The Role of Religiosity and Spirituality in Responding to Survivors of SuicideBonnie M. Benson, MEdBong Joo Hwang, PhDRobert M. Bennett, MSWTodd Gibbs, BADanielle Finch, BAThe Ohio State UniversityCounseling and Consultation Service

Big 10 Counseling Centers ConferenceFebruary 10, 2011Minneapolis, MN

Overview

•Our own reactions to suicide•Rationale for applying religiosity and

spirituality to treatment of suicide survivors

•Religious and spiritual perspectives on suicide

•Bereavement in suicide survivors•Assessment and intervention with

survivors•Case example •Discussion and questions

Introduction

•A note about language•Introduction of presenters•Our own reactions

▫How do I feel when I learn that someone died by suicide?

▫How do I make sense of death by suicide?▫How comfortable do I feel helping a client

explore religious or spiritual beliefs related to suicide or another means of death?

Rationale: College Student Mental Health•Suicide 2nd leading cause of death on

college campuses•High documented rates of suicidal

thoughts and attempts on college campus•Developmental risk of mental illness•Increased number of students on campus

with previously diagnosed mental disorders

(Suicide Prevention Resource Center, 2004)

Rationale: The Big 10 Study: “The Gold Standard”•Most comprehensive study of suicide among

college students• Initiated by University of Illinois in 1983,

transferred to University of Chicago in 1986•Recorded deaths of 261 students who

completed suicide, 1980-1990, among 12 Big Ten schools

•Rate of suicide among college students half the rate of general population (7.5/100,000 vs. 15/100,000)

(Silverman, Meyer, Sloane, Raffel,  & Pratt, 1997)

Rationale: Statistics for OSU•2009 ACHA survey of 10,000 randomly

selected OSU students; 21.2% response rate▫19.6% diagnosed with depression▫4.6% intentionally injured themselves▫ 6.8% seriously considered suicide▫1.5% attempted suicide

(American College Health Association, 2009)

Rationale: OSU Suicide Cases from 9/1/00 to 8/31/10*

1st year

2nd year

3rd year

4th year

Grad/prof

Total

Male 5 6 8 12 5 36

Female 0 0 0 0 2 2

Total 5 6 8 12 7 38

* Provided by the OSU Student Advocacy Center compiled by: Ellen S Grudowski

Rationale: Survivors

•Each suicide leaves at least six, and possibly hundreds of, survivors

•On college campus, survivors are many, including friends, faculty, and staff of different cultural/religious backgrounds

•May experience particularly difficult grief process related to religiosity/spirituality

•Understudied area of suicide research

(American Association of Suicidology , 2011)

Religious and Spiritual Perspectives on Suicide•Buddhism•Hinduism•Agnosticism•Atheism•Islam•Judaism•Christianity

•Four Noble Truths▫Suffering▫Origins of suffering▫Cessation of suffering▫The way leading to cessation of suffering

•Suffering is the result of craving▫Craving for sensual pleasure▫Craving for existence▫Craving for non-existence

Religious and Spiritual Perspectives on Suicide: Buddhism

(Disayavanish & Disayavanish, 2007)

Religious and Spiritual Perspectives on Suicide: Buddhism•Skillful vs. Unskillful Acts

▫Suicide as unskillful act ▫Results in rebirth to a lower plane of

existence with increased suffering

(Disayavanish & Disayavanish, 2007)

Religious and Spiritual Perspectives on Suicide: Hinduism•Precepts prohibit violence and murder•Suicide for selfish reasons

▫“Bad death” ▫Results in karmic debt that negatively

affects rebirth

(Lakhan, 2008)

Religious and Spiritual Perspectives on Suicide•Agnosticism

▫Belief that a deity may or may not exist•Atheism

▫Complete disbelief in all deities past, present, or future Higher power is not required to behave

ethically and morally Afterlife is not required to enjoy living or avoid

an early death▫Fundamentalist atheist may identify as a

‘strong atheist’(Morton, 2011; Lizardi & Gearing, 2010; Robinson, 2010)

Religious and Spiritual Perspectives on Suicide: Islam• Only one phrase in Qur’an about suicide: “…do

not kill yourselves. Surely God is merciful toward you” (Surah 4: 29-30)

• Prophetic tradition clearly prohibits suicide• Those who complete suicide

▫Spend eternity in hell reenacting their death▫Still regarded as believers but survivors may be

stigmatized▫May be refused burial by cemeteries

(Clarke, Oxford Islamic Studies Online, accessed 2011)

Religious and Spiritual Perspectives on Suicide: Islam•Self-sacrifice for a religious cause is

restrained by ethic of caution•“Suicidal” military missions perceived as

martyrdom rather than suicide

(Clarke, 2011; Sarfraz & Castle, 2002)

Religious and Spiritual Perspectives on Suicide: Judaism•Preservation of human life valued above

all else▫Suicide and non-suicidal self-injury

regarded as criminal acts akin to murder▫Soul of one who completes suicide in state

of limbo – soul cannot return to the body nor be let into any soul world

•Strict believers do not permit post-death rituals or burial

(Gearing & Lizardi, 2009; Jacobs, 1995)

Religious and Spiritual Perspectives on Suicide: Christianity•Bible

▫The word “suicide” does not appear ▫Judas and Saul neither condemned nor

praised•St. Augustine, 5th Century CE - suicide a

violation of the sixth Commandment•St. Thomas Aquinas - suicide one of most

dire sins because individual cannot confess or repent the act

(Gearing & Lizardi, 2009; Phipps, 1985; Kennedy, 2000)

Religious and Spiritual Perspectives on Suicide: Christianity•Catechism of the Catholic Church

▫Mental competence is a prerequisite to sin▫If suicide is a result of mental illness, it

cannot be considered a sin▫Historically refused burial in Catholic

cemeteries but rarely practiced currently▫Funeral rites include prayers for

forgiveness and comfort for survivors

(Phipps, 1985; Gearing & Lizardi, 2009; Catholic Church, 1994)

Bereavement in Suicide Survivors: Unique concerns•Guilt, responsibility

▫Foundational beliefs about world▫Connection to the suicide▫“Personal psychological autopsy”

•Shame, stigma, social isolation, family relational disturbance▫Blaming▫Secret-keeping, silence▫Self-stigma

(Jordan, 2008)

Bereavement in Suicide Survivors: Unique concerns• Perceived rejection/abandonment by deceased

▫Causality multiply-determined Choice Life situation Mental illness

▫Anger toward deceased• Trauma symptoms

▫Horror, intrusive reliving, avoidance, insomnia, numbing, loss of meaning

▫Normal for all survivors, intensified if witnessed event or found body

(Jordan, 2008)

Bereavement in Suicide Survivors: Unique concerns•Complicated grief

▫Intense, unremitting yearning for deceased + trauma-like symptoms

▫Increased risk of suicidality▫More likely to experience complicated grief

than survivors of natural death

(Jordan, 2008)

Fielden’s Model of Grief for Survivors of Suicide: Research Methods •Semi-structured interviews•N = 6

▫Four mothers▫One father▫One sister

•New Zealand

Fielden’s Model of Grief for Survivors of Suicide: Thrown-ness•Thrown-ness into the lifeworld of

surviving the suicide of a loved one▫Discovery▫Turmoil

•Experiencing chaos▫Shock, disbelief, numbness, paralysis

•Dreaming as a way of saying “goodbye”▫Finishing unfinished business

Fielden’s Model of Grief for Survivors of Suicide: Survival Mode•Fear of not coming through

▫Disbelief: Difficulty accepting & confusion•Living in the world of stigma and shame

▫Embarrassment & avoidance•Moving through the lifeworld of blame

▫Family, friends, & acquaintances

Fielden’s Model of Grief for Survivors of Suicide: Searching Mode •The “why” questions•Clues: Suicide notes and written passages•Reflecting on their relationship with their

loved one•Living in the lifeworld of guilt

▫Recovery guilt•Living in the lifeworld of anger

▫Directed toward mental health providers•Searching for reminders of their loved one

▫Places & activities

Fielden’s Model of Grief for Survivors of Suicide: Moving On Mode•Creating a different lifeworld

▫Acceptance▫Outward focus▫Future orientation▫Not forgetting but forgiving

Fielden’s Model of Grief for Survivors of Suicide: Implications for Treatment•Non-linear process•Inward & outward focus•Calmness & turmoil

Assessment and Intervention• Engage students in discussion about their

religious/spiritual beliefs▫ Importance of belief system

Attendance at services, observation of practices Importance of religious community relationships Strength of identification with religious tenets Recent changes in degree of religious commitment

▫How client conceptualizes, perceives relationship between suicide and spirituality Sanctions against suicide Interpretation(s) of suicide within spiritual community Conflicts between personal and community beliefs

(Gearing & Lizardi, 2009)

Assessment and Intervention•Engage students in discussion about their

religious/spiritual beliefs▫Role of beliefs in previous coping

Source of comfort or contribution to distress Impact involvement with services, leaders Lead to avoidance of using spirituality as

resource▫Value of strengthening beliefs and practices

Identify protective elements of belief system Identify distressing elements

(Gearing & Lizardi, 2009)

Assessment and Intervention•Consider student development level

▫Coping skills – emotions, boundaries▫Autonomy, interdependence, identity, values▫Level of tolerance for divergent views

•Provide psychoeducation about grief process•Use expressive arts in therapy

▫Destruction Creation▫Receptive vs. Expressive - letter-writing,

journaling, poetry, visual arts, music

(Chickering & Reisser, 1993; Stepakoff, 2009)

Assessment and Intervention• Outreach to the bereaved• Resources

▫Support Groups▫Self-help/bibliotherapy▫Online memorials

Increase connection with others Enhance relationship with deceased May decrease ability to let go of loss

▫Websites Few encourage seeking mental health services No way to assess trustworthiness, helpfulness Nothing offensive, harmful found(Krysinska & Andriessen, 2010)

Case ExampleNancy is a 20 year-old White female sophomore at a Midwestern university who came in for therapy because of her best friend’s suicide. During the first session, Nancy talked about how close she was to her friend while growing up and going to school together. She said the suicide was shocking because her friend was always positive about life and did not tell her about any serious issues. Nancy felt sad and betrayed by her friend. She also reported feeling responsible for her friend’s suicide because as a best friend she did not do anything to prevent it. Nancy identified as Christian in her intake paperwork and is struggling with the idea that her kind friend may spend eternity in Hell.

Group Discussion Questions

1. Think about your personal beliefs about death, afterlife, and the consequence of suicide. How would you approach the session with Nancy if your personal beliefs are different from hers?

2. How would you respond if Nancy asked about your beliefs?

3. How would you go about helping Nancy work on her issues?

Discussion and Questions

ReferencesAmerican Association of Suicidology (2011).  Survivors of Suicide Fact Sheet.

Retrieved February 7, 2011, from http://www.suicidology.org/c/document_library/get_file?folderId=232&name=DLFE-160.pdf

American College Health Association (2009). Ohio State University Executive Summary Spring 2009:  American College Health Association National College Health Assessment II. Retrieved February 7, 2011, from http://slra.osu.edu/posts/documents/exec-summary.pdf

Chickering, A. W. and Reisser, L. (1993). Education and identity. 2nd Ed. San Francisco: Jossey-Bass.

Clarke, L. (2011). Suicide. The Oxford encyclopedia of the Islamic world. Oxford Islamic Studies Online. Retrieved January 25, 2011, from http://www.oxfordislamicstudies.com/article/opr/t236/e0761

Disayavanish, C., & Disayavanish, P. (2007). A Buddhist approach to suicide prevention. Journal of the Medical Association of Thailand, 98(8), 1680-1688.

Fielden, J. M. (2003). Grief as a transformative experience: Weaving through different lifeworlds after a loved one has completed suicide. International Journal of Mental Health Nursing, 12, 74-85.

ReferencesGearing, R. E., & Lizardi, D. (2009). Religion and Suicide. Journal of

Religion & Health, 48(3), 332-341.Jacobs, L. (1995). The Jewish religion: A companion. Oxford: Oxford

University Press.Jordan, J. R. (2008). Bereavement after suicide. Psychiatric Annals, 38,

679-685.Kennedy, T. D. (2000). Suicide and the silence of scripture. Christianity

Today. Retrieved January 25, 2011, from http://www.christianitytoday.com/ct/2000/julyweb-only/42.0.html

Krysinska, K. & Andriessen, K. (2010). On-line support and resources for people bereaved through suicide: What is available? Suicide and Life-Threatening Behavior, 40, 640-650.

Lakhan, S. E. (2008). Hinduism life and death. Student BMJ, 16, 310-311.Lizardi, D., & Gearing, R. E. (2010). Religion and suicide: Buddhism,

Native American and African religions, Atheism, and Agnosticism. Journal of Religion and Health, 49, 377-384.

ReferencesMorton, C. (2011). Funerals—dying an atheist. American Atheists.

Retrieved January 25, 2011, from http://www.atheists.org/Funerals_-_Dying_an_Atheist

Phipps, W. (1985). Christian perspectives on suicide. Christian Century (Chicago, Ill.: 1902), 970–972.

Robinson, B. A. (2010). Agnostics and agnosticism: Uncertainty about whether God exists. Retrieved January 20, 2011, from http://www.religioustolerance.org/agnostic.htm

Sarfraz, M., & Castle, D. (2002). A Muslim suicide. Australasian Psychiatry, 10(1), 48-50.

Silverman, M. M., Meyer, P. M., Sloane, F., Raffel, M., & Pratt, D. M. (1997). The Big Ten Student Suicide Study: A 10-year study of suicides on Midwestern university campuses. Suicide Life-Threatening Behavior, 27 (3):285-303.

Stepakoff, S. (2009). From destruction to creation, from silence to speech: Poetry therapy principles and practices for working with suicide grief. The Arts in Psychotherapy, 36, 105-113.

ReferencesSuicide Prevention Resource Center. (2004). Promoting Mental

Health and Preventing Suicide in College and University Settings. Prepared for Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services Supported by Grant No. 1 U79 SM55029-01 October 21, 2004. Accessed on February 7, 2011 at http://www.sprc.org/library/college_sp_whitepaper.pdf

The Role of Religiosity and Spirituality in Responding to Survivors of SuicideBonnie M. Benson, MEdBong Joo Hwang, PhDRobert M. Bennett, MSWTodd Gibbs, BADanielle Finch, BAThe Ohio State UniversityCounseling and Consultation Service

Big 10 Counseling Centers ConferenceFebruary 10, 2011Minneapolis, MN