The Arts in Psychotherapy 36 (2009) 105113

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The Arts in Psychotherapy
From destruction to creation, from silence to speech: Poetry
therapy principles and practices for working with suicide grief
Shanee Stepakoff, PhD, PTR
Private Practice, 754 E. 6th Street, Suite 2B, New York, NY 10009, United States
a r t i c l e i n f o
This article is dedicated to the memory of
Liam Rector, poet and instructor in the MFA
program in creative writing at New School
University, who died by suicide in August
2007.
Keywords:
Suicide bereavement
Traumatic grief
Suicide survivors
Poetry therapy
Expressive writing
Creative arts therapies
a b s t r a c t
Survivors of suicide must contend not only with traumatic grief but also with shame, stigma, and
silence. Poetry therapy is a powerful tool for healing in this population. The utilization of preexisting
poems, 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 capacity
for the verbal representation of psychological pain. Further, creative expression serves as a means
for rejecting the implicit message of destructiveness that characterizes suicide. The author describes
a 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 facilitated
treatment.
2009 Elsevier Inc. All rights reserved.
Introduction
Grief refers to the intense emotional distress that typically
follows the death of a loved one. Factors that can make a loss
particularly difcult include suddenness, violence, and/or a per-
ception that the death was preventable (Doka, 1996). The causes
of such losses include medical conditions (e.g., heart attack), acci-
dents, homicide, suicide, terrorism, and war. The term traumatic
grief serves to capture the idea that these types of losses are often
inherently traumatic, and when they occur, the bereaved may show
signs of both trauma and grief.
In this article, I focus on one type of traumatic grief, namely,
that which occurs in the aftermath of a suicide. Researchers, clini-
cians, and the bereaved themselves have observed that the suicide
of a loved one is almost always exceedingly painful (Baugher &
Jordan, 2002; Carlson, 2000; Stillion, 1996). Unlike most other
forms of death, in many cultures suicide has a long history of
being viewed as sinful or dishonorable (Stillion, 1996). For exam-
ple, suicide was criminalized in England in the 10th century, and
remained on the criminal statutes throughout Europe until the
Enlightenment (Jamison, 1999; Lieberman, 2003). Medieval law
supported such practices as abusing the suicides corpse (includ-
ing driving a stake through the heart), refusal to bury the deceased
in consecrated ground, seizure of property, and punishment of the
E-mail address: drshaneestep@aol.com.
suicides family. Suicide was decriminalized in the United States
during 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 contemporary
times (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 for
acquaintances, relatives, neighbors and even strangers to blame
the persons 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 of
suicide must also contend with feelings of guilt, stigmatization, and
shame.
Many survivors remain silent about their anguish for years,
either because others have conveyed the message that they are
not comfortable with the topic or because the survivor fears social
disapproval 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 froma state of formless anguish to
one in which the pain can be symbolized or represented, either in
words or innon-verbal media suchas drawings, music, anddance. It
is also necessary to move beyond self-imposed or socially enforced
isolation into a state of meaningful contact with at least one other
human 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
0197-4556/$ see front matter 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.aip.2009.01.007
106 S. Stepakoff / The Arts in Psychotherapy 36 (2009) 105113
can serve this purpose, but engagement in the expressive arts may
yield particular benets. Maintaining silence about the experience
of loss, and about the loved ones life and death, prevents survivors
from experiencing the sense of solace and release that result from
authentic self-expression.
In this movement from silence to speech, poetry therapy can be
a particularly helpful tool. Poetry therapy refers to the utilization
of poetry and related forms of literature and creative writing in
order to improve psychological functioning (Mazza, 1999). This can
take place in a solitary, spontaneous way or in a formal professional
setting. Usually, it is most effective to engage in a combination of
receptive and expressive approaches, either within each session or
across a series of sessions.
Receptive methods: Self-directed and facilitated
Receptive methods of poetry therapy are those that rely on the
utilization of preexisting poems (Mazza, 1999). This usually refers
to poems that have beenpublished incollections, anthologies, liter-
ary journals, and so forth, or that are circulated among individuals
or on the Internet. It can also refer to songs. The poems or songs
do not have to specically mention suicide; in fact, most do not.
Rather, they capture particular aspects of the experience of over-
whelming grief (Stepakoff, 2002). Mazza (1999) proposed the term
receptive/prescriptive in order to differentiate this way of work-
ing from expressive/creative approaches, which focus on the act
of writing poems.
Receptive methods are generally employed in two different
ways. Inthe rst, the bereavedpersonchooses a poemthat is mean-
ingful to him or her, and that captures a particular aspect of his or
her feelings and experiences, and either reads it to him/herself or
shares it withothers. I call this receptive methodself-directed (for
those 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-
seling or psychotherapy). A second way that receptive methods
of poetry therapy are employed is referred to as a facilitated or
therapist-guided approach (Stepakoff, 2003). These terms refer
to situations in which the therapist or group facilitator carefully
chooses a poemthat s/he feelsbasedonhis or her ownlife, experi-
ences with other individuals or groups, input fromother clinicians,
and/or intuitionwill help survivors focus on and grapple with
particular aspects of their grief. In these situations, the facilita-
tor/therapist supports the client/group in using the preexisting
poem as a springboard for talking about their own experiences
and concerns. This method is described in detail in the classic
text Biblio/Poetry Therapy: The Interactive Process (Hynes & Hynes-
Berry, 1994). In the pages that follow, there are examples of both
self-directed and therapist-guided receptive poetry therapy with
survivors of suicide.
Self-directed
Many survivors of suicide have reported that in the aftermath
of the death, they felt compelled to search for or cite preexisting
poems and songs that expressed what they were not able to nd
the words to express, and that they found solace when they located
a poem or song that was salient. For example, one survivor came
to a therapy session with a photocopy of Adrienne Richs (1991)
Tattered Kaddish, a poemthat is a poignant tribute to people who
have died by suicide. She read it aloud to the therapist, and spoke
about what it evoked in her.
One of the most common methods of self-directed receptive
poetry therapy is the utilization of preexisting poems or songs
on memorial websites, booklets, or cards. One couple with whom
my colleague, Dr. Jack Jordan, and I worked, whose son died by
suicide, chose to place the poem A Litany of Remembrance
(Gittelsohn, 1975) in a card they sent to all who had attended his
funeral:
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 utilizationof poems andsongs canbe
found on websites created by survivors. For example, Faye Martin
created a website in memory of her daughter, Lisa, who ended her
life at age 23 (http://www.lisalamb3.com). The website features a
poem by Maya Angelou (When Great Souls Die), several songs
(e.g., Celine Dionnes My Heart Will Go On, Julie Golds Heaven
as sung by Bette Midler, Precious Child by Karen Taylor-Good),
and several inspirational quotes, along with some original poems
by Lisas relatives.
A website created by Rea de Miranda (http://Emile-de-
Miranda.last-memories.com), whose son, Emile, died by suicide at
age 20, contains a powerful song by Simple Plan entitled, How
Could This Happen to Me? The lyrics aptly express the thoughts
and feelings of a person who is suicidal, but could refer equally
well to the feelings of the bereaved survivor:
I cant stand the pain
and I cant make it go away. . .
I wanna start this over again
So I try to hold on. . .
and I cant explain what happened. . . .
No, I cant stand the pain.
How could this happen to me?
For additional examples of memorial websites createdbysuicide
survivors, most of which contain a combination of preexisting and
original writing, see Appendix A.
Facilitated/guided
Although survivors are quite adept at choosing poems that are
meaningful to themand that they feel capture important aspects of
their experiences and emotions, there are many situations in which
the facilitator or therapist may be better equipped to select poems
than 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 process
of study, practice, and credentialing, are specially trained to iden-
tify poems that are likely to serve as safe, effective springboards for
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) (See
Table 1). Such groups can be helpful at any stage of healing, even
Table 1
Topics for suicide grief support groups (Jordan, 2002).
Session Topic
1 Orientation and introductions
2 Remembering our loved ones
3 Psychological reactions to suicide
4 Coping strategies
5 Social reactions
6 Making sense of suicide
7 Impact on families
8 Continuing bonds
9 Holding on while going on
10 Commemorating and ending
S. Stepakoff / The Arts in Psychotherapy 36 (2009) 105113 107
decades after the loss, but are especially meaningful for persons
who are newly bereaved (i.e., within the preceding year). Nearly
all survivors can benet from group support, as long as they have
intact reality-testing, adequate social skills, and a capacity for affect
regulation.
We used a preexisting poem in virtually every session, with
the intention of deepening the participants dialogue and explo-
ration of the designated theme. Poems were selected with the
intent of achieving four main therapeutic goals: (a) to describe, in
a fresh, creative manner, common aspects of the grieving process
after a suicide, thereby helping participants feel less isolated; (b)
to model exceptionally honest and brave self-expression, thereby
freeing participants to express themselves more frankly and fully;
(c) to give external form to internal, difcult-to-articulate emo-
tions and perceptions, thereby helping participants contain their
psychological pain; and (d) to serve as objects of aesthetic beauty,
thereby instilling in participants renewed feelings of vitality and
hope.
A copy of the specially selected poemwas provided to each par-
ticipant, and either a co-leader or participant read the poemaloud.
Sometimes, the poem would be read aloud by several participants,
because hearing a poem in different voices can deepen its impact.
After hearing the poem, participants were invited to discuss their
responses, and to explore how the themes in the poem resembled,
or differed from, issues they were struggling with in their own
grieving process.
For example, early in the cycle, we used a poignant 15-line poem
by William Stafford (1990). Staffords eldest son, Bret, died by sui-
cide in 1988. By accurately capturing the experience of traumatic
grief, in addition to modeling candid self-expression and touching
participants at the level of emotion rather than intellect, the poem
paved the way for group members to share about the tragic loss
that had befallen them and their families. The title, Tragedy, is
very evocative because it consists of a single word that potently
conveys the essence of suicide:
It happens. You knew it could.
No one ever said it wouldnt,
and now it has.
The world just goes onthe air
moves, trees keep standing there and maybe
grieve a little, the sun stays steady. . . (1990)
Some survivors were exposed to the extreme trauma of nding
their loved one seriously injured or deceased after the suicidal act.
For many, however, the most traumatic moment was the instant
in which they learned that their loved one had died. Indeed, the
memory of being informed of the death is often associated with
stronger and more frequent traumatic repetitions (e.g., ashbacks,
nightmares, intrusive images) than the actual time, place, and sit-
uation in which the death occurred. In order to help clients talk
about this difcult topic, I have used a poem entitled How Bad
News Comes, by Debra Marquart (1998), excerpted below:
A telephone is ringing
like an emergency
in a room down the hall,
I think of the one
to whom bad news is coming. . .
Unclipping an earring
as she leans in to hear
the voice on the other end
saying, Ive got some
bad news, feeling
in that long second
before the words come
the difference between
the way it was
and the way
it will be. . .
This poem has a great deal of specic sensory imagery, a feature
that 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 anxiety
that accompany the receiving of catastrophic news. After hearing
the poemreadaloudby the facilitator, groupmembers tendto feel a
greater readiness to share about their own experiences of learning
that their loved one had died.
In exploring survivors coping strategies as well as the social
reactions they must deal with, Dr. Jordan and I also found it help-
ful to use a 15-line poem by Paul Laurence Dunbar (1993), an
AfricanAmerican poet who wrote fromthe late 19th into the early
20th century. The poem(excerpted below) is entitled We Wear the
Mask.
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 while
We wear the mask. . .
We chose this poem because Dunbar skillfully captures aspects
of the experience of coping with a suicide. More specically, 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 the
full reality of their paininorder to functionwithsome semblance of
normalcy inday-to-day life. Survivors oftenreport that their friends
want them to behave as though they have gotten over the death,
andthat this results inself-censorshipandhiding(masking) of ones
real emotions. Thus, thepoemserves as a catalyst for dialogueabout
these 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 topic
for exploration is the early twentieth century poet Edna St. Vincent
Millays (2001) sonnet Time Does Not Bring Relief:
Time does not bring relief; you all have lied
Who 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 what
she does, she continues to think of her loved one. For example,
if she visits a site that her loved one frequented, then she nds
the site brimming with memories of him, yet if she enters a
place in which he never set foot, she becomes acutely aware of
his absenceAnd so stand stricken, so remembering him. Dr.
Jordan and I found that in the Suicide Grief Support Group, use
of this poem led to productive discussions about the experience
of grief. For example, many survivors noted that their recovery
from the trauma of suicide loss was not a simple linear process in
which they felt better and better each day, but rather more like a
sharply winding, bumpy road in which there were many ups and
downs, twists and turns. They pointed out that even though the
overall trajectory tended to be toward a greater capacity to endure
the loss, a trigger such as the anniversary of the death or other
reminder (e.g., a particular song, scent, etc.) could catapult them
back to a grief nearly as intense as that which they experienced
in the rst weeks after the death. One survivor with whom we
worked felt that the poem expressed her feelings so aptly that she
chose to read it aloud at a memorial service for her son.
108 S. Stepakoff / The Arts in Psychotherapy 36 (2009) 105113
Asonnet is a poemof 14 lines that follows a strict rhyme scheme
and a specic structure. Most English sonnets employ iambic pen-
tameter. In receptive poetry therapy, sonnets can be useful for
dealing with particularly difcult topics because the formprovides
containment and the rhythm provides solace. Indeed, some have
suggested that iambic pentameter has a natural comforting effect
because it is similar to the rhythm of the human heartbeat, which
infants hear when in proximity to their mothers (Ibrahim, 2006;
Varon, 2008).
Expressive methods: Self-directed and facilitated
Receptive methods of poetry therapy are usually combined
with expressive methods. The latter are sometimes referred to
as expressive writing (Lepore & Smyth, 2002; Mazza, 1999) or
poem-making (Fox, 1997), and can be understood as the process
whereby survivors engage in their own, original writing. This can
take various forms, among the most common of which are jour-
naling, letter-writing, and the creation of poems. It can also include
oral andimprovisational poem-making, inwhichthewords arespo-
kenaloudrather thaninscribed(Spring, 2003; Stepakoff &Marzelli,
2007).
Expressive methods encompass the writing of poems by indi-
viduals as well as collaborative writing by dyads, families, groups,
or communities (e.g., in which each person contributes a line or
phrase). The theoretical foundations of expressive methods include
the concepts of catharsis and externalization, that is, the human
need to symbolize or represent, via external form, emotions, and
images that have been purely internal. As with receptive meth-
ods, expressive approaches can be self-directed or professionally
facilitated.
Self-directed
In the aftermath of suicide, the process of writing poems about
the loved one and/or the death may help to counter silence, stigma,
and shame. When survivors are successful at converting their
unformulated, raw emotions and sensations into the medium of
language, they often feel a sense of relief. This positive effect is
somewhat paradoxical, because for most survivors the process of
writing about the loss is excruciatingly painful. It is possible, thus,
that a phenomenon similar to desensitization occurs, in which by
spending a certain amount of time focusing on and writing about
the pain, the survivor becomes better able to bear it. This view is
consistent with ideas explored in recent work on the physiological
and psychological benets of expressive writing (Pennebaker, 1997,
2002).
The material created during this solitary endeavor may be kept
private, sharedwitha select groupof friends or relatives, or brought
into the public domain via publication, websites, or open readings.
This decision to bring the work out of the closed room and into the
public sphere is consistent with Judith Hermans (1992) observa-
tions on the last stage of trauma recovery, in which an important
component is regaining the capacityfor meaningful participationin
civic life. The open sharing of original work can be psychologically
and socially ameliorative because it directly counters the destruc-
tive psychosocial dynamics that characterize isolation, stigma, and
silence.
Poem-making
Self-directed expressive poetry therapy can be viewed, essen-
tially, as a form of auto-poetic healing (Stepakoff, 2007b). This
termrefers to processes whereby a trauma survivor utilizes written
or oral poem-making as part of a spontaneous process of self-repair.
When people ask, What is poetry? I sometimes answer, Poetry is
a form of speech that naturally arises when the heart is full. It has
beenobservedinnumerous contexts that whenevents of enormous
magnitude occur, events that are difcult to cognitively and emo-
tionally assimilate, the urge to make poems is intensied. Although
this innate desire to put feelings, experiences, and memories into
poetic language is evident with regard to many forms of trauma,
the experience of mourning is often associated with a particularly
strong desire to write poems, perhaps because of the universal need
to 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 striving
to heal from trauma. She or he may feel that the identity of artist
supersedes that of trauma survivor, and that the primary aimis aes-
thetic value rather than psychological repair. Nevertheless, in the
aftermath of a signicant loss, it can be argued that the effort to
write poems arises from a psychological need to come to terms
with the enormity of what has occurred.
There are many examples of accomplished, recognized poets
who have collections in which a substantial portion of the poems
address the struggle to cognitively and/or emotionally process the
suicide of a loved one. Among the most noteworthy are Nick Flynn
(2000) (mother); Jeffrey Harrison(2006) (brother); andTedHughes
(1998) (wife). In addition to these collections, in which suicide
grief is a major theme, there are numerous examples of individual
poems 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 husband
to suicide include Ruth Stone (1987, 2002, 2004), Virginia Hamilton
Adair (1996), and Adrienne Rich (1973, 1986, 1991). The suicide of
a close friend is explored in poems by Erica Jong (1991a,b), Maxine
Kumin (1997a,b, 2001), and Anne Sexton (1982). A closely related
approach is to write a song about the suicide, in which the lyrics
serve essentially the same function as the words of a poem, except
that they are intended to be sung rather than spoken or read. An
example is Chicken Wire, by Joe Pernice (1998), which focuses on
the singersongwriters effort to come to terms with the suicide of
a friend.
In addition to the above-mentioned examples of auto-poetic
healing by professional writers, there are countless examples of
non-professionals engaging in spontaneous writing as a tool for
self-repair. In my interactions with diverse individuals and families
bereaved by suicide, many survivors have provided me with exam-
ples of the writing they did on their own as part of their efforts
to self-heal. Indeed, I have found that the urge to write poems is
amazingly widespread among survivors, even those who had never
written poems before the suicide.
Beloware some excerpts frompoems by suicide survivors. These
individuals consider their breaking of silence to be an important
part of their recovery, and therefore have requested that their real
names be included:
The sunshine is dimmer, the moon glows less bright
The stars do not twinkle as serenely at night.
No yearning to explore the new fallen snow
Or sit by a warm crackling re all aglow.
Nothings the same since you left us that day.
Not autumns bright colors, nor spring owers 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. . .
Its 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 untold
that ll me with guilt and leave my heart cold. . .
S. Stepakoff / The Arts in Psychotherapy 36 (2009) 105113 109
And so it will go on, the rest of my years,
yearning for answers, ghting back tears.
excerpt from a poem by Diane, whose son, Pete, ended his life
at age 25.
One spring day, not long ago
You 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.
Letter-writing
Sometimes survivors of suicide will write poems in which they
directly address their lost loved one. In many instances, they may
wish to write pieces that are longer and that are perceived as less
constrained by formal and aesthetic requirements than are poems.
The writing of letters can be a useful approach (Vance, 1998). Often,
survivors will feel a particular desire towrite letters tothe lovedone
on important occasions, such as yearly birthdays or anniversaries
of the death.
Carol de Clercq, a member of an online support group called Par-
ents of Suicide (POS), wrote a series of letters to her daughter, Sara
Dawn, after the latter died by suicide at age 26. She has titled this
unpublished manuscript Letters to Sara. In explaining her experi-
ence of writing these letters over the course of several years, Carol
remarked:
These letters to her are my thoughts, my feelings, my percep-
tions, and my actions in response to my loss. . . They honestly
portray my process of grief. They showmy 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 go
on. . . I want the evolution of my grief to be seen exactly as it was
felt. . . I want the pain to be felt by the reader. . . I want all of the
feelings and thoughts to be seen as they were. . . I can only hope
andpray that it will. . .helpsome other mother who is struggling
withthe unbearable andunimaginable painassociatedwiththis
type of tragic loss. (2008, personal communication)
Rosana, who is likewise a member of POS, and whose 18-year-
old son, Ian, died by suicide, has similarly used letters to her son,
written over a several-year period, as a way of coping with her loss
and preserving her relationship with her son. She remarked, From
the day my sondied, I have writtenletters tohimas a way of holding
on to our connection. . . My letters have changed in tone somewhat
fromthe early days of our familys tragedy to the more recent ones
(2008, personal communication):
Dear Ian,
Today is such a beautiful day. . . Maybe thats why my heart is
hurting so much I can barely breathe. If only I could share the
beauty of this day with you. . . Do you knowhowmuch we miss
you? Do you know how much we love you?. . . Oh. . ., why did
you leave? You tore my heart right out of my chest. Do you know
howspecial you were to everyone who ever met you? I hear the
samethings over andover again. Youweresosmart, sokind, such
a good listener, so funny, so wise. . . I can remember you trying
to engage me in peek-a-boo in the middle of the night when you
were only a fewmonths old. It seems like yesterday. . . What was
it that caused you to give up so totally?. . . I cannot bear to think
of you as gone. . .
Journaling
Journaling, like letter-writing, allows for a lengthier, freer style
of expressive writing than is typical of poems. It differs fromletter-
writing, however, inthat inthe journal the survivor usually does not
address someone directly, in an I-Thou format, but instead writes
about his or her thoughts, feelings, and memories. Below are two
examples of journaling by survivors of suicide. The rst consists of
a single entry, by a woman whose daughter, Katie, ended her life
at age 28. The second is a series of entries written over the course
of nearly 10 months, by a woman whose 17-year-old son died by
suicide.
Dancing in the living room to rock and roll songs . . . sometimes
fast, sometimes slow. Splashing each other with water from
the puddles after a summers rain. . . sometimes a lot, some-
times a little. Walking in the mornings around the block for
exercise . . . sometimes slower, sometimes quicker. . . Cranking
up the radio in the car . . . sometimes singing, sometimes no. I
must savor the memories of the good times. . ., for . . . there are
no 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 sonmy
youngest. The grief is unbearable and life will never be the
same. I feel as though Im lost in a fog with no senses. I tor-
ture myself with ways I could have prevented it. If only I had
stayed home that day. . . Questions assail meand there are no
answersexcept my Ben is gone. How can that be?
10-13-02
I dont remember writing the last [8-4-02] entry. Its all a blur. It
seems so unreal to say Bens death or Bens funeral. I made
the rst ower arrangement for his grave a couple of weeks ago.
It was a beautiful fall arrangement in a brass container. I put a
lizard, frog, buttery and ladybug on the side. I bought a ceramic
pumpkin for his grave. His graveanother impossible phrase.
11-10-02
My thoughts are still consumed with grief and loss. I see Ben as I
found him [when he died] several times a day. Thoughts of him
and the loss of him are the last thing on my mind when I go to
sleep. . . He is among the rst thoughts I have as I greet each day.
Its always a let-down when I realize hes really not here. And
even though I know he is with God and I will see him again, I
feel deprived of knowing him more fully here on earth. The loss
has no boundaries. The grief touches all parts of me. I miss him
so much.
5-30-03
Not much new to write. I feel like all I want to say is BenI miss
you. I love you. . . The pain of missing him isand has beenso
strong. (Mary Butler, used with permission)
I have observed that self-directed journaling is a very common
response to the suicide of a loved one. DeSalvo (1999) provided a
helpful delineation of characteristics that increase the probability
that this process will be psychologically benecial. These include:
rendering the experience precisely, truthfully, explicitly, and with
110 S. Stepakoff / The Arts in Psychotherapy 36 (2009) 105113
rich detail; naming emotions, and linking them with the event;
describing both positive and negative aspects of the person or
event; mentioning insights that have been gained from the painful
experience; and telling a complete, complex, and coherent story.
By reading survivors letters and journals, as well as their
remarks about how they experienced the writing process, I have
discerned that writing to or about the lost loved one serves at
least seven psychological functions: (1) it is inherently cathartic
to unburden ones heart and pour ones feelings onto the page;
(2) written self-expression provides an opportunity to communi-
cate ones deepest emotions with the reader, thereby allowing for
the possibility of being accurately understood and of reducing the
terrible sense of isolation that is so often associated with suicide
bereavement; (3) the survivor who uses writing to share his or her
experience of loss and grief may feel that s/he is thereby able to
contribute to the healing of other suicide survivors, and this sense
of altruismandmeaning canbe benecial for trauma survivors, par-
ticularly during the latter stages of their recovery (Herman, 1992);
(4) letters inparticular, thoughtosomeextent alsojournals, provide
an opportunity to maintain a sense of ongoing connection with the
loved one, who is no longer physically present but remains very
much a part of the survivors psyche; and (5) writing can serve
as a means of memorializing or paying tribute to the loved one,
which can be particularly important given that persons who die by
suicide are often unfairly viewed as condemnable and disgraced.
Additional aims include: (6) helping the survivor to cognitively pro-
cess the loved ones life as a whole and the often mystifying events
surrounding the death, and (7) providing an opportunity for the
survivor to directly express his or her love rather than keeping it
locked within, unspoken.
Suicide is always perceived as a particularly tragic form of
death and is associated with exceptional agony in the hearts of the
bereaved. In its aftermathas the above-described poems, letters
andjournals clearlyindicatesurvivors appear tohaveafundamen-
tal need to verbally represent the experience of grief. Perhaps this
is what Neruda (1969) was alluding to in his line verse falls to the
soul like dew to the meadow, or what Shakespeare (1997) hinted
at over four centuries ago when he coined the phrase give sorrow
words.
Facilitated/guided
In contrast to auto-poetic healing, facilitated/guided expressive
poetry therapy takes place in the context of a formal therapeutic
relationship. The particular clinical approach may vary, as long as
writing and other expressive verbal techniques are utilized. Such
techniques have been used effectively in mutual support groups,
cognitive-behavioral therapy, and psychoanalysis, but are most
closely associated with the formal discipline known as the expres-
sive (or creative arts) therapies. In many instances, intermodal
approaches are used, in which survivors combine verbal and non-
verbal techniques (for example, writing a poem and then dancing
to its sound while someone else reads it aloud, or drawing an image
and then listing words that the image calls to mind) (Rogers, 1993).
In each session of the Suicide Grief Support Group, Dr. Jor-
dan and I introduced writing exercises and activities intended to
help participants give voice to their experiences and emotions.
Group members approached these activities with earnestness and
courage. The goals of the expressive writing essentially paralleled
those for the receptive approach: reduce isolation; encourage free
expression; give form to painful emotions; and foster hope.
The writing assignments had varying degrees of structure and
guidance. We usually integrated the expressive writing with the
utilization of preexisting poems. More specically, after devoting
a portion of the session to participants responses to a preexisting
poem, they were typically given a writing exercise, after which they
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 poem
and use that as a starting point for their own writing, that is, as the
title or rst line of a new poem.
For example, after reading the aforementioned WilliamStafford
poem, 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 5min, non-
stop, without self-censoring and without lifting their pens fromthe
page. They were told that if they felt stuck, they should just keep
writing whatever came to mind. The material that the clients thus
generated was potent and moving.
Among the most widely used facilitated expressive approaches
are poem-making, journaling, and letter-writing.
Poem-making
Just as a preexisting sonnet has formal characteristics that ren-
der it potentially useful for receptive poetry therapy, assigning a
particular poetic form for clients to use in the creation of poems
can likewise provide a sense of containment for overwhelming
emotions. For example, clients can be invited to write a poem of
a particular number of lines, or using a particular rhyme scheme
or syllabic structure. One expressive method that I have used suc-
cessfully with survivors of suicide and other traumatic losses is the
acrostic.
The acrostic is a form of constrained writing, in which the rst
letter of an important word is written vertically down the page, and
then each letter is used to begin a line. The total set of lines consti-
tutes the acrostic poem, and by underscoring the rst letter of each
line, the reader can discern the vertical word. In my clinical work
with survivors of traumatic grief, I have adapted this form by invit-
ing clients to write the loved ones name vertically down the page,
and then use each letter of the name to begin a line that captures a
positive quality or memory of the loved one. The form serves as a
container for the painful affect associated with the loved one, and
fosters a focus on positive images that can serve to counterbalance
or, ideally, to overpower the traumatic imagery associated with the
manner of death (Stepakoff, 2007a). In addition, the physical page
on which the poem is written can serve as a transitional object,
thereby allowing the survivor to hold onto the loved one even in
his or her physical absence.
Below is an example of an acrostic written by a woman with
whom I worked; her father, whose name was David, died by his
own hand a few years before she composed this poem:
Devoted father
Active in the community
Very thoughtful and caring
Insightful and wise
Deep feelings, deep thoughts, and a capacity for strong love.
Another facilitated poem-making technique, which is used
specically in group settings, is called collaborative poem-
making. This technique canbe helpful at various stages of a groups
existence, but is particularly empowering at the end of a group
cycle. 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 rst asked to
write 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 or
phrase, such that one group poem emerges.
The group poem weaves the participants diverse feelings into
one coherent whole, and serves as both a container in which the
S. Stepakoff / The Arts in Psychotherapy 36 (2009) 105113 111
full range of feelings can be held and a transitional object that
participants can keep with themafter the group has ended. As with
any form of creative expression, there is usually a sense of satis-
faction and wonder at having been able to successfully transform
inner truth into outward form.
Below is an example of a collaborative poem entitled The Kin-
ship of Pain. Each line represents one participants contribution to
the whole. This poem was created jointly by the 10 members of a
Suicide Grief Support Group that Dr. Jordan and I co-facilitated in
2003:
As each session starts and nishes
our feelings are shared
and 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 group
is the kinship of pain.
I would like to remember
and read the poems again.
This collaborative poem-making technique can be adapted for
dyads, families, andlarge groups. For instance, twoparents caneach
contribute lines to a poemabout their lost son or daughter; surviv-
ing family members can each contribute a line to a poemabout the
family member who has died; and a number of people can con-
tribute lines to a poem about a death that affects an entire group.
Examples of the latter include members of a professional associ-
ation who assembled lines to create a poetic tribute to a recently
deceased colleague (Rojcewicz, 2002), and a classroom of pupils
who each contributed a line to a poem memorializing a peer who
had died (Stepakoff, 2003).
Journaling
Usually, poetry therapy is viewed as including a broad range
of expressive writing techniques and, thus, as encompassing the
therapeutic use of journal-writing. Some practitioners, however,
have viewed journaling as a therapeutic modality in its own right,
which has areas of overlap with, but also differences from, tra-
ditional poetry therapy (Adams, 1990). Expressive therapists who
utilize journaling as a formal modality oftenuse prompts (Adams,
1990), dened as questions the writer seeks to answer in his or her
journaling and/or suggestions for specic themes to explore.
Below is an example of a journal entry that was written in
response to a facilitators suggestion that the participant use her
journal to explore the theme of forgiveness. This womans grand-
daughter ended her life at age 17:
Howdo I forgive myself, so I can begin to accept her death? How
do I forgive myself for not saving her?. . . How do I forgive her
friends for not telling what she shared with them?. . . How do I
forgive the adults in her . . . school who could have helped her?
Howdo I forgive her for lying about her suicidal thoughts? How
do I forgive her for not asking for help? How do I forgive her
for thinking she was dispensable? How do I forgive her for not
thinking of us? Howdo I forgive her for passing her deep despair
on to us and sentencing us to a life of grief? How do I forgive
myself for focusing on our pain now when hers was so great?
How do I forgive myself so that I can alleviate this grief even
momentarily? How do I tackle these impossible tasks? (Used
with permission, name withheld by request)
Letter-writing
In an earlier section, I described the experience of suicide
survivors who spontaneously wrote letters to a lost loved one.
Letter-writing, however, can also be systematically incorporated
into clinical treatment. Usually, the clinician will give the client(s)
a particular suggestion regarding to whom the letter should be
directed 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, in
which they accurately and honestly expressed some of their feel-
ings. A man widowed by suicide, leaving hima single parent of two
youngdaughters, respondedbywritingaletter tohis deceasedwife,
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 its difcult for me to take
care of the girls. In your note, you said you dont hate me, but in
many ways I do [hate me]. You have sentenced me to a lifetime
of pain and questions that will never be answered. I honestly
feel that you are probably not at peace. It would seem to me
unfair, that you would be at peace while the remnants of what
once was a family lie broken and bleeding fromthe heart. (Used
with 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 his
feelings by writing a letter to himself:
Dear C.,
You need to work at letting go of some of the anger you feel. It
is taking too much of your energy. That energy would be better
used caring for your children, and getting your own physical
health in order. F. was a very sick person, and what she did was
out of a desperate attempt to end her own pain. She loved you
and the girls, but couldnt handle her own demons. Dont let her
death kill you too. (Used with permission, initials changed by
request)
Whether a spontaneous solitary process or part of a structured
therapeutic exercise, the psychological functions of the act of writ-
ing are fairly similar. Whenexpressive writing is incorporatedintoa
formal therapeutic relationship, however, either through the shar-
ing of spontaneously created work or of material generated in
response to a clinicians suggestion, the survivor has the opportu-
nity to increase the probability that his or her internal experience
will be accurately understood by the clinician. In addition, given
how overwhelming and terrifying it can be for a suicide survivor
to encounter the full extent of his or her anguish, the process of
sharing original written material with the therapist can help the
survivor feel that s/he does not have to bear the pain alone but
rather that the therapist will bear or hold a portion of the pain
for him or her. This possibility for the therapeutic relationship to
foster a reduction in overwhelming affect occurs as a result of the
therapists empathy (which the survivor senses and which, there-
fore, makes the survivor feel joined in, rather than alone with, his
or her pain), as well as the therapists readiness to lend the survivor
his or her own internal resources so as to provide a safe, reliable
container for the survivors anguish.
Conclusions
I have endeavored to show a variety of ways that receptive and
expressive 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 of
shattering loss, the receptive and expressive utilization of writing
often occurs spontaneously. Nevertheless, survivors may benet
fromutilizing preexisting poems and expressive writing in the con-
text of a formal clinical relationship. This relationship can be one in
whichpoetrytherapyhas beenspecicallyagreedonas theprimary
treatment modality, or one in which poetry, writing, and perhaps
112 S. Stepakoff / The Arts in Psychotherapy 36 (2009) 105113
other expressive arts are integrated into more traditional treatment
approaches. With the sensitive support of a trained professional,
particularly one who is aware of the synergistic effects of ordinary
and poetic modes of expression, survivors may become better able
to cope with the experience of shattering loss. Thus, even though
the grieving process after suicide is arduous and lifelong, it is possi-
ble to help survivors move fromformless anguish to symbolization,
fromisolationtoconnection, fromdestructiontocreation, andfrom
silence to speech.
Acknowledgements
I amdeeply indebtedtoDr. Jack Jordanfor immeasurably enrich-
ing my understanding of traumatic grief in general and suicide grief
inparticular. I amalsotremendouslygrateful toKaryl Chastain-Beal,
Coordinator of Parents of Suicide, for her invaluable assistance with
outreach to survivors. In addition, I extend heartfelt thanks to the
many survivors of suicide whogenerously sharedtheir poems, jour-
nals, letters, and other written materials with me. These include
Brenda Adkins, Nicci Bergman, Pamela Bonilla, Mary Butler, Carol
deClercq, Rea de Miranda, Donna Fitts, Magdaline Halous, Christine
Hambrecht, Patty Jacobs, Joyce, Rosana Smith Ladik, Linda Mar-
shall, Faye Martin, Phyllis Mulford, Leslie Phillips, Diane Prater,
Nikki Reeves, Lesa Shelton, Shirley Sherwood, Carla Snellen, Arline
Stumpff, Jean Sutton, Stacy Varner, Joan Zdun, and many others,
who wished to remain anonymous.
Appendix A. Partial list of memorial websites created by
survivors of suicide
http://adam-mooregrigg-thelittlesailorboy.memory-
of.com/about.aspx
http://erickgeorge.virtual-memorials.com
http://jay-mcmurdo.virtual-memorials.com/main.php?action=
view&mem id=9181&page no=1
http://members.tripod.com/dsf 13/Poems.html
http://prole.myspace.com/index.cfm?fuseaction=user.
viewprole&friendid=207095976
http://virtual-memorials.com/main.php?action=view&mem id=
9787&logoff=true
http://www.cusp.org.nz
http://www.runningwiththewind.com
Note: Each of the creators of these websites wished to be
included in this Appendix. Most of these websites contain a com-
bination of preexisting and original poems/songs. Two additional
websites are mentioned in the text of the article.
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