Suicide bereavement overview
Losing a family member or friend is a difficult experience, but it is one that most people will experience at some time in their lives. Grief is the normal and natural emotional reaction to loss or change. While every person grieves uniquely, there are a few characteristics that are common. Immediately after a death, a person may feel numb, in shock, detached, or disbelieving that their loved one is really gone. As the numbness and disbelief gradually wears off, emotions may include sadness, anger, loneliness, hopelessness, fear, or detachment. Grief can also affect a person’s thoughts, resulting in ruminating about the death, difficulties with memory and concentration, worrying that their grieving means they are ‘going crazy’, or wanting to die too. Grief can affect a person’s sleep, energy, appetite, digestion, or libido. The person may somatise grief as physical pain, dizziness, difficulty breathing or heart palpitations. The bereaved person may also experience changes in their social habits or supports, feeling like they prefer to be alone or are being avoided by others who do not know how to respond.
Losing a loved one to suicide can make grief even more challenging. As well as feeling the loss of the individual who has died, there are some elements of grief that may be heightened. The bereaved may feel angry at the deceased because they feel abandoned, rejected, or hurt. There may also be anger towards people or services that they perceive as not having done enough to prevent the suicide, sometimes including themselves. The process of questioning why the death happened and how may also be prolonged. The bereaved may feel guilty or responsible for the death, or sometimes relieved at the certainty of the death when it was something that was long dreaded. Another aspect that may be heightened with suicide bereavement is shock. Suicide deaths are sudden deaths and often traumatic in nature. The bereaved person may have prolonged numbness and disbelief. They may experience derealisation or often forget the person has died. If the family member found the deceased or saw the body, there may be symptoms of posttraumatic stress, including panic attacks, nightmares and sleep disturbance. Suicide bereavement can be made worse by avoidant or negative responses from a stigmatising community.
Given that grief after suicide may be more prolonged and intense, we hope that this section will give GPs the information they need to support families bereaved by suicide.
Responding to people bereaved by suicide
A GP may encounter suicide bereaved family members because of the suicide of a patient or because a family member of a patient takes his/her own life. If the deceased was a patient, the nature of contact with the GP may vary, from a one-off visit for a physical complaint to a long history of engagement with a complex picture of psychiatric disorders, social issues and physical health problems. In some cases, the GP may have seen the patient hours before the suicide or may have been the person to find the body. As a GP, it is important to reflect on how losing a patient to suicide has affected you and to integrate this experience within the context of your broader professional experience. Read our section on coping and self-care here.
When it comes to supporting a patient (or patient’s family member) bereaved by suicide, there are many ways a GP can help. The GP is often the first port-of-call for families in difficult times. Family members really appreciate when a GP offers condolences for their loss, either through attending the funeral or proactively making contact in the days or weeks afterwards (Corry et al, 2016). A GP can be a powerful resource for a suicide-bereaved family member, helping them to better understand the grieving process and to navigate sources of therapeutic support. At the early stages of grief, the family member may appreciate a listening ear and reassurance that the suicide was no-one’s fault, that the family did the best they could, and that their grieving is ‘normal’.
There is ongoing debate about the common practice of prescribing benzodiazepines to stabilise those who are suffering from grief. Current research indicates that benzodiazepines might increase the severity of PTSD, and lead to sleep problems in those experiencing complicated grief. Moreover, starting benzodiazepine use after bereavement may lead to a situation of long-term dependence. There is preliminary evidence of the efficacy on SSRIs in complicated grief. Overall, if the patient can be stabilised with non-pharmacological interventions, this would seem to be the preferable option.
The majority of people bereaved by suicide will require some additional psychological support, given suicide’s suddenness, trauma, and the element of choice associated with it. Bereavement by suicide is more likely to result in complicated grief, which is characterised by:
- Persistent, intense yearning or longing for the deceased loved one
- Frequent feelings of intense loneliness or emptiness
- Repetitive negative thoughts about life without the deceased loved one, or repetitive urges to join the deceased
- Preoccupying thoughts about the deceased that impact your ability to carry out everyday tasks
- Rumination about the circumstances of the death
- Frequent disbelief or inability to accept the death
- Persistent feeling of being shocked, stunned, or emotionally numb since the death
- Recurrent feelings of anger or bitterness regarding the death
- Difficulty trusting or caring about others since the loss
- Experiencing pain or other somatic symptoms the deceased person had, hearing the voice of the deceased, or seeing the deceased person
- Intense emotional reactions to memories of the deceased
- Avoidance or preoccupation with places, people, and things related to the deceased or death
For children, professional support may be especially relevant when the child has ongoing outbursts, sleep disturbance or withdrawn behaviour.
A professional counsellor can help in several ways, depending on the patient’s current needs. In the early stages, a patient may simply require supportive counselling to express their intense thoughts and feelings with an independent, non-judgmental person. Later on, where a patient is still struggling to come to terms with the death, a professional counsellor can help them to make sense and meaning out of the death. Grief therapy is especially important if the person is experiencing symptoms of complicated grief.
The format of bereavement support services varies, and the patient should be made aware of the options that are available to them, such as face-to-face individual counselling, support groups, home visits, and telephone support. The usual routes of psychosocial treatment such as Counselling in Primary Care and mental health services may be appropriate. In some areas (such as the South East of the country), GPs can refer patients bereaved by sudden death to free counselling through a written request to the Regional Bereavement Care Liaison Officer in Waterford. Finally, the GP may be aware of accredited counsellors or support groups in the local area.
An alternative route to relevant services is self-referral, whereby patients can engage with services directly.
- The Psychological Society of Ireland provides a list of specially trained psychologists and psychotherapists who specialise in bereavement on its website here.
- For children bereaved by suicide, Barnardos provides a face-to-face suicide bereavement service for children in Cork and Dublin, and a helpline (01 473 2110) from 10am-12pm Monday to Thursday.
- Samaritans is an organisation that provides support for those who need to talk through their concerns, worries and troubles. Their helpline (116123) operates 24 hours a day, seven days a week, and is free of charge. They also are contactable by email at jo@samaritans.org or by dropping in to one of their branches in Athlone, Cork, Drogheda, Dublin, Ennis, Galway, Kilkenny, Limerick, Newbridge, Sligo, Tralee, and Waterford.
- Túsla Family Resource Centre can also help patients navigate available resources in your area and provide counselling and support.
- An informative and evidence-based website for people bereaved by suicide is Healthtalkonline.
It is helpful to remind patients that they are the consumer of the bereavement support service. If they are not satisfied with the intervention they receive, the GP can help to locate an alternative that is a better fit.
Grief therapy is especially important if the person is experiencing symptoms of complicated grief.
The grief associated with suicide will remain relevant to the patient for a long time, and family members bereaved by suicide are many times more likely than the general population to also die by suicide. An attentive approach to the suicide bereaved family represents an important step in suicide prevention in the future.
Conversation with a GP: Responding to people bereaved by suicide
In the video below Professor Colin Bradley, Head of the Department of General Practice University College Cork, offers his guidance on how to respond to people bereaved by suicide, including how to respond to children and young people.
Support services are also highlighted.
Liaising with the Coroner and Gardaí
Deaths that appear to be the result of an accident or which occurred in violent or unexplained circumstances must be investigated by Gardaí and reported to the Coroner to identify the cause of death. A GP may be called on to declare the person dead at the scene of the suicide. The majority of suicide deaths are by hanging where there is no obvious visible damage to the integrity of the body, while other suicides might entail more violent methods or disturbing circumstances. Family members or passers-by may still be present when you attend. If you find that the scene or circumstances of a suicide continue to bother you after attending the scene, please visit our section on coping and self-care here.
As well as being called on to attend the scene of a suicide, a GP may be called upon to assist the Gardaí and Coroner by providing a medical history of the deceased, via a Garda statement, letter or deposition at the inquest. An inquest is an official public inquiry, presided over by the Coroner, into the cause of a sudden, unexplained or violent death. Inquests will not take place until at least 6 weeks after the death. They are open to the public, but in practice, only family and witnesses usually attend.
The inquest will return a verdict of suicide if the cause of death can be established beyond reasonable doubt, or an open verdict, where this criterion cannot be satisfied. In open verdict cases, the family may have strong views that the death was intentional or accidental. Conversely, the family may have difficulty with the uncertainty brought by an open verdict. It is important to respect the family’s interpretation of the circumstances of the death, even if it clashes with your own.