The Special Grieving Needs of Suicide Survivors

CONTENTS
1. Stigma and shame
2. Regrets
3. Detective obsession
4. Telling the story
5. Keeping control of feelings
6. Odd ways to sooth
7. Filling the void
8. Creating a grieving ritual
9. Individualized grieving process
10. Blaming and family conflict
11. Parental grief

Introduction

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. Through the efforts of the American Foundation for Suicide Prevention and many other local organizations, progress has been made to bring public awareness to the suffering of suicide survivors. This information has been presented in Maine but I wanted to make it available so that survivors and professionals could access it on their own. Among other things, I am a survivor and an LCSW clinician. When I lost my brother in 1999 there were few services available in my community. I eventually found services for my grieving and later, I provided individual and group support to survivors as a volunteer. If this material helps anyone to better support a client or friend, my aim will have been achieved.

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 feel 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. There may be efforts to hide the fact that self-harm is involved. 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 and describing various ways the family kept this information from them. Sometimes survivors find out by accident perhaps when an adult who was instrumental in keeping the secret passes away. Breaking the silence in a safe setting is a significant step. Whether this is in the 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 but not always be prevented. 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 their loved-one's 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. This "telling" can initially be gory with details that others may not be comfortable with. It is not helpful to pry and ask a survivor to talk about this when they are not ready. It is helpful to be prepared when they are ready with gentle/nonjudging encouragement. The first "hearing" for a group facilitator may be during the 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. Keeping control of 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 that come upon them suddenly. It may be watching a mother and son interacting at the store, coming across information about marriage, or during a training program at work. Survivors also express embarassment when this happens long after the death occured in anticipation of some judgment by others or their own feelings that they should be finished with these kind of tears by now. The fact is that these episodes will continue for most survivors for a very long time. It is important for survivors to feel supported that this is part of a healty 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" when this happens 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 renovate or change the room where the death occurred. 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. 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 self care is important. An underlying substance use issue complicates things and may 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.

8. Creating a grieving ritual

Creating a "grieving ritual" is one way to get together as a family to remember the person who died. It can be helpful to show that a loved-one has not been 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 can be simple, such as going to a location that meant something to their loved-one. 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 can arise in families with conflict where the religion has difficulty with the concept of suicide or where the fact of suicide is a secret from some members. When families will not follow the same ritual, individual survivors can create something personal. A sacred location such as: gardens, 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. Individual 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 because family and friends don't want to hear about it any more there is something wrong with them for wanting 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 the majority of survivors. The fact that others are moving on or see ways that the survivor might move on, can increase the survivor's feelings of islolation. 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 precedes a partner's suicide. I have seen overt blame for signs that "should have been seen." I have also heard of towns splitting 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 cannot be responsible for family member's anger or grief or the loved one's death. But this part of the journey is very painful. It is important for a loved-one in a family conflict situation 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 friends, neighbors and others. Professional, individual counseling would be helpful in this situation.

11. Parental grief

While any loss by suicide is very difficult, parents feel a special position of care 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 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 unexpected. I heard Frank Campbell, PhD, Baton Rouge Crisis Intervention Center, at a presentation indicate that family members are exactly the wrong people to rely on to see these signs clearly. According to Dr. Campbell, their love and hopes for the best for their children prevents parents from forming thoughts that children 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.

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Sources

1. Created by the Baton Rouge Crisis Intervention Center, The History of Suicide, accessed June 2010 on the website of the Jacob Crouch Foundation at: www.injacobsmemory.org/history-of-suicide.html

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: 1999, accessed June 2010 at: www.surgeongeneral.gov/library/mentalhealth/chapter1/sec1.html