Evidence-Based Reviews

Helping survivors in the aftermath of suicide loss

Current Psychiatry. 2018 August;17(8):27-33

References

1. Feigelman W, Jordan JR, McIntosh JL, et al. Devastating losses: how parents cope with the death of a child to suicide or drugs. New York, NY: Springer; 2012.
2. McIntosh JL. Research on survivors of suicide. In: Stimming MT, Stimming M, eds. Before their time: adult children’s experiences of parental suicide. Philadelphia, PA: Temple University Press; 1999:157-180.
3. Sanford RL, Cerel J, McGann VL, et al. Suicide loss survivors’ experiences with therapy: Implications for clinical practice. Community Ment Health J. 2016;5(2):551-558.
4. Jordan JR, McMenamy J. Interventions for suicide survivors: a review of the literature. Suicide Life Threat Behav. 2004;34(4):337-349.
5. Survivors of Suicide Loss Task Force. Responding to grief, trauma, & distress after a suicide: U.S. national guidelines. Washington, DC: National Action Alliance for Suicide Prevention; 2015.
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7. Jordan JR. Is suicide bereavement different? A reassessment of the literature. Suicide Life Threat Behav. 2001;31(1):91-102.
8. Cvinar JG. Do suicide survivors suffer social stigma: a review of the literature. Perspect Psychiatr Care. 2005;41(1):14-21.
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13. Jordan, JR, McIntosh, JL. Is suicide bereavement different? A framework for rethinking the question. In: Jordan JR, McIntosh JL, eds. Grief after suicide: understanding the consequences and caring for the survivors. New York, NY: Routledge/Taylor & Francis Group; 2011:19-42.
14. Dunne EJ, McIntosh JL, Dunne-Maxim K, eds. Suicide and its aftermath: understanding and counseling the survivors. New York, NY: W.W. Norton & Co.; 1987.
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17. Van Dongen CJ. Social context of postsuicide bereavement. Death Stud. 1993;17(2):125-141.
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19. Range LM. When a loss is due to suicide: unique aspects of bereavement. In: Harvey JH, ed. Perspectives on loss: a sourcebook. Philadelphia, PA: Brunner/Mazel; 1998:213-220.
20. 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.
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22. Shneidman ES. Foreword. In: Cain AC, ed. Survivors of suicide. Springfield, IL: Charles C. Thomas; 1972:ix-xi.
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29. Sands DC, Jordan JR, Neimeyer RA. The meanings of suicide: A narrative approach to healing. In: Jordan JR, McIntosh JL, eds. Grief after suicide: understanding the consequences and caring for the survivors. New York, NY: Routledge/Taylor & Francis Group; 2011:249-282.
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33. Grad OT, Treven M, Krysinska K. Suicide bereavement and gender. In: Andriessen K, Krysinska K, Grad OT, eds. Postvention in action: the international handbook of suicide bereavement support. Cambridge, MA: Hogrefe; 2017:39-49.
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Family disruption. It is not uncommon for a suicide loss to result in family disruption.^6,31-32 This may manifest in the blaming of family members for “sins of omission or commission,”⁶ conflicts around the disclosure of the suicide both within and outside of the family, discordant grieving styles, and difficulties in understanding and attending to the needs of one’s children while grieving oneself.

Despite the common elements often seen in suicide grief, it is crucial to recognize that this process is not “one size fits all.” Not only are there individual variants, but Grad et al³³ found gender-based differences in grieving styles, and cultural issues such as the “meanings” assigned to suicide, and culturally sanctioned grief rituals and behaviors that are also likely to affect how grief is experienced and expressed. In addition, personal variants such as closeness/conflicts with the deceased, histories of previous trauma or loss, pre-existing psychiatric disorders, and attachment orientation³⁴ are likely to impact the grief process.

Losing close friends and colleagues may be similarly traumatic, but these survivors of suicide loss often receive even less social support than those who have kinship losses. Finally, when a suicide loss occurs in a professional capacity (such as the loss of a patient), this is likely to have many additional implications for one’s professional functions and identity.³⁵

Interventions to help survivors

Several goals and “tasks” are involved in the suicide bereavement process (Box 2^1,6,30,36-40). These can be achieved through the following interventions: Support groups. Many survivors find that support groups that focus on suicide loss are extremely helpful, and research has supported this.^1,4,41-44 Interactions with other suicide loss survivors provide hope, connection, and an “antidote” to stigma and shame. Optimally, group facilitators provide education, validation and normalization of the grief trajectory, and facilitate the sharing of both loss experiences and current functioning between group members. As a result, group participants often report renewed connections, increased efficacy in giving and accepting support, and decreased distress (including reductions in PTSD and depressive symptoms). The American Association of Suicidology (www.suicidology.org) and American Foundation of Suicide Prevention (www.afsp.org) provide contact information for suicide loss survivor groups (by geographical area) as well as information about online support groups.

Box 2
Goals and 'tasks' in suicide bereavement

The following goals and "tasks" should be part of the process of suicide bereavement:

Reduce symptoms of posttraumatic stress disorder and other psychiatric disorders. Given the traumatic nature of the loss, an important goal is to understand and reduce posttraumatic stress disorder and other psychiatric symptoms, and incrementally improving functionality in relation to these.
Integrate the loss. Recent authors^36-38 have highlighted the need for survivors of suicide loss to "bear" and integrate the loss, as opposed to the concept of "getting over it." In these paradigms, the loss becomes an important part of one's identity, and eventually ceases to define it. Optimally, the "whole person" is remembered, not just the suicide. Part of this involves a reinvestment in life, with the acceptance of a "new normal" that takes the loss into account. It is not unusual for survivors of suicide loss to report some guilt in "moving on" and/or experiencing pleasure; often this is felt as a "betrayal" of the deceased.
Create meaning from the loss. A major goal for those who have lost a loved one to suicide is the ability to find and/or create meaning from the loss. This would include the creation of a loss narrative³⁹ that incorporates both ambiguity and complexity, as well as a regained/renewed sense of purpose in ongoing life.
Develop ambiguity tolerance. A related "task" in suicide grief is the development of ambiguity tolerance, which generally includes an understanding of the complexity underlying suicide, the ability to offer oneself a "fair trial"³⁰ in relation to one's realistic degree of responsibility, and the acceptance that many questions may remain unanswerable. In addition, in concert with the current understanding of "continuing bonds,"⁴⁰ survivors should attempt to attend to the ongoing relationship with the deceased, including any "unfinished business."⁶
Develop skills to manage stigmatized social responses and/or changes in family and social relationships.
Memorialize and honor the deceased. Healing for survivors is facilitated by memorializations, which both validate the mourning process itself while also paying tribute to the richness of the deceased person's life.
Post-traumatic growth. The relatively new understanding of "post-traumatic" growth is certainly applicable to the "unexpected gifts" many survivors of suicide loss report after they have moved through suicide grief. This includes greater understanding toward oneself, other survivors of suicide loss, and suicidal individuals; gratitude toward those who have provided support; and a desire to "use" their newfound understanding of suicide and suicide grief in ways to honor the deceased and benefit others. Feigelman et al¹ found that many longer-term survivors of suicide loss engaged in both direct service and social activism around suicide pre- and postvention.

Individual treatment. The limited research on individual treatment for suicide loss survivors suggests that while most participants find it generally helpful, a significant number of others report that their therapists lack knowledge of suicide grief and endorse stigmatizing attitudes toward suicide and suicide loss survivors.^45-46 In addition, Sanford et al³ found that survivors of suicide loss who endorsed PTSD symptoms were not assessed, diagnosed, or treated for these symptoms.

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Helping survivors in the aftermath of suicide loss

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Interventions to help survivors

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