From Trauma to Transformation

Nina J. Gutin

The phone woke me up around 2 am on April 1, 1995. It was my father’s wife, calling from the Caribbean island where they had been vacationing.  “Your brother. He killed himself.” “What?! NO!!!” I tried to rouse myself from what I was sure must have been a dream, a nightmare. “Write this down,” she continued, and gave me the details of where I was to meet them at a police station the next day in Connecticut, where my brother had lived.

What happened afterwards was a blur. I vaguely remember the meeting with police, reading the notes that Jeff had left for each of us (the one to me said “I know you’ll understand,” and the one to my father: “Don’t ask why; you won’t understand.”) The funeral in New Hampshire, the furtive conversation with my stepsister about Jeff’s recent disclosure to me of flashbacks of maternal abuse, not long after he’d told me that he had “no memories” of living with her before he went to live with our father when he was 12. I’d begged him to try therapy, but he refused “I don’t want to know what they are: I just want them to go away!” 

I returned home to New York City, where I was trying to complete my dissertation for my Ph.D. program in Clinical Psychology, I was dazed and marginally functional, but knew that I had to finish my thesis, as I had lined up a post-doctoral fellowship which was to start shortly after graduation. I felt compelled to quit my clinical job at a nearby clinic, and tried hard to focus on doing what I needed to do to graduate.

I was very surprised at the way that my colleagues and professors related to me after the loss. Those who I’d considered friends avoided me like the plague, and a few weeks after the loss, the director of my program told me that I was “still too negative.” I now know that the stigmatizing and pathologizing reactions of others are very common for survivors of suicide loss, even in clinical contexts, but at the time these reactions just solidified my shame, both around the loss and the related distress. I learned quickly that I’d have to keep both hidden in order to maintain credibility and respect in my chosen field.

I tried to power through the completion of my dissertation but seemed to have developed a brand new addiction: Jigsaw puzzles! I’d never had an addiction before, so this took me by surprise. I craved them. I obsessed about them. I dreamt about pieces being scattered as I struggled to retrieve them. And once I started a 500-piece puzzle, I couldn’t stop until it was completed. So I bargained with myself: I’d work on my dissertation for several hours a day, and then I could do my longed-for jigsaw. I seldom left my apartment except to buy new puzzles. I realize now that this “addiction” was an apt metaphor for my need to re-assemble the fragments of this traumatic loss into a “picture” that was coherent and cohesive.

Ultimately, I finished my dissertation, graduated and moved to Los Angeles, where I was to start my Post-Doctoral Fellowship. This was at a Community Mental Health Center which offered walk-in crisis intervention services, and I was expected not only to provide these services, but to teach and supervise interns as well. In my "normal" mode, I'd have been up for such a challenge, and eager to integrate whatever new knowledge would help me to meet it. Instead, I found myself to be extremely anxious, with grave doubts about my general competence. Even before I began, I felt besieged by my dread of losing a client to suicide, questions about my general ability to help them (when couldn’t even help my own brother), and concerns that I'd become overly anxious when dealing with high-risk clients. I also had grave ambivalence about disclosing these feelings or my brother's death to the clinic staff, for fear that they too would pathologize my concerns and any countertransference reactions, and reconsider their decision about choosing me for this competitive position, 

Almost immediately, I could see that the impact Jeff’s death had on my work and my professional identity was profound. I quickly became aware of changes in the ways in which I related to and/or acted with some of my clients, particularly those who were themselves suicidal or reacting to loss. Although I was able to maintain some degree of awareness of these changes, at times I would feel powerless in relation to these reactions, or else was only able to recognize them in retrospect.  

The first thing I quickly became aware of was hypervigilance in relation to issues of distress, complete with "ready to spring into action" impulses to rescue at the merest hint of a risk factor. I was well aware that this stance was fueled by guilt over not having saved my brother, and a desire to resurrect him symbolically through my clients. I became a “helicopter” therapist, taking over what should have been clients' responsibilities, thus depriving them of the opportunities for experiencing their own capacities for motivation and growth. Interestingly, this stance was reinforced by clinic staff, who saw me as intensely motivated to work with "difficult clients," and so referred most of the "crisis-oriented" clients to me. 

 At other times, I found myself over-identifying with my clients' distress, and too easily sharing their belief that suicide was in fact the only way to relieve their unbearable, seemingly intractable pain. I felt paralyzed, helpless and utterly unable to access hopeful feelings towards my clients. Instead, I found myself uttering platitudes, while soothing myself by imagining that at least my brother was no longer experiencing the type of pain that my client was. Clearly, I had lost distance, and even when I was able to retain my own reflective capacity in relation to these issues, it often felt as though this awareness was not "enough" to fight the gravitational pull of joining my dead brother through the suicidal despair of my clients.

At the other end of the spectrum, I observed a tendency to avoid connecting with my clients' pain through affective distancing techniques, most often when clients were dealing with loss issues.  It often felt like walls had been erected: between the client and me and between my own heart and mind. My default mode became "clinical autopilot," overly intellectualized and reliant on therapeutic "technique" rather than my usual emotional presence and empathic attunement. Despite my psychodynamic orientation, I found myself becoming a really good behaviorist, exhorting clients to "Exercise!  Schedule activities!" or take other concrete steps in order to minimize their distress. While these techniques are certainly not counter-indicated for distressed individuals, they were poor compensation for my inability to share or bear their painful feelings. And again, although I was able to recognize the defensive function of my stance, I initially felt unable to control my reactions. 

My awareness of my limitations came to a head when, about 6 months into the post-doc, a distraught middle-aged man walked into my office, sat down and announced "My 12-year-old step-daughter just killed herself. How on earth do I deal with something like that?" As I sat there and watched him bend down and weep, the only thoughts that came into my mind were "I don't have a bloody clue!" (this is the expurgated version!) Luckily, I was able to censor myself, but once again found myself uttering Hallmark platitudes through a glass wall. I knew that I couldn't work with him. After spending frenetic hours on the phone trying to find an appropriate grief group for this man, I discovered that there was a group specifically for Survivors After Suicide not far from the clinic. He was grateful for the referral, and started attending around the same time that I realized that maybe I should have referred myself! 

So shortly thereafter, I started attending a Survivors After Suicide group in another area. Ultimately, I found that the type of support and validation provided by other survivors played a large role in my own bereavement progress and healing. 

I also learned as much as I could about what is normative after the suicide loss of a loved one, and how it differs from other types of loss. To start with, in most instances, suicide loss is traumatic. Thus, it’s not unusual for survivors of suicide loss to manifest PTSD symptoms such as avoidance, flashbacks or even dissociation when faced with activators of related memories. These can complicate and prolong the grief process. 

In addition, this is a stigmatized loss: researchers have found that the stigma associated with suicide "spills over" to bereaved family members. Kenneth Doka refers to "disenfranchised grief," in which the bereaved receives the message that his/her grief is not legitimate, and is likely to internalize this view. Indeed, studies have shown that those believed to be bereaved by suicide were viewed by others as "more psychologically disturbed, less likable, more blameworthy, more ashamed, and more in need of professional help" than other bereaved individuals (Calhoun and Allen, 1991). These judgments often mirror survivors’ own self-punitive assessments, which then become exacerbated by and intertwined with both externally imposed and internalized stigma.  

Thus, it is not uncommon for suicide survivors to question their own right to grieve, to have low expectations of social support, and to feel compelled to deny or hide the mode of death.  To the extent that they are actively grieving, they often feel that they must do so in isolation. The perception of stigma, whether real or imagined, can have a profound effect on decisions about disclosure, requesting support, and ultimately on one's ability to integrate the loss.

All of this knowledge helped to validate my experience of Jeff’s loss. But my search for any information that might address the impact of the loss on my professional work and identity was still pretty proving to be fruitless.

I was hopeful when I discovered that there was going to be a local AFSP Suicide conference, with programs both for clinicians and for survivors of suicide loss. I walked into the registration area and was immediately asked if I was a Clinician or a Survivor. "Both," I answered. "You can't be both; you can only be one or the other." "What do you mean-I'm a psychologist and I also lost my brother!" "Well, you'll have to choose one or the other-there are separate name tags and separate programs." Since I suspected that I might run into professional colleagues at the conference, I "chose" to register as a clinician. However, when I asked if it would be possible to get a copy of the survivor’s program as well, there was furtive conversation with the "Survivor Registration" staff, who handed me a program with a "we're not supposed to do this" look.

At the conference, it was easy to tell who was who. The professional-looking badges of the clinicians had their degrees and professional affiliations; the badges of survivors were hand-written. Even on the ubiquitous women's rest room lines (the only time I believe in penis envy), I learned that these distinctions held up. A trio of women with degrees glanced briefly at another trio of women huddled around the sink—they were hugging each other as one sobbed loudly. "Survivors," noted one of the clinicians dismissively, as the trio quickly averted their gaze. 

I immediately wanted to enlarge the Ph.D. on my badge. Throughout the rest of the conference, I became the hyper-intellectual clinician. I assiduously avoided going to survivor-oriented presentations that might make me feel vulnerable and exposed in relation to the colleagues with whom I felt compelled to align myself. In retrospect, I knew that I'd wasted an opportunity to obtain support and validation for my survivor side, but also felt that to do so would have meant sacrificing my alignment with both my professional colleagues and professional self, and to risk the scorn and judgment of both. 

I wondered how I could be both clinician and survivor when my own field said I could only be one or the other. I wondered how this split in the field contributed to, or was reflected by, the split in my own identity. It didn’t seem that there was room, at least in the public or clinical spaces of my chosen profession, to actually be both. So I continued to compartmentalize, even sequester, my clinician and survivor sides.

This led me to think about what first seemed like an intriguing paradox. Mental health professionals, both by virtue of our training and, I tend to assume, our natures, are supposed to be sensitive, understanding and empathically attuned to the pain and suffering of our clients. We encourage our clients to be more open to their own vulnerability and to share this with us. Yet I've observed and experienced that when professional colleagues display vulnerability in a public way, we often respond by distancing ourselves, or even with disparagement. I've witnessed publicly vulnerable colleagues lose professional credibility, and even face ostracism.

Put in overly simplistic terms, our professional identities may be predicated, at least somewhat, upon a power differential between our clients and ourselves: US being the competent, healthy and benevolent ones, THEM being needy, pathological, looking to us for care. To what extent does this distinction serve defensive functions? Do we rely upon this distinction in order to reify our healthy, benevolent status to ourselves? Does allying with our professional role allow us to deny or compartmentalize our own vulnerability, the THEM residing within us, or even allow us to project it onto our clients?

To the extent that our professional identities do serve to protect or preserve our status, then the vulnerability of colleagues could also be seen as threatening, as it challenges the US/THEM distinction, and may bring the dreaded THEM parts of ourselves "too close to home." And if our own identities were to be vicariously threatened by identification with those vulnerable colleagues, there may be an even greater pressure to preserve the US/THEM distinction by distancing ourselves from the threat. 

This process is quite consistent with the imposition of stigma. As Goffman notes in his essay on Stigma and Social Identity, one may experience what he terms "identity ambivalence" when he observes one of his "own kind…acting out the negative attributes which he has imputed to him…The sight may repel him." Through this repulsion, the stigmatizers may preserve their feelings of health and integrity, while those stigmatized are left not only with their own vulnerability, but with the projected judgment and scorn of others as well, which are likely to be further internalized.

Both "vulnerable professionals" and “survivors” were groups against which I felt stigma was leveled. Thus, I initially felt compelled to use my alignment with the "Clinicians” to distance myself from my own identifications with the discredited survivor’s group and the grieving parts of myself.  Ultimately, I realized that by doing so, I risked silencing the part of myself that had come to the conference hoping to be heard. 

Nevertheless, despite my conviction that I needed to keep my survivor identity out of the clinical arena, after several years I felt like I’d healed enough from my loss and had regained enough clinical skill to agree to take on survivors as clients. I also felt like I could potentially bear witness to others’ pain around suicide loss without it activating my own grief or defensive reactions.  So I let people know that I was willing to start running groups and take referrals for survivors.

I got my first referral, a mother who had just lost her 13-year daughter to suicide. I quickly realized that my sense of "readiness" didn't exclude profound ambivalence. Even before my first meeting with my client, who I'll call 'Meg,’ I was besieged with questions and potential conflicts. As a parent myself, the loss of a child to suicide seems unimaginably painful. Although I already felt compassion toward my future client, I was still unsure whether or not I could make empathic space for her pain without running from it. I also wondered if I’d be looking for culpability in Meg's parenting history, whether arising from theoretical biases around attachment or, perhaps, a tendency to project the blame I hold for my own mother’s abusive parenting onto my client. And if I found Meg to be culpable in her daughter's death, would I then be able to sustain an empathic stance? 

Meg arrived at my office. She fidgeted with her purse as she sat down. She tentatively met my eyes, then quickly looked down at her shoes.  In a trembling voice, she said, “I’ve never seen a counselor before, but my 15-year-old daughter just killed herself and I just don’t know what to do.”

I suggested she could start by telling me what happened. In a monotone, with eyes still downcast, she started: “I could tell that she was moody.” “But the church counselor met with her and told me that she was just a normal teenager and that I shouldn’t worry.” Meg desperately wanted to understand how this could have happened, chastened herself for not taking her daughter's passively expressed pain more seriously, and for putting her faith in a lay counselor who had assured her that her daughter's self-destructive statements were merely “typical teenage attempts to get attention."

Like so many other survivors of suicide loss, Meg was filled with guilt and was on an excruciating quest in search of “why?” She went on to describe reading book after book on depression and suicide, poring over her daughter's diary and short life for clues to her state of mind and how she could have made such a drastic decision, and most importantly, how she could and should have prevented it. She finally looked up at me with a flat, almost empty expression. “None of this can bring my daughter back,” she said.  “And that’s all I want. So what do I do now?”

As Meg spent her initial sessions searching for “clues” to make sense of her daughter’s choice, I also found myself searching for clues, both those that might have contributed to the suicide and those that would exonerate Meg as a parent. I almost felt like I was "keeping score," but clearly rooting for exoneration, as I liked and cared about Meg, and wanted to keep any negative feelings at bay. I was relieved to agree with Meg when she ultimately decided that given what she knew at the time, there was probably nothing more she could have done to help her daughter. 

As our sessions continued, I found myself admiring, even envying Meg as she pro-actively digested book after book, and easily disclosed her loss to others. But what just didn’t “fit” was the way she related to me. While she passionately threw herself into the bereavement process, there was a distant "flatness" in the way she responded to me, a “matter of fact” way of relating that seemed lacking in emotional flavor. It almost felt that the substantial empathy and compassion I felt towards her "bounced back." 

I began to assume that this was just Meg’s interpersonal style, and found myself wondering if this related to her daughter's journal entries about “no one being able to feel my pain.'”  Maybe Meg was simply unable to connect to her daughter in this deeper emotional way. 

A couple of months later, Meg opened the session with a bombshell, for me, at least. She told me that she was planning to attend the local Suicide Prevention Center’s Healing Day, which was specifically for suicide loss survivors and included a ceremony to publicly honor their lost loved ones. 

Oh, Bloody Hell!  

I’d just RSVP’d for this and was planning to attend with my daughter.  I was really looking forward to this, as it was one of the rare occasions when I could safely let myself be a vulnerable survivor, not a shrink. And now Meg would be there! So I smiled, nodded, and panicked. 

Being a good obsessive, the questions began. Should I not attend? Well, I really wanted to!  So if I did, should I opt out of the healing ceremony and "pretend" I was there as a professional?  No, that would be a waste! So that meant I’d have to tell Meg that I was also a survivor. Yet most of my training framed a therapist’s intentional disclosure of personal details as a boundary violation, a lapse in therapeutic judgment, and rarely beneficial to clients. And I had convinced myself, mostly as a result of the previously noted negative reactions, that my suicide loss had to be kept far away from anything related to my clinical work.

So I went on to consider the potential dire consequences of this disclosure. How would this harm the treatment relationship? Affect the transference? What about seeing me with my daughter? Would it be too painful to her? Induce envy? She already felt distant; would she detach even further?

Only afterwards, I wondered how I would feel.  Would I feel too exposed? Would I feel the need to hide my vulnerability at the event?  Would I then resent Meg? I ruminated on, never considering that my self-disclosure could have a positive effect for either of us.

But I knew I had to tell her, so in our next session, I started. “Meg, there’s something I want to tell you. I lost my brother to suicide several years ago. And I’m also planning to attend the Healing ceremony. I know it might be awkward for both of us at the event, so I wanted to discuss this ahead of time, as well as how it feels to know that I’m also a survivor.” 

Much to my surprise, Meg's whole demeanor shifted. She broadly smiled, laughed and exclaimed: “Oh my god, you’re a real person, not just a shrink in a chair!" 

From that moment on, she felt alive and engaged with me like never before. Her speech became rich and vibrant. Our relationship deepened along with her newly complex and expansive emotions. She told me that she now felt that I could truly understand her, instead of just "reading about survivors in a book." 

After the ceremony, she told me: “When I saw you with your daughter, I could see how much you love her, and I know you can understand that losing her would feel like your heart gets ripped right out of your chest.”  When she cried for the first time in our sessions, and I teared up too, she said, “it feels good to see you cry; it makes me feel less alone.”  She said that knowing that I survived the loss of my brother gave her faith that her loss could also be survivable. 

I was stunned! Following my disclosure, not only did Meg feel more present to me; I felt more present to myself, as this seemed to “unlock” parts of me that had been hidden away in secret shame. I realized that what I initially saw as Meg's "distant" relational style was in fact her reaction to my defensive need to hide my vulnerability from the treatment, so it couldn’t be known, felt or used by either of us. Was Meg finally able to make use of me in this new way because I finally had something useful to offer? 

This prompted me to think about how I could integrate my clinician and survivor sides into a fuller sense of professional identity, which could be "made use of" in the personal, clinical and conference spaces. So I decided to challenge the institutional splits by doing a presentation on these issues at a Psychoanalytic conference back in 2003. Afterwards, many clinicians who had experienced suicide losses of both loved ones and clients thanked me for validating their experiences and expressed a desire to have a safe place to discuss these issues. 

Since that time, I’d been co-chairing the Clinician-Survivors Task Force through the American Association of Suicidality, with Vanessa McGann, a clinician who lost her sister.  We have recently transformed this into the independent Coalition of Clinician Survivors, with the generous assistance of Marcia Epstein and Paula Marchese. The Coalition provides online support and resources to Clinicians and other professional caregivers who have experienced the loss of clients/patients, loved ones, client, students, colleagues, etc. We have a website, an international listserve, and the opportunity to join monthly Video support groups for both client/patient, and personal losses.  And in addition to doing trainings on Suicide Assessment and Intervention, and Suicide Bereavement, Vanessa and I also do trainings on the Clinician-Survivor experience, and how institutions can best support clinicians, staff and surviving family members when suicides occur in these settings. 

Being able to make something meaningful out of both my personal and professional experience has not only allowed me to integrate the loss of my brother, but it has ultimately made me a better clinician. In addition, (in concert with the principles of post-traumatic growth) it’s fueled my passion to help others. In closing, my hope is that those of us who are Clinician-Survivors (of anything) can feel free to engage in open dialog about how all aspects of our selves, including those that may be stigmatized or silenced by ourselves or others, may contribute to our clinical work, our professional identities and our personal integrity.