Those Left Behind: Working With Suicide-Bereaved Families
Rumination is common in individuals experiencing suicide bereavement and is unique compared with the responses to bereavement for other reasons.
Suicide, the tenth leading cause of death in the United States, is on the rise.1 In 2016, nearly 45,000 Americans 10 or older died by suicide, up by 30% since 1999.1 An individual's death by suicide has far-reaching effects on a wide range of people, including immediate and extended family, friends, acquaintances, and healthcare and mental health professionals.2
“The grief after losing a loved one to suicide has points of commonality with grief following other types of losses of loved ones, but it also has unique features,” Sidney Zisook, MD, professor of psychiatry, University of California, San Diego, told Psychiatry Advisor.
Shrouded in Silence
“Stigma is probably at the top of the list of issues that affect people bereaved by a loved one's suicide,” Dr Zisook said.
A literature review comparing suicide-bereaved (SB) families to other bereaved groups found that SB families report higher levels of rejection, shame, stigma, the need to conceal the loved one's cause of death, and blaming.3 Stigma may derive from a “societal perception that the act of suicide is a failure by the victim and the family to deal with some emotional issue.”4 Stigma and shame are barriers to seeking help and receiving support from mental health professionals as well as friends and family.5
“I have treated people where a suicide in the family has never been acknowledged or talked about,” Dr Zisook recounted.
He described a patient in his 70s who had lost his father to suicide when he was young, but it was never mentioned or discussed by his family. “Finally, he was able to talk and cry about it and regretted that he had never been allowed to talk about it until now and that it had been shrouded in silence,” he said.
Guilt and Blame
Feelings of guilt often overlap with shame, compounding the sense of stigma. SB individuals often experience “intense guilt or feelings of responsibility for the death.”6
Although self-blame can be present after any loss, it is more common after a suicidal loss, Dr Zisook observed. “There is a frequent feeling that you could or should have done something to prevent it, and guilt is very common.”
Self-blame is one aspect of a broader tendency to find someone to blame for the suicide, he noted.
“The survivor may blame the person who made the choice to die or may blame someone else who didn't do enough, didn't provide enough care, didn't return a phone call, missed important cues, had an argument or disappointed the person, or could have interrupted or prevented the death in some way. Or the survivor may blame the doctor for missing signals, not treating depression, or prescribing the wrong drug,” Dr Zisook said.
Self-blame is particularly strong when the deceased is an individual's child.
“Losing any relative to suicide is traumatic, but there's probably no greater nightmare [than losing a child to suicide], since parents feel their job is to support their children, care for them, make them happy, and make their lives good, so suicide can make parents feel like a failure in this most important job of their lives,” he commented.
Rumination and Anger
Rumination is common in SB individuals and is unique compared with the responses of bereaved individuals to other losses, Dr Zisook pointed out.
“When someone dies of cancer, relatives do not typically wonder why the person died, while in suicide, survivors are plagued as to why the person did it — why, why, why,” he said.
The suicide sometimes comes as a “total shock” to the survivors, who may think, “He seemed to be doing better.” “She had turned her life around.” “He was making plans for the future.”
Coupled with rumination are feelings of rejection and abandonment: “Why did she do this to me?” “Didn't he love me?” “How could she leave me?”
These feelings can lead to anger at the deceased,6 which can compound the guilt.
Complicated Grief and Depression
Rumination contributes to complicated grief (CG), a “painful and debilitating condition…characterized by prolonged, acute grief and complicating psychological features such as self-blaming thoughts and excessive avoidance of reminders of the loss.”7 Conversely, instead of avoiding reminders of the deceased, some SB people may “spend long periods of time trying to feel closer to the deceased through pictures, keepsakes, clothing, or other items associated with the loved one.”8 Left untreated, CG can last for years, if not indefinitely.7 “Losing a loved one to suicide can be a risk factor for CG,” Dr Zisook said.
“Mourning is the process by which bereaved people seek and find ways to turn the light on in the world again. When successful, mourning leads people to feel deeply connected to deceased loved ones while also [being] able to imagine a satisfying future without them…Grief has been transformed and integrated” and the “continued presence of the loss is no longer insistent and disruptive.”8
In contrast, CG is a “chronic impairing form of grief brought about by interference with the healing process” that “derails” the mourning process and “prevents the natural healing process from progressing.”8
Mental and Physical Health Sequelae
SB individuals are vulnerable to physical, psychological, and psychosomatic difficulties.9 One study found that one-quarter of people bereaved by suicide experience elevated levels of depression and stress and close to one-fifth have elevated levels of anxiety,10 as well as posttraumatic stress disorder (PTSD) and impairment in social and employment settings.6 Psychosomatic reactions included physical or severe abdominal pain, loss of appetite, low energy levels, and sleep disruptions.10
Survivors are themselves at high risk for suicidal thoughts or completed suicide.11 A study of 3432 young adults who had lost close friends or family members to suicide found they had a higher probability of attempting suicide than individuals bereaved by deaths due to sudden, natural causes. Of note, the effect of SB was similar regardless of whether bereaved participants were or were not blood-related to the deceased.12
Impact on the Family Unit
The suicide of a family member leaves an indelible mark on the survivors, affecting each individual, the family as a whole, and also larger social networks.13 The impact of the suicide is to some extent informed by the family's function or dysfunction prior to the suicide.13 Moreover, the suicide may affect family communication and the developmental processes of children.13 Marital breakup is also more common in parents of children who died by suicide.14
“Postvention,” a term coined by Schneidman, refers to clinical care provided after a suicide.2,15
Complicated grief therapy
Complicated grief therapy (CGT), a manualized, structured, 16-session protocol, has been shown to be effective in treating CG in SB adults.7 It includes self-regulation, focusing on aspirational goals, rebuilding connections, revisiting the story of the death, revisiting the world, and creating memories/continuing bonds.7
Proactive discussion and education
Dr Zisook recommended “opening a dialogue and talking to patients who have lost someone to suicide to normalize it, in a sense — meaning, to normalize their reactions, let them know how difficult it can be to talk about, and educate the person about lingering feelings, such as self-blame.”
He suggested addressing guilt and “letting the survivor know — for example, if they had an argument with the deceased — that the argument is not what killed the person, but rather a host of events that occur in someone with a mental illness, creating a perfect storm that overwhelmed the person and made him or her feel there was no other option.”
Emotional support is important, and a homogeneous support group is more helpful than a generalized group, Dr Zisook said. For example, SB parents will likely benefit more from a support group specifically for parents whose children have died by suicide than a heterogeneous group of parents who have lost children.
Education and information about support groups can be found at the American Foundation for Suicide Prevention (https://afsp.org/) and the American Association of Suicidology (https://www.suicidology.org/).
Does pharmacotherapy have a role?
Pharmacotherapy without psychosocial interventions is not helpful, Dr Zisook emphasized. His group compared citalopram monotherapy with citalopram with citalopram plus CGT in 58 individuals who suffered CG following suicide bereavement and found that only 35% of participants in the medication group completed medication treatment vs 81% in the combination group.7 Moreover, improvements in the CGT were “substantial.” CGT was both well accepted and effective in ameliorating symptom severity, passive suicidal ideation, grief-related functional impairment, avoidance, and maladaptive beliefs.7
Bereavement family counseling can facilitate the grieving process.16 It is important to educate family members about the different ways in which individuals may deal with grief to facilitate their understanding of each other.16 Family members may also need practical or financial assistance — eg, help with funeral arrangements and expenses or childcare.16
Other Healing Modalities
Helpful activities might include rituals, ceremonies, lighting candles, reviewing pictures and mementoes, finding new information about the deceased person or even his/her death, and engaging in artistic expression.2 Religious and spiritual activities can be helpful to some people, as can engaging in regular physical activity, good nutrition, sleep hygiene, and “taking time out” from grief.2
The suicide of celebrities such as Robin Williams and Anthony Bourdain have drawn attention to the issue of suicide and opened up channels for discussion, Dr Zisook noted, and the designation of September as National Suicide Awareness Month17 is an important step in bringing awareness to this urgent issue.
“These inroads are helping us to break through stigma, but we still have a long way to go,” he said.
- Centers for Disease Control and Prevention (CDC). Suicide rising across the US. www.cdc.gov/vitalsigns/suicide/. Accessed September 20, 2018.
- Shear MK, Zisook S. Suicide-related bereavement and grief. In: Koslow SH, Ruiz P, Nemeroff CG (eds). A Concise Guide to Understanding Suicide. Cambridge, UK; Cambridge University Press: 2014.
- Sveen CA, Walby FA. Suicide survivors' mental health and grief reactions: a systematic review of controlled studies. Suicide Life Threat Behav. 2008;38(1):13-29.
- Cvinar JG. Do suicide survivors suffer social stigma: a review of the literature.Perspect Psychiatr Care. 2005;41(1):14-21.
- Kučukalić S, Kučukalić A. Stigma and suicide. Psychiatr Danub. 2017;29(Suppl 5):895-899.
- Tal I, Mauro C, Reynolds CF 3rd, et al. Complicated grief after suicide bereavement and other causes of death.Death Stud. 2017;41(5):267-275.
- Zisook S, Shear MK, Reynolds CF, et al. Treatment of complicated grief in survivors of suicide loss: a HEAL report. J Clin Psychiatry. 2018;79(2).
- Shear MK. Grief and mourning gone awry: pathway and course of complicated grief. Dialogues Clin Neurosci. 2012;14(2):119-128.
- Spillane A, Larkin C, Corcoran P, Matvienko-Sikar K, Riordan F, Arensman E. Physical and psychosomatic health outcomes in people bereaved by suicide compared to people bereaved by other modes of death: a systematic review. BMC Public Health. 2017;17:939.
- Spillane A, Matvienko-Sikar K, Larkin C, Corcoran P, Arensman E. What are the physical and psychological health effects of suicide bereavement on family members? An observational and interview mixed-methods study in Ireland. BMJ Open. 2018;8(1):e019472.
- Jordan JR. Postvention is prevention-The case for suicide postvention. Death Stud. 2017;41(10):614-621.
- Pitman AL, Osborn DP, Rantell K, King MB. Bereavement by suicide as a risk factor for suicide attempt: a cross-sectional national UK-wide study of 3432 young bereaved adults. BMJ Open. 2016;6(1):e009948.
- Cerel J, Jordan JR, Duberstein PR. The impact of suicide on the family. Crisis. 2008;29(1):38-44.
- Bolton JM, Au W, Leslie WD, et al. Parents bereaved by offspring suicide: a population-based longitudinal case-control study. JAMA Psychiatry. 2013;70(2):158-67.
- Shneidman, E. Postvention: The care of the bereaved. In: Pasnau R. (ed.), Consultation in Liaison Psychiatry. New York, NY; Grune and Stratto; 1975.
- Flynn L, Robinson E. Family issues in suicide postvention. Australian Institute of Family Studies. AFRC Briefing No. 8 (February 2008). https://aifs.gov.au/cfca/publications/family-issues-suicide-postvention. Accessed September 20, 2018.
- American Association of Suicidology. National Suicide Prevention Week—September 9-15, 2018. www.suicidology.org/about-aas/national-suicide-prevention-week. Accessed September 20, 2018.