Grief After Suicide: Understanding the Consequences and Caring for the Survivors
Is grief after the loss due to suicide different from grief from an accident or not? How should we care for all those who are grieving including those who’ve lost due to suicide? These are the questions that Grief After Suicide: Understanding the Consequences and Caring for the Survivors answers.
Ripples
Every suicide has ripples of impact on others. Other people are impacted by the loss of another life. One key question is how many people are impacted by a suicide. There are two key challenges in answering this question. The first challenge is understanding what we mean by “impacted.” Do we mean that they have a kinship relationship – and how close of a kinship relationship? Obviously, parents, children, and siblings count, but what about aunts, uncles, grandparents and cousins? This leads to the broader group of those whom we have relationships with. Perhaps one particular aunt is closer than the other. Could it be that the nature of the relationship – or friendship – defines the impact of the suicide? If that’s the case, what degree of friendship counts for impacted?
Taking a further leap, what about parasocial relationships? This is the sense of connectedness we feel to celebrities and people with whom we have no direct relationship. The research related to the deaths of Marilyn Monroe, Robin Williams, and many others makes it clear that many people feel impacted by celebrity deaths to the point of deciding to die by suicide. Clearly, this has a substantial impact.
The challenge of where to draw the line has largely confined research to close kinship relationships, thereby substantially restricting the number of people considered. Research does indicate that roughly 7% of the US population were acquainted with someone who died by suicide in the preceding year. Some estimates of the number people were aware the death was a suicide put the number at around 425 people. It’s still an average, but it’s something.
The second challenge is that the question presumes that every suicide impacts the same number of people. The death by suicide of a homeless person without family may impact relatively few people – those people in their community and the medical staff that treated them. Conversely, the celebrity deaths will have impacted substantially more people. As Clayton Christensen explains in How Will You Measure Your Life?, averaging the data sometimes destroys important details.
Similarities and Differences
The research on the differences between a suicide death and a non-suicide death are mixed. There are certainly differences, but they tend to fade with time. Importantly, they also seem to disappear when we compare suicide deaths exclusively to accidental and violent deaths, suggesting that the differences in grieving are triggered by the unexpected or unexplainable nature of the death rather than the mode.
We are, as humans, prediction machines. (See The Righteous Mind, The Blank Slate, and Mindreading.) We seek to be able to predict our environment, our world, and our outcomes. When our ability to predict fails, it often causes us to seek meaning, so we can update our views of the world in hopes of better predicting the future. It’s not surprising that an event as large as a death would trigger us to reevaluate our belief about the world.
In fact, when we speak of trauma, we describe it as the connectedness between the person and the event – and the degrees to which it personally impacts us and requires reevaluating our fundamental beliefs about the world. (See Trauma and Recovery and Traumatic Stress.) Reevaluating our worlds due to trauma is intensively disruptive.
Guilt and Shame
The disturbing question for parents losing a child is how your child couldn’t endure the life you gave them. Working backwards from the perspective of seeing suicide as the best solution to the pain they’re feeling (whether or not this is true, it was likely their perspective) we must face the fact that they felt that their life – the life that the parents gave them – was too painful.
The suffering cry from those who’ve lost their significant other to suicide is similar yet different. They may wonder why they weren’t enough. Why weren’t they enough to stay for – to endure for?
There are, of course, no answers to these questions. What we can offer the bereaved is that they’re not responsible, and their loved one likely wasn’t considering their full life because their pain was too great.
Judith Rich Harris provides an exhaustive exploration of why parents can’t be truly responsible for their children in No Two Alike and The Nurture Assumption. Basically, the argument is that we cannot control what they’re exposed to in the world and therefore can’t completely shape their development. Additionally, there’s no way for us to foresee all the circumstances of their lives prior to conception. The weathermen can’t predict the weather more than a few days in advance, why should we believe we can predict the way the world will be – for them – decades into the future? The outcome remains a tragedy – but there is no way we could have known what the circumstances would have been.
Additionally, the body of research supports Shneidman’s assertion for cognitive constriction. That is, at the point of suicidal crisis, people aren’t able to see beyond their pain. They can’t see the joy beyond the cloak of struggle. It may be that, on objective observation, life is more happiness than sorrow. It can be that the logical mind can see the pot of gold at the end of the rainbow – but it’s not the rational mind that is driving the decisions of the suicidal person.
The logic of these arguments falls short of stopping guilt and shame from entering into the minds of those left behind. They play the nasty game of “what if.” What if I had just called them? What if I went to visit more often? What if I had done something, anything, to change the outcome?
Our minds, while marvelous, are limited. We regret those things we didn’t do more than those things we did. (See The Top Five Regrets of the Dying, Originals, and Thinking, Fast and Slow.) Survivors are haunted by the decisions they made to protect their boundaries, their reserves, and their own needs. What if that one thing they didn’t do was the one thing that would have made the difference? Even if it was, there’s no way they could have known that at the time.
Guilt is that we’ve done (or decided) something wrong. Shame is that we are bad. When guilt stops being about the moment and becomes about us personally, we experience shame – shame that’s often not deserved. (See Brene Brown’s work in Daring Greatly and I Thought It Was Just Me (But It Isn’t) for more on guilt, shame, and working through those feelings.)
Psychological Autopsies
One thing that can be helpful for families is a psychological autopsy. Shneidman writes about a mother who reached out to him to do a psychological autopsy in Autopsy of a Suicidal Mind. In a strange twist of fate, after reading my review, the mother who approached Shneidman reached out to me and let me know that the autopsy and the book were helpful to her. Despite the value they can bring, I’m still skeptical of them, because I believe they can sometimes bring harm. (See The Prediction of Suicide and Review of Suicidology, 2000.)
Nina Gutin explains in her chapter that psychological autopsies can feel like fact-finding missions instead of validating experiences for the clinicians. What families may not be able to appreciate (having their own degree of cognitive constriction) is that the clinicians are hurting, too. It’s not a comparison or a competition, but the clinicians were in a relationship with the deceased, and that relationship is now gone.
Despite the evidence to the contrary, people often start with the perspective that a clinician has done something wrong if a patient dies by suicide. (See The Suicide Lawyers.) The fact is that we’re lousy at determining short term risk of suicide by survey instrument or clinician judgement. It’s not necessarily a clinician problem. It’s a problem that our ability to predict is very low. When a psychological autopsy starts with the assertion that the clinician must have done something wrong, it can be hurtful and unfair.
Right to Grieve
“It is not uncommon for suicide survivors to question their own right to grieve…” It’s a foreign statement to me. I feel like everyone has the right to grieve. The research on emotions seems to indicate that holding back emotions can be bad. Richard Lazarus in Emotion and Adaptation makes the point clearly that you can’t completely suppress an emotion – it’s still there. In our work on burnout (see Extinguish Burnout), we traced the problem of not expressing emotions all the way to Freudenberger’s original work, Burn-Out. Subsequent work, like Burnout: The Secret to Unlocking the Stress Cycle, gets the impact of emotional suppression right (while missing on the role of stress).
People will encounter fewer downstream consequences if they can find a way to let grief take its course. Suppression generally ends badly – as White Bears and Other Unwanted Thoughts makes clear.
Inadequate Support
If you ask bereaved parents about the support they received post death, you’re likely to hear statements like “inadequate” or “chaotic.” With the notable exception of the work of LOSS teams, most responses to loss by suicide are haphazard at best. It’s rare enough that people don’t plan for it – and common enough that they should.
If your child was a member of the military, organizations like Tragedy Assistance Program for Survivors (TAPS) have support programs. However, even learning about them isn’t guaranteed. Disconnects prevent automatic introduction to the families that are grieving to the programs that can help them. The lack of training and centralized resources means that it’s difficult to connect loss survivors to the resources that do exist.
Support Options
There’s no one thing that will be right for every survivor. For some, having a counselor or clergy is right. For others, the support group, which necessarily means that you’re not alone in having survived a tragedy, is best. In a convenience sample of bereavement group attendees, the bereavement group edged out individual support by clergy or mental health professionals. However, what was more interesting about the survey is the approximately 40% of people still attending bereavement (or survivors of suicide) groups 10 years or more after their loss.
Of course, it can be that these attenders are no longer actively processing their grief and are instead in the group for the community (framed as friendship and personal growth), or it could be that they’ve transitioned to leadership or quasi-leadership roles in the groups. What is clear is that suicide loss radically changes the trajectory of lives – and, in some cases, those changes may be permanent.
Grief Overload
When a family (or community) faces the loss of a member, it intuitively stretches each member’s coping capacity to – or beyond – their limits. At an individual level, this is well understood and accepted. What isn’t quite so clear is the impact this has on the relationships between the people. In a normative case, a person is impacted by tragedy, and those around them rush into help. However, in the case of an overwhelming loss by a member of the network, no one has the capacity to help others – they’re working their hardest simply keep themselves functioning.
It can seem like the time people need it most that their network fails to support them. This can be a frustrating and disorienting experience. It’s only when evaluating the situation later that people can realize that it wasn’t that their network didn’t want to support them – it’s that they couldn’t.
Fear of Judgement
It’s no myth that people who are bereaved by suicide loss get less support from their friends and community than those of other death types. It’s also no myth that survivors of suicide loss may self-censor. Because of the feared judgement, they may not reach out and stay connected to their communities in the same way that survivors of other loss do. The stigma of suicide sticks to the survivor like syrup. (See Stigma for more on stigma.)
Clinician Conversations
It’s common for loss survivors to want to talk to treating clinicians. Survivors often feel an overwhelming desire to understand why their loved one died by suicide; in that quest, a conversation with the clinician is something they find useful. Clinicians are appropriately concerned about how the conversation will go both because they’re struggling with their own reaction and because the suicide death of a patient is reported to be the largest area of litigation.
In the United States, client confidentiality extends beyond death, but decisions about these confidential records can be made by the executor of the estate. However, there is much that the clinician can say without impacting client confidentiality.
Clinicians are encouraged to be “fully compassionate” toward the family. It’s appropriate to collect outstanding fees – but not aggressively. Advice is shared about initial contact soon after the death to reduce the displacement of anger towards the therapist. A later meeting, if requested, to allow for the family to organize their thoughts and questions can also be helpful. Appropriate contact with the family has been shown to be helpful for the clinician’s healing as well.
It’s important to note that, while malpractice litigation may be the most common when there is a loss due to suicide, it doesn’t mean that every family intends to sue. Many families are simply trying to understand and recognize that bad things happen even when no one has done anything wrong. There’s no need to blame.
Communication and Exposure
There’s been a lot of information provided about how to communicate about suicide deaths – and how not to communicate. However, most of this research is shaky at best. While there is solid research that exposure to a suicide increases the risk for a subsequent suicide by the exposed person, there’s nothing to say that denying that a death was suicide has any impact on the exposure or the downstream consequences.
In fact, the broader research about substance use disorder seems to imply that the more openly and frankly we speak about a topic, the less we shame and stigmatize it. The results are generally a reduction in the undesirable behavior. (See The Globalization of Addiction and Chasing the Scream for more.) This is the same experience that we saw in teen pregnancy rates when we started more openly discussing sex and pregnancy in the US. (Dr. Ruth Westheimer is well known for her frank conversations of sexuality. Her latest book, The Joy of Connections, provides some context for this.)
My perspective is that much of what we say about how to communicate about suicide is flat wrong. While well intended, it’s not supported by research and reinforces the very stigma and shame that we’re trying to eliminate. Guidance that says to treat a suicide death different is hidden in the larger statements to treat all death the same. The guidance for communication shouldn’t be difficult. Don’t glamorize it or explain it as a way out of problems. Don’t report or discuss unnecessary details. Don’t blame it on mental illness, depression, family, or social pressures. It’s as unpredictable as accidents – so treat it the same. (See Rethinking Suicide for more on unpredictability.)
Leaning on Clergy
For many people, they have some sort of a religious experience that includes clergy – both professionals and lay-clergy. The advice is to lean on clergy for support around grief and grief rituals. The problem is that the clergy that I know feel woefully unprepared for a death by suicide and only marginally prepared for grief more broadly. As an ordained elder (lay-clergy), my interactions with professional clergy has led me to realize that they receive only superficial training about trauma and grief and even less about suicide.
The separation of church and state often creates concern for communities trying to respond to tragedy. Hopefully, greater partnerships between churches, community organizations, schools, and government can use all the resources available – whether they’re clergy or not.
The Tyranny of Hindsight
Perhaps one of the most difficult challenges that survivors face is the tyranny of hindsight. Suddenly, the significant detail buried in a mountain of trivia burns bright as a star. Suddenly, the decision to rest and recover seems like the wrong answer. There’s no way to consistently find the one thing that matters in the middle of millions of details. We can’t slow down life to make only correct decisions. It’s not perfect, but what we may be left with is Grief After Suicide.