With a recent spate of celebrity and assisted suicides in the news, the issue of suicide loss and how to work with it is at the top of many minds, mine included. November 22, 2014 is International Survivors of Suicide Loss Day. The day is not a celebration, but a remembrance and a time of heightened awareness.
Of course celebrities are not the only people who have conditions that lead to seeing suicide as the best or only option. More typically, suicide loss might look like:
- An 87-year-old man with advanced lung cancer, whose wife died last year, who knows he is close to death anyway, feels lonely, and lacks social support;
- A 27-year old female physician, a recent medical school graduate, who is overwhelmed by her residency, professional competitiveness, and perfectionism;
- A 15-year old boy, plagued with intrusive thoughts that he might be gay, seemingly uncontrollable behaviors, and social rejection, who is ashamed of his strangeness and doesn’t know to ask for help.
I am a psychologist, a Certified Bereavement Facilitator with a specialty in suicide loss, and a person who has lost two immediate family members to suicide. My father and my brother both lived and died with severe mental illness. This experience enriches my work with survivors, of whom there are many. The American Association of Suicidology notes that 40,000 Americans per year end their lives by suicide, each one adding to the pool of over 4.5 million survivors (AAS, 2012).
The basic facts leading to the existence of Survivors Of Suicide (SOS) or Survivors After Suicide (SAS) are grim. A person dies by suicide every 13.3 minutes (AAS, CDC). The after-effects last a lifetime for those who are survivors.
As therapists, we are trained to treat depression, grief, and loss, but there are relatively few of us who specialize in bereavement, and the presentation of suicide loss in a clinical setting may be overwhelming due to its uniqueness and complexity. And in fact, many people who have a suicide loss in their lives are experiencing complicated bereavement.
The special issues associated with suicide loss include:
- Finding the body: Unlike deaths from old age or medical illness, the survivor has often happened upon their loved one’s body unexpectedly. The person may have still been struggling for life in overdose attempts, and even after a gunshot or hanging. This likely elicited fear, horror, and shock and, ultimately, resulted in a traumatic imprinting on the brain. Many survivors who found the body will report PTSD-like symptoms, particularly flashbacks and avoidance.
- Cleaning up after the death: Although professional crime scene cleaning companies are usually utilized, some survivors cleaned the suicide area themselves. They may have been exposed to blood, bone or brain fragments, or other bodily parts or fluids, particularly after gunshot deaths. Again, this may create or compound trauma in the survivor.
- Legal and financial issues: Sometimes it is not clear that a death was a suicide, which may result in extensive police investigations that involve the family and contribute to a sense of incompleteness and confusion about the death. Payouts on insurance policies and other survivor benefits may be delayed or limited by the cause of death.
- Post-death discoveries: Less dramatic, but no less important, may be the discovery of new and distressing information about the person who died – having a terminal illness, being involved in crime, having a drug addiction, money problems, or an unusual sexual life. And, there is no way to query the person who died, which may lead to research, obsessional thinking, guilt, and shame.
- Shock/no time to say goodbye: Sometimes there are warnings, such as with chronic mental illness, prior attempts, or known current suicidal thoughts or behaviors. But just as often, there was no warning, and the survivor experiences deep regret, yearning, and longing to complete the relationship and say a proper goodbye. Rituals, termination issues, and healthy goodbyes are often key elements of therapy.
- Need to understand: Sometimes therapy is focused intensely on the “why” of the suicide. The need to understand may be particularly intense in cases with no documented history of substance abuse or mental illness. A de facto psychological autopsy may take place within the context of the therapy or grief counseling.
- Stigma: In spite of the openness in our society, mental illness still carries stigma and deaths by suicide have historically carried great stigma. Note that, for a person whose loss occurred many years ago, this may be more of an issue than for a person whose loss is newer.
- Religious taboo: Similar to the general issues of cultural stigma, religious taboos against suicide still linger from centuries ago. For some people, they may bring in judgments or fears about the suicide or where the person ended up after death.
- Anger: One of the most common reactions to suicide is anger. Normalizing, accepting, and expressing the anger are all important parts of the recovery process.
- Relief: Many survivors report a distinct feeling of relief after a suicide, along with accompanying guilt about having the relief. I certainly felt this way after my brother died, because his illness had resulted in so much pain for our family for many years. Relief is a normal feeling when a person’s life, lifestyle, mental illness, or chronic suicidal condition resulted in enormous fear, burdens, expense, worry, and danger.
- Activation of mental illness, addiction, or physical illness: the stress of grief and loss is profound, and more so in the survivor. If they struggled with mental illness or addiction themselves before the death, their symptoms may be exacerbated or reactivated. Likewise, the stress of grieving affects the body and may result in serious new diagnoses, numerous smaller illnesses, or flare-ups of existing disease.
As a therapist, you can help by knowing what this particular form of grief looks like in your clients, offering specific resources for education and support groups (see .pdf handout), and sensitively utilizing your compassion, empathy, and therapeutic training to help move the survivor of suicide through their grief process.
Gretchen Kubacky, Psy.D. is a Health Psychologist specializing in chronic illness and a Certified Bereavement Facilitator specializing in suicide loss. She has a private practice in Los Angeles, California, serves on the Board of the Los Angeles County Psychological Association, and is a frequent speaker, author, and consultant in these specialties. For more information, please see DrGretchenKubacky.com.