Harvard Mental Health Letter

Supporting survivors of suicide loss

Family, friends, co-workers, and mental health clinicians are all affected.

More than 30,000 Americans, and roughly one million people worldwide, die by suicide each year. The aftermath of grief and bereavement extends much further, with a conservative estimate of six survivors left behind for every suicide death.

Survivors of suicide loss include immediate family members, other relatives, friends, and co-workers. And because 90% of people who die by suicide have a psychiatric disorder, mental health clinicians are also among those affected.

More than 60% of people who take their own lives have major depression. Other diagnoses that increase suicide risk are bipolar depression, schizophrenia, anxiety disorders, eating disorders, and personality disorders (especially borderline personality disorder). Alcohol or drug dependence, especially in combination with a psychiatric disorder, further increases risk of suicide. A stressful situation — such as job loss, death of a loved one, or divorce — often precipitates suicide in someone who is vulnerable.

But while researchers have identified groups of people most at risk for killing themselves, and the types of behavior that might precede this event, the sad reality is that suicide cannot be predicted on an individual basis. A further challenge is that most suicide attempts are made quickly. One study of people who have survived suicide attempts found that 70% said later they had tried to take their lives less than an hour after first thinking about doing so — and one in four of them made the attempt within five minutes.

But while death by suicide often occurs on impulse, it has long-lasting ramifications for those left behind.

Key points

  • Survivors of suicide loss include family, friends, coworkers, and mental health clinicians.

  • Survivors may grieve more intensely, and for longer periods, than people mourning other types of loss.

  • Various psychotherapies and practical ways of expressing support can help survivors cope.

Helping family and friends

Most of the controlled studies that have followed survivors of suicide loss find that their grieving process is similar in many ways to that of survivors of other unexpected or violent deaths — such as those due to homicides or car accidents. But survivors of suicide loss experience additional challenges, such as shame (which is reinforced by societal stigma about suicide), guilt over being unable to prevent the death, and a preoccupation with understanding why the death occurred.

Survivors of suicide loss, particularly close family and friends, are therefore likely to grieve longer and more intensely than those who lose loved ones to other illnesses — a type of prolonged mourning known as "complicated grief." Whereas uncomplicated or "normal" grieving usually lasts less than six months, complicated grief can go on for years and involves more intense variations of emotions such as sadness, loneliness, anger, and yearning for the deceased. Relatives and friends who have lost someone to suicide are also susceptible to developing symptoms of depression and post-traumatic stress disorder.

Further adding to the personal and family strain, these grieving survivors usually do not benefit from the support and compassion offered to people grieving other losses. One study found that about half of survivors chose not to reveal the cause of death to friends or acquaintances, and nearly one-third sometimes lied about it. Even when the details are known, well-meaning friends may not know what to say or how to offer support.

A wide variety of interventions — sometimes called postventions because they are offered after the death occurs — are available for survivors of suicide loss. Unfortunately, not enough research has been done on postventions to determine whether they actually reduce the length or intensity of grieving. Nor are there any guidelines for how long therapy should last to offer the best chance of recovery.

Even so, options exist and are probably worth trying. These include various forms of cognitive behavioral therapy, interpersonal therapy, and support groups. Because choice of therapy is likely to depend on the patient's preference and needs, one review that was written by mental health clinicians who themselves survived a suicide loss recommended focusing on achieving specific goals with therapy, regardless of which method is used.

Normalize the grief. Encourage the patient or family to engage in the same rituals they would use to grieve any death. It may be helpful to remind them that suicide is a tragic outcome of depression or another mental illness, just as death by heart attack or stroke may result from cardiovascular disease.

Ease guilt. Survivors of suicide loss typically experience lacerating guilt about what they think (unrealistically) they could have done to prevent a loved one's death. It may help to remind survivors how even mental health professionals cannot predict when such a death might occur, and how little control anyone has over someone else's behavior.

Respect differences. Remind the patient or family that everyone grieves in different ways and at a different pace.

Encourage openness. Suggest ways that individuals can talk about their loved one and reveal whatever details about the death they are comfortable sharing.

Plan ahead. Assist the family in finding ways to mark a loved one's birthday, family holidays, or other milestones.

Make connections. Provide information about support groups and resources specifically for survivors of suicide loss, to supplement therapy and ease isolation. (See "Online resources for survivors.")

A note about terminology

The American Foundation for Suicide Prevention recommends against using the verb "commit" when talking about suicide, because this word is often used to connote criminal or sinful behavior (for example, people commit crimes). We have followed their advice to use phrases such as "die by suicide" to avoid further stigmatizing this type of death.

Supporting mental health clinicians

About one in six people who die by suicide is undergoing mental health treatment at the time of death. Others may have resisted treatment or decided to stop therapy. Surveys indicate that roughly 20% of psychotherapists, and 50% of psychiatrists, have at some point in their careers lost at least one patient to suicide.

The impact can be devastating. One small but in-depth study that enrolled 26 therapists who lost patients to suicide found that the clinicians experienced many of the same emotions as other people mourning a suicide loss: shock, grief, guilt, shame, anger, betrayal, self-doubt, and self-blame. In addition, they also struggled with anxiety over whether they would be sued for malpractice — a valid worry, given that lawsuits following suicide are the most common type of legal action against mental health clinicians.

Yet clinicians may be ill prepared for dealing with the emotional consequences of losing a patient to suicide. Some are so distraught that they decide to leave the mental health field. At the same time, depending on the reactions of colleagues or the institutions that employ them, they may become "disenfranchised" mourners, whose grief is neither acknowledged nor supported.

The subject of a clinician's reaction to suicide is seldom a routine part of training curricula. One review found that fewer than half of U.S. psychiatry residency programs provide any instruction in handling the loss of a patient to suicide. If the subject comes up at all, it may be broached in the aftermath of a death by suicide, and the discussion may involve only those directly involved in the patient's care.

Hospitals, mental health centers, and other institutions that employ clinicians may lack systems to deal with the challenge of a patient's suicide — or may handle the cases in a way that makes it worse. In the study of mental health clinicians cited earlier, clinicians who had lost a patient to suicide felt supported by colleagues, but reported that they perceived that the institution employing them either made them feel responsible for what happened or dismissed their patients' deaths as "inevitable."

Recognizing the challenges, several clinicians who are themselves survivors of suicide loss (either personally or professionally) have published papers offering advice about how colleagues and institutions can help a clinician deal with the suicide of a patient — and how the clinicians can help themselves.

For example, they recommend that colleagues can best help by offering emotional support and reassurances about professional competency. Managers can best head off rumors by calling a staff meeting as soon as possible after a suicide death occurs, to inform people about what has happened and to develop a plan to break the news to other patients who may know the person who died, and redistribute the case load of a therapist who may need some time off. In a training setting, this is a time for clinician-educators to provide extra teaching about the unpredictability of suicide and the helplessness it engenders in everyone connected to the person who died by suicide, including surviving clinicians.

Further advice is available from the American Association for Suicidology, which has established a Clinician Survivor Task Force that offers online information, support, and contacts.

Online resources for survivors

American Association of Suicidology
Click on "Suicide loss survivors," and then find "Resources for survivors" (for friends and family) or "Clinician-survivors."
www.suicidology.org

American Foundation for Suicide Prevention
Click on "Surviving Suicide Loss."
www.afsp.org

Harvard Women's Health Watch
Read a companion article, "Left Behind After Suicide," published in our sister publication.
www.health.harvard.edu/left-behind

Hawton K, et al. "Suicide," Lancet (April 18, 2009): Vol. 373, No. 9672, pp. 1372–81.

Hendin H, et al. "Therapists' Reactions to Patients' Suicides," American Journal of Psychiatry (Dec. 2000): Vol. 157, No. 12, pp. 2022–27.

Sakinofsky I. "The Aftermath of Suicide: Managing Survivors' Bereavement," Canadian Journal of Psychiatry (June 2007): Vol. 52, No. 6, Suppl. 1, pp. 129S–36S.

Sudak H, et al. "Suicide and Stigma: A Review of the Literature and Personal Reflections," Academic Psychiatry (March-April 2008): Vol. 32, No. 2, pp. 136–42.

For more references, please see www.health.harvard.edu/mentalextra.