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Left behind after suicide

JUL 2009

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People bereaved by a suicide often get less support because it's hard for them to reach out — and because others are unsure how to help.

Every year in the United States, 33,000 people take their own lives. Every one of these deaths leaves an estimated six or more "suicide survivors" — people who've lost someone they care about deeply and are left grieving and struggling to understand.

The grief process is always difficult, but a loss through suicide is like no other, and the grieving can be especially complex and traumatic. People coping with this kind of loss often need more support than others, but may get less. There are various explanations for this. Suicide is a difficult subject to contemplate. Survivors may be reluctant to confide that the death was self-inflicted. And when others know the circumstances of the death, they may feel uncertain about how to offer help. Grief after suicide is different, but there are many resources for survivors, and many ways you can help the bereaved.

What makes suicide different

The death of a loved one is never easy to experience, whether it comes without warning or after a long struggle with illness. But several circumstances set death by suicide apart and make the process of bereavement more challenging. For example:

A traumatic aftermath. Death by suicide is sudden, sometimes violent, and usually unexpected. Depending on the situation, survivors may need to deal with the police or handle press inquiries. While you are still in shock, you may be asked whether you want to visit the death scene. Sometimes officials will discourage the visit as too upsetting; at other times, you may be told you'll be grateful that you didn't leave it to your imagination. "Either may be the right decision for an individual. But it can add to the trauma if people feel that they don't have a choice," says Jack Jordan, Ph.D., clinical psychologist and co-author of After Suicide Loss: Coping with Your Grief.

You may have recurring thoughts of the death and its circumstances, replaying the final moments over and over in an effort to understand — or simply because you can't get the thoughts out of your head. Some suicide survivors develop post-traumatic stress disorder (PTSD), an anxiety disorder that can become chronic if not treated. In PTSD, the trauma is involuntarily re-lived in intrusive images that can create anxiety and a tendency to avoid anything that might trigger the memory.

Stigma, shame, and isolation. Suicide can isolate survivors from their community and even from other family members. There's still a powerful stigma attached to mental illness (a factor in most suicides), and many religions specifically condemn the act as a sin, so survivors may understandably be reluctant to acknowledge or disclose the circumstances of such a death. Family differences over how to publicly discuss the death can make it difficult even for survivors who want to speak openly to feel comfortable doing so. The decision to keep the suicide a secret from outsiders, children, or selected relatives can lead to isolation, confusion, and shame that may last for years or even generations. In addition, if relatives blame one another — thinking perhaps that particular actions or a failure to act may have contributed to events — that can greatly undermine a family's ability to provide mutual support.

Mixed emotions. After a homicide, survivors can direct their anger at the perpetrator. In a suicide, the victim is the perpetrator, so there is a bewildering clash of emotions. On one hand, a person who dies by suicide may appear to be a victim of mental illness or intolerable circumstances. On the other hand, the act may seem like an assault on or rejection of those left behind. So the feelings of anger, rejection, and abandonment that occur after many deaths are especially intense and difficult to sort out after a suicide.

Need for reason. "What if" questions may arise after any death. What if we'd gone to a doctor sooner? What if we hadn't let her drive to the basketball game? After a suicide, these questions may be extreme and self-punishing — unrealistically condemning the survivor for failing to predict the death or to intervene effectively or on time. Experts tell us that in such circumstances, survivors tend to greatly overestimate their own contributing role — and their ability to affect the outcome.

"Suicide can shatter the things you take for granted about yourself, your relationships, and your world," says Dr. Jordan. Many survivors need to conduct a psychological "autopsy," finding out as much as they can about the circumstances and factors leading to the suicide, in order to develop a narrative that makes sense to them. While doing this, they can benefit from the help of professionals or friends who are willing to listen — without attempting to supply answers — even if the same questions are asked again and again.

Sometimes a person with a disabling or terminal disease chooses suicide as a way of gaining control or hastening the end. When a suicide can be understood that way, survivors may feel relieved of much of their what-if guilt. "It doesn't mean someone didn't love their life," says Holly Prigerson, Ph.D., associate professor of psychiatry at Harvard Medical School. Adds Dr. Prigerson, "The grieving process may be very different than after other suicides."

A risk for survivors. People who've recently lost someone through suicide are at increased risk for thinking about, planning, or attempting suicide. After any loss of a loved one, it's not unusual to wish you were dead; that doesn't mean you'll act on the wish. But if these feelings persist or grow more intense, confide in someone you trust, and seek help from a mental health professional.

Support from other survivors

Research suggests that suicide survivors find individual counseling (see "Getting professional help") and suicide support groups to be particularly helpful. There are many general grief support groups, but those focused on suicide appear to be much more valuable. In a small pilot study that surveyed 63 adult suicide survivors about their needs and the resources they found helpful, 94% of those who had participated in a suicide grief support group found it moderately or very helpful, compared with only 27% of those who had attended a general grief group. The same study found that every survivor who had the opportunity to talk one-on-one with another suicide survivor found it beneficial. These results were published in the journal Suicide and Life-Threatening Behavior (July 2008).

"Some people also find it helpful to be in a group with a similar kinship relationship, so parents are talking to other parents. On the other hand, it can be helpful for parents to be in a group where they hear from people who have lost a sibling — they may learn more about what it's like for their other children," says Dr. Jordan.

Some support groups are facilitated by mental health professionals; others by laypersons. "If you go and feel comfortable and safe — [feel] that you can open up and won't be judged — that's more important than whether the group is led by a professional or a layperson," says Dr. Prigerson. Lay leaders of support groups are often themselves suicide survivors; many are trained by the American Foundation for Suicide Prevention, which has a support group locator on its Web site (see "Selected resources").

For those who don't have access to a group or feel uncomfortable meeting in person, Internet support groups are a growing resource. A 2008 study comparing parents who made use of Internet and in-person groups found that Web users liked the unlimited time and 24-hour availability of Internet support. Survivors who were depressed or felt stigmatized by the suicide were more likely to gain help from Internet support services. Interestingly, people in urban areas were just as likely to make use of the Internet as those in more isolated places.

You can join a support group at any time: soon after the death, when you feel ready to be social, or even long after the suicide if you feel you could use support, perhaps around a holiday or an anniversary of the death.

Selected resources

American Association of Suicidology
202-237-2280
www.suicidology.org (Click on "Suicide loss survivors.")

American Foundation for Suicide Prevention
888-333-2377 (toll-free)
www.afsp.org (Click on "Surviving Suicide Loss.")

After Suicide Loss: Coping With Your Grief , by Bob Baugher, Ph.D., and Jack Jordan, Ph.D. (available through Web site above)

Aftershock: Help, Hope, and Healing in the Wake of Suicide , by Arrington Cox (B & H Publishing, 2003).

Dying to Be Free: A Health Guide for Families after a Suicide , by Beverly Cobain and Jean Larch (Hazelden Foundation, 2006).

My Son… My Son: A Guide to Healing After Death, Loss, or Suicide , by Iris Bolton and Curtis Mitchell (The Bolton Press, 1995).

No Time to Say Goodbye , by Carla Fine (Main Street Books, 1999).

Silent Grief: Living in the Wake of Suicide , by Christopher Lukas and Henry Seiden (Jessica Kingsley Publishers, 2007).

Understanding Your Suicide Grief: Ten Essential Touchstones for Finding Hope and Healing Your Heart , by Alan D. Wolfelt, Ph.D. (Companion Press, 2009).

Getting professional help

Suicide survivors are more likely than other bereaved people to seek the help of a mental health professional. Look for a skilled therapist who is experienced in working with grief after suicide. The therapist can support you in many ways, including these:

  • helping you make sense of the death and better understand any psychiatric problems the deceased may have had

  • treating you, if you're experiencing PTSD

  • exploring unfinished issues in your relationship with the deceased

  • aiding you in coping with divergent reactions among family members

  • offering support and understanding as you go through your unique grieving process.

Immediately after the suicide, assistance from a mental health professional may be particularly beneficial if you experience any of the following:

  • increased depression (or if you have a history of depression).

  • flashbacks, anxiety, or other symptoms of PTSD.

  • unwillingness of family or friends to continue talking about the loss.

  • suicidal thoughts or plans.

  • physical symptoms, such as ongoing sleep problems, significant weight gain or loss, or increasing dependency on tobacco or alcohol.

  • feelings of being stuck or unable to move forward (however slowly and painfully) in the grieving process.

  • discomfort in discussing troubling aspects of your relationship with the deceased.

  • little improvement after several months.

The value of family therapy after a suicide has not been well studied, but a family therapist can sometimes help relatives communicate better and manage feelings of guilt and anger. However, it may not be possible to work through your own feelings in the presence of family members who are concerned mainly with finding someone to blame.

A friend in need

Knowing what to say or how to help after a death is always difficult, but don't let fear of saying or doing the wrong thing prevent you from reaching out to suicide survivors. Don't hold back. Just as you would after any other death, express your concern, pitch in with practical tasks, and listen to whatever the person wants to tell you. Here are some special considerations:

Stay close. Families often feel stigmatized and cut off after a suicide. If you avoid contact because you don't know what to say or do, family members may feel blamed and isolated. Whatever your doubts, make contact. Survivors learn to forgive awkward behaviors or clumsy statements, as long as your support and compassion are evident.

Avoid hollow reassurance. It's not comforting to hear well-meant assurances that "things will get better" or "at least he's no longer suffering." Instead, the bereaved may feel that you don't want to acknowledge or hear them express their pain and grief.

Don't ask for an explanation. Survivors often feel as though they're being grilled: Was there a note? Did you suspect anything? The survivor may be searching for answers, but your role for the foreseeable future is simply to be supportive and listen to what they have to say about the person, the death, and their feelings.

Remember his or her life. Suicide isn't the most important thing about the person who died. Share memories and stories; use the person's name ("Remember when Brian taught my daughter how to ride a two-wheeler?"). If suicide has come at the end of a long struggle with mental or physical illness, be aware that the family may want to recognize the ongoing illness as the true cause of death.

Acknowledge uncertainty. Survivors are not all alike. Even if you are a suicide survivor yourself, don't assume that another person's feelings and needs will be the same as yours. It's fine to say you can't imagine what this is like or how to help. Follow the survivor's lead when broaching sensitive topics: "Would you like to talk about what happened?" (Ask only if you're willing to listen to the details.) Even a survivor who doesn't want to talk will appreciate that you asked.

Help with the practical things. Offer to run errands, provide rides to appointments, or watch over children. Ask if you can help with chores such as watering the garden, walking the dog, or putting away groceries. The survivor may want you to sit quietly, or perhaps pray, with him or her. Ask directly, "What can I do to help?"

Be there for the long haul. Dr. Jordan calls our culture's standard approach to grief the "flu model": grief is unpleasant but is relatively short-lived; after a stay at home, the bereaved person will jump back into life. Unfortunately, that means that once survivors are back at work and able to smile or socialize again, they quickly get the message that they shouldn't talk about their continuing grief.

Even if a survivor isn't bringing up the subject, you can ask how she or he is coping with the death and be ready to listen (or respect a wish not to talk about it). Be patient and willing to hear the same stories or concerns repeatedly. Acknowledging emotional days such as a birthday or anniversary of the death — by calling or sending a card, for example — demonstrates your support and ongoing appreciation of the loss.