The loss of a loved-one or special friend to suicide is sudden and devastating. Some professionals refer to the healing journey in this situation as complicated grief. The American Foundation for Suicide Prevention (AFSP) and other local organizations have increased public awareness of survivor suffering. The information in this article has been used to train New England clinicians and bereavement counselors.
Among other things, I am a survivor and a licensed mental health clinician. When I lost a brother in 1999 few services were available in my community. I eventually found services for my own grieving and later provided individual and group support to others as a volunteer. I offer this material as support to those who may not have services available in their community and to clinicians who wish to further their knowledge of this topic. It comes from my work with survivors and knowledge of trauma, abuse and recovery.
Contents of this article
- Stigma and shame
- Detective obsession
- Telling the story
- Regulating emotions/feelings
- Odd ways to sooth
- Filling the void
- Creating a grieving ritual
- Individualized grieving process
- Blaming and family conflict
- Parental grief
- Survivor grieving and the workplace
1. Stigma and shame
Though many of us understand mental illness and the dynamics of depression, suicide sigma is still very much a factor in grieving this type of loss. Social stigma comes from a variety of influences:
- Both ancient and (some) modern religious views;
- The concept that it is not a “natural death;”
- The concept for that suicide is a crime and it’s location a crime scene;
- The stigma already associated with mental illness;
- The blame and judgment survivors perceive from others; and
- The guilt survivors feel about what they “should” have done differently.
The stigma and shame associated with suicide can manifest in a number of painful ways. Family members, police, funeral home personnel and other community members make subtle or overt judgment of survivors that ignores the reality of depression. Some family members may deny that a suicide has taken place. Efforts to hide the fact that self-harm is involved are more common than we might think. A survivor’s religious beliefs can be comforting but can also play a negative role in the family and community response. It is common for survivors to keep the secret of a family suicide for decades. I know survivors who attend group to process a parent’s suicide 20 years before — describing various ways the family kept this information from them. Sometimes survivors find out by accident when an adult who was instrumental in keeping the secret passes away. Breaking the silence in a safe setting is a significant forward step. Whether this is in a group setting, individual therapy or with a safe friend, support can take the form of acknowledging the pressures a survivor feels to meet other’s needs for silence and providing the safe place for them to voice their feelings of anger, sorrow and shame.
2. Regrets – If only I had done this, seen this . . .
In addition to the normal emotions of grieving, survivors feel shock, guilt and responsibility. The nature of a suicide loss is that it can sometimes be prevented if only temporarily, by others. Loved-ones who die this way sometimes keep secrets about how badly they were feeling and some never fully understood the depression they suffered. Sometimes loved-ones sought and received treatment but did not get relief (treatment-resistant depression). Despite this, survivors can become obsessed with all the ways they might have prevented this act.
“What if I had taken them to the hospital? What if I had listened more carefully? What if their doctor had changed their medication? What if they had taken their meds as prescribed. I should have been a better parent, spouse or friend.”
Resolving this issue is one of the greatest challenges in the healing process. The truth many survivors eventually come to understand – is that there is generally no one key action or event that could have guaranteed a change of events. Logic and rationalization is not generally helpful here. Survivors move to this realization over time.
3. Detective obsession
Many survivors experience a transient “detective” obsession where they spend time gathering information; visiting the death scene; speaking those who had last contact with their loved-one; retracing the loved-one’s steps; and generally seeking every detail surrounding the suicide. The idea is that if they gather enough information it will all make sense. The typical scenario, however, is that there are always unanswered questions about the events of the days or weeks leading to the event. Finally, the question that can’t be answered except in a personal–spiritual way is: Why did this happen to me? Telling a survivor to stop focusing on these facts or questions is not helpful. Gaining comfort with unanswered questions is part of the gradual healing journey. As long as the obsession does not overtake obligations to family, work or self-care, it will shift over time.
4. Telling the story
A major healing component of the group process is that survivors have a chance to tell the “story” of what happened to their loved one and what they are going through. Because of their guilt and the social stigma survivors may have no other safe place to discuss this or fully debrief the event. Part of the story includes the events of the day they learned of the death but the story evolves. Survivors report that as the whole story is told over time, it becomes less about the facts and details of the death as it is about the story of their loved-one and their own healing journey. The clinical term for this process is desensitization. This “telling” can initially be gory with details that others have difficulty tolerating. It is not helpful to pry and ask a survivor to talk about this when they’re not ready or comfortable. It’s helpful to be prepared when survivors are ready with gentle/nonjudging encouragement. The first “hearing” for a group facilitator may be during a pre-screening interview before a survivor joins a support group. This provides an opportunity for the screener to hear the story and provide support and guidance about the telling the story in the group. For facilitators or therapists, listening without judgment is essential to build participant trust.
5. Regulating emotions/feelings
Because the healing process is long with significant “downs” and hopefully, an increasing number and duration of “ups,” it can be difficult to keep emotions in check as survivors go about their work or just their daily routine. Survivors describe the overwhelming feelings of deep sorrow or even anger that come upon them suddenly. It may be while watching a mother and son interacting at the store, coming across information about the marriage or other seemingly benign events. This phenomenon can be like a flash-back, a re-experiencing or it can just be a sudden experience of deep sorrow. Survivors express embarrassment when it happens long after the death perhaps in anticipation of some judgment by others that they should be finished with these tears by now. The fact is that these episodes continue for most survivors for months and years. It is important for survivors to understand that this is part of a healthy and “normal” grieving/healing process and that it doesn’t mean there is something wrong with them. Further, it is helpful for survivors to feel empowered to control some aspects of their surroundings to avoid constant reminders. This is more difficult early in the loss but gets easier over time. Friends and coworkers can provide support by listening to cues about whether the survivor “wants to talk” and when the survivor wants to “keep it together” and wait until a more private moment to let the tears flow. For survivors who don’t normally show their emotions to others, this phenomenon can be especially troubling.
6. “Odd” ways to sooth
Survivors sometimes develop means of comforting themselves that can seem odd to non-survivors. Examples: a mother whose son killed himself by firearm keeping the bullet on a chain around her neck; a brother might keep the weapon used in a suicide; or parents might keep blood-stained clothing. Sometimes families argue about whether to clean blood stains off the floor. Another question is whether to move from the house where the event occurred or to change the loved-one’s room. The idea of holding on to objects is a common general grief response but suicide is sudden and sometimes violent. Group facilitators and individual therapists must be prepared for these disclosures and to listen without judgment. Early on, survivors have difficulty separating their need to comfort themselves in these ways from how some people may react to the information. One survivor told me years later: “I can’t believe I showed that stupid bullet to everyone in the beginning. What was I thinking!” Providing affirmation of their right to choose the way to sooth themselves is helpful.
7. Filling the void
Filling the empty space, particularly for a parent survivor, can result a powerful need to remove the pain. Deep sorrow about the fact that loved-ones are gone with no more chances for amends or reconciliation is very difficult to move through. There are adaptive and maladaptive ways survivors might use: from healthy support and self-care to substance use and drugs. Encouragement for rest, taking a break from normal responsibilities and good general self-care is important. An underlying substance use issue complicates the grieving process might escalate. For a few families, trauma and increased drug or alcohol use can create a chaotic environment that makes professional support for the grieving process difficult or impossible until other issues are more resolved.
8. Creating a grieving ritual
Creating a “grieving ritual” is one way families can join together to remember the person who died. It’s helpful to show that a loved-one isn’t forgotten and provides a comforting routine. The date might be the loved-one’s birthday, the date of death or other significant date. These times can be difficult even several years after the death. Rituals range from simple to more complicated/religious. It could be spending the day with a trusted friend talking about the loved-one. It may also be a more formal religiously sanctioned celebration. Challenges for survivors arise in families with conflict where the practiced religion has difficulty with the concept of suicide or where the fact of suicide is a secret from some members. When families aren’t able to unite around one ritual celebration survivors can create something more private/personal. A sacred location such as a garden, the shore or even the place where the person died are often mentioned as places survivors feel close to their loved-one. Survivors should be supported to craft rituals that mean something to them. As time goes on, this can be a day that survivors feel comfortable letting their sad feelings flood in and then resume activities after a time.
9. Individualized grieving process
Each individual’s grieving is unique. There is no correct way or accepted timetable for the grieving process though there are some common stages survivors may move through. Close friends and relatives may wish to “move on” or find it painful to discuss the suicide. This can transmit subtle or not-so-subtle messages to the survivor that there is something wrong with them for continuing to process their feelings. Friends may suggest that the deceased’s room be changed, that the family move or that the deceased clothes be given away. Comments about dating (when a spouse has died) or having more children (when a child has died) probably reflect the speaker’s need to conceive of hope for the future. It is, however, insensitive to the long process of adjustment needed by most survivors. The fact that others are moving on or see ways that the survivor might move on can increase the survivor’s feelings of isolation. Survivor support will include much, repeated reassurance that this is not their problem nor is it their role to make those around them comfortable. Another common scenario is for some family members to seek helpful support outside the family and for others to withdraw or refuse to discuss it. The ideal is for everyone to become more comfortable with the fact that differences exist and not to hitch one’s healing to someone else’s internal process or needs.
10. Blaming and family conflict
Family conflict is common among survivors. Family members can blame spouses or significant-others when unhealthy relationships or a difficult break-up immediately precedes a partner’s suicide. I have seen overt blame for signs that “should have been seen.” I have also heard of entire towns split with police and the deceased blood relatives on one side and those related to the deceased by marriage on the other. In extreme cases, survivors actually move to get away from this dynamic. Group participants typically come to learn that blame and shame are an expression of someone else’s grief. Survivors can be supported to understand that they are not responsible for a loved-one’s death or a family member’s angry reaction. But this part of the journey is very painful. It is important for a loved-one in family conflict to have a safe place to talk about the isolation and sorrow that comes with it. Here, the loss may not be just the loved-one, but also friends, neighbors and others. Professional, individual counseling may be the only safe place a survivor can process their thoughts and feelings without judgment.
11. Parental grief
While any loss by suicide is very difficult, parents feel a special care=taking responsibility for a child who dies by suicide. The guilt and shock when a child or young adult is lost can be especially debilitating. Often survivor parents are unable to share their true feelings of shame except with other survivor parents. Particularly when a child is young, outsiders naturally wonder how parents missed the signs – parents are supposed to keep their children “safe.” In reality, no parent is with their child every minute of every day. Suicide by a child is so unimaginable. I heard Frank Campbell, PhD, Baton Rouge Crisis Intervention Center indicate that family members are exactly the wrong people to see early warning signs. According to Dr. Campbell, their love and hopes for the best for their children prevents parents from forming thoughts that their child could actually be unsafe in this manner. In addition, children like adults are not always honest about their feelings. They sometimes tell bits about how they are feeling to more than one person leaving no one individual with the whole picture. It is essential that facilitators and therapists provide a nonjudgmental atmosphere for grieving parents. Aside from participating in a group, survivor parents benefit greatly from contact with a fellow parental survivors.
12. Survivor grieving and the workplace
We spend so much time at work every day that it is important to understand how the deep grieving of a survivor affects the workplace and how the workplace affects the survivor. First, many times coworkers are involved in the actual events of the suicide itself. They may have provided support to the survivor if the suicide is discovered during the work day. For survivors whose close friends are in the workplace, coworkers may play a central role in survivor support outside the workplace. Second, the workplace has policies related to bereavement and then the use of sick time since bereavement days are insufficient for most survivors to return to work. Typical bereavement provisions are less than a week. Even adding available sick time may be insufficient. To a person, every survivor I’ve talked with either needed more than two weeks to resume work or they resumed work too soon and required more time later when their “batteries” ran dry. Many survivors end up having to file for a short-term disability leave. Third, the length of time needed by the survivor can exceed coworkers’ tolerance for the absence and filling-in needed to cover a survivor’s work. Coworkers will also just be ready to move on from the topic before the survivor. Finally, survivors describe a desire to change jobs so that they can have more privacy regarding their survivor status. When everyone at work knows about the loss the survivor can begin to feel like the “suicide person” there. When he or she changes jobs, revealing the death is more of an over choice, empowering the survivor with more control over how much of the topic is “out” in the workplace. For this and all the reasons noted above, survivors often end up making an employment change.
1. Created by the Baton Rouge Crisis Intervention Center, The History of Suicide, accessed June 2010 on the website of the Jacob Crouch Foundation
2. Sudak, Howard, MD, Maxim, Karen, MS, RN, and Carpenter, Maryellen, Suicide and Stigma: A Review of the Literature and Personal Reflections, Journal of Academic Psychiatry, American Psychiatric Publishing, Inc.: February 16, 2007
3. Office of the Surgeon General, Mental Health, a Report of the Surgeon General, Chapter One: Introduction and Themes