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Eric Bui (ed.)Clinical Handbook of Bereavement and Grief Reactions Current Clinical Psychiatryhttps://doi.org/10.1007/978-3-319-65241-2_77. Grief Reactions in the Suicide Bereaved
(1)
Department of Psychiatry, School of Medicine, University of California, San Diego, CA 92093, USA
(2)
VA San Diego Healthcare System, San Diego, CA, USA
Keywords
SuicideLossBereavementTreatmentStigmaComplicated griefSuicide bereavement is common and its effects ripple throughout society. In the United States, suicide is the 10th leading cause of death and there are approximately 120 completed suicides per day [1]. Approximately 7% of people in the United States are exposed to bereavement by suicide every year [2]. Survey results indicate that for every completed suicide, 60 people—the suicide bereaved—are intimately affected [3, 4]; countless others are affected for each suicide, albeit less intensely.
Regardless of the cause of death, grieving the loss of a loved one can be one of the most painful of life experiences. Despite the fact that every bereaved person’s grief is unique, grieving the loss of a loved one to suicide adds layers of complexity to what can be an already profoundly painful experience. On one hand, suicide bereavement shares many features with bereavement in general: the intensity and duration of the acute grief response can range considerably; the bereaved often experience their grief in waves; and yearning, denial, anger, and sadness can be intermixed with positive recollections of the deceased. Despite these similarities, many aspects of suicide bereavement in particular add to its complexity and set it apart from bereavement in general [5]. This chapter will focus on these factors, delineating the unique context, qualitative features, sequelae, and treatment considerations for suicide bereavement.
Suicide Bereavement in the Context of Stigma
Understanding stigma is pivotal to understanding the context of suicide bereavement and suicide bereavement itself. Common definitions of stigma include a set of negative and often unfair beliefs that a society or group of people have about something or “a mark of disgrace or reproach.” Despite valiant efforts by many organizations to counter and reduce the stigma around mental illness and suicide, stigma associated with suicide remains pervasive. It is seen in insurance policies’ built-in clauses regarding suicide [6]. It is evident in the historical practices of the US government, which only recently [7] began to honorably acknowledge military families bereaved by suicide with the same presidential condolence letters sent to other families bereaved by deaths occurring in combat zones. Stigma is also apparent in the practice of certain religions which impose shameful restrictions on the grief rituals allowed for survivors of suicide loss [8]. Such religious practices rob the suicide-bereaved of the solace, comfort and guidance that religion often provides in their time of loss, perpetuating stigma, and complicating the suicide loss survivor’s grief.
Bereaved individuals typically move from the acute stages of grief to integrated grief by processing their loss [9]. However, the stigma surrounding suicide held by many members of society is often internalized by the suicide bereaved themselves, affecting and interfering with this healing process. Stigma and resultant shame lead many suicide bereaved to feel the need to conceal the cause of death and avoid discussing the suicide lest they make others uncomfortable. Commonly, the suicide bereaved will, in turn, avoid social interactions with friends and family [10], resulting in isolation, loneliness, and the absence of those very sources of support so essential to healing after loss [8]. Simultaneously, the suicide bereaved experience more stigmatization from their friends, family, colleagues, and neighbors—their “social networks” [10]. Part of the stigmatization is overt. However, most of the stigmatization reflects a more subtle social phenomenon in which people’s lack of norms and knowledge about how to best help support someone after the death of a loved one by suicide triggers them to avoid the suicide bereaved—the concept Dyregrov has termed “social ineptitude” [11]. It is, thus, not surprising that in a review of 41 studies, the suicide bereaved experienced higher incidences of stigma, shame, and the need to conceal the cause of death from others, compared to other bereaved individuals [12]. The layers of stigma regarding suicide that exist in our society lay the foundation for suicide bereavement and pose barriers to the healing process [13].
Qualitative Features of Bereavement after Suicide
In addition to the inevitable yearning, sadness, and at times disbelief common to all grief, prominent symptoms of overwhelming guilt, confusion, shame, rejection, and anger are classic features of suicide bereavement [10, 14]. Although these qualitative features are not solely unique to suicide bereavement, they are common features of suicide bereavement, especially in aggregate. The common perception that suicide is preventable and reflects a poor decision on the behalf of the deceased provides the foundation for these qualitative features of suicide bereavement—the cascade of self-doubt, feelings of abandonment, and displaced and projected anger [5].
Self-Blame, Guilt, Confusion, and Shame
Once individuals who have lost a loved one to suicide get past the commonly experienced utter shock, confusion, and disbelief surrounding the death, most are subsequently consumed with trying to understand why their loved ones decided to end their life. Invariably, this need to understand involves holding the mirror to themselves, questioning the role that they played in the suicide. The mirror often turns into a microscope. A heightened process of self-blame may ensue [13]. The suicide bereaved micro-examine scenes from their life with the now deceased, especially those just prior to the completed suicide. These scenes are on auto-repeat, as the individual combs these memories searching for clues and warnings that they missed in real time. They are often haunted by the “what ifs,” the “could haves,” the “should haves,” and the “if onlys.” They replay past arguments and conversations, ruminate about unfulfilled plans, regret not returning calls or texts, all while trying to convince themselves that if only they had said or done something differently, their loved one would still be alive [15].
While near strangers learning of an acquaintance’s suicide death will often ask themselves, “if only I had stopped to say hello” or “if only I had smiled at them as I passed them on the street,” such ruminations are significantly more frequent and pronounced in the deceased’s inner circle—the spouse, sibling, child, or parent. Overwhelming feelings of guilt and responsibility are particularly seen in parents who lost a child to suicide [16]. The death of a child is one of, if not the most difficult loss imaginable [17], and this is even magnified when that loss is by suicide.
Thoughts of Abandonment and Rejection
Grieving individuals commonly perceive death from any cause as a form of abandonment, often unconsciously, and at times consciously. This is especially pronounced when the death is by suicide. The suicide bereaved often see the suicide as a choice—a choice to “give up” on life, leaving loved ones behind [15]. Feelings of abandonment are particularly profound for children and spouses of individuals who died by suicide. When children lose the person to suicide whom they expect to protect them, nourish them, and comfort them, the person who brought them into this world, they understandably feel abandoned [18, 19]. Interestingly though, feelings of abandonment are less pronounced for children whose parent struggled with an alcohol use disorder prior to their completed suicide [20]. Meanwhile, considering that a marriage is typically the most intimate relationship in a person’s life, individuals whose spouse completes suicide often suffer from feelings of utter rejection and abandonment [21]. Surviving spouses are left haunted by the question of why they and their relationship with the deceased were not enough to help their loved one choose life over death [22].
Anger
It is rare for the suicide bereaved not to experience anger. The anger can be pervasive or have a direct focus. Its focus can shift with time. Common foci of the anger experienced by individuals grieving a loss by suicide include themselves, the person who died, family members, friends of the deceased, health providers, caregivers, God, and the world in general [15].
Suicide bereaved often experience anger towards the dead for leaving them, anger for not giving them a chance to help, anger for causing such heartache, shame, and rejection. At times, anger about being left to “clean up the mess” from the suicide, both literally and figuratively, can also be present. Fundamentally, aggression is part of suicide. The deceased is both the murdered and the murderer. Anger and aggression are intertwined and the surviving loved ones can experience visceral anger towards the “murderer.” There can be anger about the date of the suicide, especially when the suicide occurred on a birthday, anniversary, or celebrated holiday. The suicide will forever change the meaning of that day. Commonly, the anger morphs into guilt, as the bereaved recognize that their loved one suffered deeply. At times, the anger is intermixed with envy and is directed towards individuals who have never suffered the loss of a loved one to suicide—individuals the bereaved perceive can and will never understand the depth of their suffering.
Sequelae of Suicide Bereavement
Partly related to the layers of guilt, shame, stigma, rejection, abandonment, and anger that characterize suicide bereavement and partly related to the same conditions that set the stage for their loved one’s suicide, the suicide bereaved are at higher risk for various psychiatric comorbidities. These include Posttraumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), suicidal ideation and behaviors, and Complicated Grief (CG)—a prolonged form of grief associated with significant morbidity and mortality.
Comorbid Traumatic and Depressive Disorders
Much about suicide is traumatic. Most suicide methods involve significant bodily damage. This is most striking in regard to suicide by gunshot, but is also apparent with jumping from great heights, cutting, stabbing, hanging, suffocation, poisoning, and other suicide methods. Individuals grieving from suicide are often the first to discover the dead body, and, at times, are witnesses to the actual act of suicide. For those who witness the suicide or are the first to find the body, the haunting, consuming images of the death are often seared into their memories into perpetuity [23]. This is also the case for those who did not witness the death or body, but have to clean up after the death or live in the same residence in which the suicide occurred. Even those who did not witness the death or the body often struggle with the gruesome images created in their mind’s eye after learning the details of the completed suicide. The common involvement of the police, firefighters, and the medical examiner’s office adds to the traumatic qualities of the suicide. Particularly, insensitive death notification procedures can add to the traumatic stress of the bereaved. Important efforts by the American Foundation for Suicide Prevention (AFSP) and the Association for Death Education Counseling (ADEC) have tempered the trauma associated with suicide [5], but cannot fully erase it. Suicide is inherently violent, “unnatural,” and traumatic.
It is thus not surprising that individuals who lost a loved one to suicide are at higher risk of developing PTSD than are other bereaved individuals [24, 25]. Overlapping symptoms of grief and PTSD, including withdrawal, preoccupation with the death, anxiety symptoms, and hyperarousal are more common, prolonged, and intense in individuals grieving from suicide as compared to nontraumatic deaths [26].
Although the evidence is mixed, several studies have found that individuals grieving a loss to suicide are at higher risk for developing a major depressive episode (MDE) [4, 10, 12, 27, 28]. This is especially the case for people who have a pre-existing mood disorder in whom the stressors inherent to losing a loved one to suicide can trigger a major depressive episode.
Suicidal Ideation and Behaviors
Reflecting a combination of genetic and environmental factors, individuals who have a family history of suicide are at higher risk for suicide [29, 30]. Even knowing the profound layers of suffering associated with grieving a loved one’s death to suicide, the suicide bereaved are at increased risk for developing suicidal ideation and behavior [31–33]. The results are quite clear and striking. In one study, knowing someone who died by suicide in the prior year was associated with a 1.6 increased risk for suicidal ideation, a 2.9 increased risk for suicidal plan, and a 3.7 increased risk for making a suicide attempt [2]. While alarming, these data also suggest powerful opportunities for primary prevention [27].
The intergenerational effects of suicide are nuanced and, at first thought, contradictory. For example, why would the people who most intimately understand the profundity of suicide’s impact on loved ones choose to take their life? Several factors help explain this seeming contradiction. First, one of the clearest and most predictive risk factors for suicide is having a mental illness [34]. An exacerbation of the suicide bereaved’s own mental health condition can be triggered by the suicide, putting the bereaved at risk for their own suicide. Additionally, the pain of the loss, which is interconnected with anger, perceived responsibility, rejection, and isolation, can be unbearable. For these individuals, suicide may seem like the only solution to alleviating their pain [15]. For others, the intensity of yearning for a loved one who completed suicide can lead them to kill themselves in order to reunite with their loved one in death. Similarly, killing themselves could be a way in which to feel closer to their now deceased loved one. Case reports indicate that certain people grieving the loss of a loved one to suicide will take their own lives, mimicking everything down to the details of suicide method, date, time, and/or location [15].
Complicated Grief
In the usual healing process after a loss, acute grief transforms into integrated grief, in which the grief takes up less emotional space with time and the bereaved integrates back into a meaningful life [9]. At times, as with non-suicide bereavement, CG can ensue. As indicated in the other chapters, CG, also referred to as prolonged grief disorder [35] and persistent complex bereavement disorder [36], is a bereavement reaction in which the intensity of the acute phases of grief does not abate, causing distress, interfering with functioning and leading to poor psychological and general medical health outcomes [37, 38]. The “if onlys, could haves, and should haves” prevail, adaptation to the loss is blocked, and healing is thwarted. Common CG symptoms include recurring, self-blaming thoughts related to the death, anger about the death, intrusive images of the death, excessive avoidance of reminders of the loss, feelings of disbelief about the death, isolation from others, loss of meaning in life, and suicidal ideation [39–44]. These features also often characterize individuals bereaved by suicide [15] and may be magnified by the feelings of confusion, rejection, trauma, and stigma associated with suicide bereavement in particular.
Indeed, survivors of suicide loss are at high risk of developing CG [10, 11, 15, 45–49]. In one small sample of suicide-bereaved participants, Mitchell and colleagues reported CG rates of 43% [48], much higher than CG rates of 7–15% reported in the general bereaved population [50]. Further, suicide-bereaved individuals who developed CG were almost ten times more likely than those who did not develop CG to have reported suicidal ideation 1 month after the death of their loved ones, even after controlling for depression [41]. Finally, compared to other individuals with CG, some suicide-bereaved individuals with CG may have higher rates of depression, PTSD, and suicidal ideation in addition to greater impairment, isolation, and self-blame [28].
When symptoms are apparent and impairing, CG may be diagnosed as soon as 6–12 months following the death of a loved one. Some experts [51] suggest that 3–5 years is the time point at which grief after a suicide loss begins to integrate, raising the question of the applicability of the CG criteria to the “normal” timeline for grief after suicide. That said, in at least one sample studied [52], symptoms of traumatic grief 6 months after a peer suicide predicted the onset of depression or PTSD at subsequent time points. Therefore, it is important for clinicians to know how to identify CG in order to provide appropriate support and treatment when needed, especially if symptoms are impairing, however “normal” they may be. Left untreated, CG symptoms may persist indefinitely, leaving the bereaved stuck in the acute stages of their grief. But when properly managed, CG can carry an excellent prognosis [53].
Treatment Considerations
Grief is a normal and adaptive response to the loss of a loved one and the vast majority of bereaved individuals get through their grief without any need for professional intervention. Grief should not be pathologized or medicalized, regardless of cause of death. However, in light of the complexities of suicide bereavement outlined in this chapter, friends, family, colleagues, and providers should all be attuned to the importance of providing needed support. Simply stated, grief works best in the context of the love and support of others. However, the love, support and reassurance of friends, family, and, at times, spiritual leaders is often not available or sufficient for the needs of the suicide bereaved, and more help may be needed. Unfortunately, there is a paucity of treatment studies available to help guide the treatment decisions for the suicide-bereaved population [54]. Clearly, treatment must involve issues related to both separation and trauma. For many, there is a prominent role for focused support groups. For others, especially those with comorbid mental health conditions, such as major depressive disorder, posttraumatic stress disorder, and/or complicated grief, more comprehensive assessment and evidence-based treatment is warranted [55].
Support Groups
Support groups are one of the mainstays of assisting people who lost a loved one to suicide. Extant studies of support groups for the suicide bereaved indicate they are at least moderately helpful [56]. Support groups for the suicide bereaved can help participants with everything from dealing with the practicalities of life to coping with the gripping emotional wounds of suicide. For many suicide bereaved, the “check-list” of what needs to be taken care of after the death can be suffocating, especially when the items are unknown territory. Members of support groups can help each other with tips and guidance on the pragmatic aspects of life, including handling estates, finances, and legal matters. Support groups are also a place in which participants can learn valuable ideas about how to best cope with the holidays, plan for a meaningful memorial, and speak to others who are also grieving, including children, about the suicide. It is a safe place in which participants learn from others who have done the unimaginable—setting and enacting new goals for a life that will always be marked by this tremendous, unthinkable loss.
The emotional support inherent in support groups for the suicide bereaved cannot be underestimated. Support groups are a place in which participants can feel understood, where their at times overwhelming emotions and thoughts are acceptable to share. Participation helps the bereaved normalize their experiences and simultaneously helps them feel connected to others who can fundamentally understand and relate to their struggles and pain. In essence, support groups help participants transition from feeling desperately alone in their grief to feeling connected to a caring, accepting community. Support groups also help participants find purpose by creating the circle of giving and getting, teaching and learning, supporting and being supported.
There are specific groups for whom support groups are known to be particularly helpful, including groups for children who lost a parent or other relative to suicide [55]. In fact, the more targeted (suicide bereaved versus general bereaved; parents who lost a child to suicide versus individuals who lost a loved one in general to suicide; etc.) the group is, the more therapeutic it tends to be [14]. The general consensus among experts and clinicians is that support groups are clinically useful, although more formal empirical efficacy testing may be needed. Interestingly, despite its inherent therapeutic value, few suicide bereaved seek any help, including from support group participation [57]. The reasons for this are multifactorial and warrant further study and intervention.
Treatment of Associated Mental Health Conditions
Although Section III of the handbook details the management of and treatment approaches to grief reactions, we will briefly review here specificities of suicide bereavement. Natural healing processes, even when supplemented by support groups, are not always enough. This often is the case when suicide bereavement is associated with one or more mental health condition(s). It is common for providers to rationalize that everyone who lost a loved one to suicide would be depressed or that everyone who found the body of a loved one after a completed suicide would be traumatized by that experience. Rather than being conceptualized as MDD or PTSD that might be triggered or worsened by suicide bereavement, the symptoms often are rationalized as expected under the circumstances. With suicide bereavement associated with depressive or PTSD symptoms, the fear of unnecessarily medicalizing a normal process can intervene with needed treatment. Resultantly, there is a tendency not to treat the depression or the trauma. This tendency can lead to missed opportunities for important and necessary intervention.
Before initiating treatment, one must first determine if additional mental health conditions exist, and, if so, to next refine the diagnoses. In regard to MDD, the first step is to distinguish between depressive symptoms and a major depressive episode. Sadness, grief, and sorrow are ubiquitous human experiences that should not be confused with the clinical disorder, MDD [58]. One simple way of distinguishing everyday sadness from MDD is by using the 3 “Ps”: MDD is more persistent, occurring most days, most of the day, for at least a few weeks; more pervasive, affecting not only emotions, but also the way people interact with others and think, behave, and feel about themselves; and more pathological, triggering ongoing distress, suffering, and impairment [59].
The next step is to remember precisely what grief and MDD represent, how to distinguish between them, and how to conceptualize their relationship. Grief is the normal, expected, generally adaptive psychological, biological, interpersonal and social response to loss. MDD, on the other hand, is a serious, sometimes malignant, life-threatening mental disorder marked by intense, persistent and pervasive sadness and/or anhedonia. MDD generally is a recurrent condition and often is quite chronic. The death of a loved one almost always triggers grief; but, as an exquisitely stressful and sometimes traumatic life event, it may also precipitate a number of adverse health consequences, including (but not limited to) MDD.
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