Shrouded in Silence
“Stigma is probably at the top of the list of issues that affect people bereaved by a loved one’s suicide,” Dr Zisook said.
A literature review comparing suicide-bereaved (SB) families to other bereaved groups found that SB families report higher levels of rejection, shame, stigma, the need to conceal the loved one’s cause of death, and blaming.3 Stigma may derive from a “societal perception that the act of suicide is a failure by the victim and the family to deal with some emotional issue.”4 Stigma and shame are barriers to seeking help and receiving support from mental health professionals as well as friends and family.5
“I have treated people where a suicide in the family has never been acknowledged or talked about,” Dr Zisook recounted.
He described a patient in his 70s who had lost his father to suicide when he was young, but it was never mentioned or discussed by his family. “Finally, he was able to talk and cry about it and regretted that he had never been allowed to talk about it until now and that it had been shrouded in silence,” he said.
Guilt and Blame
Feelings of guilt often overlap with shame, compounding the sense of stigma. SB individuals often experience “intense guilt or feelings of responsibility for the death.”6
Although self-blame can be present after any loss, it is more common after a suicidal loss, Dr Zisook observed. “There is a frequent feeling that you could or should have done something to prevent it, and guilt is very common.”
Self-blame is one aspect of a broader tendency to find someone to blame for the suicide, he noted.
“The survivor may blame the person who made the choice to die or may blame someone else who didn’t do enough, didn’t provide enough care, didn’t return a phone call, missed important cues, had an argument or disappointed the person, or could have interrupted or prevented the death in some way. Or the survivor may blame the doctor for missing signals, not treating depression, or prescribing the wrong drug,” Dr Zisook said.
Self-blame is particularly strong when the deceased is an individual’s child.
“Losing any relative to suicide is traumatic, but there’s probably no greater nightmare [than losing a child to suicide], since parents feel their job is to support their children, care for them, make them happy, and make their lives good, so suicide can make parents feel like a failure in this most important job of their lives,” he commented.
Rumination and Anger
Rumination is common in SB individuals and is unique compared with the responses of bereaved individuals to other losses, Dr Zisook pointed out.
“When someone dies of cancer, relatives do not typically wonder why the person died, while in suicide, survivors are plagued as to why the person did it — why, why, why,” he said.
The suicide sometimes comes as a “total shock” to the survivors, who may think, “He seemed to be doing better.” “She had turned her life around.” “He was making plans for the future.”
Coupled with rumination are feelings of rejection and abandonment: “Why did she do this to me?” “Didn’t he love me?” “How could she leave me?”
These feelings can lead to anger at the deceased,6 which can compound the guilt.
Complicated Grief and Depression
Rumination contributes to complicated grief (CG), a “painful and debilitating condition…characterized by prolonged, acute grief and complicating psychological features such as self-blaming thoughts and excessive avoidance of reminders of the loss.”7 Conversely, instead of avoiding reminders of the deceased, some SB people may “spend long periods of time trying to feel closer to the deceased through pictures, keepsakes, clothing, or other items associated with the loved one.”8 Left untreated, CG can last for years, if not indefinitely.7 “Losing a loved one to suicide can be a risk factor for CG,” Dr Zisook said.
“Mourning is the process by which bereaved people seek and find ways to turn the light on in the world again. When successful, mourning leads people to feel deeply connected to deceased loved ones while also [being] able to imagine a satisfying future without them…Grief has been transformed and integrated” and the “continued presence of the loss is no longer insistent and disruptive.”8
In contrast, CG is a “chronic impairing form of grief brought about by interference with the healing process” that “derails” the mourning process and “prevents the natural healing process from progressing.”8
Mental and Physical Health Sequelae
SB individuals are vulnerable to physical, psychological, and psychosomatic difficulties.9 One study found that one-quarter of people bereaved by suicide experience elevated levels of depression and stress and close to one-fifth have elevated levels of anxiety,10 as well as posttraumatic stress disorder (PTSD) and impairment in social and employment settings.6 Psychosomatic reactions included physical or severe abdominal pain, loss of appetite, low energy levels, and sleep disruptions.10
Survivors are themselves at high risk for suicidal thoughts or completed suicide.11 A study of 3432 young adults who had lost close friends or family members to suicide found they had a higher probability of attempting suicide than individuals bereaved by deaths due to sudden, natural causes. Of note, the effect of SB was similar regardless of whether bereaved participants were or were not blood-related to the deceased.12
Impact on the Family Unit
The suicide of a family member leaves an indelible mark on the survivors, affecting each individual, the family as a whole, and also larger social networks.13 The impact of the suicide is to some extent informed by the family’s function or dysfunction prior to the suicide.13 Moreover, the suicide may affect family communication and the developmental processes of children.13 Marital breakup is also more common in parents of children who died by suicide.14