“You never get over a suicide. You just learn to deal with it. The worst part is not knowing WHY. If I could just say he had been seeing a shrink, or anything that might have explained it, it would have been better. But I just don’t know why he did it”
Julie, whose teenage son hanged himself.
Fred’s 35 year old son had suffered from severe manic depression for over 4 years when he jumped from a high rise apartment building. Mike’s condition explained his action, but Fred found little comfort in that knowledge:
“It was just unbelievable to me. Why did he do this? For four and a half years, I had tried everything under the sun to get him help. What else could I have done? Why didn’t he come to me and say, `Dad, I need help. ` And then I felt angry.
While we correctly say of grief that “there is no such thing as more or less difficult, it is just different”, there are some situations that are “uniquely difficult”. One is the loss of a child. Another is death by suicide. And when these two situations come together, it can be a devastating blow to “suicide survivors” (for the purposes of this article, this term refers to those who have lost someone to suicide.)
It is not my intention to outline the many and varied theories of suicidal behavior, many of which are conflicting. The focus here is on how we help support suicide survivors through their unique process. There are some sobering facts, however:
- Every day, throughout the world, over 1000 people complete suicide
- It is estimated that for every suicide there are 15 unsuccessful attempts
- White males over the age of 50 make up approximately 10% of the population but account for 28% of the total suicide deaths
- Men complete suicide three times more than women, but women attempt suicide five times more than men. Most attempts of suicide are made by women in their 20’s and 30’s
- Suicide tends to run in families, but it is learned not genetic. Often it is unconsciously suggested as a means of coping with overwhelming moments.
- People who talk about suicide DO complete suicide. Suicide RARELY happens without warning
When someone completes suicide, the mourning process for survivors is different in at least 2 ways. 1) The period of numbness and disbelief will be longer, extending the duration of the grief process; and 2) there is the added burden of understanding the motivation for the death.
For suicide survivors, the grief process is particularly long given the complexity of issues survivors struggle with. This means that one year after the death, the griever may still be in the depths of their grief, long after society expects people to be over their grief. Fred observes:
“I think before the grief really set in, it took over a year. I mean there are times when I still think this is unbelievable. But I think it took a year for me to really believe it. And I think that it was because I surrounded myself with him, looking at pictures, and talking about him to everyone that helped me come to terms with it in such a short period of time. I don’t know if a year is a short period of time or not, but it is very real to me today.”
For this reason, patience on the part of the helper is most important. There is no way to speed up the grief process. One can only go through it! Perseverance is also required because, for many survivors, basic trust in relationships with others was broken when the person completed suicide, leaving them feeling cautious about reconnecting or establish new relationships.
Some of the things survivors might be feeling and saying to themselves:
- Shame – “What would people think of me if they knew my child completeted suicide?”
- Blame – “I must have been a lousy parent if my child killed himself!”
- Guilt – “I noticed she was depressed. Why didn’t I do something?”
- Anger– “How could he do this to me?”
- Fear – “Will my other children end up killing themselves too?”
- Relief – “It’s finally over!” (This feeling is more evident in cases where the person who died was abusive or had a difficult history of mental illness.)
- Rejection – “I guess he didn’t really care about me or he would still be alive.”
- Hopelessness– “What’s the point in going on?”
- Confusion – “How could this have happened? I just saw her yesterday and she looked fine.”
- Isolation – “I feel so ashamed and guilty that I don’t want to see anyone.”
One of the differences in the grief process after suicide is that the act involves a conscious decision, albeit often under great duress and it is this element that often complicates the grief process, causing the survivor to search for `reasons`.
There are four areas of conversation that are particularly helpful to suicide survivors:
- Listening to the story of the death
- Expressing and understanding feelings
- Anniversaries and special occasions
- Stress, coping and using support systems
1. LISTENING TO THE STORY.
To facilitate the telling of the story of the death, it is important to create a supportive atmosphere through gentle enquiry. Questions should be asked about the relationship of the person that died and the sequence of events just prior to and after the death.
- What was your relationship to the person who died? What were they like? What do you miss about them?
- How long ago was the death?
- How did he or she die?
- How was the person discovered?
- How was each person told? Where were they when they heard? What were the reactions of those around them?
- Did the person leave a note?
- Who else did they have to deal with, and what was that like? (police, coroner, hospital, funeral home, newspaper reporter, clergy)
- What have they told relatives, friends and the larger community?
These types of questions are intended to provide an outline the point that the story needs to be expanded through a recounting of the many details of what happened.
Many survivors feel uncomfortable talking to friends about the details of the suicide feeling that these details are too horrific for others to absorb. Families sometimes avoid talking about difficult and painful parts of the story, even in discussions with one another.
The fear is that these difficult elements may be too overwhelming for family members to bear because of their own grief. Relief will occur through the experience of talking in a supportive atmosphere that allows the expression of all the details, feelings and thoughts related to the death.
Families who feel they have had an opportunity to tell the whole story related to the death, and have their feelings validated are better able to move on to issues in the present. Families who have not had assistance in making sense of the death are far more likely to get stuck in the repetitive talking about the death without resolution.
It is helpful to encourage tolerance for differences by helping members listen to each other’s different explanations and interpretations of events and to accept that each one’s perspective and rate of acceptance of what is happening is okay. The tendency can be for each person to want to convince the others that his or her version of the facts is the only “true version”.
Going over the events in detail allows family members to appreciate that everyone is in pain and to realize that they may all be at different stages in their grief, with each attributing a different meaning to what has happened.
“If there is one thing I would say to people going through this situation, it is this. Talk about it. Get help. I found the greatest therapy was in talking to my friends, my colleagues, to anyone who will listen. So lean on your friends, because they want to help. But it is difficult when you don’t want to talk about it.” Fred.
Having the individual or family tell the story of the death of their relative or friend helps to facilitate a number of key processes, namely:
- Each person will begin to ascribe meaning to the suicide (a beginning for the ever present “Why?” question)
- Each person will begin to experience some relief through acknowledging, identifying and working through their feelings of loss.
- Each person will begin to create their own understanding about what has happened.
2. EXPRESSING AND UNDERSTANDING FEELINGS
When his son Michael took his own life, Fred was overwhelmed by an avalanche of feelings and emotions:
“At first disbelief, not wanting to believe that this had happened. Then a tremendous sense of anger. Wondering what I could have done to prevent what happened. It seemed so unbelievable that Michael could do this, and that I hadn’t seen it coming and stepped in to help him.”
The sheer force and complexity of the reaction of survivors of suicide make it likely the emotional effects will be more intense than after many other types of loss. When talking about these feelings it is important to validate and acknowledge how painful they can be, while at the same time normalizing their intensity.
“What would people think of me if they knew my child completed suicide?
Until relatively recently, suicide was not openly discussed nor dealt with as a problem deserving the attention and education of the community. Stigma came from the erroneous assumption that anyone who completes suicide is insane, and the accompanying supposition that “insanity runs in families.” Shame can also be rooted in long held beliefs such as it is wrong or “a sin” to take ones own life, and the fear that their loved on has “gone to hell.” This feeling intensifies the family’s perception that they failed in some way. They often feel disgraced by what has happened.
“My neighbors must think I’m a terrible mother because my son killed himself. I bet they blame me for his death.”
Families who lose someone to suicide often feel blamed. In trying to make sense of the death, other people will sometimes blame (scapegoat) a relative for not having done more to prevent the suicide. Or there may even be suggestions that the survivor “drove them to it.” Scapegoating is partly due to the need to have some answer – to make sense out of something that is senseless. Sometimes even police, coroners or insurance representatives can challenge the survivor’s motives, morality or integrity, where they have to defend themselves against the suggestion that they were somehow complicit in the act.This kind of thought or statement assumes that suicide is a “cause and effect” situation, meaning that one singular circumstance caused the death. But suicide, as with many situations in life, is a complex phenomenon, and we dare not oversimplify.
“I think there is always guilt after a tragedy. Over four and a half years, I can say without hesitation that I did everything under the sun to help my son. But after all is said and done, the guilt feelings are still there. What else could I have done? What didn’t I do? Because if there was anything I could have done to save him, I would have done it.”
Suicide survivors frequently use the word “should”. For example:
“He had talked of suicide before. Therefore we should have done more to listen to him”.
“We knew she was depressed and should have got her better professional help”
Although guilt may serve a purpose, eventually it is helpful to examine evidence to the contrary of their perceived short-comings. It is important to remind the family of the efforts they did make to assist their relative, and taking them back to times when they went the extra distance to support them. This will eventually assist them to move beyond this painful feeling. But also remind them that sometimes even superhuman efforts to protect the person are not enough to prevent them making their own decisions.
“I guess he didn’t really care about me or he would still be alive. How could he do this to me?”
Although the survivor’s rage is often directed at multiple targets (incompetent doctors, demanding bosses, insensitive neighbors, thoughtless friends, uncaring relatives, or even an impotent God), the real source of much of the anger is the action of the person who chose to die and “abandoned, rejected or otherwise hurt me”.
Perhaps what makes us most angry is that WE saw their life as viable, but THEY saw it differently and chose to die. It is that decision that makes this so hard to bear. The survivor may feel the deceased acted with contempt towards them. Or perhaps they perceived themselves as unloved. Either way, we ask why they didn’t see how hurtful this would be, or why they didn’t seek alternatives.
Anger at a loved one is often the last area that survivors are able to acknowledge and work through. Permission to process this anger can be prompted with “what would you like to say to them if they could hear you now?” Simple suggestions such as writing a letter to the deceased and saying it out loud can help process these feelings.
Many families who have lost someone to suicide have a lot of anxiety and fear. One reason is concern for the safety of other family members. “Might they opt for suicide as an answer too?” is a question they have. Another worry is that members cannot tolerate talking about certain painful aspects of the death and that doing so “will make them feel worse and they will be less able to get through each day.”
If we suspect the presence of these issues, the most effective way of reducing anxiety is to address the issues directly. “Are you worried that Jim or Jane may hurt themselves too?” followed by asking the individual, “Jim, do you have any thoughts of suicide?” This gives the family permission to discuss and to clarify their anxiety and fear.
The usual reaction at “getting the unspeakable said” is relief. Expressing our fears can reduce them from the “imagined insurmountable” to “actually manageable”.
3. ANNIVERSARIES AND SPECIAL OCCASIONS
Anniversaries and special occasions can be particularly difficult to deal with, especially in the first year after the death. All the “firsts” can be a challenge, such as Christmas, Birthdays, Holidays and special family occasions, which are usually times of joy, but which now are sad and difficult.
Survivors are often reluctant to create rituals that honor the life of a person who died by suicide, worrying that people might think this is abnormal or socially unacceptable. A woman whose daughter had died in the winter wanted to bring her friends together on her daughter’s birthday in June to spend an evening reflecting on the young lady’s life. But she was worried that others would be reluctant. However she went ahead, and much to her surprise, her daughter’s friends were thrilled to have the opportunity to participate in the occasion and talk about her. It helped the grieving mother embrace the significance of that date in her own life, and celebrate her daughter’s life, in spite of the difficult circumstances surrounding her death.
4. STRESS, COPING AND SUPPORT SYSTEMS
Grief particularly after suicide is an exhausting process, both physically and mentally. It is important to ask survivors about the physical toll the event has exacted on them as well as asking them about their emotional well-being. Changes in eating and sleeping patterns, concentration and energy levels in survivors can all be significantly affected after a suicide.
Some survivors may feel suicidal themselves during their grief process. This can be frightening for caregivers and family, and they need to understand the reasons “WHY” someone is feeling suicidal. The main reason people take their own life is to end the pain. It is imperative to provide survivors strategies and directions as to what to do if and when their pain becomes unbearable.
If the survivor suggests they might act on their suicidal thoughts, assist them in creating a safety plan, which involves helping them identify what they will do if they become overwhelmed by their thoughts and feelings. These safety plans always involve non-destructive coping strategies such as doing something positive for themselves, calling a friend, doctor, seeing their “priest,” or going to the nearest hospital emergency department or Distress Centre. Supply the names and numbers of emergency clinics or resources they can reach out to if they feel that they might act on their suicidal thoughts.
Ask them to enter into a “no harm” agreement with you for a period of time such as 6 months. You are promising to help them, but as part of that covenant, they agree not to harm themselves. In my own practice, clients have later told me that this had been a strong motivator in stopping them from considering harming themselves.
“As difficult as it is, tragedy sometimes allows you to see that there is something incredible inside all of us. When, in the midst of pain, you reach down deep inside yourself, you become much more than you think you are. More than you could ever imagine possible. You survive.”