theory m e t h o d for theory generation ( H u t c h i n s o n , 1986). M o r e o v e r , grounded theory methods are appropriate w h e n attempting to gather data o f a unique and h i g h l y personal nature that describes experiences and perceptions w i t h contextual m e a n i n g . F i n a l l y , since social processes are fundamental to families, it f o l l o w s that the g r o u n d e d theory m e t h o d is appropriate for the study o f i n d i v i d u a l healing w i t h i n families.  E l i g i b i l i t y Criteria T h e p o p u l a t i o n o f interest i n this study were i n d i v i d u a l s w h o identified themselves as h a v i n g had experience w i t h healing f o l l o w i n g the suicide o f a b e l o v e d f a m i l y youth. Participants were required to meet the f o l l o w i n g eligibility criteria: 1.  A t the time the study began, participants needed to have experienced a youth (10-19 years o f age) suicide p r i o r to the study, and be able to speak about the concept o f healing (either pro or  Healing Within Families  50  con) i n response to their experience. H o w e v e r , as the study proceeded, theoretical s a m p l i n g indicated the value o f i n c l u d i n g t w o older adults and their f a m i l i e s i n the study. 2.  Informants were r e q u i r e d to be able to read, write, speak, and c o m p r e h e n d E n g l i s h .  3.  Participants were members o f a f a m i l y . V a r i o u s f a m i l y constellations were i n c l u d e d (e.g., t w o parent f a m i l i e s , single parent families, b l e n d e d families, gay and/or lesbian families).  4.  I n d i v i d u a l s and f a m i l i e s f r o m a l l s o c i o - e c o n o m i c , r a c i a l , c u l t u r a l , and r e l i g i o u s groups were i n v i t e d to participate i n this study.  5.  V o l u n t a r y participation i n the study was a basic requirement.  D a t a C o l l e c t i o n and Procedures In accordance w i t h grounded theory m e t h o d o l o g y , the m a i n methods o f data collection were i n t e r v i e w s w i t h i n d i v i d u a l f a m i l y survivors and f a m i l y units w h e n e v e r possible, supplemented b y participant observation ( L o f l a n d & L o f l a n d , 1984; S p r a d l e y , 1979). In this study, data i n c l u d e d textual data, observational data, and non-technical data. In addition, genograms and ecomaps ( M c G o l d r i c k , 1982; W r i g h t & L e a h e y , 1984) were c o m p l e t e d for each  •  f a m i l y as part o f the data base (see A p p e n d i c e s A - l and A - 2 ) . T h e s e tools p r o v i d e d a means o f gathering family-related information and were especially helpful i n terms o f understanding f a m i l y d y n a m i c s . T h e genogram is a three generational d i a g r a m d e p i c t i n g historical, structural, functional, and relational aspects o f the f a m i l y system ( M c G o l d r i c k , 1982; W r i g h t & L e a h e y , 1984). T h e ecomap is a d i a g r a m representing the quantity and quality o f each f a m i l y m e m b e r ' s connections w i t h external resources ( M c G o l d r i c k , 1982; W r i g h t & L e a h e y , 1984).  Informed Consent P r i o r to c o l l e c t i n g data for the study, informants were p r o v i d e d w i t h a complete description of the study, i n c l u d i n g : an explanation o f the purpose o f the research; a description o f the procedures to be used (e.g., use o f i n t e r v i e w and observation) a n d time c o m m i t m e n t i n v o l v e d ; an explanation o f the voluntary nature of the research; and an assurance o f confidentiality related to a l l aspects o f the research. Participants were i n f o r m e d o f their right to w i t h d r a w f r o m the study at any  Healing Within Families  51  time w i t h o u t reason. Further, they were p r o v i d e d w i t h an opportunity to ask questions a n d to discuss any aspect o f the research. E a c h participant was p r o v i d e d w i t h an information letter and an appended consent f o r m c o n t a i n i n g the names and phone numbers o f appropriate contact people (see A p p e n d i x B ) . F o l l o w i n g this i n f o r m a t i o n session, I obtained written i n f o r m e d consent f r o m all informants. I retained one c o p y o f the s i g n e d consent f o r m for m y file and p r o v i d e d a personal c o p y for each participant. B e c a u s e c h i l d r e n cannot legally p r o v i d e consent, parents were requested to sign a consent f o r m ( i n c l u d e d i n A p p e n d i x B ) for m i n o r c h i l d r e n (less than 10 years o f age). H o w e v e r , c h i l d r e n also gave assent for participation. A s s e n t i m p l i e s that the c h i l d understands the purpose o f the research study a n d his/her participation i n it, a n d agrees to participate i n the study. In an effort to be sensitive to the needs o f each participant, i n f o r m e d consent was c o n t i n u a l l y negotiated d u r i n g the research process ( G e r m a i n , 1986). T h i s negotiation process entailed constantly educating the participants about the research process, a n d m a k i n g sure that informants felt free to act i n their o w n best interests, regardless o f what that m a y have meant i n terms o f the research study. F o r e x a m p l e , i n one instance I was i n v i t e d b y a mother to i n t e r v i e w a f a m i l y i n their h o m e . W h e n I arrived at the f a m i l y h o m e , I was w a r m l y greeted b y the mother i n the front y a r d . T h e father, w h o was w o r k i n g i n the y a r d at the t i m e , a c k n o w l e d g e d m y presence b y a brief n o d o f his head. T h e mother i n v i t e d m e into the house where w e sat at the kitchen table. I began to set up the tape recorder. M o m e n t s later, the father appeared i n the k i t c h e n . H e began to m a k e c o m m e n t s about m y research, a n d as he spoke it was apparent that he was angry. I listened to h i m and d i d not interrupt. W h e n he finished expressing his v i e w s , I once again p r o v i d e d a detailed explanation o f the purpose o n m y study. I e m p h a s i z e d that v o l u n t a r y participation was a basic requirement. I assured h i m that the health and w e l l - b e i n g o f his f a m i l y was o f p r i m e importance, far above the importance o f the study. I suggested that i f he was uncomfortable w i t h any aspect o f b e i n g i n v o l v e d i n the study, that he m a y w i s h to d e c l i n e the opportunity to participate. Subsequently, he asked to sign the consent form, a n d requested that I i n t e r v i e w his f a m i l y . W h e n I turned the tape-recorder o n ( w i t h p e r m i s s i o n ) , he s p o k e for 4 5 minutes non-stop about his experience related to his son's suicide. T h i s i n t e r v i e w t o o k p l a c e three years post-suicide. A p p a r e n t l y , he a n d his w i f e h a d not discussed the s u i c i d e o f their son p r i o r to the i n t e r v i e w . W h e n  Healing Within Families  52  I left the f a m i l y home, both husband and wife w a l k e d m e to m y car. T h e husband thanked m e for i n c l u d i n g h i m and his f a m i l y i n the study and both he and his w i f e gave m e a h u g .  Theoretical S a m p l i n g Theoretical s a m p l i n g , or " s a m p l i n g on the basis o f concepts that have p r o v e n theoretical relevance to the e v o l v i n g theory" (Strauss & C o r b i n , 1990, p. 176) was u s e d d u r i n g the data c o l l e c t i o n process. A s the study progressed, participants were deliberately selected a c c o r d i n g to the theoretical needs and direction o f the data analysis. T h i s approach h e l p e d to ensure that the e v o l v i n g theory was representative o f the concept under investigation. M o r e o v e r , it a l l o w e d for e x a m i n a t i o n o f a f u l l range o f variation o f the p h e n o m e n o n under study (i.e., h e a l i n g f o l l o w i n g youth suicide). F i r s t , at the onset o f the study, " i n f o r m a t i o n - r i c h cases" (Patton, 1990, p. 169) were identified. T w o f a m i l i e s , w h o had participated i n a previous research study, and w h o were k n o w n by m y s e l f to be r i c h sources o f relevant data, indicated an interest and w i l l i n g n e s s to participate i n this study w h e n contacted to f o l l o w - u p on their expressed interest. S e c o n d , potential participants were sometimes located v i a "network s a m p l i n g " (Burns & G r o v e , 1993), or s n o w b a l l i n g as it is sometimes c a l l e d . T h i s technique takes advantage o f p r e v i o u s l y established i n f o r m a l social networks that often exist a m o n g those w h o have shared a c o m m o n experience. I n d i v i d u a l s w i t h i n the first t w o families i n t e r v i e w e d referred other potential participants to this study. T h i s strategy was, i n fact, an e x t r e m e l y v a l u a b l e recruitment strategy, especially d u r i n g selective s a m p l i n g that o c c u r r e d as the study progressed. T h i r d , I recruited families through contact w i t h palliative care personnel i n health care institutions and c o m m u n i t y health agencies i n southern A l b e r t a (e.g., L e t h b r i d g e , M e d i c i n e Hat, Taber, B r o o k s , C l a r e s h o l m , B o w Island). T h e s e were i n d i v i d u a l s w i t h w h o m I already have established w o r k i n g relationships. I met i n f o r m a l l y w i t h these i n d i v i d u a l s at times convenient to them. D u r i n g these meetings, I described the purpose o f m y study, o u t l i n e d e l i g i b i l i t y criteria, required time c o m m i t m e n t s , and other pertinent i n f o r m a t i o n .  Healing Within Families  53  F i n a l l y , I accepted an i n v i t a t i o n to be i n t e r v i e w e d by the l o c a l m e d i a (e.g., newspaper and television) for the purpose o f recruitment. D u r i n g an i n t e r v i e w w i t h the l o c a l newspaper, I p r o v i d e d a description o f the study, the e l i g i b i l i t y criteria, and an i n v i t a t i o n for l o c a l i n d i v i d u a l s to participate i n the study (see A p p e n d i x C ) . T h i s strategy extended the i n v i t a t i o n for participation to i n d i v i d u a l s and f a m i l i e s w h o m a y not have had access b y other means. In addition, this strategy raised the profile o f the study w i t h i n the c o m m u n i t y and l e d to n e t w o r k i n g w i t h other interested professionals f r o m a variety o f disciplines w h o 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 ( v i a n e t w o r k sampling), those i n d i v i d u a l s obtained v e r b a l consent f r o m the potential participants for m e to contact them. I then f o l l o w e d up by telephoning potential participants to describe the project i n greater detail and to arrange to meet w i t h t h e m at a convenient time and place. O n c e an i n d i v i d u a l indicated a w i l l i n g n e s s to participate i n the study, I i n f o r m e d the participant about m y interest i n understanding the i n d i v i d u a l healing process. I i n v i t e d the participant to encourage other f a m i l y members to participate i n the project. I requested that the participant obtain verbal consent from other potential participants, a l l o w i n g m e to initiate contact w i t h them. I then contacted these potential participants v i a telephone or in-person d u r i n g a scheduled h o m e visit w i t h a p r e v i o u s l y identified participant. In e a c h case, I then described the study i n greater detail, determined their w i l l i n g n e s s to meet w i t h m e , and arranged a m u t u a l l y convenient time and place to meet. Theoretical s a m p l i n g g u i d e d data c o l l e c t i o n . A s categories emerged, cases w h i c h further explicated the category and cases where the category was nonexistent, were sought and e x a m i n e d . In order to further e n r i c h and e x p a n d the e v o l v i n g theory, cases that offered a different perspective were also p u r p o s e f u l l y i n c l u d e d . F o r e x a m p l e , the h e a l i n g processes o f f a m i l y s u r v i v o r s w h o had experienced the suicide o f an adult were purposefully i n c l u d e d to e n r i c h and e x p a n d the e v o l v i n g theory. N i n e families w h o experienced the suicide o f a f a m i l y youth and t w o f a m i l i e s w h o dealt w i t h the suicide o f an adult were i n c l u d e d i n the sample population. T h e data obtained f r o m families w h o experienced the suicide o f an adult were comparable to other study data i n terms o f  Healing Within Families  54  representativeness o f the concept (Strauss & C o r b i n , 1990), a n d thus w e r e i n c l u d e d to further e x p a n d the p h e n o m e n o n o f interest (i.e., healing) i n this i n q u i r y . I n this sense, d i v e r s i t y was e x p l a i n e d and integrated to enrich rather than disprove the e m e r g i n g theory, consistent w i t h G l a s e r and Strauss's (1967) idea o f seeking conceptual density and theoretical sensitivity. T h e n u m b e r o f i n t e r v i e w s per i n d i v i d u a l and f a m i l y was dependent u p o n o n g o i n g data analysis. A s stated b y S a n d e l o w s k i (1995), " D e t e r m i n i n g adequate sample size i n qualitative research is ultimately a matter o f judgment and experience i n evaluating the quality o f the information c o l l e c t e d against the uses to w h i c h it w i l l be put, the particular research m e t h o d and purposeful s a m p l i n g strategy e m p l o y e d , and the research product i n t e n d e d " (p. 179). T h e o r e t i c a l s a m p l i n g c o n t i n u e d until: 1. no new or relevant data seemed to be e m e r g i n g regarding a category; 2. category development was r i c h and dense, m e a n i n g that a l l p a r a d i g m elements were accounted for, a l o n g w i t h variation and process; and 3. the relationships between categories were w e l l established a n d v a l i d a t e d b y the participants (Glaser, 1978; G l a s e r & Strauss, 1967; Strauss & C o r b i n , 1990). I j u d g e d that theoretical saturation had o c c u r r e d f o l l o w i n g 18 months o f f i e l d w o r k w i t h forty-one i n d i v i d u a l s i n eleven families.  Interviews Interviews were conducted most often i n participants' homes o r other preferred locations such as i n m y w o r k 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 t w o hour in-depth i n t e r v i e w w i t h each i n d i v i d u a l f a m i l y m e m b e r a n d the f a m i l y unit whenever possible. I n d i v i d u a l f a m i l y members were i n t e r v i e w e d separately, a n d then i n dyads and/or as f a m i l y units. T h i s strategy was designed to engage participants i n a d i s c u s s i o n o f their experiences to the greatest extent possible. In some instances, I i n t e r v i e w e d participants a second or third time to clarify and e x p a n d upon ideas that were shared d u r i n g the i n i t i a l i n t e r v i e w . T h e interviews were tape recorded and verbatim transcripts were prepared by a transcriptionist. F o r t y - f o u r i n f o r m a l , semi-structured, in-depth i n t e r v i e w s ( F o n t a n a & F r e y , 1994) were c o n d u c t e d d u r i n g an 18-month p e r i o d d u r i n g 1996 through 1998. A l t h o u g h 41 i n d i v i d u a l s participated i n the study, 12 persons (7 c h i l d r e n , 3 adults, a n d 2 grandparents) were present o n l y  Healing Within Families  55  d u r i n g the f a m i l y interviews. These i n d i v i d u a l s preferred not to be i n d i v i d u a l l y i n t e r v i e w e d . A n interview guide was used to i n i t i a l l y focus the interviews (see A p p e n d i x D ) . D u r i n g i n d i v i d u a l interviews, participants were encouraged to reflect on their experiences related to healing f o l l o w i n g youth suicide. B r o a d open-ended questions and c o m m e n t s were presented at the b e g i n n i n g o f the interviews. F o r e x a m p l e , I generally began i n d i v i d u a l conversations w i t h s o m e t h i n g such as: " T e l l m e about y o u r life since X took his l i f e . " or, " W h a t has this experience been l i k e for y o u ? " A s the i n t e r v i e w s progressed, more focused questions were asked, for e x a m p l e , " W h a t does h e a l i n g mean to y o u ? " and, " H o w d i d y o u heal f o l l o w i n g X ' s s u i c i d e ? " S p e c i f i c a l l y , I w a n t e d to understand the i n d i v i d u a l ' s v i e w s about healing, as w e l l as what h e l p e d a n d h i n d e r e d this process. D u r i n g f a m i l y i n t e r v i e w s , questions were framed to i n c l u d e the perspectives o f others w i t h i n the f a m i l y unit. F o r e x a m p l e , f a m i l y interviews often began w i t h questions such as: " T e l l m e about life i n y o u r f a m i l y since X took his l i f e . " and, " W h a t has this experience been l i k e for y o u r f a m i l y ? " A s f a m i l y interviews progressed, I used specific questions to focus the conversation. F o r instance, I asked a father the f o l l o w i n g questions: " C a n y o u describe the effect of X ' s suicide on y o u r c h i l d r e n ? " and, " W h a t helped them to h e a l ? " F l e x i b i l i t y d u r i n g the interview process was vital to a l l o w for further e x p l o r a t i o n o f leads a n d cues p r o v i d e d b y participants. S i m i l a r l y , it was important to remember that neither the content o f the interviews n o r the needs o f participants c o u l d be predetermined. Interview data were supplemented b y other n o n - t e c h n i c a l literature (e.g., diaries, photographs, letters, newspaper c l i p p i n g s , art w o r k , a n d poetry) shared b y participants. Informants were i n v i t e d to share their stories about these items. T h e s e discussions were taperecorded, transcribed, and textually analyzed. These data supplemented a n d e n r i c h e d the i n t e r v i e w and observation data. D u r i n g the research project I h i r e d a transcriptionist a n d a research assistant. T h e transcriptionist prepared the verbatim transcripts o f a l l participants' i n t e r v i e w s . W o r k i n g under m y direct s u p e r v i s i o n , the research assistant helped d u r i n g certain phases o f the project. Initially, he gathered relevant literature and helped w i t h data management. Later, after he gained an in-depth understanding o f the study, he assisted w i t h data analysis. F o r e x a m p l e , both the research assistant  Healing Within Families  56  and I separately c o d e d several interviews and then c o m p a r e d o u r f i n d i n g s . T h i s process h e l p e d to validate the e m e r g i n g theory. B o t h the transcriptionist and the research assistant were requested to sign an oath o f confidentiality ( A p p e n d i x E ) p r i o r to b e i n g i n v o l v e d i n this research.  Participant Observation D a t a were also c o l l e c t e d through the use o f participant observation. Observations generally o c c u r r e d d u r i n g h o m e visits and lasted the duration o f the i n t e r v i e w (i.e., a p p r o x i m a t e l y t w o hours). S i n c e m e a n i n g creates b e h a v i o r and b e h a v i o r is constructed through interaction, it f o l l o w s that it was necessary to e x a m i n e participants' interactions i n natural settings w h e n e v e r possible. I f f a m i l y members have a c h o i c e regarding the l o c a t i o n o f the interviews and observations, they are more l i k e l y be more relaxed and comfortable w h i l e sharing personal and intimate details about their lives. Participant observation usually occurred once or t w i c e for each participant and once for most families. I was interested i n g a i n i n g insight about alterations i n day-to-day f a m i l y life and learning about the meaning that i n d i v i d u a l s and families attributed to their experiences i n relation to youth suicide. F a m i l y d y n a m i c s (e.g., c o m m u n i c a t i o n patterns and interactions) that further i l l u m i n a t e d an understanding o f i n d i v i d u a l healing were o f particular interest. I observed for s y m b o l s used i n c o m m u n i c a t i o n (e.g., use o f artifacts, l a n g u a g e — v e r b a l and nonverbal), for i n d i v i d u a l behaviors (e.g., readiness and/or w i l l i n g n e s s to participate), a n d for patterns o f interaction amongst f a m i l y m e m b e r s (e.g., w h o speaks to w h o m ? w h o speaks, a n d w h o does not?). I c h e c k e d m y perceptions about m y observations w i t h informants i m m e d i a t e l y f o l l o w i n g an interaction to clarify informants' self-definitions and shared meanings. B a s e d on the s y m b o l i c interactionist perspective, the researcher is v i e w e d as necessarily both an observer and a participant i n the research project. It is o n l y as the researcher enters the w o r l d o f the participant that he or she is able to understand the c o m p l e x i t y o f that w o r l d ( A t k i n s o n & H a m m e r s l e y , 1994; C h e n i t z & S w a n s o n , 1986; S c h a t z m a n & Strauss, 1973). I n order to capture this c o m p l e x i t y to the best extent possible, I became an instrument for data c o l l e c t i o n ( L i n c o l n & G u b a , 1985) b y i m m e r s i n g m y s e l f i n the lives o f these f a m i l i e s to the extent that such  Healing Within Families  57  i n v o l v e m e n t 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 w i t h them. F o r e x a m p l e , I was i n v i t e d to j o i n f a m i l i e s for meals, v i e w mementos and treasured f a m i l y photo albums, and, i n one instance, to partake i n a m e m o r i a l service. Often this exposure to participants' private lives p r o v i d e d sensory data and insights that enabled m e to formulate immediate comments, probes, and prompts, i n addition to relevant questions for future i n t e r v i e w s . F i e l d n o t e s d e p i c t i n g observations, s o c i a l processes, and reflections were prepared i m m e d i a t e l y f o l l o w i n g contact w i t h participants. In each and every situation, I g a i n e d a fresh perspective about what was important to these families. M o r e o v e r , I learned about their insight, courage, and strength despite difficult life circumstances. A s p r e v i o u s l y mentioned, I was interested i n understanding the participants' c o m m u n i t y and h o m e environment. F o r instance, I was i n v i t e d to i n t e r v i e w a f a m i l y o f six w h o l i v e d o n a farm. T h e large f a r m was located on p r i m e f a r m l a n d about thirty kilometers f r o m a s m a l l t o w n . I arrived at the f a r m at the pre-arranged time o f 1600 hours. A s I turned into the d r i v e w a y I noted t w o houses i n the f a r m y a r d . I made m y w a y to the larger o f the t w o houses as p r e v i o u s l y instructed. W h e n I stopped m y car, a b i g d o g c a m e r u n n i n g t o w a r d the car. S o o n the o w n e r came to m y rescue. I was greeted b y Jan (a p s e u d o n y m for the mother o f a deceased youth) w h o had forgotten about the i n t e r v i e w . She soon r e c a l l e d that w e had agreed to meet and i n v i t e d m e into the house. W e w a l k e d through a huge laundry r o o m and I observed that the w a s h i n g m a c h i n e and dryer were i n use. W e then entered a spacious country k i t c h e n w i t h lots o f light, and m a n y o a k cupboards w i t h a huge m a t c h i n g oak table i n the center o f the r o o m . T h e furnishings and decor were o f fine quality. I i m m e d i a t e l y sensed the aroma o f fresh garden vegetables m i n g l e d w i t h the pleasant smell of h o m e c o o k i n g . T h i s added to the characteristic w a r m atmosphere I r e a d i l y sensed. I soon noted that another female adult was present. Jan i n f o r m e d m e that her sister f r o m the east coast was v i s i t i n g for the summer. A s I began to set up for the i n t e r v i e w , I noted that the t w o youngest c h i l d r e n (both daughters aged 11 and 9) settled themselves at the far end o f the large table. T h e y began to o c c u p y themselves w i t h paper and pencil activities. T h e interview took place at the k i t c h e n table w i t h Jan  Healing Within Families  58  and her husband, M a r t i n , a n d their t w o daughters present. T h e t h i r d s u r v i v i n g c h i l d i n this f a m i l y , a 16-year o l d m a l e youth, was not at home d u r i n g the time o f the i n t e r v i e w . T h e m o t h e r ' s v i s i t i n g sister c o n t i n u e d to w o r k i n the k i t c h e n d u r i n g the i n t e r v i e w . T h e w h o l e f a m i l y seemed r e l a x e d and the m o t h e r ' s sister even participated every n o w and then i n the i n t e r v i e w process. Coffee was served as w e c o n v e r s e d . I was i n v i t e d to stay for d i n n e r — I accepted. A w e l l - b a l a n c e d m e a l was served (roast beef, potatoes, vegetables, salad, home-made bread, and beverage). W h i l e the girls d i d not participate d u r i n g the i n t e r v i e w , they were both the center o f attention d u r i n g the m e a l . T h e r e was m u c h light talk a n d laughter shared a m o n g f a m i l y members d u r i n g the m e a l . B o t h parents spoke v e r y p o s i t i v e l y about the girls i n their presence, and it was evident that they appreciated the attention. After dinner, M a r t i n i n v i t e d me into their tastefully furnished l i v i n g r o o m to l o o k at a photo a l b u m and other c h e r i s h e d mementos. I noted that there were no pictures o f the deceased youth i n the house. M a r t i n c o m m e n t e d that he c o u l d not b r i n g h i m s e l f to d i s p l a y photos. H e c o m m e n t e d that his parents, w h o l i v e i n the other house i n the same y a r d , have a b i g picture o f P a u l (deceased son) on the w a l l o f their l i v i n g r o o m . In a s e c o n d case, I was i n v i t e d to conduct an i n t e r v i e w w i t h a s u r v i v i n g sister, C l a r e , w h o was diagnosed w i t h s c h i z o p h r e n i a . She was l i v i n g on social assistance at the time o f the i n t e r v i e w . C l a r e l i v e d i n a basement suite i n a l o w - i n c o m e , m u l t i p l e f a m i l y d w e l l i n g i n a s m a l l urban center. A s I entered her suite, I noted that it was dark because a l l the b l i n d s were d r a w n . She turned on a light as I stood i n the entrance. She then g u i d e d m e to the l i v i n g r o o m . O n the w a y , I noted that her place was generally unkempt w i t h dishes p i l e d on a l l the available counter space. A l s o , there were items o f c l o t h i n g strewn a l o n g the narrow h a l l w a y . T h e doors to the other r o o m s i n the suite were closed. W h e n w e entered the s m a l l l i v i n g r o o m , C l a r e turned o n an o v e r h e a d l a m p . S h e then p i c k e d the cat up off the sofa and cleared a s m a l l space for m e to sit. S h e cheerfully offered m e a cup o f coffee. C l a r e i n f o r m e d m e that she was getting m a r r i e d soon. S h e s a i d that she wanted to show m e something. She disappeared d o w n the hall and returned w i t h a j a c k e t that she h a d made. P r o u d o f her a c c o m p l i s h m e n t , she p o i n t e d to the cross-stitch w o r k on the b a c k o f the jacket. She seemed pleased that I c o m m e n t e d p o s i t i v e l y about her w o r k . She then sat d o w n on a w e l l w o r n  Healing Within Families  59  recliner r o c k e r and began t a l k i n g about her experience related to her brother's suicide. A s w e carried o n our conversation, I observed some figurines l i n e d up a l o n g the opposite w a l l o f the l i v i n g r o o m . I i n q u i r e d about them. C l a r e said that she had made t h e m as a w a y o f d e a l i n g w i t h her brother's death. E a c h figurine represented one facet o f her grief. In a t h i r d situation, I was i n v i t e d to visit L i z , a single mother o f t w o c h i l d r e n , i n her m o b i l e home i n a s m a l l urban center. L i z was very w a r m and most receptive to b e i n g i n t e r v i e w e d . It had been over a year since her husband had taken his life. S h e had made a d e c i s i o n to return to s c h o o l and was i n the process o f m o v i n g to another country at the time o f data c o l l e c t i o n . O n the day o f the i n t e r v i e w , the youngest c h i l d was i n kindergarten and the older c h i l d was i n s c h o o l . B e c a u s e the m o v e r s h a d just r e m o v e d the furniture f r o m her home, w e sat o n the l i v i n g r o o m floor w i t h our ' legs crossed i n front o f us. A s we sat there, L i z p o i n t e d out m a n y features o f her h o m e , and I c o u l d see that she took a great deal o f pride i n her surroundings. A s w e c o n t i n u e d our conversation, L i z f o l d e d a b i g basket o f c h i l d r e n ' s c l o t h i n g . S h e t a l k e d e a s i l y and effortlessly. After about an hour and a half, the telephone rang. A p p a r e n t l y , L i z h a d forgotten to p i c k up the youngest c h i l d f r o m kindergarten. T h e caller suggested an alternative c h i l d care arrangement and w e c o n t i n u e d our conversation. I c o n c l u d e d the i n t e r v i e w shortly thereafter. A s part o f the f i e l d w o r k experience, I kept a two-part " r e f l e x i v e j o u r n a l " ( L i n c o l n & G u b a , 1985, p. 327) i n w h i c h I d o c u m e n t e d m y thoughts, ideas, and reflections about the study. These authors r e c o m m e n d i n c l u d i n g the f o l l o w i n g information i n a reflexive j o u r n a l : a c h r o n o l o g i c a l l o g containing pertinent details related to the organization and execution o f the study, the researcher's personal notes about the total research experience, and a m e t h o d o l o g i c a l l o g d o c u m e n t i n g the d e c i s i o n m a k i n g process used d u r i n g theory development. T h e first part o f m y j o u r n a l contained a calendar that served as a c h r o n o l o g i c a l l o g o f the progression o f events throughout the study. H e r e , I recorded the i n t e r v i e w schedule along w i t h technical i n f o r m a t i o n related to the study. In the second part o f the j o u r n a l , I documented m y thoughts and ideas about the study i n c l u d i n g : e m o t i o n a l reactions to participants' stories, ideas gleaned f r o m conversations w i t h other grounded theorists, and m e t h o d o l o g i c a l decisions a l o n g w i t h supporting rationale. T h i s j o u r n a l was i n v a l u a b l e because, i n it, I was able to write detailed notes d e s c r i b i n g m y v i e w s about what was  Healing Within Families  60  happening i n the study, draw conceptual diagrams representing the data, and experiment w i t h m y ideas about the m e a n i n g o f the data. F o r instance, I was able to reflect o n the d i c h o t o m y (e.g., experiences o f great pain and great j o y ) I often sensed d u r i n g m y encounters w i t h f a m i l i e s and its relevance to the study. A t other times, I s i m p l y wrote about m y feelings related to hearing participants' stories. J o u r n a l i n g also facilitated the conceptualization phase o f theory development. F o r e x a m p l e , one particular incident stands out i n m y m i n d . I h a d just attended the funeral o f m y brother-in-law and the f o l l o w i n g day e m b a r k e d on the l o n g d r i v e h o m e (a 13-hour j o u r n e y ) . A s m y husband was d r i v i n g , I was t h i n k i n g about m y research w h e n I e x p e r i e n c e d a strong urge to attempt to represent the data through d r a w i n g . W i t h i n moments our v e h i c l e was transformed into a suitable w o r k space. D a t a were spread out along the dashboard and o n the f l o o r b o a r d ; some even f l o w e d into the b a c k seat. A l m o s t l i k e m a g i c , responding to m y felt sense, I d r e w a d i a g r a m o f m y conceptualization o f the data. T h i s diagram has since b e c o m e an integral component o f the theory presented i n this dissertation. M a y (1986) supports this m e t h o d for s t u d y i n g abstract concepts such as healing. T h e creation o f this d i a g r a m represented an important m e t h o d o l o g i c a l d e c i s i o n because it captured m y interpretation o f the healing process as experienced b y f a m i l y s u r v i v o r s o f youth suicide, and served to further m y conceptualization o f this process.  D a t a Management I n i t i a l l y , each f a m i l y was assigned an i d e n t i f i c a t i o n n u m b e r (e.g., f a m i l y 0 0 1 , 0 0 2 , etc.). E a c h i n d i v i d u a l f a m i l y m e m b e r was also identified b y a letter f o l l o w i n g the f a m i l y identification n u m b e r (e.g., f a m i l y m e m b e r 0 0 1 - A , 0 0 1 - B , etc.). A f a m i l y file was then created w i t h transcripts c h r o n o l o g i c a l l y o r g a n i z e d a c c o r d i n g to the date o f each i n t e r v i e w . F i e l d notes were handled i n a . s i m i l a r manner. A s categories emerged f r o m the data, other files were created. F o r example, a file name specific to a category was created and a second c o p y o f pertinent data f r o m a l l families was then stored i n that file. B o t h hard and c o m p u t e r i z e d copies o f the data were prepared. A back-up disc c o n t a i n i n g the data was stored i n a l o c k e d f i l i n g cabinet. A s the theory d e v e l o p e d , other files were created and handled i n a s i m i l a r fashion. O r g a n i z i n g data i n this w a y a l l o w e d m e to analyze it  Healing Within Families  61  f r o m m a n y perspectives. T h i s m e t h o d o f data management permitted easy access to a large v o l u m e of data and w o r k e d w e l l d u r i n g the process o f m a n u a l analysis.  Data Analysis D a t a c o l l e c t i o n and data analysis occurred simultaneously w i t h analysis g u i d i n g subsequent data c o l l e c t i o n (Strauss & C o r b i n , 1990). T h e constant c o m p a r a t i v e m e t h o d (Glaser, 1978) was u t i l i z e d to a l l o w for m o d i f i c a t i o n a c c o r d i n g to the a d v a n c i n g theory. U s i n g the constant comparative method, I c o m p a r e d n e w l y c o l l e c t e d data w i t h p r e v i o u s l y obtained data i n an o n - g o i n g fashion to further refine theoretically relevant data (Polit & H u n g l e r , 1999). Subsequently, data were categorized ( S w a n s o n , 1986a) and n a m e d . I sought participants' input regarding the n a m i n g o f categories. A s stated earlier, at the onset o f the study I had o r i g i n a l l y p l a n n e d to study ' f a m i l y h e a l i n g . ' It was o n l y as I began to listen to the stories shared b y f a m i l y members that I r e a l i z e d their stories focused o n l y on their personal experiences related to healing. C o n s e q u e n t l y , the p r i m e focus o f the study was m o d i f i e d to reflect an emphasis on the experience o f i n d i v i d u a l s w i t h i n the context o f the f a m i l y . T h i s m o d i f i c a t i o n was negotiated w i t h m y dissertation c o m m i t t e e and j u s t i f i e d on the basis of what the research f i e l d w o u l d a l l o w . B e c a u s e l i m i t e d scientific k n o w l e d g e is currently available specific to healing f o l l o w i n g youth suicide, a focus on the i n d i v i d u a l experience o f healing was d e e m e d appropriate for the purposes o f this study. T h e N U D * I S T ( N o n - n u m e r i c a l , Unstructured, D a t a I n d e x i n g , S e a r c h i n g and T h e o r i z i n g ; R i c h a r d s & R i c h a r d s , 1991, 1995) software package for qualitative data management was investigated. T h i s p r o g r a m w o u l d have required considerable time for m e to learn to use it efficiently. G i v e n m y u n f a m i l i a r i t y w i t h computer technology at the time I began this project, and given the l i m i t e d time available to devote to this research w h i l e r e s u m i n g m y regular teaching responsibilities, I chose to use m a n u a l methods o f m a n a g i n g the data. M o r e i m p o r t a n t l y , I p e r c e i v e d that the f a m i l i a r "hands-on" methods a l l o w e d a sense o f greater i m m e r s i o n i n the data. T h i s , i n fact, turned out to be true.  Healing Within Families  62  D u r i n g the process o f data analysis, I solicited input f r o m several "experts." A s data c o l l e c t i o n and analysis progressed, I c o m m u n i c a t e d w i t h m y dissertation supervisor on a regular basis v i a telephone a n d electronic m a i l . D u r i n g the early stages o f data c o l l e c t i o n and analysis, I met first w i t h m y supervisor to discuss and compare some o f the early i n t e r v i e w s a n d to r e v i e w the code lists as they e v o l v e d . L a t e r as the theory e v o l v e d , I met w i t h m y entire committee to discuss a matrix that represented m y early conceptualization o f the e m e r g i n g theory and the original version of the d i a g r a m presented i n Chapter F i v e . A s the study e v o l v e d , c o m m u n i c a t i o n w i t h m y supervisor and committee continued. T h i s o n g o i n g dialogue definitely enhanced m y first research experience f o c u s i n g on theory development. A s m e n t i o n e d p r e v i o u s l y , taped interviews and f i e l d notes were t y p e d b y a transcriptionist u s i n g M i c r o s o f t W o r d 6.0.1 ( G o o k i n , 1994). H a r d c o p i e s were transcribed o n the left half o f the page o n l y , l e a v i n g the right half o f the page b l a n k for hand analysis. T h e right half o f each page was then d i v i d e d into three sections, one for each l e v e l o f c o d i n g .  Coding A s soon as the v e r b a t i m transcripts were prepared, the data were read t w o or three times to b e c o m e f a m i l i a r w i t h t h e m (J. A n d e r s o n , personal c o m m u n i c a t i o n , September 2 0 , 1996). C o d i n g , the l i n k between data a n d theory (Glaser, 1978), began w i t h open c o d i n g . T h e open c o d i n g technique was used as the first l e v e l o f data analysis. O p e n c o d i n g entailed b r e a k i n g d o w n , e x a m i n i n g , c o m p a r i n g , c o n c e p t u a l i z i n g , and c a t e g o r i z i n g data for the purpose o f theory generation (Strauss & C o r b i n , 1990). T h i s process y i e l d s codes w h i c h have been l a b e l e d descriptive ( C h a r m a z , 1983; S w a n s o n , 1986b), objective ( S e i d e l , 1995), o r substantive (Carpenter, 1995; Glaser, 1978) because they represent the uninterpreted facts w i t h i n the data. T h i s procedure often i n v o l v e s c o d i n g each event or happening, usually i n a l i n e - b y - l i n e fashion, to get at the ideas w i t h i n the data. In consideration o f the subject matter, I departed f r o m Strauss a n d C o r b i n ' s (1990) idea o f open c o d i n g . In k e e p i n g w i t h m y analytic approach o f " t h i n k i n g w i t h stories" (Frank, 1995), d i s c u s s e d earlier i n this chapter, I opted to code textual data b y u s i n g ' m e a n i n g units.' M e a n i n g units were w o r d s , phrases, or paragraphs representing s o m e m e a n i n g f u l i d e a expressed  Healing Within Families  63  b y a participant or group o f participants. I reasoned that this unit o f analysis w o u l d more accurately reflect the informants' v i e w s . M e a n i n g units were d e r i v e d b y a s k i n g questions o f the data (Glaser, 1978) such as: " W h a t is b e i n g c o m m u n i c a t e d here?" and, " W h a t does this mean i n terms o f h e a l i n g ? " I speculated that b y a n a l y z i n g data i n this manner, I w o u l d be able to honor the w i s d o m w i t h i n each story, and at the same time, preserve each i n f o r m a n t ' s v o i c e . C o d e s (i.e., m e a n i n g units) were then e x a m i n e d for similarities and differences and were then grouped into categories. T h e conceptual name g i v e n to a category reflected the data that it represented. In an effort to remain grounded i n the data, I used informant's t e r m i n o l o g y whenever p o s s i b l e to create " i n v i v o codes" (Carpenter, 1 9 9 5 ; C h a r m a z , 1983; G l a s e r , 1978, p. 7 0 ; Strauss, 1987, p . 33). In a d d i t i o n , selected participants were also i n v i t e d to provide input related to the n a m i n g o f categories. Initially, three major categories were d e v e l o p e d from the data through the process o f c o d i n g m e a n i n g units. U s i n g " i n v i v o c o d e s " (Carpenter, 1995; C h a r m a z , 1983; G l a s e r , 1978, p. 7 0 ; Strauss, 1987, p. 33), these major categories were i n i t i a l l y named: H o l d i n g O n T o L e t t i n g G o ; L e t t i n g G o ; and L e t t i n g G o and M o v i n g B e y o n d . A l t h o u g h each major category e x p l a i n e d one aspect o f the topic under study (i.e., i n d i v i d u a l h e a l i n g f o l l o w i n g y o u t h suicide), each major category h a d m e a n i n g o n l y i n relationship to the other t w o major categories. M o r e o v e r , w i t h i n each o f the three major categories, five elements were d e v e l o p e d f r o m the data, each element further d e f i n i n g the parameters w i t h i n each major category. S i m i l a r l y , w i t h i n each element, a n u m b e r o f ideas emerged from the data. These ideas further defined each element. A x i a l c o d i n g was used d u r i n g the second l e v e l o f data analysis. D u r i n g a x i a l c o d i n g , I put the data back together again b y m a k i n g connections between the major categories (i.e., concepts) and its elements (Strauss & C o r b i n , 1990). T h e three i n i t i a 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 initial ones. S i m i l a r l y , the elements were further refined and sometimes renamed and/or c o m b i n e d w i t h former elements. T h e t h i r d l e v e l o f analysis, selective c o d i n g , i n v o l v e d the synthesis o f p r e v i o u s l y identified concepts and elements to formulate a " c o r e " concept (Strauss & C o r b i n , 1990). T h e core concept emerged as a result o f u s i n g constant c o m p a r i s o n to analyze for relationship patterns between and  Healing Within Families  64  a m o n g substantive codes ( C h e n i t z & S w a n s o n , 1986; G l a s e r , 1978). S e l e c t i v e c o d i n g , m o r e abstract than substantive c o d i n g , was used to conceptualize h o w substantive codes were related and then to raise substantive c o d i n g to a theoretical level (Strauss & C o r b i n , 1990). T h e core concept represented the basic social p s y c h o l o g i c a l processes ( B S P s ) (Carpenter, 1995; F a g e r h a u g h , 1986) that e x p l a i n e d the story as portrayed i n the data.  Memoing T h r o u g h o u t the analysis, m e m o s were kept d o c u m e n t i n g m y t h i n k i n g processes w h i l e c o d i n g the data, identifying and l i n k i n g the data, and n a m i n g the core p h e n o m e n o n (Glaser & Strauss, 1967). A " c o n d i t i o n a l m a t r i x " ( C o r b i n & Strauss, 1988; Strauss & C o r b i n , 1990) representing the interrelationships a m o n g the categories was designed. F i e l d notes d o c u m e n t i n g observations a n d m y intuitive grasp o f the participants' stories were prepared. O n numerous occasions I referred b a c k to these notes. F o r e x a m p l e , I o r i g i n a l l y separated "Intuitive V i s i o n i n g " f r o m " F i n d i n g M e a n i n g / E x p l o r i n g S p i r i t u a l i t y . " A s I r e v i e w e d m y notes about m y t h i n k i n g processes regarding this d e c i s i o n , I was able to determine that the s e c o n d element s h o u l d be c o l l a p s e d w i t h i n the first.  E s t a b l i s h i n g Scientific R i g o r W h i l e the w o r t h o f quantitative research is determined p r i m a r i l y b y assessing its reliability and v a l i d i t y , the w o r t h o f a qualitative study is ascertained b y assessing its trustworthiness ( E l d e r & M i l l e r , 1995; K r e f t i n g , 1991; L e i n i n g e r , 1994; L i n c o l n a n d G u b a , 1 9 8 5 ; Streubert, 1995). I n qualitative research, reliability and v a l i d i t y are often e x p l a i n e d i n terms o f credibility, fittingness o f the data, auditability, a n d c o n f i r m a b i l i t y ( S a n d e l o w s k i , 1986). S i m i l a r l y , L i n c o l n a n d G u b a (1985) stipulate four criteria that can be used to determine the trustworthiness o f qualitative i n q u i r y , specifically: c r e d i b i l i t y , transferability, dependability, and c o n f i r m a b i l i t y . F i n d i n g s are credible to the extent they represent the i n d i v i d u a l truths expressed b y each participant i n v o l v e d i n the study. Transferability is addressed b y ascertaining the extent to w h i c h the researcher has p r o v i d e d adequate descriptive data to enable others to apply or transfer the findings to other contexts or  Healing Within Families  65  respondents. B e c a u s e the naturalistic inquirer expects variability i n every aspect o f the research project, i n c l u d i n g changes i n the informants, the setting, or the researcher, the c o n c e r n regarding r e p l i c a b i l i t y or consistency o f the study focuses on d e t e r m i n i n g dependability, or the extent to w h i c h the researcher can account for the variability w i t h i n 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 b e i n g neutral or free f r o m the biases o f the researcher is shifted to a detennination o f the extent to w h i c h the data are neutral, or can be c o n f i r m e d . I elected to establish scientific r i g o r b y determining trustworthiness a c c o r d i n g to the criteria set forth b y L i n c o l n and G u b a (1985).  Credibility I used a n u m b e r o f strategies to establish c r e d i b i l i t y . First, triangulation, or the use o f a n u m b e r o f different data c o l l e c t i o n methods, sources o f data, investigators, or c o m p e t i n g theories was used ( K r e f t i n g , 1991; L i n c o l n & G u b a , 1985). I triangulated a variety o f data c o l l e c t i o n methods (e.g., i n t e r v i e w s , participant observations; use o f n o n - t e c h n i c a l data sources, and m y reflexive journal) to secure m a x i m u m variation w i t h i n the data and to ensure accurate representation of the participants' experiences i n d e v e l o p i n g the theory. T h e s e c o n d strategy i n v o l v e d the careful f r a m i n g o f questions. A c c o r d i n g to K r e f t i n g (1991), "the r e f r a m i n g o f questions, repetition o f questions, or e x p a n s i o n o f questions on different occasions are w a y s i n w h i c h to increase c r e d i b i l i t y " (p. 220). In m y effort to understand the v i e w s of each participant, I proceeded b y a s k i n g questions c l e a r l y and c o n c i s e l y . I n addition, I used paraphrasing to ensure that I r e c e i v e d the participant's intended message. A t h i r d strategy used to increase credibility was p r o l o n g e d engagement w i t h participants, defined b y L i n c o l n and G u b a (1985) as, "the investment o f sufficient time 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 o f several hours w i t h each participant. M u c h attention and time were spent b u i l d i n g rapport and trust w i t h participants i n addition to f o c u s i n g on the research questions. P r o l o n g e d engagement w i t h participants accentuates one o f the dangers inherent i n naturalistic i n q u i r y — t h e potential for the researcher to "go native" b y b e c o m i n g over-identified  Healing Within Families  66  w i t h respondents ( C h e n i t z & S w a n s o n , 1986; K r e f t i n g , 1991). I used t w o strategies to prevent this and thus maintain credibility: peer e x a m i n a t i o n (Krefting, 1991) or peer debriefing ( L i n c o l n & G u b a , 1985), a n d j o u r n a l i n g ( C h e n i t z & S w a n s o n , 1986). P e e r d e b r i e f i n g , d e f i n e d as " e x p o s i n g oneself to a disinterested peer. . . . for the purpose o f e x p l o r i n g aspects o f i n q u i r y that m i g h t otherwise r e m a i n o n l y i m p l i c i t w i t h the i n q u i r e r ' s m i n d " ( L i n c o l n & G u b a , 1985, p. 308), was a c c o m m o d a t e d b y sharing this w o r k w i t h professional colleagues a n d i n v i t i n g their feedback. A n o t h e r helpful strategy was m y routine participation i n debriefing sessions w i t h a trusted professional colleague. In addition, I felt free to contact m y dissertation supervisor about any concerns d u r i n g the course o f m y i n v o l v e m e n t i n this study. J o u r n a l i n g , the s e c o n d strategy, was discussed above i n the section d e a l i n g w i t h participant observation and f i e l d w o r k . C r e d i b i l i t y was also a c h i e v e d through m e m b e r c h e c k i n g . A c c o r d i n g to L i n c o l n and G u b a (1985), "the m e m b e r c h e c k , whereby data, analytic categories, interpretations, a n d c o n c l u s i o n s are tested w i t h members o f those stakeholding groups f r o m w h o m the data were o r i g i n a l l y collected, is the most c r u c i a l technique for establishing c r e d i b i l i t y " (p. 314). O n g o i n g m e m b e r c h e c k i n g ( L i n c o l n & G u b a , 1985) w i t h selected participants was carried out as the research study progressed. M i n o r m o d i f i c a t i o n s to the theory were made based on participant feedback. A d d i t i o n a l l y , this w o r k was presented at a conference where delegates were s u r v i v o r s o f youth suicide. T h e s e i n d i v i d u a l s indicated that the substantive theory presented i n this dissertation c o m p r e h e n s i v e l y reflected their experiences related to healing f o l l o w i n g y o u t h suicide. N e g a t i v e case analysis was the final strategy I used to enhance c r e d i b i l i t y . T h e goal o f 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). O n e e x a m p l e o f negative case analysis i n m y study was the need to account for t w o i n d i v i d u a l s w h o , i n contrast to the other participants, d i d not consider themselves to be m o v i n g t o w a r d healing. In sharing the d e v e l o p i n g theory w i t h them, they identified w i t h the theory even though they were not yet ready to heal. T h u s , even these t w o i n d i v i d u a l s validated the theory and the critical aspect o f v o l i t i o n i n healing.  Healing Within Families  67  Transferability T o augment transferability o f the study, I used t w o techniques. T h e first o f these was the use o f " t h i c k d e s c r i p t i o n " ( L i n c o l n & G u b a , 1985, p. 316) or "dense b a c k g r o u n d i n f o r m a t i o n " ( K r e f t i n g , 1 9 9 1 , p . 220) gathered d u r i n g the data c o l l e c t i o n process ( C h e n i t z and S w a n s o n , 1986). S e c o n d , I engaged i n theoretical s a m p l i n g , d i s c u s s e d p r e v i o u s l y , to ensure both depth and breadth w i t h i n the t h i c k descriptions and to accommodate saturation o f the data ( L i n c o l n & G u b a , 1985).  Dependability M e a s u r e s that enhanced the credibility o f this research endeavor also helped to increase its dependability. I took three additional measures to establish the dependability o f this w o r k . T h e first o f these r e c o m m e n d e d b y K r e f t i n g (1991) was the "code-recode p r o c e d u r e " (p. 221) w h i c h i n v o l v e s c o d i n g the data, w a i t i n g a p e r i o d o f t w o weeks, and then r e c o d i n g . T h i s technique was used d u r i n g the i n i t i a l phase o f the project, w h i l e w o r k i n g w i t h the research assistant, to ensure that we were thoroughly c o d i n g the data and a r r i v i n g at categories that accurately reflected the data. T h e s e c o n d step taken to enhance dependability was to p r o v i d e , i n this chapter, "dense descriptions of [the] m e t h o d s " ( K r e f t i n g , 1991, p. 221) used d u r i n g the entire research u n d e r t a k i n g . T h e final measure used to increase the dependability o f this study was to p r o v i d e an " i n q u i r y audit" ( L i n c o l n & G u b a , 1985, p. 317). T h i s i n v o l v e d e x a m i n i n g the process o f the study recorded as an "audit t r a i l " ( L i n c o l n & G u b a , 1985, p. 319). Streubert (1995) defines the audit trail as " a r e c o r d i n g o f activities over time w h i c h c a n be f o l l o w e d b y another i n d i v i d u a l . . . [the] objective [of w h i c h ] is to, as c l e a r l y as possible, illustrate the evidence and thought processes w h i c h l e d to the c o n c l u s i o n s " (p. 26). A study is dependable to the extent that the audit trail documents the sources o f variability i n the study. T h e audit trail I left i n c l u d e d the thesis proposal d o c u m e n t i n g the research p l a n , the r a w data (e.g., i n t e r v i e w data and f i e l d notes), the c h r o n o l o g i c a l l o g o f research events, m y reflexive j o u r n a l , a portfolio c o n t a i n i n g an assortment o f non-technical information shared b y participants, and documentation related to data analysis and synthesis c o n t a i n e d i n this dissertation.  Healing Within Families  68  Confirmability C o n f i r m a b i l i t y is s y n o n y m o u s w i t h the traditional n o t i o n o f objectivity. It is concerned w i t h ensuring that the data, interpretations, and outcomes o f the study accurately represent the v i e w s o f those w h o participated i n the study. A s the study e v o l v e d , selected participants were i n v o l v e d i n identifying and n a m i n g k e y concepts and categories. T h i s approach kept data analysis and synthesis g r o u n d e d i n participants' stories. In addition, the e v o l v i n g theory was presented to suicide survivors at a research conference; these i n d i v i d u a l s further v a l i d a t e d the research findings. T o further ensure c o n f i r m a b i l i t y , an audit trail was kept d o c u m e n t i n g the d e c i s i o n m a k i n g process used d u r i n g the theory development process. T h i s strategy enhanced c o n f i r m a b i l i t y i n that it a l l o w s others to trace the research findings to their o r i g i n a l data sources.  E t h i c a l Considerations P r i o r to b e g i n n i n g the research project, a p p r o v a l was granted b y the U n i v e r s i t y o f B r i t i s h C o l u m b i a B e h a v i o r a l Sciences S c r e e n i n g C o m m i t t e e for Research I n v o l v i n g H u m a n Subjects ( N o v e m b e r 6, 1996). W i t h i n this section, I address the steps taken to ensure that ethical standards were a p p l i e d d u r i n g the study and ethical care was p r o v i d e d to participants. Issues related to i n f o r m e d consent have been discussed p r e v i o u s l y i n this chapter w i t h i n the data c o l l e c t i o n section. In addition, other steps were taken to ensure confidentiality d u r i n g the research process. P s e u d o n y m s were assigned by the researcher d u r i n g the data c o l l e c t i o n process as one w a y o f securing a n o n y m i t y for participants. In one case, a participant i n d i c a t e d that she preferred b e i n g identified by her full name. S i n c e the participant was f l e x i b l e i n this regard, it was j o i n t l y d e c i d e d that a p s e u d o n y m 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 c o d e d so that n o i d e n t i f y i n g information was recorded o n the transcripts. C o d e sheets were stored separately f r o m the data. D a t a were secured i n l o c k e d f i l i n g cabinets i n m y home. D a t a were accessible o n l y to a l l dissertation c o m m i t t e e members, the research assistant, and myself. Participants were advised that  Healing Within Families  69  audio tapes w o u l d be erased and transcripts appropriately d i s p o s e d o f three years after the c o m p l e t i o n o f the study. G i v e n the sensitive nature o f the topic o f this research, i n t e r v i e w s were also c o n d u c t e d w i t h great sensitivity t o w a r d f a m i l y members. It was anticipated that participation i n this research m i g h t be cathartic for some i n d i v i d u a l s . Several authors c o m m e n t on the emancipatory potential that story telling often evokes i n research participants ( A l t y & R o d h a m , 1998; B a n k s - W a l l a c e , 1998; D e m i & W a r r e n , 1995; H u t c h i n s o n , 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 r e c o g n i z e d that the interviews m i g h t induce intense e m o t i o n a l reactions for some participants. A l t h o u g h not needed, arrangements were i n place for an appropriate referral for i n d i v i d u a l s and f a m i l i e s i n the event they required such assistance. M o r e o v e r , participants were a d v i s e d that u p o n c o m p l e t i o n o f the study, a s u m m a r y o f the k e y findings o f the research project w o u l d be shared w i t h them.  Summary T h e research was designed as a grounded theory f o c u s i n g on i n d i v i d u a l f a m i l y m e m b e r s ' experiences o f h e a l i n g f o l l o w i n g youth suicide. C o n g r u e n t w i t h a relativist p h i l o s o p h i c a l position, a s y m b o l i c interactionism perspective g u i d e d the methods used i n this i n q u i r y . T h e study was conducted i n a natural setting—the homes o f i n d i v i d u a l or f a m i l y m e m b e r s w h o consented to participate. Theoretical s a m p l i n g g u i d e d data c o l l e c t i o n and the constant comparative m e t h o d was used d u r i n g data analysis. Interviews, supplemented b y participant observation and non-technical data, were used to gain an understanding about f a m i l y m e m b e r s ' healing experiences. E l e v e n families participated i n the study d u r i n g an 18-month p e r i o d o f time. T h i s study generated a detailed, contextually-grounded description and theoretical explanation o f i n d i v i d u a l healing w i t h i n families f o l l o w i n g youth suicide. G r o u n d e d theory was an effective m e t h o d for addressing the research questions. A n o v e r v i e w o f grounded theory that was d e v e l o p e d f r o m 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 h e a l i n g process is presented i n Chapters F i v e , S i x , and S e v e n .  Healing Within Families  CHAPTER  70  FOUR  JOURNEYING TOWARD WHOLENESS: A CONTEXTUALIZED EXPERIENCE  You think that something like this will never happen to you. That's what I used to think. And then one day it happened. When it happens, you begin to understand things differently . . . you're treated differently after it happens . . . you're judged by others. (Dale, a father).  T h e purpose o f this chapter is threefold. First, it provides a d e s c r i p t i o n o f the participants. S e c o n d , it presents a p r e v i e w and an o v e r v i e w o f the g r o u n d e d theory that e m e r g e d as a result o f this study w h i c h w i l l be further d e v e l o p e d i n the chapters that f o l l o w . B e g i n n i n g w i t h the precipitating event, this chapter also addresses several important contextual factors that influence the h e a l i n g process.  D e s c r i p t i o n o f Participants (The S a m p l e ) E l e v e n families from rural c o m m u n i t i e s (8 families) and s m a l l urban centers (3 families) i n three W e s t e r n C a n a d i a n provinces participated i n the study (see T a b l e 4-1). These families ranged i n size f r o m 3 to 12 i n d i v i d u a l s . A total o f 41 f a m i l y members participated.  TABLE 4-1:  RESIDENCE OF PARTICIPANTS  Rural Characterization  Number of Families N = 11  Number of Individuals Within Families N = 41  Canadian Aboriginal Reserve (more than 50 km from urban center) Town or village (population less than 25,000) Area surrounding town or small urban center (at least 25 km from town or urban center) Small urban center (population less than 65,000—market center serving rural area)  1  5  5  20  2  4  3  12  A c h r o n o l o g i c a l profile o f the participants i n this study is presented i n the f o r m o f a chart i n T a b l e 4-2. T h e i n f o r m a t i o n i n these charts was gleaned f r o m data p r o v i d e d i n response to the  Healing Within Families  71  D e m o g r a p h i c Questionnaire (see A p p e n d i x F ) and information obtained d u r i n g i n d i v i d u a l and f a m i l y interviews. A l l potential participants w i t h w h o m I spoke and e x p l a i n e d the study agreed to participate. A l t h o u g h some chose to participate o n l y d u r i n g the f a m i l y i n t e r v i e w , a l l o f those w h o became i n v o l v e d i n the study f o l l o w e d it through to its c o m p l e t i o n . In total, 4 4 i n t e r v i e w s , i n c l u d i n g 33 i n d i v i d u a l and 11 f a m i l y i n t e r v i e w s , were conducted. A little more than one half o f the participants were female (n=26). T h e participants i n c l u d e d mothers (n=9), fathers (n=8), sisters (n=8), brothers (n=3), grandparents (n=2), significant others (n=7), w i v e s (n=2), and c h i l d r e n o f the deceased (n=2). Participants r a n g e d i n age f r o m 6 to 80 years w i t h a m e a n age o f 38 years. T h e average length o f time since the s u i c i d e was 3.1 years, r a n g i n g f r o m 6 months to 12 years. T w o s u r v i v o r s f r o m t w o different f a m i l i e s h a d previous experience w i t h the suicide o f a significant other. S o c i o e c o n o m i c diversity a m o n g families was evident w i t h four f a m i l i e s reporting an annual f a m i l y i n c o m e o f less than $30,000; three families reporting an annual i n c o m e o f $30,000 or more and less than $80,000; three families reporting an annual i n c o m e o f $ 8 0 , 0 0 0 or m o r e and less than $150, 0 0 0 ; and one f a m i l y reporting an annual i n c o m e e x c e e d i n g $ 1 5 0 , 0 0 0 . T h e occupational status o f adult f a m i l y members i n c l u d e d currently u n e m p l o y e d , students, homemakers, blue and w h i t e c o l l a r w o r k e r s , semi-professionals, professionals, and retired persons. E d u c a t i o n a l status ranged f r o m those without high s c h o o l c o m p l e t i o n to those h o l d i n g graduate degrees. A l l participants were fluent i n E n g l i s h ; all interviews were conducted i n E n g l i s h . Three-quarters o f participants described their health status as "excellent" or "very g o o d " w h i l e one-quarter rated their health status as " f a i r " or " p o o r . " T e n i n d i v i d u a l s were diagnosed w i t h health p r o b l e m s . N i n e participants h a d mental illness diagnoses i n c l u d i n g depression (n=5), and s c h i z o p h r e n i a (n=4). O n e participant had experienced the death o f a four month o l d infant and h a d r e c e i v e d a diagnosis of cancer a w e e k p r i o r to b e i n g interviewed. W h i l e most participants (33 o f the 41) identified w i t h the dominant E n g l i s h C a n a d i a n culture o f Western C a n a d a , eight i n d i v i d u a l s c l a i m e d links w i t h one o f the f o l l o w i n g ethnic minorities: C a n a d i a n A b o r i g i n a l , D a n i s h , G e r m a n C a n a d i a n , or F r e n c h C a n a d i a n . Just over half o f the participants (n=24) specified a particular r e l i g i o u s affiliation as Protestant, R o m a n C a t h o l i c , B u d d h i s t , M o r m o n , or J e h o v a h ' s W i t n e s s .  Healing Within Families  72  A l l 11 persons w h o ended their l i v e s were males. T h e y took their o w n l i v e s b y h a n g i n g (n=5), s h o o t i n g (n=5), and d r o w n i n g ( n = l ) . S u i c i d e notes were left b y s i x i n d i v i d u a l s . N i n e youths r a n g i n g i n age f r o m 14 to 19 years ended their lives; t w o others were older (29 and 24 years o f age). F i v e i n d i v i d u a l s w h o took their l i v e s were single, three were m a r r i e d , and three were l i v i n g i n c o m m o n l a w relationships at the time o f their deaths. N i n e i n d i v i d u a l s w h o ended their lives came f r o m families w i t h m a r r i e d parents w h i l e t w o c a m e f r o m families where the parents were separated at the time o f the suicide. M o s t (n=9) suicides o c c u r r e d w i t h i n the four years just prior to the time o f data c o l l e c t i o n . T w o o f the self-inflicted deaths o c c u r r e d o n H a l l o w e e n and one o c c u r r e d on the deceased y o u t h ' s mother's birthday.  T A B L E 4-2: SAMPLE POPULATION DATA Family  Number of Persons in Family (including deceased)  Individual Inter-views  Family Interviews  Total Interviews  Gender & Age of Suicide Victim  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-20  2.5  007  4  2  0  2  M - 24  1  008  5  1  1  2  M-19  .5  009  5  2  1  3  M-17  .5  010  4  3  1  4  M-16  1.5  01 1  6  2  0  2  M-29  4  I n d i v i d u a l H e a l i n g Process F o l l o w i n g Y o u t h S u i c i d e : A P r e v i e w In this study, i n d i v i d u a l h e a l i n g f o l l o w i n g youth suicide is c o n c e p t u a l i z e d as a d y n a m i c , o n g o i n g , recursive, and seamless process that I have l a b e l e d Journeying  Toward Wholeness.  Healing Within Families  73  S u r v i v o r s consistently described their h e a l i n g experience as " a j o u r n e y . " T h e y also spoke repeatedly about b e i n g "fragmented" and feeling "torn apart i n s i d e " b y the tragedy. S u r v i v o r s expressed the w i s h to regain a sense o f " w h o l e n e s s . " T h e y p e r c e i v e d this c o u l d be a c c o m p l i s h e d by e m b a r k i n g o n a personal j o u r n e y . T h e w o r d toward, i n the phrase Journeying  Toward  Wholeness is not used to indicate linear direction. W i t h i n this study, this t e r m i n o l o g y i s used i n its broadest sense to indicate a direction rather than a destination. S i m i l a r l y , this w o r d has been used in expressions such as " t o w a r d an understanding." U n d e r s t a n d i n g , l i k e h e a l i n g , s e l d o m occurs as a solely linear activity. T h e j o u r n e y t o w a r d h e a l i n g is g r a p h i c a l l y depicted as a love knot. T h e t e r m love knot was selected because d u r i n g the interviews, survivors repeatedly m e n t i o n e d that, despite suicidal death, they c o n t i n u e d to l o v e the deceased youth. T h i s b o n d o f l o v e between the s u r v i v o r and deceased youth was e m p h a s i z e d several times over the course o f the study. I n a d d i t i o n , d u r i n g m y "aha experience" mentioned i n the previous chapter, I attempted to represent the data through the use o f a d i a g r a m . I later f o u n d out that the d i a g r a m I drew represented an Israeli l o v e knot. It also came to m y attention through reading that 'the k n o t ' is a preserver o f the life force, and a s y m b o l of attachment and unity (Petzl, 1998). B a s e d on this b a c k g r o u n d i n f o r m a t i o n a n d m y felt sense d f the data, I d e d u c e d that the term love knot accurately represented the study data. T h e love knot represents the healing process depicted b y the three major concepts i n the theory that emerged f r o m the data i n this study. C o l l e c t i v e l y , I have l a b e l e d these three major concepts as healing themes. B a s e d on s u r v i v o r s ' stories about h e a l i n g , I have also l a b e l e d each o f the three healing themes (i.e., major concepts) i n m y theory as Cocooning, Centering, and Connecting. T h e love knot is depicted as three endless ovals e x i s t i n g i n separate realms at slightly different angles to one another and c o n v e r g i n g at the healing epicenter. T h e healing epicenter is the place where h e a l i n g manifests itself, s y n o n y m o u s w i t h the s u r v i v o r ' s consciousness. A l t h o u g h each healing theme (represented b y an oval) explains one aspect o f the o v e r a l l j o u r n e y o f healing, each one has m e a n i n g o n l y i n relationship to the other t w o healing themes (see F i g u r e 4-1). T h e three healing themes o f the i n d i v i d u a l healing process are:  Healing Within Families  74  •  Cocooning - T u r n i n g i n w a r d as a means o f s u r v i v a l f o l l o w i n g y o u t h s u i c i d e .  •  Centering - E x p e r i e n c i n g personal g r o w t h as a result o f m a k i n g k e y d e c i s i o n s i n the aftermath of youth suicide.  •  Connecting - U n i t i n g w i t h self, others, G o d / h i g h e r p o w e r , a n d the e n v i r o n m e n t ; m o v i n g b e y o n d m e d i o c r i t y as a self-chosen response to youth s u i c i d e .  F I G U R E 4-1: I N D I V I D U A L H E A L I N G P R O C E S S  REPRESENTED  BY A  LOVE KNOT  COCOONING J ourney of Descent  Journey of Transcendence  Journey of Growth  W i t h i n each theme i n the healing process, five elements o r healing patterns were developed f r o m the data. A l t h o u g h represented here as discrete entities, these healing patterns are i n d i v i d u a l l y identified o n l y for the purpose o f understanding the theory presented i n this dissertation. In effect, each healing pattern remains inextricably intertwined w i t h a l l the other healing patterns. T h e five healing patterns that portray the s u r v i v o r ' s h e a l i n g j o u r n e y include: •  Relating - Interaction and c o m m u n i c a t i o n ( i n c l u d i n g the e x p r e s s i o n o f e m o t i o n ) w i t h self, others, and G o d o r a h i g h e r power, e m b e d d e d w i t h i n a broader s o c i a l context, i n the aftermath of youth s u i c i d e .  Healing Within Families  •  75  Thinking - C o g n i t i v e processes such as r e m i n i s c i n g , r e m e m b e r i n g , b e l i e v i n g , learning, d e c i s i o n m a k i n g , a n d u s i n g intuition i n response to y o u t h s u i c i d e .  •  Functioning - B e h a v i o r associated w i t h activities o f d a i l y l i v i n g i n response to the suicide o f a beloved family youth.  •  Energizing - C a p a c i t y for p h y s i c a l exertion, vigorous a c t i v i t y , a n d a felt sense o f personal o r authentic p o w e r f o l l o w i n g youth suicide.  •  Finding Meaning/Exploring  Spirituality - H i g h e r p o w e r source and/or i n f o r m a t i o n indicating  that meaning is b e g i n n i n g to emerge i n 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. T h e f o l l o w i n g template illustrates the relationship between the healing themes and the healing patterns (see F i g u r e 4-3).  T A B L E 4 - 3 : INDIVIDUAL H E A L I N G T E M P L A T E * HEALING  PATTERNS  HEALING THEMES COCOONING  CENTERING  CONNECTING  RELATING  STRUGGLING  GETTING A GRIP  REACHING OUT  THINKING  CHAOTIC THINKING  M A K I N G DECISIONS  LEARNING  AUTOPILOTING  RE-ENGAGING  ORCHESTRATING LIFE  ENERGIZING  CONSUMING  REPLENISHING  CHANNELING  FINDING MEANING/ EXPLORING SPIRITUALITY  AWAKENING  TRANSFORMING  TRANSCENDING  FUNCTIONING  * T h i s template is p r o v i d e d 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 i n a three-dimensional, r e c u r s i v e , a n d seamless process.  Healing Within Families  76  B e g i n n i n g i n this chapter, and c o n t i n u i n g i n subsequent chapters, the stories o f 41 i n d i v i d u a l s w i t h i n 11 families are w o v e n into a theory that explains their experiences o f healing f o l l o w i n g youth suicide. T h i s presentation format is used to p r o v i d e an effective means o f h o n o r i n g participants' voices and capturing the truths e m b e d d e d w i t h i n their stories.  O v e r v i e w o f the G r o u n d e d T h e o r y Y o u t h suicide was the precipitating event that created a crisis w i t h i n each o f the 11 families that participated i n this study. W i t h o u t m e r c y , this single, irreversible event catapulted suicide survivors o n a perilous and uncertain j o u r n e y . S u r v i v o r s ' l i v e s were drastically altered w h e n they received the n e w s about the tragedy. W i t h i n this instant, s u r v i v o r s were left alone, left l i v i n g , and left l o v i n g the one w h o had just taken his life. D r a w i n g o n inner strength and courage, survivors began the frequently scary and a l w a y s d e m a n d i n g process o f reconstructing their lives. T h e theory described i n this dissertation study does not c o n c e p t u a l i z e healing i n terms o f discrete stages o r phases, nor does it e x p l a i n h e a l i n g i n terms o f a c h i e v i n g some final predetermined outcome. Rather, this theory represents the d y n a m i c and u n i q u e l y i n d i v i d u a l nature of the h e a l i n g process w h i c h varies i n expression and intensity o v e r the course o f each s u r v i v o r ' s life. W i t h i n this study, i n d i v i d u a l healing f o l l o w i n g youth suicide is c o n c e p t u a l i z e d as Journeying Toward Wholeness. I n d i v i d u a l h e a l i n g is a personal and unique j o u r n e y experienced b y most, but not a l l , f a m i l y s u r v i v o r s o f youth suicide. T h i s j o u r n e y is characterized b y the interrelationships a m o n g three e n f o l d i n g , d y n a m i c , f l u i d , and iterative healing themes entitled: Cocooning; Centering; and Connecting. E a c h healing theme represents one portion o f the overall h e a l i n g j o u r n e y . S p e c i f i c a l l y , Cocooning focuses o n the s u r v i v o r ' s j o u r n e y o f descent into self; Centering deals w i t h the s u r v i v o r ' s j o u r n e y o f personal g r o w t h ; a n d Connecting addresses the s u r v i v o r ' s j o u r n e y o f transcendence. W i t h i n each healing theme, f i v e s e l f - o r g a n i z i n g and inter-  relating healing patterns (i.e., relating, thinking, functioning, energizing, and finding meaning/exploring  spirituality) operate i n mutual r h y t h m i c a l interchange w i t h each other. E a c h o f  the five healing patterns describes one facet o f the s u r v i v o r ' s o v e r a l l experience o f healing  Healing Within Families  77  f o l l o w i n g youth suicide. W i t h i n this dissertation, the healing patterns are presented as distinct entities, o n l y for the purpose o f understanding the various facets o f the w h o l e process. T h e o n g o i n g healing j o u r n e y varies i n expression and intensity o v e r time i n response to a variety o f contextual factors i n c l u d i n g the s u r v i v o r ' s personal history, factors related to the suicide, social considerations, and the health care environment. Importantly, h e a l i n g emanates as an act of volition f r o m the s u r v i v o r ' s consciousness (i.e., the h e a l i n g epicentre) i n response to three key decisions made by each s u r v i v o r o f youth suicide. T h e degree to w h i c h healing occurs depends o n a n u m b e r o f intervening variables (i.e., healing characteristics) reflecting the s u r v i v o r ' s capacity to say yes to life; step out and speak up; achieve a sense o f peace, h a r m o n y , and balance; and e x p a n d personal consciousness. A s a major outcome o f the h e a l i n g process, each s u r v i v o r creates a love knot w h i c h represents a healthy and c o n t i n u i n g b o n d o f l o v e between the s u r v i v o r and deceased youth enacted through the use o f healing strategies. These healing strategies are based o n the m e a n i n g the s u r v i v o r attributes to his or her experience w i t h youth suicide, and the relationship between the s u r v i v o r and youth p r i o r to his death. I n d i v i d u a l healing is both a solo and shared experience that is created and re-created d u r i n g the course o f each s u r v i v o r ' s life. Further, it is hypothesized that i n d i v i d u a l h e a l i n g ultimately expands o u t w a r d i n f l u e n c i n g f a m i l y , societal, and g l o b a l spheres (see F i g u r e 4-2). C o n c e p t u a l i z e d as a w h o l e , the healing process is represented b y the g r o u n d e d theory d e v e l o p e d i n this research study.  Healing Within Families  78  H E A L I N G AS 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  T h e Precipitating E v e n t T h e precipitating  event that launched survivors on " a j o u r n e y o f n o return" was that o f  hearing the news about the suicide o f a y o u n g f a m i l y m e m b e r . U n d e r s t a n d a b l y , the p s y c h o l o g i c a l trauma associated w i t h youth suicide initially e v o k e d an o v e r w h e l m i n g sense o f terror and helplessness a m o n g f a m i l y s u r v i v o r s .  H e a r i n g the N e w s Hearing the news was an "earth shattering" and " e m o t i o n a l l y traumatic" experience for all f a m i l y suicide s u r v i v o r s . Sue, a bereaved mother, c o m m e n t e d , " n o t h i n g i n life e v e n c o m e s close to preparing one for that k i n d o f news—sometimes I can't b e l i e v e I ' m still here." T h e harsh news e v o k e d w i t h i n survivors a sense of b e i n g m e r c i l e s s l y l a u n c h e d o n a treacherous j o u r n e y without time for preparation. Characteristically, survivors described their initial reactions to their unfortunate circumstances w i t h phrases such as b e i n g "lost w i t h o u t a c o m p a s s , " and h a v i n g " a map w i t h o u t a destination." Hearing the news was c o m p r i s e d o f five concepts i n c l u d i n g : the  Healing Within Families  79  survivor's initial responses, the horror of discovery, breaking the news to others, dealing with suicide notes, and dealing with issues related to suicidal death.  Initial Responses Initial responses to the tragedy varied considerably. Survivors frequently became disoriented in response to hearing the news. They spoke of feeling "out of sync with the rest of the world," and as if one had "just awakened from a nightmare." Suicide survivors vividly recalled a variety of somatic sensations that appeared soon after the trauma such as being "in a strange awful place," immersed in a "dense haze," or suspended in a "thick fog." The shock of hearing the news was traumatic. Survivors frequently experienced shock, denial, disbelief, emotional numbness, and a sense of unreality and depersonalization. Denial was a common initial response to the tragedy: "At first you deny it." This response provided survivors with much needed time to comprehend the shocking news. A few survivors struggled as they tried desperately to hold on to life as it once was when all was well. Not wanting to believe her reality, Tanya, the fiancee of a young man who took his life commented, "I would close my eyes and make him come into the room. . . . I could feel his touch and see his smile . . . sometimes I would think that it didn't really happen." Beth, a sibling, expressed a need to run from the experience as the reality of the situation was "just too much to bear." Carmen expressed initial disbelief, "it was like a nightmare.... I thought, this can't be happening to me and to my family." May reiterated Carmen's point of view: After what seemed like hours on that Father's Day, my dad and stepmother arrived. We hesitantly exchanged greetings. I was apprehensive as to what was to come. I felt myself back away as dad's words slowly poured out—"Ryan has taken his own life." Everything in me wanted to turn, run, and scream 'No!' I felt like we were suddenly entering the twilight zone, that I must be having a nightmare, this wasn't real and it couldn't be happening to me! I turned to Randy and frantically began to repeat, "I knew it! I knew it!" As his words began to sink in, I became aware of my dad's presence, his shakiness, his awkward stance—he looked totally defeated and incredibly vulnerable. My heart went out^  Healing Within Families  80  to h i m . W e began to hear some o f the d e t a i l s — b a s i c a l l y R y a n had entered their b e d r o o m , taken dad's gun a n d shot himself. F o r the participants i n eight families, news o f the suicide c a m e as " a complete surprise;" most survivors m a i n t a i n e d that the suicide o c c u r r e d "out o f the b l u e . " T h i s was especially hard to cope w i t h because s u r v i v o r s often r e c a l l e d that life, p r i o r to the s u i c i d e , w a s satisfying a n d that e v e r y t h i n g seemed to be g o i n g "pretty m u c h as u s u a l . " C o n s e q u e n t l y , the sheer s h o c k o f hearing the n e w s was o v e r w h e l m i n g for most s u r v i v o r s as i n d i c a t e d b y J i m , a father and husband: It's o v e r w h e l m i n g and y o u are dealing w i t h a l l o f it at the same time and not seeing b e y o n d it because i t ' s just c o m e out o f the blue. . . . Y o u w o u l d think that s o m e b o d y w h o c o m m i t t e d suicide w o u l d be depressed a n d o n the edge. T h i s w a s n ' t the case. It just c o m e s out o f b a s i c a l l y nowhere, and that's what y o u have to deal w i t h . S u r v i v o r s i n three families r e c a l l e d not b e i n g surprised that the y o u t h h a d ended his life. In one f a m i l y , a s u r v i v o r k n e w that "something w a s n ' t quite right" but was unable to identify exactly what it was that was troublesome. In another f a m i l y , C a r m e n recounted h o w her b o y f r i e n d h a d been d e a l i n g w i t h a n u m b e r o f problems p r i o r to the suicide: W h e n K e v i n was g r o w i n g up he h a d a really h o r r i b l e life. H i s m o m a n d d a d were never m a r r i e d but they h a d three k i d s a n d they separated. A n d then h e ' d a l w a y s t o l d m e that his real m o m was dead. A n d so that's what I b e l i e v e d for years, l i k e the w h o l e time that we were dating u n t i l our son was six months o l d . S h e s h o w e d up at o u r doorstep, and then I d i d n ' t really ever understand w h y he t o l d m e his m o m w a s dead. S o w h e n he d i e d , w e were f i g h t i n g a n d w e were t r y i n g to m o v e to [new town] a n d get our lives on the road. A s I l o o k b a c k and l o o k at the note he left me, and I got to k n o w his m o m very w e l l after he d i e d , a n d m y question was, " W h y d i d n ' t he do it s o o n e r ? " L i z l i v e d for years i n a situation o f not k n o w i n g w h e n , a n d if, the s u i c i d e w o u l d take place. She recalled the "tragic r e l i e f she initially experienced: " A n d so where I have c o m e f r o m i n this w h o l e thing is that it was a tragic relief because he is not tormented a n y m o r e a n d neither a m  Healing Within Families  81  U p o n h e a r i n g the n e w s , a few s u r v i v o r s reported intense p h y s i c a l responses. C h r i s recalled her initial post-suicide response: "I b a c k e d up into a c h i n a cabinet and b l a c k e d out and fainted, and w h e n I w o k e up, I was on the g r o u n d and I was k i c k i n g a n d s c r e a m i n g and y e l l i n g . " Three mothers indicated their p h y s i c a l experiences were 'guttural responses' to the p a i n associated w i t h loss. L i z r e m a r k e d , " O h yes, there were times w h e n I m o a n e d so m u c h p a i n , f r o m the depths o f m y s o u l , it w a s n ' t even a cry . . . w h e n y o u are g i v i n g birth y o u d o n ' t e v e n go there." M a r i e , a mother, writes about her experience this w a y : T h e screams that erupted from m y body on this day were the b e g i n n i n g o f m a n y such screams o v e r the next year and a half. T h e y were screams that terrified y o u r d o g and he began to h o w l . I have never heard sounds l i k e that before, a n d I too, was scared. I later came to compare that sound to the w a i l i n g o f a pain f i l l e d a n i m a l . H o w true that I was wounded. Sara, a mother, was brought to her knees w h e n she f o u n d out that her 16-year o l d son had taken his life. She v i v i d l y described her b o d i l y experience o f " g r i e f at the c e l l u l a r l e v e l . " She recalled f a l l i n g to her knees, i m m o b i l i z e d b y intense pain r e s e m b l i n g that o f labor pains. I n v o l u n t a r i l y , she felt the need to "bear d o w n , " as i f g i v i n g b i r t h . T h i s spontaneous, intense, and total b o d i l y experience was a c c o m p a n i e d b y deep w a i l i n g and c r y i n g out i n agony for her deceased son. S a r a felt a c o n n e c t i o n to her son through this experience. S u r v i v o r s ' responses to youth suicide, to a great extent, m i r r o r e d s o c i e t y ' s avoidance o f and d i s c o m f o r t w i t h the topic o f suicide. S u r v i v o r s were sensitive to the d i s c o m f o r t o f others and consequently a v o i d e d the subject i n the hope o f putting others at ease. S u r v i v o r s characteristically s u c c u m b e d to the " n o talk r u l e . " H o w e v e r , this response was not w i t h o u t consequences. L i n d a , a mother c o m m e n t e d , " T h i s [suicide] is a loss that w e d o n ' t talk about." T h i s ' c o n s p i r a c y o f silence' further c o m p o u n d e d the isolation felt b y m a n y s u r v i v o r s . In the midst o f tremendous upheaval, m a n y s u r v i v o r s demonstrated remarkable insight. Immediately upon d i s c o v e r i n g the suicide o f her son, R o s e r e a l i z e d the potentially devastating i m p a c t o f such tragedy on her f a m i l y . J i m , R o s e ' s husband, r e c a l l e d his w i f e ' s i n i t i a l response to the hearing the news:  Healing Within Families  82  T h a t m o r n i n g w e were a l l d o w n i n the basement w i t h Jason [deceased son] a n d w e were all so e m o t i o n a l l y distraught. S h e [Rose, J i m ' s wife] turned to m e a n d the first thing she said was, " W h a t e v e r happens, i f I forget, remember, w e d o n ' t b l a m e one another for this. W e c a n ' t b l a m e one another for this." H e r strength has been what has brought us together. T h i s is s o m e t h i n g that w e have experienced together. It's l i k e y o u ' v e seen the worst together a n d that makes y o u stronger.  The Horror of Discovery T h e "horror o f d i s c o v e r y " was catastrophic for s u r v i v o r s w h o reported the experience: " F i n d i n g the b o d y is the worst possible experience that anyone c o u l d ever have to face i n l i f e . " T h e horrific d i s c o v e r y often haunted these survivors. A s w e l l , even the i m a g i n e d d i s c o v e r y sometimes haunted those w h o were not present at the scene o f d i s c o v e r y . H a u n t i n g thoughts frequently centered o n the f a m i l y s u r v i v o r ' s i m a g i n e d e m o t i o n a l state o f the youth i n the moments preceding the suicide: "I a l l o w e d m y s e l f to think about the actual process o f what T i m m i g h t have gone through, a n d what he m i g h t have been t h i n k i n g o r f e e l i n g . " In several cases, it appeared that the youth h a d g i v e n considerable thought to staging the suicide. In three cases, f a m i l y survivors p e r c e i v e d that the s u i c i d e w a s staged b y the youth so that a particular f a m i l y m e m b e r (e.g., the father) w o u l d d i s c o v e r the b o d y . It w a s suggested that the m o t i v e for staging the suicide was to protect certain other f a m i l y m e m b e r s (e.g., the mother) f r o m the trauma o f d i s c o v e r y . T h e 'scene o f d i s c o v e r y ' e v o k e d a variety o f responses a m o n g s u r v i v o r s . S o m e wanted to be present at the scene o f d i s c o v e r y w h i l e others preferred to a v o i d the setting. H u m a n service providers at the scene o f d i s c o v e r y frequently took control o f the situation b y either i n c l u d i n g or e x c l u d i n g s u r v i v o r s i n c a r i n g 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 s u r v i v o r s as often they were i n a state o f s h o c k . H o w e v e r , a few s u r v i v o r s preferred to take charge o f the situation and requested i n v o l v e m e n t i n the post-mortem care p r o v i d e d to their b e l o v e d f a m i l y member. M a r t i n , the father o f a youth w h o ended his life, became assertive regarding his right to be i n v o l v e d at the scene o f d i s c o v e r y . H e r e m a r k e d that it was  Healing Within Families  83  better for h i m to be present and see for himself, rather than let his i m a g i n a t i o n "run w i l d w i t h what m i g h t have been the case." H e insisted on b e i n g i n v o l v e d i n c a r i n g for his son's b o d y as a w a y o f s h o w i n g respect to his deceased son. H e needed to be assured that "things were done right," m e a n i n g that his s o n ' s b o d y was cared for i n a respectful manner. I n another case, s u r v i v o r s a v o i d e d the scene o f d i s c o v e r y because the emotions were too intense to endure. In most cases, m e m o r i e s associated w i t h the scene o f d i s c o v e r y haunted s u r v i v o r s over the l o n g term. R e t r i e v a l o f the l o v e d one's b o d y for the purpose o f b u r i a l or cremation was important to all f a m i l y members. In one case, a youth ended his life b y j u m p i n g o f f a bridge. F a m i l y survivors suffered i m m e n s e l y i n the weeks and months that f o l l o w e d . A t one point, the parents launched a canoe trip on the r i v e r where their son d r o w n e d as a w a y o f c o m i n g to terms w i t h the p o s s i b i l i t y that his b o d y m i g h t never be located. D e s p i t e search efforts, the b o d y was not d i s c o v e r e d for six months. Sara, the mother, e x p l a i n e d that it was o n l y after she h a d released a l l hope o f r e c o v e r i n g his b o d y that it was f i n a l l y retrieved. R e t u r n i n g to the place where his b o d y was f o u n d was important to both parents because it enabled them to a c k n o w l e d g e and accept his death, and thus b r i n g closure to one facet o f their experience w i t h suicide.  D e a l i n g W i t h S u i c i d e Notes S u r v i v o r s had difficulty dealing w i t h suicide notes because they c o n f i r m e d what survivors were struggling to believe—that a b e l o v e d f a m i l y youth had ended his o w n life. H o w e v e r , i n situations where suicide notes were left, survivors f o u n d them to be valuable sources o f information. S u i c i d e notes sometimes contained information that released survivors o f the responsibility for the death, often gave clues as to the m o t i v e for the s u i c i d e , and a l w a y s c o n f i r m e d the intentions o f the youth w h o took his life. S u i c i d e notes were left b y six i n d i v i d u a l s . In cases where notes were left, survivors studied them endlessly, searching for answers to the m a n y unanswered questions that haunted them both day and night. S u i c i d e notes c o n f i r m e d the l o v e d o n e ' s d e c i s i o n to c o m m i t suicide, as illustrated i n the f o l l o w i n g suicide note, written b y a 14-year o l d male:  Healing Within Families  84  I feel m y time is o v e r and m y life is l i v e d to its fullest i n m y o w n w a y . M y life m a y seem short to some b y e n d i n g it today but i n m y life I f o u n d out the m e a n i n g o f m y life w h i c h I was unable to succeed i n f u l f i l l i n g , yet on m y j o u r n e y to m y c o n c l u s i o n , I was able to f i n d what true friends are, what enemies are a n d h o w a heartbreak feels. A l t h o u g h some m i g h t feel it is w r o n g to take one's life I v i e w it as G o d ' s w a y o f s a y i n g that y o u r life is fulfilled and it is y o u r c h o i c e on c o n t i n u i n g it or j o i n i n g m e i n heaven, a n d I hope I ' m right but i f I ' m not, " G o d I hope y o u can f o r g i v e m e . " Bye!  Y o u r s truly Steve  B r e a k i n g the N e w s to Others B r e a k i n g the news to others, both w i t h i n a n d outside the f a m i l y , was difficult for at least t w o reasons. First, s u r v i v o r s were reluctant to break the news to others because o f the traumatic nature o f what they h a d to tell. S u r v i v o r s r e a l i z e d that such n e w s w o u l d forever change the lives o f f a m i l y m e m b e r s , and i n s t i n c t i v e l y , they wanted to protect their l o v e d ones. S e c o n d , survivors understood s o c i e t y ' s general "no talk r u l e " and sensed the discomfort a n d perturbation that b r e a k i n g the n e w s w o u l d elicit i n others. B r e a k i n g the news to those closest to the deceased was a heart w r e n c h i n g experience. T e l l i n g people external to the f a m i l y was almost as difficult. T h e task was a l w a y s dreaded and sometimes postponed. C l a r e , a s i b l i n g , r e c a l l e d , " d r o p p i n g this b o m b s h e l l i n the n e i g h b o r h o o d was s o m e t h i n g else . . . the silence says so m u c h . " U p o n hearing the news, several s u r v i v o r s spoke o f their p e r c e i v e d need to be strong for the sake o f others, although at a costly price to themselves. M a y r e c a l l e d her response: D a d shared scant details w i t h us i n i t i a l l y and w e began to consider what h a d to happen next, w h o needed to be notified, etc. A t one point, I o b s e r v e d d a d b e g i n n i n g to c r u m b l e before m y eyes as his knees gave out and he began to s i n k to the floor. I went to his side a n d g u i d e d h i m to m y bed, where he c o l l a p s e d i n m y arms a n d w e sobbed together. I s o m e h o w determined at that point and i n m y o w n m i n d that I needed to be strong for everyone else's sake. I d o n ' t think I was totally c o n s c i o u s o f that d e c i s i o n at the time, but years later I r e c o g n i z e d that I h a d chosen to set aside some o f m y o w n grief.  Healing Within Families  85  W i t h great sensitivity, most parents i m m e d i a t e l y i n f o r m e d their s u r v i v i n g c h i l d r e n about the suicide. H o w e v e r , an exception was noted; i n one situation, the parents were so distraught that they were unable to speak to their s u r v i v i n g c h i l d r e n about the suicide for an entire day. A s might be expected, the c h i l d r e n sensed that something was dreadfully w r o n g . A l t h o u g h shaken and saddened by the news, they were r e l i e v e d w h e n their parents f i n a l l y spoke to t h e m about their brother's suicide.  S u m m a r y o f Precipitating E v e n t W i t h i n this study, youth suicide precipitated a major crisis for f a m i l y s u r v i v o r s . U p o n hearing the n e w s o f the suicide o f a f a m i l y youth, each survivors began his or her h e a l i n g j o u r n e y w i t h i n the Cocooning theme. S o o n after hearing the news, most s u r v i v o r s needed to f i n d a sanctuary where they c o u l d begin to sift and sort through the remains o f their "never to be the same a g a i n " w o r l d . Initial reactions to the tragedy were as v a r i e d as s u r v i v o r s . Indeed, processing the trauma was d e m a n d i n g and difficult w o r k . W i t h d i g n i t y and courage, s u r v i v o r s faced m a n y challenges such as confronting the horror o f d i s c o v e r y , d e a l i n g w i t h s u i c i d e notes, and b r e a k i n g the news to others. T h e suffering i n d u c e d b y d e a l i n g w i t h these unpleasant but necessary aspects of suicide was an important element o f the healing process. F o r most s u r v i v o r s , suffering entailed r e l i v i n g 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 p e r i o d o f acute suffering p r o v i d e d the seeds for future g r o w t h . T h e stigma surrounding suicide and the silence and secrecy that persist w i t h i n society often isolated and s i l e n c e d f a m i l y survivors o f youth suicide. T h i s aspect o f d e a l i n g w i t h youth suicide intensified s u r v i v o r s ' suffering. In response to their experiences w i t h y o u t h suicide, most survivors e m b a r k e d on a l i f e - l o n g j o u r n e y a i m e d at m a k i n g sense o f the grievous experience, and l i v i n g a meaningful life despite horrific loss. A n u m b e r o f contextual variables influenced h o w this process o c c u r r e d .  Healing Within Families  86  Contextual Factors Y o u t h suicide is not an isolated event. It always occurs w i t h i n the context o f the f a m i l y . S i m i l a r l y , families l i v e w i t h i n c o m m u n i t i e s embedded w i t h i n a broader s o c i a l structure. C o n s e q u e n t l y , s u r v i v o r s ' h e a l i n g experiences need to be understood w i t h i n the context i n w h i c h they occur. T h e f o l l o w i n g contextual factors emerged f r o m the data and i n f l u e n c e d the s u r v i v o r s ' h e a l i n g experiences: the s u r v i v o r ' s personal history, factors related to the suicide, s o c i a l factors, and the health care environment.  Personal History S i x personal history variables were identified as h a v i n g an i m p a c t on the s u r v i v o r s ' healing experiences: the s u r v i v o r ' s relationship w i t h the youth p r i o r to s u i c i d e , gender, r e l i g i o u s affiliation, cultural practices, previous experience w i t h loss, and health status. P e r s o n a l history variables that d i d not appear to influence h o w the s u r v i v o r m o v e d t o w a r d h e a l i n g i n c l u d e d age, occupational status, i n c o m e l e v e l , and marital status.  Relationship W i t h the Deceased Y o u t h P r i o r to S u i c i d e T h e s u r v i v o r s ' positive appraisal o f their relationships w i t h the deceased y o u t h p r i o r to suicide was the m a i n variable that determined the s u r v i v o r s ' propensity to m o v e t o w a r d healing. . S u r v i v o r s w h o p e r c e i v e d they had a special and l o v i n g relationship w i t h the y o u t h and those w h o felt e m o t i o n a l l y and spiritually close the youth prior to his death were m o r e l i k e l y to embark on a healing j o u r n e y sooner than those unable to make this c l a i m . R a e described her relationship w i t h her brother this w a y : T w o weeks p r i o r to his death he had p h o n e d me and asked m e i f he c o u l d m o v e out f r o m [town] to [town] to l i v e w i t h me. A n d I was t h r i l l e d . I was r e a l l y e x c i t e d about it because w e were really close as k i d s g r o w i n g up because he was m y next s i b l i n g . A n d w h e n the f a m i l y had m o v e d to the farm w e were the o n l y t w o not i n s c h o o l . M y younger sister h a d n ' t been b o m yet. T h e rest o f the k i d s were a l l i n s c h o o l , I was f i v e and he was three, and so w e became the best o f friends and w e grew up that w a y .  Healing Within Families  87  A l t h o u g h often o v e r l o o k e d , youth suicide had a tremendous i m p a c t o n extended f a m i l y members. I n particular, grandparents had to contend w i t h a " d o u b l e - e d g e d s w o r d . " T h e y simultaneously g r i e v e d for the loss o f a g r a n d c h i l d and witnessed the suffering endured by their o w n c h i l d . C o n s e q u e n t l y , youth suicide intensified the g r i e v i n g process for grandparents. Indelible on J i m ' s m i n d was the enormous sense o f devastation e x p e r i e n c e d b y his father at the loss o f his grandson. J i m r e c a l l e d his father's absolute adoration o f his grandson: M y d a d w o u l d sit i n the coffee shop i n t o w n 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 t o w n and he w o u l d l o o k 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 p u m p s . H e was so efficient and such a d i l i g e n t w o r k e r , and so c o m m i t t e d and dedicated, and h e ' d say to his friends, his coffee buddies, h e ' d say " T h a t ' s m y grandson out there." In part, the extra demands required to deal w i t h this double exposure to loss, i n addition to the life-threatening m e d i c a l diagnosis o f a granddaughter, m a y have accounted for the fact that these grandparents experienced tremendous difficulty f o l l o w i n g the suicide o f their grandson.  Gender G e n d e r i n f l u e n c e d the s u r v i v o r s ' j o u r n e y towards wholeness. A l t h o u g h more w o m e n (n=26) than m e n (n=15) participated i n the study, both m e n and w o m e n v i e w e d themselves as m o v i n g t o w a r d healing. N o t s u r p r i s i n g l y , w o m e n were able to speak about their h e a l i n g experiences w i t h greater ease than men. A l t h o u g h based on a s m a l l sample size, this f i n d i n g is most l i k e l y attributed to the fact that p s y c h o s o c i a l support is generally more readily available to w o m e n than m e n . In addition, i n this study, congruent w i t h the traditional m a l e role i n society, adult male survivors often deferred their g r i e v i n g and healing i n favor o f " w a t c h i n g o v e r " or " s h a d o w i n g " other f a m i l y members. T h e y needed to be sure that others i n the f a m i l y were c o p i n g w i t h the suicide before they were able to deal w i t h their o w n issues related to the loss.  Healing Within Families  88  Religious Affiliation R e l i g i o u s practices affected the s u r v i v o r s ' experiences w i t h h e a l i n g . R e l i g i o u s values and beliefs generally i n f l u e n c e d s u r v i v o r s ' ideas about death and suicide. Just o v e r half o f the participants specified a particular religious affiliation and the majority felt comforted by their religious practices. A few i n d i v i d u a l s questioned their faith, and some even felt abandoned b y G o d . S u r v i v o r s w h o were able to understand y o u t h suicide w i t h i n the f r a m e w o r k o f their religious values and beliefs m o v e d t o w a r d healing w i t h less tension and t u r m o i l than those unable to f i n d this k i n d o f peace. T h e s u r v i v o r ' s r e l i g i o u s values and beliefs were o c c a s i o n a l l y questioned. F u n d a m e n t a l assumptions that formerly gave life value and m e a n i n g were sometimes challenged. A few s u r v i v o r s questioned former r e l i g i o u s beliefs, w h i l e others turned either t o w a r d or a w a y f r o m r e l i g i o n after the suicide. L i n d a , a mother, gained a sense o f strength a n d peace through practicing her faith: " T h e first three days [ f o l l o w i n g the suicide] I felt c o m p e l l e d to be on m y knees p r a y i n g and f i g h t i n g for A l l a n i n prayer. . . . I gained such a sense o f peace." I n contrast, M a r t i n , a husband and father, remarked, " W h e n a suicide c l a i m s someone w h o y o u have l o v e d so very m u c h , y o u r r e l i g i o n is c h a l l e n g e d . " Jan, another mother, expressed a s i m i l a r v i e w , " F o r a l o n g time I d i d n ' t go to c h u r c h . I just c o u l d n ' t . I c o u l d not understand h o w G o d c o u l d let this happen to our son a n d to us." A f e w s u r v i v o r s were angry and felt betrayed b y G o d . C h r i s , an o n l y s u r v i v i n g s i b l i n g , a n g r i l y 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 s c r e a m , or I ' d c r y and I ' d b a l l , and I ' d y e l l at G o d . " W e s t e r n society has been strongly i n f l u e n c e d b y J u d e o - C h r i s t i a n values and beliefs, w h i c h above a l l else, enshrine the sanctity o f life. A c c o r d i n g to this b e l i e f system, o n l y G o d determines w h o dies and w h e n death occurs. H e n c e , y o u t h suicide is v i e w e d as a sinful act. In some cases, s u r v i v o r s felt j u d g e d b y others. Y o u t h suicide sometimes triggered a tension between f a m i l y s u r v i v o r s and others w i t h i n the broader c o m m u n i t y w h o , through subtle and sometimes subversive means, h e l d the f a m i l y responsible for the suicide. D a l e , the father o f a teen w h o ended his life described his experience this w a y :  Healing Within Families  89  Y o u t h i n k that something l i k e this w i l l never happen to y o u . T h a t ' s what I used to think. A n d then one day it happened. W h e n it happens, y o u b e g i n to understand things differently . . . y o u ' r e treated differently after it happens . . . y o u ' r e j u d g e d b y others a c c o r d i n g to their r e l i g i o n .  C u l t u r a l Practices M o s t families were C a u c a s i a n (predominantly o f E u r o p e a n descent); one f a m i l y was C a n a d i a n A b o r i g i n a l . F a m i l y survivors w h o honored their cultural practices m o v e d t o w a r d healing w i t h a degree o f peace. These i n d i v i d u a l s were helped b y the use o f death-related cultural practices such as the use o f c e r e m o n y and ritual. C a n a d i a n A b o r i g i n a l f a m i l y members f o u n d m u c h comfort and support b y acting according to their cultural values and beliefs. T h i s f a m i l y h e l d certain cultural v i e w s that afforded survivors some sense o f solidarity and support i n d e a l i n g w i t h the suicide o f a 14-year-old f a m i l y member. W i t h i n the C a n a d i a n A b o r i g i n a l culture, death is v i e w e d as part o f life, and the afterworld is a w o r l d o f peace, regardless o f the cause o f death. N e i t h e r the i n d i v i d u a l n o r f a m i l y is b l a m e d for the death. D e a t h , i n c l u d i n g death b y suicide, signifies that the deceased i n d i v i d u a l has departed o n " a spiritual quest." F o l l o w i n g a death, there is u s u a l l y a four-day w a k e d u r i n g w h i c h t i m e the f a m i l y m a y v i e w the b o d y . F a m i l y , friends, and f o o d are a l l h i g h l y v a l u e d and very m u c h part o f the immediate post-death experience. D u r i n g this time o f m o u r n i n g , f a m i l y survivors u s u a l l y receive m u c h help and support f r o m others w i t h i n their c o m m u n i t y . S u r v i v o r s gather i n f o r m a l l y to pray, share stories, and p r o v i d e comfort to one another. D u r i n g these gatherings, f a m i l y members often seek the w i s d o m o f their elders. F u n e r a l services and b u r i a l are f o l l o w e d b y a p i p e c e r e m o n y performed or supervised b y an elder w h o has earned and been g i v e n that r e s p o n s i b i l i t y b y r e c o g n i z e d others ( B . S h a w a n d a , personal c o m m u n i c a t i o n , M a y , 28, 1998). M o r e o v e r , "the presence" o f the b e l o v e d continues to be part o f the s u r v i v o r ' s experience, w i t h messages often b e i n g c o m m u n i c a t e d f r o m b e y o n d the grave. E d spoke about a cultural practice that supported his h e a l i n g f o l l o w i n g his son's suicide:  Healing Within Families  90  W e still talk about it every once i n a w h i l e , l i k e w h e n I feel his spirit i n the house. . . . H e ' s w i t h me every day. H e ' s part o f m y existence. . . . T o m e , the s u i c i d e is part o f me. A n d I go b a c k to our traditional w a y s to get help. R e m e m b e r , I was t a l k i n g to y o u about a little r o c k w e f o u n d inside his pocket. T h e r o c k , they use it for h e a l i n g sweats. T h e r e ' s different k i n d s o f sweats where y o u go and pray o f whatever. T h a t ' s what h e l p e d me.  Previous Experience W i t h L o s s P r e v i o u s experience i n dealing w i t h loss also had an i m p a c t on s u r v i v o r s ' healing experiences. In seven out o f eleven families, other major losses i n life h a d o c c u r r e d p r i o r to the suicide; for e x a m p l e , the death o f another c h i l d , marital b r e a k d o w n , life-threatening illness, and j o b loss. D e a l i n g w i t h these previous losses enabled survivors to draw o n their earlier experiences. H o w e v e r , they also felt that death due to suicide p o s e d a different set o f challenges. F o r e x a m p l e , l a c k o f support f r o m others external to the f a m i l y , and decreased opportunity for conversations about their experiences, added stress to an already difficult situation. In a few instances, other losses f o l l o w e d the suicide and c o m p o u n d e d the challenges faced b y survivors. In addition to d e a l i n g w i t h the suicide o f their oldest grandson, J i m ' s parents also had to contend w i t h the life-threatening illness o f their oldest granddaughter: " Y e s , they had gone through a lot because o u r niece has l e u k e m i a too. It was a year after Jason's death that she f o u n d out she had l e u k e m i a . It was almost a year to the day that she was d i a g n o s e d . " S u r v i v o r s w h o h a d p r e v i o u s l y g r i e v e d f o l l o w i n g the death o f a l o v e d one r e c a l l e d that every subsequent death e v o k e d m e m o r i e s o f previous experiences w i t h death. S u r v i v o r s w h o felt supported d u r i n g their earlier g r i e v i n g experiences were able to m o v e t o w a r d h e a l i n g sooner than those w i t h o u t such support. C a r m e n , a significant other, e x p e r i e n c e d the p r e v i o u s suicide o f a former b o y f r i e n d . W h e n she was confronted w i t h the s e c o n d s u i c i d e , that o f her fiancee, she recalled that the experience o f s u r v i v i n g the first suicide enabled her to access needed help immediately. In another case, M e g , the mother o f four c h i l d r e n , experienced the death o f her six-yearo l d daughter due to accidental electrocution twelve years p r i o r to the suicide o f her oldest teenage  Healing Within Families  91  son. She c l a i m e d that even though both deaths o c c u r r e d suddenly, self-inflicted death was m u c h more difficult to c o m p r e h e n d than accidental death. M e g ' s previous experience w i t h g r i e v i n g p r o v i d e d her w i t h m u c h insight i n terms o f d e a l i n g w i t h her son's s u i c i d e . 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 h e a v y personal and f a m i l y t o l l l e v i e d b y her c h i l d r e n s ' deaths. F o l l o w i n g the death o f their y o u n g daughter, M e g ' s husband, T e r r y , started d r i n k i n g h e a v i l y . H i s d r i n k i n g c o n t i n u e d over m a n y years and d r a m a t i c a l l y 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 still i n v o l v e d i n therapy. She was just b e g i n n i n g to seek help and support f r o m others and was c o n t e m p l a t i n g separation at the time o f the interview. M a n y s u r v i v o r s w h o h a d not p r e v i o u s l y experienced loss read v o r a c i o u s l y t r y i n g to understand what was happening to them. In particular, C a r m e n c o m m e n t e d that m a n y o f the books currently o n the market o v e r - s i m p l i f y the "craziness" felt b y suicide s u r v i v o r s w h i c h is so m u c h a part o f their experience. She mentioned that suicide s u r v i v o r s , e s p e c i a l l y those without previous experience i n d e a l i n g w i t h loss, c o u l d be h e l p e d b y a frank d i s c u s s i o n about this aspect of dealing w i t h s u i c i d a l death.  H e a l t h Status F i n a l l y , s u r v i v o r s ' health status i n f l u e n c e d their m o v e m e n t t o w a r d h e a l i n g . S u r v i v o r s w h o , over the l o n g term, rated their health as "excellent'-' or " v e r y g o o d " were m o r e l i k e l y to m o v e t o w a r d h e a l i n g sooner than survivors w h o identified health concerns and/or m e d i c a l diagnoses. I n i t i a l l y , m a n y survivors experienced a variety o f short-term'somatic s y m p t o m s . Repeatedly, survivors spoke o f the intense "pressure" they experienced i m m e d i a t e l y f o l l o w i n g the suicide. M a r i e , a mother, said, "I w i s h e d I c o u l d have cut a h o l e i n m y head to release the pressure." S u r v i v o r s f o u n d w a y s to alleviate the pressure. F o r some i n d i v i d u a l s , c o n f i d i n g w i t h a trusted other was helpful; for others, an increase i n p h y s i c a l activity helped. A i r hunger and feelings o f suffocation were also c o m m o n . M a r i e recalled her experience: " A l l o f a sudden it w o u l d feel l i k e the w a l l s were c a v i n g i n o n m e . . . . S o m e t i m e s I ' d have to g o to a w i n d o w and just g u l p air." Sleep disruptions sometimes d e p r i v e d s u r v i v o r s o f m u c h needed rest and  Healing Within Families  92  relaxation. " F l a s h b a c k s " 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 t h i n k that I was t r y i n g to s o l v e the ' w h y question.'" S u r v i v o r s rarely neglected their health. O n the contrary, most survivors m a i n t a i n e d their former state o f health and w e l l - b e i n g . In one instance, G a r r y and his w i f e experienced i m p r o v e d health status: "I can hardly believe i t — w e were i n c r e d i b l y healthy after Jered's death and that is not the w a y it is supposed to be." Further exploration revealed that both he and his w i f e took extra precautions d u r i n g this stressful time to ensure they both h a d a healthy diet, plenty o f exercise, and sufficient rest and relaxation. O n l y one participant neglected his health: " I d i d n ' t k n o w where I was g o i n g or what to do. I d i d n ' t g i v e a d a m n about m y s e l f . " O t h e r s u r v i v o r s s u c c u m b e d to illnesses that, i n some cases, r e q u i r e d h o s p i t a l i z a t i o n . A n n , unable to express her emotions i n other ways at the time recalled: "I k n o w that I stored all that e m o t i o n . I d i d not let it out o f m y b o d y . . . m y b o d y was storing it s o m e w h e r e . . . it c a m e out as p n e u m o n i a . " L o m a , a mother and w i f e , spent t w o months i n a p s y c h i a t r i c unit f o l l o w i n g her son's suicide, and upon discharge f r o m hospital took a year o f f w o r k to re-establish her priorities i n life. L o m a f o u n d that she needed time to pamper herself as an important aspect o f her healing. F a m i l i e s i n w h i c h at least one m e m b e r had a mental health diagnosis faced additional stress. T h r e e i n d i v i d u a l s w i t h i n one f a m i l y ( i n c l u d i n g the father and t w o s u r v i v i n g children) had been diagnosed w i t h s c h i z o p h r e n i a prior to the suicide o f a s c h i z o p h r e n i c f a m i l y youth. Suzanne, the mother and o n l y f a m i l y s u r v i v o r without a mental illness diagnosis, chose to l i v e alone because she needed respite f r o m the pressure o f f a m i l y demands. Suzanne m a i n t a i n e d that all she c o u l d do was "manage one day at a t i m e . " A t the time data c o l l e c t i o n , Suzanne was separated f r o m her spouse, p l a n n i n g her future, and attending classes at a nearby u n i v e r s i t y . In the another f a m i l y , C l a r e , the youngest o f five s u r v i v i n g s i b l i n g s , was also d i a g n o s e d w i t h s c h i z o p h r e n i a . In an effort to m a k e sense o f her brother's suicide, she w i t h d r e w f r o m others and dealt w i t h her loss i n w a y s that made sense to her. Preferring solitary activity, C l a r e expressed her grief b y sculpting a set o f figurines, each d e p i c t i n g a unique facet o f her experience w i t h loss.  Healing Within Families  93  Factors R e l a t e d to Y o u t h S u i c i d e Y o u t h suicide was a traumatic event for a l l f a m i l y members. T w o factors had an impact on s u r v i v o r s ' h e a l i n g experiences: the nature o f the death and questions regarding whether the death was caused b y suicide or h o m i c i d e . S u r v i v o r s w h o were able to identify, grapple w i t h , and eventually resolve these aspects o f suicidal death were more l i k e l y to m o v e t o w a r d healing sooner than those w h o a v o i d e d , or chose not to explore these often a m b i g u o u s a n d a l w a y s c o m p l e x facets o f their experiences.  U n e x p e c t e d , S u d d e n , and V i o l e n t D e a t h D e a l i n g w i t h youth suicide raised seemingly i r r e c o n c i l a b l e issues for some f a m i l y members w h i c h centered o n the unexpected, sudden, and v i o l e n t nature o f the death. S o m e survivors struggled w i t h the fact that there was no p o s s i b i l i t y o f d i r e c t l y r e s o l v i n g past differences, n o r was there an opportunity to say good-bye to the deceased l o v e d one p r i o r to death. R e a l i z i n g the finality o f death was also difficult. R o s e struggled w i t h the realization o f her son's suicide: " I ' m never g o i n g to see h i m again. . . . that's m y struggle—to realize that." F a m i l y members also struggled w i t h the v i o l e n c e associated w i t h self-inflicted death. U n d e r s t a n d a b l y , these v i o l e n t deaths caused horrendous anguish and suffering for s u r v i v o r s . D e a l i n g w i t h the i m a g i n e d state o f the youth i n the moments preceding suicide, and d e a l i n g w i t h the painful memories associated w i t h the scene o f d i s c o v e r y were e s p e c i a l l y difficult for s u r v i v o r s .  S u i c i d e or H o m i c i d e T h e uncertainty about the cause o f death was t r o u b l i n g for some s u r v i v o r s . S u r v i v o r s i n four families c l a i m e d that the death m a y have been the result o f h o m i c i d e rather than suicide: "I d o n ' t k n o w w h i c h it was [murder or suicide] and I c a n ' t cope. . . . so I put it a w a y . " A n n , a s i b l i n g , c o m m e n t e d , " l i k e m a y b e he d i d , and m a y b e he d i d n ' t [take his o w n l i f e ] . " In these situations, survivors felt that a romantic partner o f the deceased y o u t h m a y have been responsible for the death. R a e , another s i b l i n g , expressed her thoughts: "Part o f m y c o n f u s i o n was related to the cause o f death. . . . A n d I t h i n k 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.  Healing Within Families  95  Societal S t i g m a T h e stigma surrounding suicide c o m m o n l y manifested itself i n what some f a m i l y members c a l l e d the "no talk rule," that is, the unchallenged silence that surrounds suicide w i t h i n W e s t e r n society. T h i s n o n v e r b a l f o r m o f c o m m u n i c a t i o n was p o w e r f u l . D e s p i t e feeling supported and validated b y those w i t h s i m i l a r beliefs, even C a n a d i a n A b o r i g i n a l survivors felt j u d g e d b y others w i t h i n society. E d , a C a n a d i a n A b o r i g i n a l father, explained: T h e r e ' s this stigma especially felt i n the native c o m m u n i t y . Y o u go f r o m one extreme to the other extreme, l i k e r e l i g i o n . . . . T h e y say the person w h o c o m m i t t e d suicide goes to h e l l or they e n d up i n purgatory or whatever. . . . It's k i n d o f embarrassing for m e that m y son comrnitted suicide because it is always interpreted a c c o r d i n g to E u r o p e a n standards. In t w o f a m i l i e s , the stigma felt b y f a m i l y m e m b e r s was c o m p o u n d e d w h e n mental illness was also present. I n one f a m i l y , the y o u t h w h o took his life was d i a g n o s e d w i t h s c h i z o p h r e n i a . B o t h parents r e c a l l e d that prior to his suicide, they h a d a d v i s e d h i m not to reveal his illness to others. These parents intended to protect their c h i l d f r o m b e i n g h u m i l i a t e d b y his peers. Unfortunately, the silence regarding his health status also l i m i t e d possibilities for initiating dialogue about his m e d i c a l c o n d i t i o n . L i n d a , the deceased y o u t h ' s mother c o m m e n t e d : " W e experienced a double w h a m m y . . . . There is stigma related to suicide, but there is also stigma associated w i t h mental i l l n e s s . " S u r v i v o r s ' responses to stigma i n f l u e n c e d their healing experiences. I n d i v i d u a l s w h o felt e m p o w e r e d to change this societal stigma m o v e d t o w a r d healing sooner than those w h o d i d not think they c o u l d " m a k e a difference." T a k i n g action a i m e d at h e l p i n g others understand more about suicide and its impact on the f a m i l y often became an integral aspect o f the s u r v i v o r ' s m i s s i o n i n life.  S o c i a l Support N o t s u r p r i s i n g l y , s u r v i v o r s w h o felt supported and understood b y at least one other person were able to face the reality o f their situation more readily than those l a c k i n g social  Healing Within Families  96  support. I n d i v i d u a l s w h o m o v e d t o w a r d h e a l i n g t y p i c a l l y d e v e l o p e d a coterie o f friends w i t h w h o m they c o u l d share their stories. In addition, w h e n e v e r necessary, they accessed external resources such as counselors and support groups. Sara c o m m e n t e d on the i m p o r t a n c e o f social support: I k n o w b e y o n d a shadow o f a doubt that I w o u l d not have made it w i t h o u t the support o f m y husband. T h e r e were times w h e n I was so w o b b l y that I c o u l d h a r d l y stand on m y o w n t w o feet. H e [husband] just seemed to k n o w what I needed and w h e n I needed it. H e ' s such a g o o d listener. H e listened to me talk about the same t h i n g over and over, and that's what h e l p e d me the most. M y friends were there for m e too, and that really helped, especially later o n .  Health Care Environment S u r v i v o r s p e r c e i v e d the health care environment to be i n a state o f transition and, therefore, not a l w a y s responsive to their needs. S u r v i v o r s w h o were able to reach b e y o n d the confines o f the health care environment b y d r a w i n g u p o n inner strength and w i s d o m , as w e l l as p r e v i o u s l y established c o p i n g capabilities, m o v e d t o w a r d h e a l i n g sooner than those w h o r e l i e d solely on e x i s t i n g health care services. In addition, survivors w h o t o o k the i n i t i a t i v e i n creating their o w n healing environments m o v e d t o w a r d healing more expediently than those w h o d i d not take such action. F o r e x a m p l e , D a l e , the father o f a 17-year o l d y o u t h w h o ended his life, took it u p o n h i m s e l f to d e v e l o p a w e b page i n the hope o f c o m m u n i c a t i n g w i t h other suicide survivors. W i t h i n six months after the suicide o f his son, he began attending death education conferences. A t the time o f the i n t e r v i e w , D a l e was also investigating possibilities for c h a n g i n g his current e m p l o y m e n t so that he c o u l d devote more time to educating others about youth suicide and its impact on the f a m i l y . H e took the initiative to i m p r o v e life for both h i m s e l f and others; D a l e said, " I f it is to be then i t ' s up to m e . "  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, andfindingmeaning/exploring spirituality), each descriptive of one facet of the survivors' overall experiences with youth suicide. The extent to which healing occurs depends on the survivors' capacity to respond to such adversity by deciding to move toward healing. Survivors who move toward healing create a Love Knot, symbolic of the healing strategies they develop to maintain a continuing bond of love with the deceased youth. These healing strategies are individualized and creative expressions that represent the unique meaning of survivors' experiences with youth suicide. Individual healing is both a solo and shared experience that is created and re-created over the course of each survivor's life. It is also suggested that individual healing ultimately expands outward influencing the family, community, and society. Four contextual variables were found to influence each survivor's journey toward healing: the survivor's personal history, factors related to the suicide, social factors, and the health care environment. Several personal history variables influenced the survivors' healing journey. Survivors most likely to move toward healing were those who felt emotionally and spiritually  Healing Within Families  98  close to the youth p r i o r to his suicide. A l t h o u g h f a m i l y s u r v i v o r s o f both genders m o v e d t o w a r d healing, adult males needed to ensure that other f a m i l y members were c o p i n g w i t h the unfortunate situation before they felt free to tend to their o w n p s y c h o l o g i c a l needs. I n a d d i t i o n , survivors w h o were able to understand youth suicide f r o m the perspective o f their r e l i g i o u s beliefs and cultural values experienced an advantage i n terms o f m o v i n g t o w a r d healing. S i m i l a r l y , those w h o rated their health as "excellent" or " v e r y g o o d , " and those w h o felt supported d u r i n g their previous experiences w i t h loss also m o v e d toward healing more expediently than others unable to m a k e these c l a i m s . C e r t a i n issues related to suicidal death were particularly troublesome for f a m i l y survivors i n c l u d i n g death by unexpected, sudden, and v i o l e n t means, as w e l l as questions about whether the death was the result o f suicide or h o m i c i d e . S u r v i v o r s w h o were able to identify and w o r k through their particular issues regarding youth suicide m o v e d t o w a r d h e a l i n g sooner than those w h o a v o i d e d or chose not to confront these aspects o f their experiences. S o c i a l factors i n c l u d i n g social support and societal s t i g m a i n f l u e n c e d s u r v i v o r s ' healing experiences. N o t s u p r i s i n g l y , s u r v i v o r s w h o felt supported b y at least one other person experienced an advantage i n terms o f dealing w i t h youth suicide. S u r v i v o r s w h o felt e m p o w e r e d to take action a i m e d at c h a n g i n g the societal stigma surrounding youth suicide m o v e d t o w a r d h e a l i n g sooner than those w h o d i d not think they c o u l d m a k e a difference. M o r e o v e r , survivors v i e w e d the health care environment as i n a state o f flux and not particularly responsive to their needs. T h o s e w h o m o v e d t o w a r d healing were not deterred because o f this p e r c e i v e d unresponsiveness. Rather, these i n d i v i d u a l s assumed r e s p o n s i b i l i t y for their o w n health b y d r a w i n g on their innate strengths and c o p i n g capabilities. In the next chapter, I turn to a description o f Cocooning, the first healing theme o f the h e a l i n g 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, allencompassing 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  H e a l i n g W i t h i n F a m i l i e s 101  that others w i t h i n the f a m i l y were " w a t c h i n g o v e r each other" p r o v i d e d a sense o f security for many survivors. S o m e i n d i v i d u a l s identified themselves as the e m o t i o n a l stronghold i n their families a n d postponed their o w n g r i e v i n g i n favor o f " b e i n g there" for other f a m i l y m e m b e r s . These i n d i v i d u a l s put their o w n struggle o n h o l d w h i l e b e c o m i n g alert, h y p e r v i g i l a n t , a n d responsive to the p s y c h o l o g i c a l needs o f other f a m i l y members. M i k e , a husband a n d father, e x p l a i n e d : I h a d a sense o f t r y i n g to keep an eye o n what w a s g o i n g o n . I k n e w that I still h a d to be strong a n d e v e r y t h i n g because I still h a d m y f a m i l y a n d m y w i f e a n d e v e r y t h i n g . . . . It was extremely important to concentrate o n m y w i f e , almost s h a d o w i n g her i n terms o f m a k i n g sure that m y w h o l e life w a s n ' t g o i n g to fall apart. . . . I h a d to k i n d o f hang back a little bit a n d m a k e sure that the water was g o i n g to be safe. I just needed to m a k e sure that they [family] were secure. I h a d to be sure that that was the w a y it w a s g o i n g before I c o u l d actually start g r i e v i n g i n m y o w n w a y . F o r m a n y s u r v i v o r s , " f i n d i n g a safe p l a c e " for p r o c e s s i n g their e m o t i o n a l trauma was o f major importance. H o w e v e r , survivors q u i c k l y sensed that they needed to exercise discretion i n terms o f f i n d i n g a safe place f o r sharing their struggle. Places d e e m e d to be safe v a r i e d a m o n g survivors a n d i n c l u d e d the f a m i l y residence, w i t h o r without the presence o f others; counselors' offices; l o c a l grief support groups; a n d natural habitats such as gardens a n d forests. A n n , a sibling, remarked: I needed to f i n d a p l a c e to express m y emotions. . . . S o . I j o i n e d a w o m e n ' s group, f o u n d a g r o u p o f friends . . . a n d began e x p r e s s i n g m y e m o t i o n s o n a d a i l y basis. . . . A s soon as I w a s able to express m y s e l f without feeling that I was g o i n g to be c r i t i c i z e d for the emotions that I w a s feeling . . . I f o u n d u n c o n d i t i o n a l l o v e a n d acceptance, a n d I began to heal.  P r o c e s s i n g Intense E m o t i o n a l T r a u m a F o r most s u r v i v o r s , struggling w i t h e m o t i o n a l trauma w a s l i k e b e i n g o n an " e m o t i o n a l roller coaster." T h e y experienced a m y r i a d o f intense emotions r a n g i n g f r o m apathy at certain  Healing Within Families  102  times, to " e x p l o s i v e n e s s " at other times. M i k e sought c o u n s e l i n g as a w a y o f processing intense emotions: I got to a point where I k n e w that I needed to press o n , and yet I c o u l d n ' t . I just c o u l d n ' t m o v e past certain situations. A n d so she [counselor] was able to break d o w n the barriers that were k e e p i n g m e f r o m b r e a k i n g d o w n , w h i c h was what I needed to do so that I c o u l d release m y emotional t u r m o i l . M o s t s u r v i v o r s struggled as they endeavored to address their loneliness, anxiety and fear, anger, p a i n and suffering, depression, guilt, and regret.  L o n e l i n e s s . F e e l i n g s o f "intense l o n e l i n e s s " and a " g n a w i n g feeling i n the pit o f one's s t o m a c h " were c o m m o n . W h e t h e r alone or i n the presence o f others, the intensity o f the loneliness was n e w to those w h o e x p e r i e n c e d it. N o t s u r p r i s i n g l y , f a m i l y s u r v i v o r s were sometimes astounded b y the intensity o f their loneliness: "I realize n o w h o w alone I a m . . . . I ' v e never felt this w a y before." F o r the most part, s u r v i v o r s ' loneliness was related to the p h y s i c a l absence o f the deceased youth. S o m e t i m e s this vehement loneliness served to e x p a n d the s u r v i v o r ' s capacity for e m o t i o n a l expression. M a n y survivors experienced intense emotions, often for the first time.  A n x i e t y and Fear. F a m i l y survivors often felt h i g h l y anxious a n d fearful f o l l o w i n g the suicide. S t r o n g emotions were l i n k e d to the place where the suicide occurred, the fear o f another f a m i l y m e m b e r c o m m i t t i n g suicide, and the fear o f forgetting the deceased. T r a u m a t i z e d b y the suicide, a few s u r v i v o r s d e v e l o p e d phobias. M a n y survivors feared the l o c a t i o n where the suicide occurred. I n i t i a l l y , they a v o i d e d this place. H o w e v e r , as time passed, s u r v i v o r s confronted their fears i n v a r i o u s w a y s . M a r t i n d e v e l o p e d his o w n unique w a y o f dealing w i t h his son's s u i c i d e . M a r t i n ' s son ended his life i n the b o d y s h o p where both he and his son w o r k e d p r i o r to the suicide. S i n c e M a r t i n c o u l d not a v o i d the place o f death, he tried f a c i n g the m e m o r y : "I d o n ' t k n o w , I ' d go i n there and I w o u l d even say, ' G o o d m o r n i n g P a u l . ' A n d I w o u l d go and stand where he h a n g e d h i m s e l f and talk to h i m e v e n . " M a r t i n f o u n d it difficult to w o r k i n the place where the suicide occurred. T w o years post-  H e a l i n g W i t h i n F a m i l i e s 103  suicide, M a r t i n and his w i f e r e a l i z e d a d r e a m and m o v e d to an acreage (i.e., a s m a l l piece o f l a n d i n the country) i n the hope o f f i n d i n g a n e w b e g i n n i n g . In n e w surroundings, M a r t i n felt the burden had been lifted. In four cases, the suicide o c c u r r e d i n the f a m i l y residence. C o n s e q u e n t l y , for some s u r v i v o r s the h o m e e n v i r o n m e n t was disturbing, whereas for others, it was a place o f comfort. W i t h i n the first year f o l l o w i n g the suicide, t w o families m o v e d w h i l e t w o other families remained i n their homes. C o n s i s t e n t l y , f a m i l y survivors feared that another f a m i l y m e m b e r w o u l d also end his or her life. T h e " w h o ' s n e x t ? " fear l o o m e d larger than life for some s u r v i v o r s . R o s e and J i m were c o n c e r n e d that their o n l y s u r v i v i n g 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 f r o m a counselor. E v e n though felt b y most s u r v i v o r s , this fear was s e l d o m discussed w i t h i n the f a m i l y unit. B e c a u s e this fear was w i t h h e l d , s u r v i v o r s frequently became hypervigilant, carefully w a t c h i n g for unusual behaviors i n other f a m i l y members. M a n y s u r v i v o r s were afraid o f forgetting their l o v e d ones. S u r v i v o r s were reluctant to address the e m o t i o n a l i m p a c t o f the suicide because they feared forgetting the deceased youth: " I ' m almost afraid to deal w i t h it because I ' m afraid I ' l l lose the m e m o r i e s o f h i m . I ' m afraid o f forgetting h i m . " F r o m a f a m i l y perspective, the fear o f forgetting was e v e n m o r e difficult to a c k n o w l e d g e . R o s e c o m m e n t e d : " T h e f a m i l y as a w h o l e is d e a l i n g w i t h J a s o n ' s suicide . . . i t ' s the fear o f forgetting and letting go w i t h i n the w h o l e f a m i l y . . . his p l a c e i n the f a m i l y is n o w void." A few s u r v i v o r s described phobias that began d u r i n g the time s u r r o u n d i n g the suicide. Characteristically, survivors were able to recall, i n great detail, the setting and other details related to the suicide. In a few cases, certain stimuli triggered phobias that c o n t i n u e d for a l o n g time. M a r i e spoke o f her fear that began soon after the suicide: " T h e sirens became terrors for me . . . i f I ever heard a siren f r o m an ambulance or fire truck . . . m y heart was beating so fast that I felt l i k e I was h a v i n g a heart attack." In another case, w h i l e J i m was getting ready to go to w o r k , his son shot h i m s e l f i n the basement o f the f a m i l y home. J i m was still i n the s h o w e r w h e n 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 allencompassing 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.  H e a l i n g W i t h i n F a m i l i e s 105  S o m e t i m e s , anger was directed t o w a r d the deceased y o u t h . S u r v i v o r s frequently expressed anger because they felt rejected and betrayed b y their deceased l o v e d one. M a n y survivors v i e w e d suicide as the "ultimate f o r m o f rejection." R e s p o n d i n g to such rejection, a father stated, " H e made this d e c i s i o n , this c h o i c e , and i f w e ' r e g o i n g to be angry at anybody, w e s h o u l d be directing our anger at h i m . " In an effort to deal w i t h her anger, i n a letter to her deceased son, M a r i e wrote: There has been so m u c h anger i n m e because o f y o u r d e c i s i o n to c o m m i t suicide. S o m e o f it surfaced i n w a y s that I d i d n ' t recognize. S i x weeks after y o u r death, I began to feel as i f I had P a r k i n s o n ' s disease. I remember teaching and h a v i n g to stand w i t h m y arms h u g g i n g m y s e l f as i f I were c o l d . P e o p l e l o o k i n g at m e w o u l d never have guessed the real reason that I h e l d m y s e l f l i k e that—it was to literally h o l d m y b o d y parts together. C h r i s , M a r i e ' s o n l y s u r v i v i n g c h i l d , expressed anger t o w a r d her brother because he took his life on their m o t h e r ' s birthday: " H e [committed suicide] o n m y m o m ' s birthday . . . and that's w h y I ' m a little bit upset. I A M A N G R Y . . . . I still have a lot o f anger b o i l e d up i n s i d e . . . I keep everything b o i l e d up inside until it breaks." S o m e s u r v i v o r s felt uncomfortable overtly expressing anger. H o w e v e r , beneath a c a l m exterior, these s u r v i v o r s struggled to contain a quiet but unrelenting rage. T h e i r anger was often revealed i n the f o r m o f somatic s y m p t o m s and atypical behavior. Jane, for e x a m p l e , w i t h d r e w f r o m others and became totally incapacitated f o l l o w i n g the suicide o f her son and eventually sought p r o f e s s i o n a l help. S u r v i v o r s ' anger was often related to the shame associated w i t h s u i c i d a l death. F e e l i n g strong enough to put w o r d s to her anger, C a r m e n raised her v o i c e and said, " I ' m ashamed . . . he w r e c k e d m y life, he w r e c k e d his o w n life, he w r e c k e d his s o n ' s life. . . . I ' l l never get o v e r it. I w i l l never change the w a y I feel. N E V E R E V E R , N E V E R . " S o m e s u r v i v o r s vented anger privately w h i l e others expressed it o p e n l y . S i m i l a r l y , some sought help w h i l e others d i d not. R o s e , a mother, r e c o g n i z e d the importance o f addressing anger as she searched for a w a y to help her o n l y s u r v i v i n g teenage son deal w i t h his anger. She c l a i m e d  H e a l i n g W i t h i n F a m i l i e s 106  that the c u l p r i t was "the anger w i t h i n h i m . A n d that's what we had to deal w i t h . . . . O n c e y o u get on w i t h that, then y o u c a n get on w i t h other things." Y o u t h suicide not o n l y triggered anger and frustration i n relationship to the death, it p r o m p t e d survivors to r e v i e w other aspects o f their l i v e s as w e l l . M i k e described it this w a y : T h e sources o f the angers and frustrations w e r e n ' t just the death o f m y son. I k i n d o f l i k e n e d it to—as y o u go through life, y o u p i c k up little packages o f c o m p l e x i t y that y o u carry w i t h y o u . F o r b o y s , i t ' s a little r e d w a g o n and for girls i t ' s a little blue baby carriage. T h e y a l l have their little packages w r a p p e d up i n them and the c o m p l e x i t i e s go w i t h y o u . Y o u r keep dragging the packages, and i f y o u are the type o f i n d i v i d u a l w h o has a c o m p l e x life, y o u are dragging a pretty heavy load. A l l o f these packages b e c o m e a pretty heavy bundle b y the time that y o u have a major crisis. T h e n y o u have to go b a c k and re-touch and r e - c l a i m every one o f those c o m p l e x i t i e s and w o r k y o u r w a y through them i n d i v i d u a l l y . It's almost l i k e starting on a regressive basis and c o m i n g back to the reality o f what is current.  P a i n and S u f f e r i n g . S u r v i v o r s ' h e a l i n g experiences were characterized b y both p h y s i c a l pain and e m o t i o n a l suffering. Y e t , the pain o f suffering was an a l l - e n c o m p a s s i n g experience and a c r u c i a l rite o f passage i n terms o f the s u r v i v o r s ' m o v e m e n t t o w a r d h e a l i n g . F o r a l l survivors, the trauma o f y o u t h suicide left i n its w a k e , a pain that was " a l w a y s there under the surface." E d , a father, c l a i m e d that the p a i n lingers l o n g 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 , s u r v i v o r s expressed their pain w i t h w o r d s such as " f e e l i n g h a r d " or " h e a v y : " "It's a lot o f w e i g h t that each person carries." O n e s u r v i v o r felt as i f she h a d b e c o m e "encased i n a hard s h e l l , " w h i l e another spoke o f b e i n g " s o l i d as a r o c k . " These e m o t i o n a l l y n u m b i n g reactions protected survivors and a l l o w e d them time to process the i m p a c t o f the suicide. A s a s u r v i v a l strategy, m a n y survivors compartmentalized or shelved their feelings for a short p e r i o d o f time f o l l o w i n g the suicide: "I t h i n k I shelved it. I put it on the backburner and d e c i d e d that I w o u l d deal w i t h m y emotions later." E m o t i o n a l numbness sometimes a l l o w e d survivors to l i v e up to the selfi m p o s e d expectation o f b e i n g i n control: "I just became s o l i d as a r o c k . S o m e t h i n g inside me said,  H e a l i n g W i t h i n F a m i l i e s 107  y o u have to be stronger than anyone else i n this because y o u are the strongest person i n this f a m i l y . I d i d n ' t c r y . " E v e n the most c o m p o s e d survivors eventually began a l l o w i n g reality to surface b y e m o t i o n a l l y " w o r k i n g t h r o u g h " the trauma. T h i s i n v o l v e d suffering. M o r e o v e r , the j o i n t experience o f suffering sometimes rendered f a m i l y members unable to support one another. A l t h o u g h f a m i l y members watched over each other, they needed to process the trauma i n d i v i d u a l l y . W i t h o u t exception, survivors c o m m e n t e d on the need to p r i v a t e l y revisit memories of the deceased w i t h i n their o w n space and time. E v e n t u a l l y they were able to a l l o w their feelings to surface: " A t first I d i d n ' t feel anything. A n d then later, as I lay a w a k e i n m y b e d at night, I w o u l d start t h i n k i n g about e v e r y t h i n g . " T h o u g h painful, m a n y survivors reported the need to r e l i v e , i n their m i n d , every e m o t i o n that the l o v e d one m a y have felt p r i o r to e n d i n g his life. R a e , a s i b l i n g , questioned, " I kept t h i n k i n g , what was he t h i n k i n g ? . . . It must have l o o k e d totally b l a c k , l i k e there was no help for h i m . . . . D i d he not k n o w h o w m u c h he was l o v e d ? " J i m , the father o f a 1 6 - y e a r - o l d w h o ended his life, r e c a l l e d s p e n d i n g hours 'staring into space' as a w a y o f p r o c e s s i n g the horror: It's a l w a y s o n y o u r m i n d , i t ' s a l w a y s there b e h i n d y o u w h e n y o u stare, and I stare n o w m o r e than I ever d i d . Y o u k n o w , y o u k i n d o f l o o k into space, a n d t i m e stands still. . . . T h e p a i n is a l w a y s there as I ' m staring. It's l i k e a m o t i o n picture right up there i n the corner o f m y m i n d . T h a t w h o l e w e e k plays through m y m i n d , i t ' s a l w a y s 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 i n a letter to her deceased son: H o w things c o u l d have been different, i f o n l y y o u ' d g i v e n y o u r s e l f time to reflect on y o u r d e c i s i o n . W h e n y o u made the c h o i c e to e n d y o u r life, K e v i n , I w o n d e r i f y o u ever c o m p r e h e n d e d h o w m u c h pain w o u l d be left b e h i n d for y o u r f a m i l y , y o u r classmates, y o u r friends, and y o u r teachers. Y o u never gave y o u r s e l f the p r e c i o u s gift o f t i m e , K e v i n . T i m e to l o o k at whatever it was that became so h u m o n g o u s , i n y o u r m i n d , that y o u felt that this was y o u r o n l y c h o i c e . T i m e to see i f someone c o u l d help y o u . T i m e to share y o u r pain w i t h people w h o l o v e d y o u deeply. T i m e to get the p a i n out o f y o u i n a healthier w a y .  H e a l i n g W i t h i n F a m i l i e s 108  T i m e to realize that y o u d i d have other choices. T i m e also for y o u r f a m i l y to see y o u g r o w , time to see y o u graduate, time to see what career y o u w o u l d choose. T i m e to l a u g h and c r y at y o u r w e d d i n g and time to celebrate the births o f y o u r c h i l d r e n .  D e p r e s s i o n . Several survivors became depressed i n response to the s u i c i d e characterized by " f a l l i n g apart e m o t i o n a l l y . " E v e n w h i l e r e c o g n i z i n g that they were s p i r a l i n g d o w n w a r d , they r e m a i n e d cognizant o f their f a m i l i a l responsibilities. D a v e , a father, remarked: H o w m u c h l o w e r can y o u really go actually because y o u feel l i k e w h a t ' s the use o f l i v i n g ? . . . but i t ' s not just y o u . Y o u have a f a m i l y a n d y o u have a w i f e , y o u have t w o other k i d s and they are g o i n g to need y o u . A l t h o u g h several survivors c o m m e n t e d that "hitting r o c k b o t t o m " was a j o l t i n g experience, they learned things about themselves they c o u l d not have k n o w n b y gentler means. C a r m e n elaborated: W h e n y o u hit r o c k b o t t o m y o u say, " I d o n ' t l i k e this. I ' v e got to get up there." Y o u hit r o c k b o t t o m a n d y o u f i n d y o u r g o a l . . . . Y o u m a k e a g o a l to a i m up. . . . I f o u n d a reason to stay alive . . . i f y o u can m a k e it through the first year . . . i t ' s a m a z i n g what y o u c a n do w i t h y o u r life. F o r some s u r v i v o r s , depression o c c u r r e d shortly after the suicide; for others it appeared years later. Jan, a significant other, r e c o g n i z e d her depression s i x to eight months after the suicide. She c o m m e n t e d o n this difficult time i n her life: S o m e t i m e s w h e n y o u are i n a depression, then i t ' s e v e n h a r d 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 ' v e e x p l a i n e d it to other people, i t ' s l i k e s o m e t h i n g else takes over, a n d y o u have n o control o v e r yourself, or v e r y little. It's h o r r i b l e — depression. F o r other s u r v i v o r s , the depression d e v e l o p e d m u c h later. S i x years after the s u i c i d e o f her brother, R a e r e c o g n i z e d her depression: It was a c o m b i n a t i o n o f p r o b l e m s . . . . T h a t ' s w h e n I hit the b o t t o m a n d it w a s n ' t a matter o f right after . . . it was a few years later. S i x years after his death I r e c o g n i z e d , I d o n ' 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 twomonth 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 1 1 2 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. M y parents were just separating at the time. M y 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. M y sister had to tell me what to wear." Initially, most survivors were preoccupied with pervasive thoughts of the deceased: "From the very beginning . . . I let it [suicide] control my mind. I couldn't think of anything else . . . I was always thinking of him and stuff... I was just like a zombie." This preoccupation enabled some survivors to hold on to their precious memories of the deceased loved one until they were able to face the reality of the suicide. Most individuals spent considerable time reminiscing about the past when the deceased youth was alive and well. Family survivors often focused, in great detail, on the events and conversations that had taken place just prior to the suicide: "That week, that whole week plays through my mind, it's there." In several cases, family survivors reported the need to relive, often frequently, their recollections of conversations and events leading up to the suicide. Jim commented: My memories are quite vivid because it's things that are always going to be with you, those thoughts and those moments, one night before, two nights before, words, conversations, events of the day will always be there very, very strong. It's something that you'll never, never forget. Frequently, survivors reported the experience of living in a world that had been "shattered," "fragmented," "torn apart," and "turned up-side-down" as a result of youth suicide. Carmen expressed the extent of disintegration when she said it was as if "my heart was being  Healing Within Families 116 ripped out, and stomped on, and thrown away." Their ability to think things through as they had before the death no longer seemed to work; in fact, many survivors reported that things seemed hopeless and meaningless. In keeping with the characteristic chaos experienced by many, Rae commented, "everything has been uprooted, down to your very being. . . . Everything has to start all over again." A few survivors questioned if, in fact, they were "going crazy." Jan recalled, "I looked around and everyone else seemed fine, so I thought "Why do I feel like I'm going crazy?" Rae expressed a similar view: "I was living on the edge. . . . I didn't understand what was happening to me . . . at one point I thought that I was over the edge." Rae decided to access the literature in the hope of finding validation for her feelings. However, she was disappointed because "the books would just gloss over the feeling of 'going crazy'. . . the books just reinforced my feelings." Finally, altered thinking patterns were characterized by post-death ambivalence toward the deceased youth because he had taken his own life. Ann vacillated between wanting and not wanting her deceased brother to be at peace in death: "It's pretty hard to wish him peace when he killed himself." Post-death ambivalence was sometimes altered by new perspectives of the deceased's pre-death situation. Looking through family photo albums was frequently the source of new perceptions. In a post-suicide review of family photo albums, survivors in three families detected sad expressions on the faces of their now deceased loved ones. One participant noted that her brother was isolated from other family members in a family photo. Discoveries such as this haunted survivors over the long term. Almost three years post-suicide, Jim gauged his healing by the contentment he experienced when viewing family photo albums: "I can't go through the photo albums—if I can ever get to the point where I can go through those with a degree of happiness and satisfaction and pleasure . . . then I would be healing." Survivors often possessed remarkable insight regarding their altered thinking which then permitted them to take action. Brenda took a leave of absence from work for a year following the suicide because of her inability to concentrate within the work environment. Liz was concerned  Healing Within Families 117 about her ability to make effective decisions and consequently postponed her decision to move for a year following the suicide.  Contemplating Own Suicide Suffering sometimes overwhelmed survivors and they saw their own suicide as a means of resolving this inner tension. Surviving parents in two families questioned the purpose of living without their loved ones and perceived their own suicide as a way of being reunited with them. Jan agonizingly recalled her thoughts on the night of her son's suicide: I know that I thought about taking my own life the night that Paul died, and I think that the thought was maybe there for a minute or two. And all that it was, was that I thought if I could die, then I could be with him and I could find out why he did this. Lana, a sibling, elaborated on her thoughts about the often tenuous dance between life and death: There is a pain that runs through the core of one's being, a pain that won't disappear. The pain nourishes a fantasy that suicide is the only option to end it. Wounded, I can now appreciate how delicate, how fine the line is between life and death. I can fully appreciate how suicide is a choice taken by those who, in many ways, succumb to the pain and loneliness of personal suffering. For now, I have chosen life. But some days, I will confess, it's a struggle to follow this decision. Again, I can appreciate why it may appear just out of the blue that someone kills himself. Because the dance between life and death is an ongoing struggle, it's so exhausting, and contributes to a loss of hope. . . . When will it ever end? It is the angst of this personal predicament. Rose reported that at the time of her son's suicide, she was contemplating suicide herself and was angry when she discovered that her son had succeeded before she was able to do so: Why couldn't it have been me? . . . At first I just wanted to die and then I was angry that he did it first. I wished that I had done it first because he would have known what it did to everybody else and he wouldn't have done it. In the aftermath of suicide, Rose discovered the far-reaching impact that her son's suicide had on others. She also became aware of the pain felt by both immediate and extended family  Healing Within Families 118 members. As a result, she made several significant changes that impacted greatly on herself and her family. Her beliefs and values about life shifted, as did her priorities. Her family became her top priority. Rose made a concerted effort to share her thoughts and feelings with other family members. In addition, she began to do the things that brought her peace of mind. Periodically, Rose lovingly cared for animals on the family farm, a comforting activity that brought peace to her as she remembered the "good times" shared with her son prior to his death. This meaningful activity enabled her to clarify her thinking and gain a fresh perspective. In addition to experiencing chaotic thinking, survivors also functioned on automatic pilot.  Functioning Pattern (Autopiloting) While Cocooning, the survivors' pattern of functioning was characterized by autopiloting. Following youth suicide, survivors characteristically functioned in a manner that required the least amount of effort: "For a long, long time, I just used automatic pilot." Autopiloting, an element in this theory, addresses several aspects of daily functioning including: decreased functioning, living with the physical absence of the deceased, experiencing altered health status, using addictive substances, and engaging in risky lifestyle behavior.  Decreased Functioning Immediately following the suicide, survivors were exhausted much of the time. For most survivors, managing day-to-day activities was a challenge in and of itself. Commonly, survivors functioned in "survival mode, "and often "in slow motion" for a period of time following the suicide. Liz described her functional status this way: "And so I did the bare necessities, just getting us what we needed.... I went into the 'doing what it took' mode." Decreased energy levels resulted in survivors being unable to function in their usual way in relation to preparing food, performing household chores, and socializing: "It's like your system shuts down and you're on automatic pilot for a while. You go through the motions, you go to work, and you go to school, but you're just on the fringe of things." Linda commented that she had "nothing left to give" because it took all her energy "just to survive." Participants recognized  Healing Within Families 119 they needed more rest and sleep; however, sleep failed to restore their previous level of functioning. Emotional pain and exhaustion robbed survivors of the "good life." They missed out on opportunities to enjoy the little things in life and activities once enthusiastically pursued. Their former spontaneity and enthusiasm for life were gone.  Living with Physical Absence Living with the physical absence of the deceased youth presented an ongoing challenge to survivors. Survivors had to continue living without their loved one and so they quickly slipped into autopiloting as a way of surviving their loss. They longed to see, touch, hold, and love their loved one. Survivors developed a number of comforting strategies that allowed them to function on autopilot while enabling them to deal with the physical absence of the deceased youth. Carmen wore one of her brother's favorite shirts as a way of maintaining closeness while Margaret slept in her deceased son's bed. Some families exhibited pictures and other mementos in their homes; others refrained from such practice. Jim, the father of a deceased youth, commented: In my folks' house, they've got a large picture of Jason, right, and it's up high and proud in their living room. It's there right front and center of all their pictures, and that's the way their living room is and always will be. And like his achievement awards, they have his achievement awards right there in the kitchen for everybody to see; they have never been removed, I think probably from grade nine. So, those are good but I just can't bring myself to do that in our house. Tanya visualized her brother on a daily basis: "And I talked to Tim every night. I would close my eyes and make him come into the room . . . I could feel his touch and see his smile." Jan frequently thought about how her son would look if he was still alive: "Well, there's still every day that I live that I think of him. You know, what would he look like now?" The thought of being unable to visualize the deceased was terrifying for a few survivors. Ed recollected, "I close my eyes and try to remember how he looks—I try but I can't, and that's scary for me. . . . It's like I've lost him."  Healing Within Families 120 Survivors consistently commented on the emptiness left by the physical absence of the deceased loved one and its impact on the family. This void was especially noticeable during certain times of the day such as mealtime and bedtime, and on certain dates such as birthdays and suicide anniversaries, as well as on holidays such as Christmas, Father's Day, and Mother's Day.  Using Addictive Substances More than anything, survivors wanted to be spared from their pain and suffering; it seemed less demanding to take the easy way out. In an attempt to escape the pain of their loss, some survivors autopiloted by using addictive substances. A few began using alcohol and drugs while others increased their use of these addictive substances. For example, Carmen began drinking excessively following the death of her fiance: "The first month I went on a drinking binge, and I did not want my son anymore. . . . I drank a lot after he [fiance] died, just trying so that it didn't hurt." While the alcohol temporarily numbed the emotional pain, the addiction created other problems such as relationship and parenting difficulties. Carmen's drinking continued for approximately one year. She then realized she had a problem and sought counseling with positive results. In another case, in response to the loss of his son, Terry increased his consumption of alcohol, a situation still present at the time of data collection. In yet another family with two surviving sons, one son began using street drugs shortly after the death of his brother, a situation uncovered just prior to the interview.  Taking Risks In a few instances, the survivors' pattern of functioning included engaging in risky lifestyle behavior. Jordan, whose brother (and closest friend) ended his life, actively sought physical pain as a substitute for staving off emotional pain. Jordan's father explained: Like he says to me, "Well it's just like you gave up. After Jason died, anything I do is fine anymore." Now everything seems like trivia to us. This last weekend, he rolled our car, like it rolled in the air five times, our new car, five times and it's just totaled and he got out of it, he walked out of it, his shoulder is broke in two places. But to me, like I think that  Healing Within Families 121 would be an awful big thing, and now it's just a matter of course. And afterwards, he's got physical problems, he broke his leg soon after because he didn't take care of himself, and he's accident prone. . . . And then he burned himself, he jumped on top of the burning camp stove. . . . He stood there and it caved in and his legs burned through— third degree bums, and it's all carved out, and he was in the hospital for some time. And like with him physical pain is nothing. . . . He wants physical pain, he says "it takes away the mental and emotional pain." You know, it's the emotional pain that he can't take. Consumed by grief, Jordan's parents were barely able to deal with Jason's death. Although aware of the situation and concerned for the welfare of their surviving son, they were initially unable to take action to rectify the situation. Eventually, with the support of his parents and others, Jordan sought professional help. In addition, survivors functioned on autopilot because their energy was consumed by the trauma.  Energy Pattern (Consuming) Within Cocooning survivors' energy was consumedby surviving the trauma and focusing on the "why question." Their energy reserves were depleted and life felt like "a chore." Ed, a father, spoke about the consuming nature of the suicide event: "It takes all the power out of the batteries and you are only operating on dim."  Surviving the Trauma Following news of the tragedy, survivors experienced an immediate and dramatic decrease in the amount of energy available for living—strength, stamina, and zest for living were drastically diminished. Any available energy was directed toward "surviving" the trauma: "I never realized, we had to start looking at ways of surviving. . . . The end result is survival." Marie commented on the extent of her exhaustion following her son's death: I used to talk about how tired I was, where at the end of half a day of teaching, I would stand by the door and I would say if the door hadn't been there to balance me, I would have gone like a fig leaf on the ground. After driving home one time, I didn't know if I  Healing Within Families 122 was going to make it home because it was taking so much energy. I was so tired. I came in and I made it to the bedroom and laid there for three hours. Many survivors had little energy for concentration on things that they previously managed easily. In the beginning, survivors were unable to find ways of replenishing energy. They experienced strain and had little energy for dealing with day-to-day family concerns. Jan spoke of the tremendous amount of energy required for processing intense emotions: "Hate takes over . . . it makes you weak. . . . I had no energy." Compounding this, survivors spoke about a pervading sense of anxiety and fear as they now realized that, "within the blink of an eye," all their hopes and dreams for the future were irretrievably lost. These feelings also were energy-draining. Initially, in response to feeling "swallowed up" or "consumed" by the trauma, survivors were unable to find ways of replenishing energy. They became very selective in how they expended their limited energy supply. They withdrew from others and focused their finite energy reserves inward in order to survive: "I just changed my focus from other people to me. . . . Gee, I barely had enough energy to take care of myself so I knew that was what I needed to do." As energy slowly returned, survivors were then able to direct some energy toward attending to other family members.  Asking Why Elusive attempts to find an answer to the pivotal "why question" consumed much of survivors' energy. Respondents in over half the families commented that a variety of factors may have influenced the youth's decision to end his life. These factors included: relationship difficulties, especially those that involved disappointment in a romantic relationship; undiagnosed depression; use of street drugs; infractions with the law; and, undisclosed homosexuality. Despite speculating on these possible explanations, survivors were initially haunted by the "why question." They spent every waking moment searching for a definitive answer to this perplexing question. For some, pursuing an answer to this confounding question became their raison d'etre. Jill, a sibling, commented, "When it is a suicide...it's a big question mark." Uncomfortable with such uncertainty, most survivors needed to privately revisit this question over and over again. In  Healing Within Families 123 particular, they needed to relive again and again the time just prior to the suicide, looking for clues that might uncover some motive for the suicide. Despite the energy it required, asking the "why question" was critical. Rae, an adult sibling, commented that it was only by asking this question that she was able to find out that there is no answer to it.  Finding Meaning/Exploring Spirituality Pattern (Awakening) Within the Cocooning theme participants' spiritual experiences were characterized by awakening to life and its meaning. This life reassessment included: waking up to life, doubting self and experience, and visiting the dark side of life.  Waking Up to Life Youth suicide often provided a "wake up call" that served as a stark reminder of needed change. For many, what worked and made sense in the past no longer seemed to fit with life in the present. The suicide awakened many survivors to aspects of life previously overlooked. Rae, a sibling, commented: "It [the suicide] was the kick that I needed to make some important changes in my life." Martin, a father, explained his experience of waking up: Maybe it took something like this to wake me up to life. You know, like I was going around like I was still a young teenager myself. A lot of times I would have a beer with the boys and stuff like that. I don't know if I was drinking that much with them. I may have had a beer with them around Christmas if they would have been there or something like that, but I don't think that I was drinking like I used to. But it certainly made me grow up a lot, I'll tell you that. I don't know what triggered it. His death made me look at life a lot differently. Survivors often developed a new appreciation for both life and death. Characteristically, they began to pay more attention to "what's really important in life." For most, this involved focusing more on "family." Some survivors garnered profound "gems of wisdom" for dealing with life's uncertainties. Others gained an understanding of the complexity and ambiguity often  Healing Within Families 124 associated with living and loving. They also began to accept the coexistence of both pain and joy that is associated with all major life events, including birth and death. Survivors became introspective and frequently turned inward to seek answers to their many questions. Moreover, they spent a great deal of time assessing self, family, and the situation: "I did a lot of self-analysis, a lot of very deep, deep thought processes." Another survivor said, "I have taken a little piece of it out at a time and looked around and investigated it— really doing an analysis of the different elements of it." Survivors frequently pondered many of life's difficult questions such as: Who am I without the deceased? When will the pain lessen? How do I carry on with life without the deceased? What next? How has each family member been affected by the suicide? and, Where do I go from here?  Doubting Oneself and Experience Soon after the loss, survivors not only questioned their beliefs but also doubted themselves, sometimes questioning their inability to have prevented the suicide: "What could I have done so that he would still be alive?" Expectations of self were high, and sometimes unrealistic: "I should have known." In one situation, a parent expressed guilt and self-doubt: "Was I a good enough parent?" Another parent lamented, "Love was not enough—if it was, he would still be alive." When expressing such distress, most survivors doubted that any meaning could be derived from the tragedy. Rather, they viewed the suicide as an experience that had to be endured, at great personal expense, for the sake of the family. Responding in frustration and exasperation, a father claimed that "suicide has no meaning whatsoever." Other survivors described suicide as "a waste;" as a death that "served no purpose;" or "didn't have to happen."  Visiting the Dark Side of Life Most survivors who claimed to be moving toward healing journeyed to the dark side of life. This exploration involved taking a serious look at many issues, specifically: addressing one's own pain and suffering; getting in touch with one's sense of deep loneliness; looking at past  Healing Within Families 125 unresolved issues within one's life; questioning one's relationships; and facing one's own mortality. Liz described her visit to the dark side of life this way: You need to destroy yourself of inhibitions [learned from within society] that stop one from experiencing one's dark side—from feeling the pain and the love. . . . It involves allowing or letting yourself go into those comers of your life and those areas and regions that are dark, into those regions that are unexplored . . . that are scary, that are totally new, and that you don't have any answers for at all. . . . It's the fear that holds you back. . . . You conquer and you go on. Sometimes visiting the dark side of life involved survivors facing their limitations. Linda openly talked about her son's mental illness and the helplessness she sometimes felt in dealing with it. When I look at it today, with the kind of knowledge available today, maybe I could have done something. You've got to remember that he was diagnosed as schizophrenic. The doctor who diagnosed him told us that he was in trouble. . . . It used to bother him. I can remember when he was in school and we went to pick him up—he would hear voices and all of that kind of stuff. . . . He would say, "I can't do this anymore." Now when I think back, I don't think he knew how to deal with it, and neither did we . . . his mind was messed up. . . . He used to get phone calls from girls and I used to tell him, "Don't tell anybody about your sickness." You can't just say, "I'm a schizo," you know.  Summary Youth suicide precipitated a major crisis for the members of the eleven families who participated in this research study. Survivors began their healing journey within the Cocooning theme of the healing process. In response to the harsh news, survivors characteristically felt vulnerable and in need of protection from society's harsh criticism for an individually determined period of time. As a result, they embarked upon a journey of descent into themselves. During this period of dormancy, they experienced time alone to sift and sort through the remains of their once calm and ordered lives. Survivors suffered immensely during this time. They struggled in terms  Healing Within Families 126 of relating to both themselves and others. Survivors recognized the need to address their own issues before they were in a position to relate to others effectively. Dealing with the intense emotions evoked as a result of youth suicide was an especially difficult but important aspect of the healing process. Initially, survivors experienced chaotic thinking. In the face of tragedy, some individuals thought they were going crazy and others contemplated their own suicide. An incredible amount of survivors' energy was consumed by the trauma, leaving them with barely enough energy to manage their lives on a day-to-day basis. They merely went though the motions of living by functioning on automatic pilot. Further compounding matters, the haunting "why question" loomed larger than life itself for most survivors, and they spent an inordinate amount of time pursing the answer to this elusive question. Invariably, survivors ventured to the dark side of life. It was here that survivors grappled with and confronted their unique issues. In doing so, they learned from their experiences and moved along on their journey toward wholeness. In Chapter Six, Centering, the second theme of the healing process is addressed.  The oracle promised the Asian Empire to the man who could untie the Gordian knot. Alexander the Great cut it with his sword then conquered Asia. But he later lost it because cutting the knot with his sword was not the true solution to the problem, but a resort to violence. If knots only have a magical power because they are made according to certain rules, they also have to be untied with patience and method. A Buddhist parable teaches that the process of becoming free comes down to untying the knots of existence. But knots which are tied in a certain order can only be untied in the reverse order. And to untie them means to find in oneself the « 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 C H A P T E R SIX CENTERING: JOURNEY OF G R O W T H 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. M y 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 M