Until recent years, survivors of the suicide of a loved one have received little consideration in suicidology's research and studies. Consequently, not much is known about a *suicide survivor's* grief experience and how it is similar to or different from the grief of a survivor in other modes of the death of loved one.
E.S. Shneidman, founder of the American Association of Suicidology, suggested that each suicide has six survivors. Based on this figure, and assuming (for computational purposes) that survivors of suicides in the U. S. since 1970 are still alive, suicidologists estimate that there are at least 3.68 million survivors. Based on 30,000 U. S. suicides annually, another 180,000 individuals in the U. S. alone become survivors of suicide each year, year after year after year. They, too, are victims.
The following is excerpted from *Chapter Nine: The Survivors of Suicide Victims* in (book): *Out of the Nightmare -- Recovery from Depression and Suicidal Pain* by David L. Conroy, Ph.D., Executive Director, Suicide Prevention Resources, New York, N.Y. The title was published by New Liberty Press, New York; copyright 1991; ISBN 1-879204-00-2.
The "survivors" are the relatives, friends, acquaintances, and caregivers of a suicide victim. Nearly all societies have mourning rituals. After death, survivors need to go through a grief-work process before they can return to normal functioning. When the deceased is a suicide victim, this process is much more difficult to complete. The grief reaction to death by illness or accident includes denial, shock, guilt, anger and depression. Death by suicide intensifies all these, and may also include feelings of shame, failure, and rejection. There are many additional burdens for the mourners of a suicide victim.
1. Stigma -- For centuries suicides, suicide attempters, and their families were badly treated by civil and religious authorities and by the general public. They were denied last rites, subjected to criminal penalties, and were the objects of social contempt of every sort. Some developments in modern science have added a fourth source of stigma: various psychological theories have held that suicide is caused by problems in parent/child relationships. Although the degree of stigma attached to suicides by these sources has diminished, it is still very real.
2. Pain and Anger -- Unexpected deaths usually produce the initial defense mechanisms of shock, numbness, and denial. All of these are increased when the death is a suicide. As they recede, reality sinks in. This reality is more painful than other forms of grief. Survivors may experience great anger -- at other people, at the victim, at God, at themselves.
3. Saying Good-bye -- When someone dies by terminal illness, survivors often have a chance to say good-bye. This can be of considerable value in the grief-work process. Suicide survivors often regret not having had this opportunity. What makes this especially difficult is that the suicide victim, without their knowing it, may have said good-bye to them. It is not uncommon for the suicide to tell a survivor, "I love you," within hours of his death.
4. Health -- Health problems, such as diabetes and high blood pressure, may get markedly worse after the suicide of a relative or friend. Survivors may have lengthy periods of heightened anxiety over the welfare of themselves and other survivors.
5. Anniversaries -- Holidays and anniversaries of the birth and death of the victim can be very difficult.
6. Less Support -- Historically, society denied the rituals of a funeral and a mourning period to the survivors of a suicide. Although this is no longer the case, the amount, quality, and duration of social support that they receive is still much less than normal. Some of the lack of support is due to uncertainty, fear, and aversion to pain: "I don't know what to do"; "I'm afraid I might say the wrong thing and make it worse"; and, in an inarticulate way, "I feel uncomfortable being around people in pain. My discomfort will be painful for me and, since I don't think I can hide my discomfort, it will add to their pain."
7. Limited Assistance -- The special problems of the survivors of suicide receive little attention in the training of therapists and counselors. There is little publicly available literature. Because suicide is not talked about, counselors for every population underestimate the extent to which their caseloads include survivors.
8. Trauma to the Family -- The family system of which the suicide was a member suffers a tremendous shock. Seventy percent of the parents of teen suicides eventually divorce. The nature of the death increases the difficulty of resolving estate, insurance, and child custody issues. Families frequently move after a suicide. They are angry at the social stigma that has unfairly been placed upon them.
9. The Mystery of Suicide -- In cases of death by accident, illness, old age, alcoholism, and homicide, the survivors know what killed the deceased. They have something specific on which to focus their feelings of guilt and anger. Survivors of suicide, however, often become preoccupied with wondering how the suicide could have happened. Only about 10 percent to 15 percent of all suicides leave note, and these are usually unsatisfactory as explanations. Existing theories of suicide do not provide answers that survivors can assimilate, and the feeling that the cause of the suicide remains a mystery causes the mourning process to be more difficult and to last longer.
10. Assault on values -- The survivors usually come from the same social, economic, and educational background as the victim. They shared the same values and attitudes. The survivor mat think to himself, "This person thought that life was not worth living, and he was a lot like me, so what should I think?"
11. Loss of faith and trust in oneself and others -- Survivors may lose self-esteem and worry about suicidal feelings in themselves and others. Child and adolescent survivors may feel, "You made me suicidal."
12. Friendships become weakened or lost, and survivors have difficulty making new ones. Each encounter with someone new may be approached with dread and anxiety. Will this new person ask, "How many children do you have? and how should I respond?
13. Delayed Grief -- It is not uncommon for the mourning process to be arrested for an indefinite period -- sometimes decades -- and then resume forcefully. This may be occasioned by some other crisis in the survivor's life, and can be extremely distressing. "Waves of grief" are common for immediate survivors during the first year or longer.
Survivors are often burdened with deep and complex feelings of guilt:
14. The most basic feeling of guilt is due to the facts that we are not perfect and that we make choices in how we deal with others. After suicide it is normal to have exaggerated feelings about one's ability to influence the life of another. The survivor may brood obsessively about things he wishes he could have done differently.
15. Guilt may help keep feelings of anger toward the deceased repressed, and keep conscious thoughts of anger from being expressed to others. The repression of anger is supported by an adage that it is wrong to think or speak ill of the dead. Not getting these feelings out may make the grieving process more difficult.
16. Sooner or later the survivors will have a few moments or hours in which they forget about the death and enjoy life as they previously did. When this interlude ends -- with a jolt -- they may have a surge of guilt.
17. Feelings of guilt often lead to self-punishment and denial. Survivors may refuse to participate in activities that normally bring them pleasure. They may feel that feeling pleasure may cause them to feel more guilt.
18. If the deceased was a burden to the family. they may have a feeling of relief. They may then feel guilty for feeling relieved.
19. Survivors may have disturbing dreams about the deceased. Some may express ideas that cause the dreamer to feel guilty.
20. It is common for survivors to idealize both the victim and the relationship they had to him. This factor may increase the guilt feelings.
21. Feelings of guilt may be very persistent. They do not seem to fade and lose strength in the same way that other emotions do.
Writers on suicide bereavement are unanimous in saying that it is essential for the survivors to talk about it. They say that the word "suicide" should be used, and encourage the survivors to talk about the death with each other. They feel that it is desirable for the conversations to take place in the home, that they begin as soon as possible, that they include children, and that each person share feelings and thoughts with as many other survivors as possible.
The growing number of self-help support groups for the survivors of suicide victims have much to teach the world about coping with pain. Members simply share their experiences and provide mutual support. A small group in Brooklyn that I attended is facilitated by two women who lost a friend to suicide. Neither is a professional counselor; both are employed in the business world. Group members simply share experiences and provide support for each other. They sometimes talk on the phone between the once-a-month meetings and actively support an annual regional conference on survivor issues. Attendance at just a single meeting of this type of group can help relieve the feeling of being alone with the tragedy, the feeling that there is no process to suicide bereavement. The support groups help circulate literature, much of which is written by the survivors themselves. One handout contained:
"I wish you would not be afraid to speak my child's name. My child lived and was important and I need to hear his name.
"If I cry or get emotional if we talk about my child, I wish you knew that it isn't because you have hurt me; the fact that my child died has caused my tears. You have allowed me to cry and I thank you. Crying and emotional outbursts are healing.
"I wish you wouldn't expect my grief to be over is six months. The first few years are going to be exceedingly traumatic for us. As with alcoholics, I will never be "cured" or a "former bereaved parent", but forevermore a "recovering bereaved parent".
"I wish you understood that grief changes people. I am not the same person I was before my child died and I never will be that way again. If you keep waiting for me to "get back to my old self", you will stay frustrated. I am a new creature with new thoughts, dreams, aspirations, values and beliefs. Please try to get to know the new me -- and maybe you'll like me still."
Unfortunately, talking about it is not easy. For centuries suicide was one of those things that should not be talked about. Even today many suicides are kept secret from family members as well as outsiders. People are afraid to talk because they are afraid of how the other person might react -- and of how they might react. Simply by offering to listen we can do a great deal to help a survivor cope with the stigma and taboo, and to come to terms with his grief.
The "leave it to the professionals" myth is a strong isolating factor in survivor situations. A police officer told me about the suicide four years earlier of his cousin-in-law and fishing partner. The victim had been under treatment for a drug problem. His father had committed suicide twenty years earlier by a different method. I asked the officer if he had ever spoken with his cousin or her two adolescent children about the death. He quickly responded, "They went for counseling." This lack of communication is sad; children need positive adult figures in their lives.
Those who work with survivors feel that there are very few situations where secrecy about suicide is a good policy. Children, for example, will nearly always find out anyway, and often under less than desirable circumstances. Secrecy, partial secrecy, and delays in providing information usually create resentment and distrust.
Resentments and distrust damage relationships among survivors, and survivors especially need strong and supportive relationships. Children are profoundly affected by a suicide in the family. They very often, on their own, reach the conclusion that they are somehow to blame for the death. To not include them in bereavement activities and discussions does nothing to discourage this idea. The people who keep the secret usually say they are doing so for the protection of others. Any benefits of secrecy for those being protected are unproved, and the secret-keepers are spared an unpleasant task and have bolstered their own feeling by saying that others cannot cope. To inform people in a timely and supportive manner is less bad than having them find out in other ways.
The mourning process is greatly extended when death is by suicide. Unfortunately, we live in a culture in which faster is better, much better. The social stigma attached to this type of mourning means that both the survivors and the people around them will feel social pressure to have the mourning period come to an end. Survivors who do not perform or pretend to perform the impossible task of "snap out of it and get on with your life," will suffer further stigma and isolation. The fact that this type of mourning takes a long time, makes it take an even longer time. Survivors need all the patience that we can give them.
An effect of the stigma is that the survivors of a suicide victim are reluctant to reach out for fear of rejection and negative judgment. A strong sense of personal privacy may be good in many situations, but in our relationships with people in pain it often contributes to isolation and a weakening of support systems. We need to be willing to take an extra step to assure them of our concern.
Something not often appreciated is that bereavement -- after death by any means -- may interact with other problems in a way that has one similarity with substance abuse. Denial on the pain of a loved one's death, or being frozen in a painful stage of grief, are often factors that block recovery in other areas. After substance abuse, bereavement deserves priority in any recovery program. To bide one's time and hope for spontaneous remission is not often the best policy after a profound loss.
Healthcare workers, mental health professionals, counselors for at-risk populations, and many others are likely to know and care about someone who dies by suicide. They experience versions of many of the emotional reactions that happen to immediate survivors. Unlike family and friends, caregivers have the grim advantage of knowing that they are at risk to suffer this kind of loss. As with survivors of someone who dies by terminal illness, caregivers can to some extent prepare themselves for the grief-work process.
A first step in this process is to put suicide postvention policies and training in place before it becomes necessary to use them. As with planning for other types of unhoped for crises, this practice will help reduce the likelihood that there will be need to use the procedures.
A second step is to recognize that perfectionistic standards among suicide prevention workers will do more harm than good. Many suicides are preventable, but the prevention of all suicides is an impossible goal. Suicide will happen, and it will happen in organizations that have the best available programs and procedures. If the caregivers were doing what they could in the circumstances, they cannot be faulted.
During the latter stages of the grief-work process it is helpful for caregivers to remember that their relationship with the deceased had its positive aspects. A caregiver can make up a list of the things he brought to your life, and you brought to his life. The support given to the person may have reduced his loneliness, and lengthened his lifespan and improved its quality. Even in the cases where what we have to give is not enough, what we do is still worthwhile. In *On Death and Dying* Elisabeth Kubler-Ross describes what it is like to befriend the terminally ill. She says that these people are glad to be interviewed by her seminar because of "...the need of the dying person to leave something behind, to give a little gift, to create an illusion of immortality perhaps." Without knowing it, the people we lose do this; they come to occupy special places in our memory. To accept these memories shows our care and concern, and it changes us as individuals. If taken properly, these changes can be positive.