Traumatic nature of suicide. Suicide loss is also quite traumatic, and posttraumatic stress disorder (PTSD) symptoms such as shock, horror, disbelief, and intrusive/perseverative thoughts and questions, particularly in the earlier stages of grief, are common. Sanford et al3 found that the higher the level of “perceived closeness” to the deceased, the more likely that survivors of suicide loss would experience PTSD symptoms. In addition, the dramatic loss of social support following a suicide loss may itself be traumatic, which can serve to compound these difficulties. Notably, Sanford et al3 found that even for those survivors of suicide loss in treatment who endorsed PTSD symptoms, many of their treating clinicians did not assess or diagnose this disorder, thus missing an important component for treatment.
Increased risk for suicidality. Studies have shown that individuals who have lost a loved one to suicide are themselves at heightened risk for suicidal ideation and behaviors.22-27 Therefore, an assessment for suicide risk is always advisable. However, it is important to note that suicidal ideation is not uncommon and can serve different functions for survivors of suicide loss without necessarily progressing to a plan for acting on such ideations. Survivors of suicide loss may wish to “join” their loved one; to understand or identify with the mental state of the deceased; to punish themselves for failing to prevent the suicide; or to end their own pain through death. Therefore, it is crucial to assess the nature and function of expressed ideation (in addition to the presence or absence of plans) before assigning the level of risk.
Elements of suicide grief
After the loss of a loved one to suicide, the path to healing is often complex, with survivors of suicide loss enduring the following challenges:
Existential assumptions are shattered. Several authors28-30 have found that suicide loss is also likely to shatter survivors’ existential assumptions regarding their worldviews, roles, and identities, as well as religious and spiritual beliefs. As one survivor of suicide loss in my practice noted, “The world is gone, nothing is predictable anymore, and it’s no longer safe to assume anything.” Others have described feeling “fragmented” in ways they had never before experienced, and many have reported difficulties in “trusting” their own judgment, the stability of the world, and relationships. “Why?” becomes an emergent and insistent question in the survivor’s efforts to understand the suicide and (ideally) reassemble a coherent narrative around the loss.
Increased duration and intensity of grief. The duration of the grief process is likely to be affected by the traumatic nature of suicide loss, the differential social support accorded to its survivors, and the difficulty in finding systems that can validate and normalize the unique elements in suicide bereavement. The stigmatized reactions of others, particularly when internalized, can present barriers to the processing of grief. In addition, the intensity of the trauma and existential impact, as well as the perseverative nature of several of the unique themes (Box 1), can also prolong the processing and increase the intensity of suicide grief. Clinicians would do well to recognize the relatively “normative” nature of the increased duration and intensity, rather than seeing it as immediately indicative of a DSM diagnosis of complicated/prolonged grief disorder.
Box 1
Common themes in the suicide grief process
Several common themes are likely to emerge during the suicide grief process. Guilt and a sense of failure—around what one did and did not do—can be pervasive and persistent, and are often present even when not objectively warranted.
Anger and blame directed towards the deceased, other family members, and clinicians who had been treating the deceased may also be present, and may be used in efforts to deflect guilt. Any of these themes may be enlisted to create a deceptively simple narrative for understanding the reasons for the suicide.
Shame is often present, and certainly exacerbated by both external and internalized stigma. Feelings of rejection, betrayal, and abandonment by the deceased are also common, as well as fear/hypervigilance regarding the possibility of losing others to suicide. Given the intensity of suicide grief, it has been my observation that there may also be fear in relation to one's own mental status, as many otherwise healthy survivors of suicide loss have described feeling like they're "going crazy." Finally, there may also be relief, particularly if the deceased had been suffering from chronic psychiatric distress or had been cruel or abusive.
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