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The Arts in Psychotherapy 36 (2009) 105–113

Contents lists available at ScienceDirect

The Arts in Psychotherapy

rom destruction to creation, from silence to speech: Poetryherapy principles and practices for working with suicide grief

hanee Stepakoff, PhD, PTRrivate Practice, 754 E. 6th Street, Suite 2B, New York, NY 10009, United States

r t i c l e i n f o

his article is dedicated to the memory ofiam Rector, poet and instructor in the MFArogram in creative writing at New Schoolniversity, who died by suicide in August007.

a b s t r a c t

Survivors of suicide must contend not only with traumatic grief but also with shame, stigma, andsilence. Poetry therapy is a powerful tool for healing in this population. The utilization of preexistingpoems, along with the expressive writing of poems, letters, and journals, contributes to the desensitiza-tion of traumatic memories and helps the bereaved move beyond formless anguish toward a capacityfor the verbal representation of psychological pain. Further, creative expression serves as a means

eywords:uicide bereavementraumatic griefuicide survivorsoetry therapy

for rejecting the implicit message of destructiveness that characterizes suicide. The author describesa variety of techniques that can be used as part of self-directed efforts at psychological repair (i.e.,“auto-poetic healing”), as well as with individuals or groups in the context of professionally facilitatedtreatment.

© 2009 Elsevier Inc. All rights reserved.

xpressive writingreative arts therapies

ntroduction

Grief refers to the intense emotional distress that typicallyollows the death of a loved one. Factors that can make a lossarticularly difficult include suddenness, violence, and/or a per-eption that the death was preventable (Doka, 1996). The causesf such losses include medical conditions (e.g., heart attack), acci-ents, homicide, suicide, terrorism, and war. The term “traumaticrief” serves to capture the idea that these types of losses are oftennherently traumatic, and when they occur, the bereaved may showigns of both trauma and grief.

In this article, I focus on one type of traumatic grief, namely,hat which occurs in the aftermath of a suicide. Researchers, clini-ians, and the bereaved themselves have observed that the suicidef a loved one is almost always exceedingly painful (Baugher &ordan, 2002; Carlson, 2000; Stillion, 1996). Unlike most otherorms of death, in many cultures suicide has a long history ofeing viewed as sinful or dishonorable (Stillion, 1996). For exam-le, suicide was criminalized in England in the 10th century, andemained on the criminal statutes throughout Europe until the

nlightenment (Jamison, 1999; Lieberman, 2003). Medieval lawupported such practices as abusing the suicide’s corpse (includ-ng driving a stake through the heart), refusal to bury the deceasedn consecrated ground, seizure of property, and punishment of the

E-mail address: drshaneestep@aol.com.

197-4556/$ – see front matter © 2009 Elsevier Inc. All rights reserved.oi:10.1016/j.aip.2009.01.007

suicide’s family. Suicide was decriminalized in the United Statesduring the 19th century, but remained a crime in Britain until 1961(Jamison, 1999; Lieberman, 2003). Religious and moral condem-nations of the deceased person have persisted in contemporarytimes (Robinson, 2001). The linguistic practice of using the verb“commit” just before the word “suicide” still leads many peo-ple to unconsciously associate suicide with crime (e.g., adultery,murder). Further, in the aftermath of suicide, it is common foracquaintances, relatives, neighbors and even strangers to blamethe person’s closest relatives and friends for the death (Ross, 1997).Thus, in addition to all of the factors that make any death painful,and that make traumatic losses especially excruciating, survivors ofsuicide must also contend with feelings of guilt, stigmatization, andshame.

Many survivors remain silent about their anguish for years,either because others have conveyed the message that they arenot comfortable with the topic or because the survivor fears socialdisapproval and rejection of him/herself and/or the lost loved one(Lukas & Seiden, 1997). Yet in order for healing to occur, it is nec-essary for the bereaved to move from a state of formless anguish toone in which the pain can be symbolized or represented, either inwords or in non-verbal media such as drawings, music, and dance. Itis also necessary to move beyond self-imposed or socially enforced

isolation into a state of meaningful contact with at least one otherhuman being.

In addition, suicide is generally viewed as an act of destruction.Hence, recovery from suicide loss can be facilitated by an active,willful countering of destructive tendencies. Any form of creativity

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individual and group exploration.My colleague Dr. Jack Jordan and I co-facilitated several cycles

of a 10-session, biweekly Suicide Grief Support Group (SGSG) (SeeTable 1). Such groups can be helpful at any stage of healing, even

Table 1Topics for suicide grief support groups (Jordan, 2002).

Session Topic

1 Orientation and introductions2 Remembering our loved ones3 Psychological reactions to suicide4 Coping strategies5 Social reactions

06 S. Stepakoff / The Arts in Ps

an serve this purpose, but engagement in the expressive arts mayield particular benefits. Maintaining silence about the experiencef loss, and about the loved one’s life and death, prevents survivorsrom experiencing the sense of solace and release that result fromuthentic self-expression.

In this movement from silence to speech, poetry therapy can beparticularly helpful tool. “Poetry therapy” refers to the utilizationf poetry and related forms of literature and creative writing inrder to improve psychological functioning (Mazza, 1999). This canake place in a solitary, spontaneous way or in a formal professionaletting. Usually, it is most effective to engage in a combination ofeceptive and expressive approaches, either within each session orcross a series of sessions.

eceptive methods: Self-directed and facilitated

Receptive methods of poetry therapy are those that rely on thetilization of preexisting poems (Mazza, 1999). This usually referso poems that have been published in collections, anthologies, liter-ry journals, and so forth, or that are circulated among individualsr on the Internet. It can also refer to songs. The poems or songso not have to specifically mention suicide; in fact, most do not.ather, they capture particular aspects of the experience of over-helming grief (Stepakoff, 2002). Mazza (1999) proposed the term

receptive/prescriptive” in order to differentiate this way of work-ng from “expressive/creative” approaches, which focus on the actf writing poems.

Receptive methods are generally employed in two differentays. In the first, the bereaved person chooses a poem that is mean-

ngful to him or her, and that captures a particular aspect of his orer feelings and experiences, and either reads it to him/herself orhares it with others. I call this receptive method “self-directed” (forhose who are not in a formal clinical setting) or “client-directed”for those who engage in this effort as part of their work in coun-eling or psychotherapy). A second way that receptive methodsf poetry therapy are employed is referred to as a “facilitated” ortherapist-guided” approach (Stepakoff, 2003). These terms refero situations in which the therapist or group facilitator carefullyhooses a poem that s/he feels—based on his or her own life, experi-nces with other individuals or groups, input from other clinicians,nd/or intuition—will help survivors focus on and grapple witharticular aspects of their grief. In these situations, the facilita-or/therapist supports the client/group in using the preexistingoem as a springboard for talking about their own experiencesnd concerns. This method is described in detail in the classicext Biblio/Poetry Therapy: The Interactive Process (Hynes & Hynes-erry, 1994). In the pages that follow, there are examples of bothelf-directed and therapist-guided receptive poetry therapy withurvivors of suicide.

elf-directed

Many survivors of suicide have reported that in the aftermathf the death, they felt compelled to search for or cite preexistingoems and songs that expressed what they were not able to findhe words to express, and that they found solace when they locatedpoem or song that was salient. For example, one survivor came

o a therapy session with a photocopy of Adrienne Rich’s (1991)Tattered Kaddish,” a poem that is a poignant tribute to people whoave died by suicide. She read it aloud to the therapist, and spokebout what it evoked in her.

One of the most common methods of self-directed receptiveoetry therapy is the utilization of preexisting poems or songsn memorial websites, booklets, or cards. One couple with whomy colleague, Dr. Jack Jordan, and I worked, whose son died by

uicide, chose to place the poem “A Litany of Remembrance”

erapy 36 (2009) 105–113

(Gittelsohn, 1975) in a card they sent to all who had attended hisfuneral:

In the rising of the sun and in its going down,In the opening of the buds and in the rebirth of spring,In the blueness of the sky and in the warmth of summer,In the rustling of the leaves and in the beauty of autumn,In the beginning of the year and when it ends. . .We will remember him.

Numerous examples of the utilization of poems and songs can befound on websites created by survivors. For example, Faye Martincreated a website in memory of her daughter, Lisa, who ended herlife at age 23 (http://www.lisalamb3.com). The website features apoem by Maya Angelou (“When Great Souls Die”), several songs(e.g., Celine Dionne’s “My Heart Will Go On,” Julie Gold’s “Heaven”as sung by Bette Midler, “Precious Child” by Karen Taylor-Good),and several inspirational quotes, along with some original poemsby Lisa’s relatives.

A website created by Rea de Miranda (http://Emile-de-Miranda.last-memories.com), whose son, Emile, died by suicide atage 20, contains a powerful song by Simple Plan entitled, “HowCould This Happen to Me?” The lyrics aptly express the thoughtsand feelings of a person who is suicidal, but could refer equallywell to the feelings of the bereaved survivor:

I can’t stand the painand I can’t make it go away. . .I wanna start this over againSo I try to hold on. . .and I can’t explain what happened . . . .No, I can’t stand the pain.How could this happen to me?

For additional examples of memorial websites created by suicidesurvivors, most of which contain a combination of preexisting andoriginal writing, see Appendix A.

Facilitated/guided

Although survivors are quite adept at choosing poems that aremeaningful to them and that they feel capture important aspects oftheir experiences and emotions, there are many situations in whichthe facilitator or therapist may be better equipped to select poemsthan are the survivors. In these situations, the facilitator or thera-pist uses a preexisting poem as a catalyst that will increase clients’willingness to talk about their own experiences and concerns. Reg-istered poetry therapists, who have undergone a rigorous processof study, practice, and credentialing, are specially trained to iden-tify poems that are likely to serve as safe, effective springboards for

6 Making sense of suicide7 Impact on families8 Continuing bonds9 Holding on while going on

10 Commemorating and ending

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ecades after the loss, but are especially meaningful for personsho are newly bereaved (i.e., within the preceding year). Nearly

ll survivors can benefit from group support, as long as they haventact reality-testing, adequate social skills, and a capacity for affectegulation.

We used a preexisting poem in virtually every session, withhe intention of deepening the participants’ dialogue and explo-ation of the designated theme. Poems were selected with thentent of achieving four main therapeutic goals: (a) to describe, infresh, creative manner, common aspects of the grieving process

fter a suicide, thereby helping participants feel less isolated; (b)o model exceptionally honest and brave self-expression, therebyreeing participants to express themselves more frankly and fully;c) to give external form to internal, difficult-to-articulate emo-ions and perceptions, thereby helping participants contain theirsychological pain; and (d) to serve as objects of aesthetic beauty,hereby instilling in participants renewed feelings of vitality andope.

A copy of the specially selected poem was provided to each par-icipant, and either a co-leader or participant read the poem aloud.ometimes, the poem would be read aloud by several participants,ecause hearing a poem in different voices can deepen its impact.fter hearing the poem, participants were invited to discuss theiresponses, and to explore how the themes in the poem resembled,r differed from, issues they were struggling with in their ownrieving process.

For example, early in the cycle, we used a poignant 15-line poemy William Stafford (1990). Stafford’s eldest son, Bret, died by sui-ide in 1988. By accurately capturing the experience of traumaticrief, in addition to modeling candid self-expression and touchingarticipants at the level of emotion rather than intellect, the poemaved the way for group members to share about the tragic losshat had befallen them and their families. The title, “Tragedy,” isery evocative because it consists of a single word that potentlyonveys the essence of suicide:

It happens. You knew it could.No one ever said it wouldn’t,and now it has.The world just goes on—the airmoves, trees keep standing there and maybegrieve a little, the sun stays steady. . . (1990)

Some survivors were exposed to the extreme trauma of findingheir loved one seriously injured or deceased after the suicidal act.or many, however, the most traumatic moment was the instantn which they learned that their loved one had died. Indeed, the

emory of being informed of the death is often associated withtronger and more frequent traumatic repetitions (e.g., flashbacks,ightmares, intrusive images) than the actual time, place, and sit-ation in which the death occurred. In order to help clients talkbout this difficult topic, I have used a poem entitled “How Badews Comes,” by Debra Marquart (1998), excerpted below:

A telephone is ringinglike an emergencyin a room down the hall,I think of the oneto whom bad news is coming. . .Unclipping an earringas she leans in to hearthe voice on the other end

saying, I’ve got somebad news, feelingin that long secondbefore the words comethe difference between

erapy 36 (2009) 105–113 107

the way it wasand the wayit will be. . .

This poem has a great deal of specific sensory imagery, a featurethat serves to stimulate participants’ own sensory recollections.Almost every line is noticeably short (e.g., three or four words),thus conveying the sense of urgency, breathlessness, and anxietythat accompany the receiving of catastrophic news. After hearingthe poem read aloud by the facilitator, group members tend to feel agreater readiness to share about their own experiences of learningthat their loved one had died.

In exploring survivors’ coping strategies as well as the socialreactions they must deal with, Dr. Jordan and I also found it help-ful to use a 15-line poem by Paul Laurence Dunbar (1993), anAfrican–American poet who wrote from the late 19th into the early20th century. The poem (excerpted below) is entitled “We Wear theMask”.

We wear the mask that grins and lies,It hides our cheeks and shades our eyes. . .Why should the world be over-wise,In counting all our tears and sighs?Nay, let them only see us whileWe wear the mask. . .

We chose this poem because Dunbar skillfully captures aspectsof the experience of coping with a suicide. More specifically, sur-vivors have noted that even when their grief is still very intense,after a certain period of time they feel that they have to hide thefull reality of their pain in order to function with some semblance ofnormalcy in day-to-day life. Survivors often report that their friendswant them to behave as though they have “gotten over” the death,and that this results in self-censorship and hiding (masking) of one’sreal emotions. Thus, the poem serves as a catalyst for dialogue aboutthese concerns.

Another important issue for suicide survivors is the recognition,reported by most, that even though they can still have rewarding,meaningful lives, they will never stop mourning, missing, and long-ing for their loved one. A poem that can serve to open up this topicfor exploration is the early twentieth century poet Edna St. VincentMillay’s (2001) sonnet “Time Does Not Bring Relief”:

Time does not bring relief; you all have liedWho told me time would ease me of my pain!I miss him in the weeping of the rain;I want him at the shrinking of the tide. . . (excerpt)In this poem, Millay deftly uses imagery and rhythm to

poignantly express the idea that no matter where she goes or whatshe does, she continues to think of her loved one. For example,if she visits a site that her loved one frequented, then she findsthe site “brimming” with memories of him, yet if she enters aplace in which he never set foot, she becomes acutely aware ofhis absence—“And so stand stricken, so remembering him.” Dr.Jordan and I found that in the Suicide Grief Support Group, useof this poem led to productive discussions about the experienceof grief. For example, many survivors noted that their recoveryfrom the trauma of suicide loss was not a simple linear process inwhich they felt better and better each day, but rather more like asharply winding, bumpy road in which there were many ups anddowns, twists and turns. They pointed out that even though theoverall trajectory tended to be toward a greater capacity to endurethe loss, a “trigger” such as the anniversary of the death or other

reminder (e.g., a particular song, scent, etc.) could catapult themback to a grief nearly as intense as that which they experiencedin the first weeks after the death. One survivor with whom weworked felt that the poem expressed her feelings so aptly that shechose to read it aloud at a memorial service for her son.

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A sonnet is a poem of 14 lines that follows a strict rhyme schemend a specific structure. Most English sonnets employ iambic pen-ameter. In receptive poetry therapy, sonnets can be useful forealing with particularly difficult topics because the form providesontainment and the rhythm provides solace. Indeed, some haveuggested that iambic pentameter has a natural comforting effectecause it is similar to the rhythm of the human heartbeat, which

nfants hear when in proximity to their mothers (Ibrahim, 2006;aron, 2008).

xpressive methods: Self-directed and facilitated

Receptive methods of poetry therapy are usually combinedith expressive methods. The latter are sometimes referred to

s “expressive writing” (Lepore & Smyth, 2002; Mazza, 1999) orpoem-making” (Fox, 1997), and can be understood as the processhereby survivors engage in their own, original writing. This can

ake various forms, among the most common of which are jour-aling, letter-writing, and the creation of poems. It can also includeral and improvisational poem-making, in which the words are spo-en aloud rather than inscribed (Spring, 2003; Stepakoff & Marzelli,007).

Expressive methods encompass the writing of poems by indi-iduals as well as collaborative writing by dyads, families, groups,r communities (e.g., in which each person contributes a line orhrase). The theoretical foundations of expressive methods includehe concepts of catharsis and externalization, that is, the humaneed to symbolize or represent, via external form, emotions, and

mages that have been purely internal. As with receptive meth-ds, expressive approaches can be self-directed or professionallyacilitated.

elf-directed

In the aftermath of suicide, the process of writing poems abouthe loved one and/or the death may help to counter silence, stigma,nd shame. When survivors are successful at converting theirnformulated, raw emotions and sensations into the medium of

anguage, they often feel a sense of relief. This positive effect isomewhat paradoxical, because for most survivors the process ofriting about the loss is excruciatingly painful. It is possible, thus,

hat a phenomenon similar to “desensitization” occurs, in which bypending a certain amount of time focusing on and writing abouthe pain, the survivor becomes better able to bear it. This view isonsistent with ideas explored in recent work on the physiologicalnd psychological benefits of expressive writing (Pennebaker, 1997,002).

The material created during this solitary endeavor may be keptrivate, shared with a select group of friends or relatives, or brought

nto the public domain via publication, websites, or open readings.his decision to bring the work out of the closed room and into theublic sphere is consistent with Judith Herman’s (1992) observa-ions on the last stage of trauma recovery, in which an importantomponent is regaining the capacity for meaningful participation inivic life. The open sharing of original work can be psychologicallynd socially ameliorative because it directly counters the destruc-ive psychosocial dynamics that characterize isolation, stigma, andilence.

oem-makingSelf-directed expressive poetry therapy can be viewed, essen-

ially, as a form of “auto-poetic healing” (Stepakoff, 2007b). Thiserm refers to processes whereby a trauma survivor utilizes writtenr oral poem-making as part of a spontaneous process of self-repair.hen people ask, “What is poetry?” I sometimes answer, “Poetry is

form of speech that naturally arises when the heart is full.” It has

erapy 36 (2009) 105–113

been observed in numerous contexts that when events of enormousmagnitude occur, events that are difficult to cognitively and emo-tionally assimilate, the urge to make poems is intensified. Althoughthis innate desire to put feelings, experiences, and memories intopoetic language is evident with regard to many forms of trauma,the experience of mourning is often associated with a particularlystrong desire to write poems, perhaps because of the universal needto elegize and memorialize lost loved ones (Berger, 1988; Bowman,Sauers, & Halfacre, 1994; Mazza, 2001; Stepakoff, 2002, 2003).

The writer who engages in an instinctive process of poem-making does not necessarily recognize that she or he is strivingto heal from trauma. She or he may feel that the identity of artistsupersedes that of trauma survivor, and that the primary aim is aes-thetic value rather than psychological repair. Nevertheless, in theaftermath of a significant loss, it can be argued that the effort towrite poems arises from a psychological need to come to termswith the enormity of what has occurred.

There are many examples of accomplished, recognized poetswho have collections in which a substantial portion of the poemsaddress the struggle to cognitively and/or emotionally process thesuicide of a loved one. Among the most noteworthy are Nick Flynn(2000) (mother); Jeffrey Harrison (2006) (brother); and Ted Hughes(1998) (wife). In addition to these collections, in which suicidegrief is a major theme, there are numerous examples of individualpoems that point to a similar process. These include “The Portrait”by Stanley Kunitz (2000) (father), and “A Memorial: Son Bret” and“For a Lost Child” by William Stafford (1998a,b).

Poets who have addressed their experience of losing a husbandto suicide include Ruth Stone (1987, 2002, 2004), Virginia HamiltonAdair (1996), and Adrienne Rich (1973, 1986, 1991). The suicide ofa close friend is explored in poems by Erica Jong (1991a,b), MaxineKumin (1997a,b, 2001), and Anne Sexton (1982). A closely relatedapproach is to write a song about the suicide, in which the lyricsserve essentially the same function as the words of a poem, exceptthat they are intended to be sung rather than spoken or read. Anexample is “Chicken Wire,” by Joe Pernice (1998), which focuses onthe singer–songwriter’s effort to come to terms with the suicide ofa friend.

In addition to the above-mentioned examples of auto-poetichealing by professional writers, there are countless examples ofnon-professionals engaging in spontaneous writing as a tool forself-repair. In my interactions with diverse individuals and familiesbereaved by suicide, many survivors have provided me with exam-ples of the writing they did on their own as part of their effortsto self-heal. Indeed, I have found that the urge to write poems isamazingly widespread among survivors, even those who had neverwritten poems before the suicide.

Below are some excerpts from poems by suicide survivors. Theseindividuals consider their breaking of silence to be an importantpart of their recovery, and therefore have requested that their realnames be included:

The sunshine is dimmer, the moon glows less brightThe stars do not twinkle as serenely at night.No yearning to explore the new fallen snowOr sit by a warm crackling fire all aglow.Nothing’s the same since you left us that day.Not autumn’s bright colors, nor spring flowers in May.Not 4th of July sparklers, or summertime swimming.Not Thanksgiving turkey with all of the trimmings. . .I asked God to keep you from being so sad

and to quiet the turmoil that made you so mad. . .It’s just that it hurts so much to let go.There are so many things I still want you to know.Things left unsaid, left undone and untoldthat fill me with guilt and leave my heart cold. . .

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And so it will go on, the rest of my years,yearning for answers, fighting back tears.

—excerpt from a poem by Diane, whose son, Pete, ended his lifet age 25.

One spring day, not long agoYou tore my heart in two,and snatched away one precious child:The child you took was you.I struggle now, to know you;I never did, I fear.The world you shared has shattered.Your voice silent, once so near.Oh spring day, so long ago,your smile so real, so sweet;The child I knew, so full of joy,I long again to greet.I struggle now to see you.So happy you were, then.I struggle to forgive you,though I love you, just the same.

—Donna, whose daughter, Shari Ann, ended her life at age 16.

etter-writingSometimes survivors of suicide will write poems in which they

irectly address their lost loved one. In many instances, they mayish to write pieces that are longer and that are perceived as less

onstrained by formal and aesthetic requirements than are poems.he writing of letters can be a useful approach (Vance, 1998). Often,urvivors will feel a particular desire to write letters to the loved onen important occasions, such as yearly birthdays or anniversariesf the death.

Carol de Clercq, a member of an online support group called Par-nts of Suicide (POS), wrote a series of letters to her daughter, Saraawn, after the latter died by suicide at age 26. She has titled thisnpublished manuscript “Letters to Sara.” In explaining her experi-nce of writing these letters over the course of several years, Carolemarked:

These letters to her are my thoughts, my feelings, my percep-tions, and my actions in response to my loss. . . They honestlyportray my process of grief. They show my evolution, and some-times my stasis and even deterioration during the process. . .It was cathartic for me and necessary in order for my life to goon. . . I want the evolution of my grief to be seen exactly as it wasfelt. . . I want the pain to be felt by the reader. . . I want all of thefeelings and thoughts to be seen as they were. . . I can only hopeand pray that it will. . .help some other mother who is strugglingwith the unbearable and unimaginable pain associated with thistype of tragic loss. (2008, personal communication)

Rosana, who is likewise a member of POS, and whose 18-year-ld son, Ian, died by suicide, has similarly used letters to her son,ritten over a several-year period, as a way of coping with her loss

nd preserving her relationship with her son. She remarked, “Fromhe day my son died, I have written letters to him as a way of holdingn to our connection. . . My letters have changed in tone somewhatrom the early days of our family’s tragedy to the more recent ones”2008, personal communication):

Dear Ian,

Today is such a beautiful day. . . Maybe that’s why my heart ishurting so much I can barely breathe. If only I could share thebeauty of this day with you. . . Do you know how much we missyou? Do you know how much we love you?. . . Oh. . ., why didyou leave? You tore my heart right out of my chest. Do you know

erapy 36 (2009) 105–113 109

how special you were to everyone who ever met you? I hear thesame things over and over again. You were so smart, so kind, sucha good listener, so funny, so wise. . . I can remember you tryingto engage me in peek-a-boo in the middle of the night when youwere only a few months old. It seems like yesterday. . . What wasit that caused you to give up so totally?. . . I cannot bear to thinkof you as gone. . .

JournalingJournaling, like letter-writing, allows for a lengthier, freer style

of expressive writing than is typical of poems. It differs from letter-writing, however, in that in the journal the survivor usually does notaddress someone directly, in an “I-Thou” format, but instead writesabout his or her thoughts, feelings, and memories. Below are twoexamples of journaling by survivors of suicide. The first consists ofa single entry, by a woman whose daughter, Katie, ended her lifeat age 28. The second is a series of entries written over the courseof nearly 10 months, by a woman whose 17-year-old son died bysuicide.

Dancing in the living room to rock and roll songs . . . sometimesfast, sometimes slow. Splashing each other with water fromthe puddles after a summer’s rain . . . sometimes a lot, some-times a little. Walking in the mornings around the block forexercise . . . sometimes slower, sometimes quicker. . . Crankingup the radio in the car . . . sometimes singing, sometimes no. Imust savor the memories of the good times. . ., for . . . there areno more to be had. (Shirley Sherwood, used with permission)

8-4-02

I lost Ben on July 19, 2002. We lost Ben. I lost my son—myyoungest. The grief is unbearable and life will never be thesame. I feel as though I’m lost in a fog with no senses. I tor-ture myself with ways I could have prevented it. If only I hadstayed home that day. . . Questions assail me—and there are noanswers—except my Ben is gone. How can that be?

10-13-02

I don’t remember writing the last [8-4-02] entry. It’s all a blur. Itseems so unreal to say “Ben’s death” or “Ben’s funeral.” I madethe first flower arrangement for his grave a couple of weeks ago.It was a beautiful fall arrangement in a brass container. I put alizard, frog, butterfly and ladybug on the side. I bought a ceramicpumpkin for his grave. “His grave”—another impossible phrase.

11-10-02

My thoughts are still consumed with grief and loss. I see Ben as Ifound him [when he died] several times a day. Thoughts of himand the loss of him are the last thing on my mind when I go tosleep. . . He is among the first thoughts I have as I greet each day.It’s always a let-down when I realize he’s really not here. Andeven though I know he is with God and I will see him again, Ifeel deprived of knowing him more fully here on earth. The losshas no boundaries. The grief touches all parts of me. I miss himso much.

5-30-03

Not much new to write. I feel like all I want to say is Ben—I missyou. I love you. . . The pain of missing him is—and has been—sostrong. (Mary Butler, used with permission)

I have observed that self-directed journaling is a very commonresponse to the suicide of a loved one. DeSalvo (1999) provided ahelpful delineation of characteristics that increase the probabilitythat this process will be psychologically beneficial. These include:rendering the experience precisely, truthfully, explicitly, and with

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ich detail; naming emotions, and linking them with the event;escribing both positive and negative aspects of the person orvent; mentioning insights that have been gained from the painfulxperience; and telling a complete, complex, and coherent story.

By reading survivors’ letters and journals, as well as theiremarks about how they experienced the writing process, I haveiscerned that writing to or about the lost loved one serves at

east seven psychological functions: (1) it is inherently cathartico unburden one’s heart and pour one’s feelings onto the page;2) written self-expression provides an opportunity to communi-ate one’s deepest emotions with the reader, thereby allowing forhe possibility of being accurately understood and of reducing theerrible sense of isolation that is so often associated with suicideereavement; (3) the survivor who uses writing to share his or herxperience of loss and grief may feel that s/he is thereby able toontribute to the healing of other suicide survivors, and this sensef altruism and meaning can be beneficial for trauma survivors, par-icularly during the latter stages of their recovery (Herman, 1992);4) letters in particular, though to some extent also journals, providen opportunity to maintain a sense of ongoing connection with theoved one, who is no longer physically present but remains very

uch a part of the survivor’s psyche; and (5) writing can serves a means of memorializing or paying tribute to the loved one,hich can be particularly important given that persons who die by

uicide are often unfairly viewed as condemnable and disgraced.dditional aims include: (6) helping the survivor to cognitively pro-ess the loved one’s life as a whole and the often mystifying eventsurrounding the death, and (7) providing an opportunity for theurvivor to directly express his or her love rather than keeping itocked within, unspoken.

Suicide is always perceived as a particularly tragic form ofeath and is associated with exceptional agony in the hearts of theereaved. In its aftermath—as the above-described poems, lettersnd journals clearly indicate—survivors appear to have a fundamen-al need to verbally represent the experience of grief. Perhaps thiss what Neruda (1969) was alluding to in his line “verse falls to theoul like dew to the meadow,” or what Shakespeare (1997) hintedt over four centuries ago when he coined the phrase “give sorrowords.”

acilitated/guided

In contrast to auto-poetic healing, facilitated/guided expressiveoetry therapy takes place in the context of a formal therapeuticelationship. The particular clinical approach may vary, as long asriting and other expressive verbal techniques are utilized. Such

echniques have been used effectively in mutual support groups,ognitive-behavioral therapy, and psychoanalysis, but are mostlosely associated with the formal discipline known as the “expres-ive” (or “creative arts”) therapies. In many instances, intermodalpproaches are used, in which survivors combine verbal and non-erbal techniques (for example, writing a poem and then dancingo its sound while someone else reads it aloud, or drawing an imagend then listing words that the image calls to mind) (Rogers, 1993).

In each session of the Suicide Grief Support Group, Dr. Jor-an and I introduced writing exercises and activities intended toelp participants give voice to their experiences and emotions.roup members approached these activities with earnestness andourage. The goals of the expressive writing essentially paralleledhose for the receptive approach: reduce isolation; encourage freexpression; give form to painful emotions; and foster hope.

The writing assignments had varying degrees of structure anduidance. We usually integrated the expressive writing with thetilization of preexisting poems. More specifically, after devotingportion of the session to participants’ responses to a preexistingoem, they were typically given a writing exercise, after which they

erapy 36 (2009) 105–113

were provided with an opportunity to share what they had written.A common exercise was to ask group members to choose a subjec-tively meaningful word, phrase, or line from the preexisting poemand use that as a starting point for their own writing, that is, as thetitle or first line of a new poem.

For example, after reading the aforementioned William Staffordpoem, we provided group members with a blank sheet of paper,and asked them to write the word “Tragedy” at the top of the page.We then invited them to “free-write,” that is, write for 5 min, non-stop, without self-censoring and without lifting their pens from thepage. They were told that if they felt stuck, they should just keepwriting whatever came to mind. The material that the clients thusgenerated was potent and moving.

Among the most widely used facilitated expressive approachesare poem-making, journaling, and letter-writing.

Poem-makingJust as a preexisting sonnet has formal characteristics that ren-

der it potentially useful for receptive poetry therapy, assigning aparticular poetic form for clients to use in the creation of poemscan likewise provide a sense of containment for overwhelmingemotions. For example, clients can be invited to write a poem ofa particular number of lines, or using a particular rhyme schemeor syllabic structure. One expressive method that I have used suc-cessfully with survivors of suicide and other traumatic losses is theacrostic.

The acrostic is a form of constrained writing, in which the firstletter of an important word is written vertically down the page, andthen each letter is used to begin a line. The total set of lines consti-tutes the acrostic poem, and by underscoring the first letter of eachline, the reader can discern the vertical word. In my clinical workwith survivors of traumatic grief, I have adapted this form by invit-ing clients to write the loved one’s name vertically down the page,and then use each letter of the name to begin a line that captures apositive quality or memory of the loved one. The form serves as acontainer for the painful affect associated with the loved one, andfosters a focus on positive images that can serve to counterbalanceor, ideally, to overpower the traumatic imagery associated with themanner of death (Stepakoff, 2007a). In addition, the physical pageon which the poem is written can serve as a transitional object,thereby allowing the survivor to “hold onto” the loved one even inhis or her physical absence.

Below is an example of an acrostic written by a woman withwhom I worked; her father, whose name was David, died by hisown hand a few years before she composed this poem:

Devoted fatherActive in the communityVery thoughtful and caringInsightful and wiseDeep feelings, deep thoughts, and a capacity for strong love.

Another facilitated poem-making technique, which is usedspecifically in group settings, is called “collaborative poem-making.” This technique can be helpful at various stages of a group’sexistence, but is particularly empowering at the end of a groupcycle. It is a technique that is widely used in poetry therapy groups,and empirical research has indicated that it enhances group cohe-siveness (Golden, 1994; Mazza, 1999).

In this technique, each member of the group is first asked towrite about his or her own feelings and thoughts. Then, each mem-ber looks over what s/he has written, and selects a line or phrase

that is particularly meaningful to him or her. Next, one by one,according to readiness, each person contributes his or her line orphrase, such that one “group poem” emerges.

The group poem weaves the participants’ diverse feelings intoone coherent whole, and serves as both a container in which the

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ull range of feelings can be “held” and a transitional object thatarticipants can keep with them after the group has ended. As withny form of creative expression, there is usually a sense of satis-action and wonder at having been able to successfully transformnner truth into outward form.

Below is an example of a collaborative poem entitled “The Kin-hip of Pain.” Each line represents one participant’s contribution tohe whole. This poem was created jointly by the 10 members of auicide Grief Support Group that Dr. Jordan and I co-facilitated in003:

As each session starts and finishesour feelings are sharedand I know I am not alone.I will never forget.We are family.We are all survivors.The thing I will take away from the groupis the kinship of pain.I would like to rememberand read the poems again.

This collaborative poem-making technique can be adapted foryads, families, and large groups. For instance, two parents can eachontribute lines to a poem about their lost son or daughter; surviv-ng family members can each contribute a line to a poem about theamily member who has died; and a number of people can con-ribute lines to a poem about a death that affects an entire group.xamples of the latter include members of a professional associ-tion who assembled lines to create a poetic tribute to a recentlyeceased colleague (Rojcewicz, 2002), and a classroom of pupilsho each contributed a line to a poem memorializing a peer whoad died (Stepakoff, 2003).

ournalingUsually, poetry therapy is viewed as including a broad range

f expressive writing techniques and, thus, as encompassing theherapeutic use of journal-writing. Some practitioners, however,ave viewed journaling as a therapeutic modality in its own right,hich has areas of overlap with, but also differences from, tra-itional poetry therapy (Adams, 1990). Expressive therapists whotilize journaling as a formal modality often use “prompts” (Adams,990), defined as questions the writer seeks to answer in his or herournaling and/or suggestions for specific themes to explore.

Below is an example of a journal entry that was written inesponse to a facilitator’s suggestion that the participant use herournal to explore the theme of forgiveness. This woman’s grand-aughter ended her life at age 17:

How do I forgive myself, so I can begin to accept her death? Howdo I forgive myself for not saving her?. . . How do I forgive herfriends for not telling what she shared with them?. . . How do Iforgive the adults in her . . . school who could have helped her?How do I forgive her for lying about her suicidal thoughts? Howdo I forgive her for not asking for help? How do I forgive herfor thinking she was dispensable? How do I forgive her for notthinking of us? How do I forgive her for passing her deep despairon to us and sentencing us to a life of grief? How do I forgivemyself for focusing on our pain now when hers was so great?How do I forgive myself so that I can alleviate this grief evenmomentarily? How do I tackle these impossible tasks? (Usedwith permission, name withheld by request)

etter-writingIn an earlier section, I described the experience of suicide

urvivors who spontaneously wrote letters to a lost loved one.etter-writing, however, can also be systematically incorporated

erapy 36 (2009) 105–113 111

into clinical treatment. Usually, the clinician will give the client(s)a particular suggestion regarding to whom the letter should bedirected and/or what issues it should explore.

For example, in one session of the SGSG, Dr. Jordan and I pro-posed that participants write a letter to the person who died, inwhich they accurately and honestly expressed some of their feel-ings. A man widowed by suicide, leaving him a single parent of twoyoung daughters, responded by writing a letter to his deceased wife,in which he gave voice to considerable anger and pain:

Dear F.,

I am very angry about what you have done to me and the girls.You have hurt me to the point where it’s difficult for me to takecare of the girls. In your note, you said you don’t hate me, but inmany ways I do [hate me]. You have sentenced me to a lifetimeof pain and questions that will never be answered. I honestlyfeel that you are probably not at peace. It would seem to meunfair, that you would be at peace while the remnants of whatonce was a family lie broken and bleeding from the heart. (Usedwith permission, initials changed by request)

In response to a suggestion that we made in a subsequent ses-sion, the same individual was able to delve into other aspects of hisfeelings by writing a letter to himself:

Dear C.,

You need to work at letting go of some of the anger you feel. Itis taking too much of your energy. That energy would be betterused caring for your children, and getting your own physicalhealth in order. F. was a very sick person, and what she did wasout of a desperate attempt to end her own pain. She loved youand the girls, but couldn’t handle her own demons. Don’t let herdeath kill you too. (Used with permission, initials changed byrequest)

Whether a spontaneous solitary process or part of a structuredtherapeutic exercise, the psychological functions of the act of writ-ing are fairly similar. When expressive writing is incorporated into aformal therapeutic relationship, however, either through the shar-ing of spontaneously created work or of material generated inresponse to a clinician’s suggestion, the survivor has the opportu-nity to increase the probability that his or her internal experiencewill be accurately understood by the clinician. In addition, givenhow overwhelming and terrifying it can be for a suicide survivorto encounter the full extent of his or her anguish, the process ofsharing original written material with the therapist can help thesurvivor feel that s/he does not have to bear the pain alone butrather that the therapist will bear or “hold” a portion of the painfor him or her. This possibility for the therapeutic relationship tofoster a reduction in overwhelming affect occurs as a result of thetherapist’s empathy (which the survivor senses and which, there-fore, makes the survivor feel joined in, rather than alone with, hisor her pain), as well as the therapist’s readiness to lend the survivorhis or her own internal resources so as to provide a safe, reliablecontainer for the survivor’s anguish.

Conclusions

I have endeavored to show a variety of ways that receptive andexpressive poetry therapy can be helpful to survivors of suicide.The utilization of preexisting poems and expressive writing activ-ities has a range of psychological functions. In the aftermath ofshattering loss, the receptive and expressive utilization of writing

often occurs spontaneously. Nevertheless, survivors may benefitfrom utilizing preexisting poems and expressive writing in the con-text of a formal clinical relationship. This relationship can be one inwhich poetry therapy has been specifically agreed on as the primarytreatment modality, or one in which poetry, writing, and perhaps

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ther expressive arts are integrated into more traditional treatmentpproaches. With the sensitive support of a trained professional,articularly one who is aware of the synergistic effects of ordinarynd poetic modes of expression, survivors may become better ableo cope with the experience of shattering loss. Thus, even thoughhe grieving process after suicide is arduous and lifelong, it is possi-le to help survivors move from formless anguish to symbolization,rom isolation to connection, from destruction to creation, and fromilence to speech.

cknowledgements

I am deeply indebted to Dr. Jack Jordan for immeasurably enrich-ng my understanding of traumatic grief in general and suicide griefn particular. I am also tremendously grateful to Karyl Chastain-Beal,oordinator of Parents of Suicide, for her invaluable assistance withutreach to survivors. In addition, I extend heartfelt thanks to theany survivors of suicide who generously shared their poems, jour-

als, letters, and other written materials with me. These includerenda Adkins, Nicci Bergman, Pamela Bonilla, Mary Butler, CaroleClercq, Rea de Miranda, Donna Fitts, Magdaline Halous, Christineambrecht, Patty Jacobs, Joyce, Rosana Smith Ladik, Linda Mar-

hall, Faye Martin, Phyllis Mulford, Leslie Phillips, Diane Prater,ikki Reeves, Lesa Shelton, Shirley Sherwood, Carla Snellen, Arlinetumpff, Jean Sutton, Stacy Varner, Joan Zdun, and many others,ho wished to remain anonymous.

ppendix A. Partial list of memorial websites created byurvivors of suicide

http://adam-mooregrigg-thelittlesailorboy.memory-of.com/about.aspxhttp://erickgeorge.virtual-memorials.comhttp://jay-mcmurdo.virtual-memorials.com/main.php?action=view&mem id=9181&page no=1http://members.tripod.com/∼dsf 13/Poems.htmlhttp://profile.myspace.com/index.cfm?fuseaction=user.viewprofile&friendid=207095976http://virtual-memorials.com/main.php?action=view&mem id=9787&logoff=truehttp://www.cusp.org.nzhttp://www.runningwiththewind.com

Note: Each of the creators of these websites wished to bencluded in this Appendix. Most of these websites contain a com-ination of preexisting and original poems/songs. Two additionalebsites are mentioned in the text of the article.

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