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 family member or friend 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. Finally, family members bereaved by suicide have to deal with Coroners and Gardaí as part of the investigation into the death. Given that grief after suicide tends to be more prolonged and intense, the support and intervention required is likely to be more intensive and specialised than with other types of loss.
This video offers guidance, by Professor Eugene Cassidy, Consultant Liaison Psychiatrist and Clinical Professor University College Cork/Cork University Hospital, on how to respond to people bereaved by suicide, including common reactions, practical support and advice, bereavement support services available and coping and self-care strategies.
Responding to people bereaved by suicide
A mental health professional may encounter suicide bereaved family members because a suicide bereaved person seeks psychological help or because a client dies by suicide.
If the person who died by suicide was a client, the nature of contact with the mental health professional may have varied, from a one-off visit to a long history of engagement with a complex set of difficulties. In some cases, the mental health professional may have seen the client hours before the suicide or may have been the person to find the body. As a mental health professional, it is important to reflect on how losing a client 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 client (or client’s family member) bereaved by suicide, there are many ways a mental health professional can help. Family members appreciate when the mental health professional caring for the deceased 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 mental health professional 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’. Clients may be surprised that this grief is so acute compared with other bereavements in their lives: suicide bereavement is unique, as discussed above. The mental health professional can urge the client to mind themselves in this difficult time, seek support, and avoid major decisions.
In terms of psychotropic treatment, 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 only. Overall, if the client can be stabilised with non-pharmacological interventions, this would seem to be the preferable option.
The majority of those 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 involves:
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- 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
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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 client’s current needs. In the early stages, a client may simply require supportive counselling to express their intense thoughts and feelings with an independent, non-judgemental person. Later on, where a client 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 client 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. With regard to referring clients for support and treatment following suicide, it would be important to verify if the service has been evaluated independently or of the health professional has been accredited.
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- The Psychological Society of Ireland provides a list of specially trained psychologists and psychotherapists who specialise in bereavement on its website.
- 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 clients navigate available resources in your area and provide counselling and support.
- An informative and evidence-based website for people bereaved by suicide is Healthtalkonline
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Grief therapy is especially important if the person is experiencing symptoms of complicated grief.
The grief associated with suicide will remain relevant to the client for a long time, and family members bereaved by suicide are many times more likely than the general population to also die by suicide. Research consistently shows poorer mental health outcomes among those bereaved by suicide:
“Exposure to suicide of a close contact is associated with several negative health and social outcomes, depending on an individual’s relationship to the deceased. These effects included an increased risk of suicide in partners bereaved by suicide, increased risk of required admission to psychiatric care for parents bereaved by the suicide of an offspring, increased risk of suicide in mothers bereaved by an adult child’s suicide, and increased risk of depression in offspring bereaved by the suicide of a parent.” (Pitman et al, 2014)
Ideation about suicide and death is not uncommon among bereaved family members, especially when the bereavement is due to suicide. Unfortunately, this higher rate of ideation is mirrored by an increased risk of suicide in this group. An attentive approach to the suicide bereaved family represents an important step in suicide prevention in the future.
Professor Eugene Cassidy, Consultant Liaison Psychiatrist and Clinical Professor University College Cork/Cork University Hospital, describes the importance of communication, outlines the supports available, and the necessity for assessment by a trained professional.