Abstract
Grief is a universal human experience, and yet is often a topic clinicians and the general public are not well versed in. Grief brings painful yet entirely natural emotions and physical experiences, which people can heal and grow through. So, the role of the mental or primary care health professional is usually supportive, helping patients to process the loss and to heal. In other words, grief is not generally a pathological experience unless particular vulnerabilities are exacerbated.
A Principles
Suicide loss produces a profoundly impactful experience, which can be traumatizing for many.
It is helpful for clinicians across specialty areas to appreciate the complexities in order to provide optimal patient care to patients who have experienced suicide loss.
The loved one who died by suicide and their memory can be integrated into one’s life moving forward, but people do not “get over” the loss of a loved one.
Suicide loss has several known associated health outcomes affecting both physical and mental health, as well as increasing suicide risk for some.
Clinicians should monitor for the potential development of Complicated Grief (CG) or Prolonged Grief Disorder, which occurs in a high percentage of people bereaved by suicide. Evidence-based treatment for CG is Complicated Grief Therapy (CGT).
Other health sequelae of suicide loss (physical and mental health changes) should be vigilantly screened for and addressed.
Clinicians can also experience significant personal and professional ramifications of losing a patient to suicide and recommendations are provided.
B Introduction
Grief is a universal human experience, and yet is often a topic clinicians and the general public are not well versed in. Grief brings painful yet entirely natural emotions and physical experiences, which people can heal and grow through. So, the role of the mental or primary care health professional is usually supportive, helping patients to process the loss and to heal. In other words, grief is not generally a pathological experience unless particular vulnerabilities are exacerbated.
The death of a loved one by any cause can be a profoundly painful experience; losing a loved one to suicide comes with layers of additional complexities, which can make suicide bereavement quite unique and extremely painful. While grief is a common human experience, most grief experiences do not require clinical intervention. Many times acute grief naturally transitions to integrated grief – this “healing” being marked by the individual’s own recognition of having worked through grief, being able to think of the deceased with equanimity, being able to return to work, to experience pleasure, and to be able to seek companionship and the love of others.2 However, just as stresses and losses of other kinds can precipitate depression or PTSD in a vulnerable individual, so can the death of a loved one. It is important to keep in mind that depression, anxiety disorders, PTSD, and/or substance misuse can co-occur with grief, and if unaddressed can significantly impede the natural process of healing from loss, leading to much greater disability and negative health outcomes.
C Suicide Bereavement
Losing someone to suicide is a particularly painful and complex type of loss. One way suicide-related grief differs from other types of loss has to do with the way their loved one died and the questions and emotions their loved one’s death by suicide evokes. Natural questions of why compound a baseline foundational knowledge that may be low concerning suicide in general. In an effort to make sense of the inexplicable and shocking event that has occurred, people generally automatically go into an intense search for information and hypothesis generating. This can lead to guilt, blame, anger at oneself, others, and the loved one who died. This is a natural part of suicide grief, often extremely intense in the initial several months, and often lessening in intensity in the second year and beyond.
Role of Stigma
Stigma is not to be underestimated as an additional layer that makes suicide bereavement more challenging. While most bereaved families receive an outpouring of support from community, there is often silence when the community members may not have had education to dispel myths concerning suicide, and when the social norms had been exceedingly harsh and discriminating in the historical past. For example, within the current lifetime of people alive today, it was not uncommon for families whose loved one took their life to be shunned in various ways, excommunicated by the church, or the deceased denied a proper burial, and in many places in the world suicide was, or is, a crime, punishable by law.
Understanding Suicide Helps Loss Survivors
We now have the science to realize suicide is better understood as a succumbing to intense health problems, where someone falls victim to the complex interaction between suffering, health, genetic, social, and environmental factors. And in some (rarer) cases of suicide, it is clear that the mental health condition could be understood similarly to the way one thinks of terminal disease – when even in the face of the best clinical treatment, self-strategies, and family support, like some forms of cancer or other terminal illness, the illness persists, proves to be recalcitrant and malignant, and the person does not survive. While the majority of suicides are not so clear cut, having higher degrees of influence over social and environmental factors in addition to the mental and/or physical health condition(s), we can help people who lose their loved one to suicide by providing this health framework for understanding suicide.
Prevalence and Impact of Suicide Loss
Suicide loss survivors have long been a major force driving the suicide prevention movement forward. And while Dr. Edwin Shneidman described the experience of suicide bereavement and the need for better support resources several decades ago,3 only in recent years has significant research shed light on the details of prevalence, sequelae, and course of suicide bereavement. A large number of individuals are affected by each suicide death, including family members, friends, colleagues, and others.4 Therefore a significant portion of community members across multiple countries have been bereaved by suicide at some point during their lifetime. An international meta-analysis of population-based suicide loss studies found 4.3% of community members experienced another’s suicide in the past year, and 21.8% during their lifetime.5 In the USA, even higher rates of exposure were found. From a national sample of 1,432 adults, 51% were suicide exposed and 35% met criteria for suicide bereaved (defined as experiencing moderate to severe emotional distress related to the suicide loss) at some point in their lives.6 In a sample of 1,736 adults in one state in the USA (Kentucky), 48% had been exposed to suicide loss in their lifetime. Correlating to the degree of perceived closeness to the deceased individual, rates of clinical depression and anxiety disorders were two times greater, and PTSD four times greater, than in suicide unexposed subjects. Suicide exposed individuals were also almost twice as likely to experience suicidal ideation (9% versus 5%)7 where suicide risk is elevated. There are also increased physical health consequences associated with suicide loss.8 It is imperative that suicide loss survivors receive the care and support they need to facilitate grieving and prevent any number of significant health risks including increased risk of suicide.
D Terminology
In the past, the commonly used term for survivors of suicide loss had been “Survivors” in suicide prevention circles. However, in recent years as stigma has decreased, an incredibly important point of progress has been people who have survived their own suicide attempt speaking up, advocating for change, and providing a new depth of expertise to the suicide prevention movement. And therefore the more appropriate and clear term for survivors of suicide loss is now “Loss Survivors.”
The following are acceptable terms:
Suicide loss survivors
Loss survivors
Survivors of suicide loss
Persons bereaved by suicide
E General Approaches for Patients Bereaved by Suicide
Various interventions have been evaluated for their impact on suicide bereaved people; these include educational and postvention programs at the community level, treatment at the clinical level, and support groups, some of which provide clinical treatment, many of which are considered non-clinical and provide peer support and facilitated processing of grief. All of these interventions, especially those involving the family or community of the bereaved, showed some level of evidence.9 However, when CG is present, these types of approaches – even treatment of depression – are often not effective.10,11 All clinicians should receive general education in the experience of suicide bereavement (see AFSP workshop Suicide Bereavement Clinician Training Program at afsp.org)12 and should also be educated about CG.
Clinical Tips for Working with Patients Bereaved by Suicide
An approach to avoid is telling a patient bereaved by suicide that they should be through their grief by now. This is an experience many loss survivors have had with physicians and therapists, and their perception of these words is that the clinician lacks knowledge about the unique features and course of suicide grief, and the overall impact on the treatment relationship can be devastating. Grief is not an experience with an end point, but rather with phases of healing and growth. If you are concerned that there may be comorbid conditions such as depression, PTSD, or CG present, then explain to the patient that for a variety of reasons including prior history, they may be developing an additional condition that actually impedes the process of grief. It is very important to help patients understand you are not going to take their grief away or make them miss their loved one less (they often do not want to let this go), by treating these very serious health conditions. In fact, the patient can expect to continue to grieve and remember their loved one in a way that may feel as intense and intimate, but healthier.
F Potential Outcomes Associated with Suicide Bereavement and Recommended Approaches
Grief in General
When grief is uncomplicated, it is still a painful, often intense, non-linear experience, but is a normal, adaptive response to loss. Noncomplicated grief that is not comorbid with depression does not warrant any formal clinical intervention in most instances. That said, supportive therapy for working through grief – especially after suicide – can be very helpful.11 Support groups for suicide loss can also be enormously helpful. The International Association of Suicide Prevention (IASP) and AFSP provide many resources for suicide loss survivors; AFSP has a listing of over 500 support groups in the USA. Of course, loss survivors should also receive family and community support as would be the case for any bereaved individuals.
If you have broader connections within the loss survivor’s community, encourage community members to shed stigma and approach the person bereaved by suicide just as they would any other person who is grieving. Offering meals, rides, spending time with them, asking if they need help, and if they want to talk about their loved one, should all be encouraged.
Complicated Grief
In addition to the potential development, recurrence, or worsening of mental health symptoms or conditions, survivors of suicide loss are at increased risk of developing CG. Without specific treatment, CG tends to have a persistent and refractory course. Consider referral to a CGT therapist, or if not available, a therapist who can provide the components of CGT. (See box on CGT components p. 268.) Treat depression or PTSD if present as well.
An estimated 10–20% of bereaved people in the general population (bereaved by any cause of death) experience a more challenging form of grief persisting more than six months beyond the death of their loved one. Among suicide bereaved people the incidence of CG is very high – from 40–80%.10 CG is characterized by extreme preoccupation and yearning for the deceased person, recurrent painful emotions, ruminations, avoidance of triggers, and difficulty feeling connected to others and their life – a sort of painful acute grief driven “stuckness.” It is important to note that CG is essentially synonymous with the newly added Prolonged Grief Disorder in the DSM-5-TR and ICD-11.13
Keeping an awareness and vigilance for identifying CG is extremely important since many clinicians mistake it for depression, and depression treatment does not tend to address CG. Distinguishing factors between the two include CG’s hallmark features of extreme yearning and overwhelming thoughts about the person the patient lost, whereas depression’s hallmark features are sadness and anhedonia that do not necessarily have the extreme longing and obsessional features of CG. Of course, the two conditions can co-occur, and in that case, both should be addressed, ideally with depression treatment as usual and CGT.
Clinical Features of Complicated Grief
Acute grief symptoms that persist for more than six months following the death of a loved one, including:
1. Feelings of intense yearning or longing for the person who died – missing the person so much it is hard to care about anything else
2. Preoccupying memories, thoughts, or images of the deceased person, that may be wanted or unwanted, that interfere with the ability to engage in meaningful activities or relationships with significant others; may include compulsively seeking proximity to the deceased person through pictures, keepsakes, possessions, or other items associated with the loved one
3. Recurrent painful emotions related to the death, such as deep relentless sadness, guilt, envy, bitterness, or anger, that are difficult to control
4. Avoidance of situations, people, or places that trigger painful emotions or preoccupying thoughts related to the death
5. Difficulty restoring the capacity for meaningful positive emotions through a sense of purpose in life, or through satisfaction, joy, or happiness in activities, or relationships with others
CG can be identified reliably using the Inventory of Complicated Grief14 more than six months after the death of a loved one.
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