Supporting those bereaved by suicide

Bereavement by suicide is perhaps one of the most sensitive topics we can discuss. Here, Professor Jim Lucey, Medical Director of St Patrick’s Mental Health Services, shares with us how we can talk to and support those experiencing grief following the death of a family member or friend by suicide. Noting again the delicacy of this topic, Professor Lucey explains that the piece below should not increase the pain of suicide, but talking about it can help us to do some essential things: to respect those who have died and to support those who are bereaved and have to carry on.

Most of us have known at least one person who has died by suicide. For many of us, this person was a close friend or a family member. For some people, this loss is very recent. More than 400 families in Ireland have lost someone by suicide in the past 12 months.[i]

Acute and integrated grief

Grief is a universal response to the loss of a loved one, whatever the cause of death. There is no such thing as a typical healthy way of grieving.[ii] Every experience is unique. Bereavement ‘is an experience that is full of intense and distressing emotions regardless of the cause of the death’.[iii]

At its best, acute grief transitions over time into integrated grief. This process is painful and it can take many months at least. The hallmarks of integration after a death ‘are the ability to think of the deceased with equanimity, to return to work, to re-experience pleasure, and to be able to seek the companionship and love of others’.[iv]

Suicide bereavement is different

Healing such as this can be slow in coming for those bereaved by suicide. This is more likely to have been a catastrophic and unexpected death. Bereavement through suicide brings with it all the features of acute grief, plus those traumatic features recognised as associated with violent or unexpected death. And, to all of these experiences, bereavement by suicide adds even more. The post-traumatic stress of the survivors is filled with especially painful bewilderment. This is even more so when the suicide is the death of a child.

This is why suicide bereavement is different.[v] The circumstances of a suicide are different from the circumstances of other deaths, and so is the intensity of the emotional and physical reaction to it. Those bereaved by suicide have a greater need to make sense of the death and to understand why the dead made their decision to end their lives. The bereaved question themselves: “why did they take their life?” or “how could I have prevented it?”.

Added to the pain of these unanswered questions are many stigmas associated with mental ill-health. Nearly 90% of all suicides are associated with a diagnosable mental health or substance-abuse disorder.[vi] Knowing this fact might help the bereaved to understand. Instead, the bereaved can feel a sense of isolation that deepens their sense of loss and increases their difficulty in seeking help.

A time of vulnerability

Suicide is associated with an exceptional loss of privacy at a time of extreme vulnerability. Consider the traumas following the discovery of the body. The emergency services are called to the scene of the death. Then, there are visits from the police. There may be media attention. The coroner’s investigation will lead to a public hearing. This can be a lengthy process, adding further uncertainty to the strain. There is always potential for these investigations to reveal some information previously unknown to family and friends.

There may be a temptation to avoid any mention of the cause of death. This can only increase existing tensions amongst family and friends. The bereaved respond with blame, of themselves and of others. As they feel blamed and excluded, these feelings further increase their sense of hurt and isolation.

Complicated grief

Very few studies in Ireland have examined the lived experience of those bereaved by suicide. One such small study by Mary Begley and Ethel Quale of University College Cork (UCC) is helpful.[vii] They suggest four main themes dominate relatives’ grief experiences after suicide. ‘First, the early months are chequered by attempts to control the impact of the death’. The second theme is an overwhelming need to make sense of the death. The third involves an intense feeling of social unease and finally, hopefully, eventually, there is the rediscovery of the purposefulness of the survivors’ own lives.

Sadly, grief after suicide is more likely to be complicated.[viii] Complicated grief lasts longer and interferes more with daily life and functioning. Complicated grief is more likely to be associated with major depression and post-traumatic stress disorder, and those bereaved by suicide are themselves more likely to experience suicidal ideas and even, subsequently, to harm themselves. For this and many other reasons, those bereaved by suicide are more likely to need help either informally or from professionals.

What to say and how to help

It can be difficult for others to know the ‘right’ thing to do or to say. A useful piece from the Harvard Women’s Health Watch puts it well: ‘knowing what to say or how to help after any death is difficult, but don’t let the fear of saying or doing the wrong thing keep you from reaching out to those bereaved by suicide’.[ix]

So what should we do or say?

It’s best to stay close to the bereaved. Avoid hollow reassurance. Don’t ask for explanations: don’t offer any either. Try to remember the deceased person’s life. Suicide is not the most important thing about the person who has died.

Acknowledge your uncertainties: follow the lead of the bereaved when broaching sensitive topics. Ask “would it help to talk about what happened?”. Be prepared to listen.

Give help with practical things: run errands; give lifts; mind pets; help with a school run.

Don’t judge. Don’t be afraid to ask directly, “what can I do to help”. Just as you would help the bereaved in any other circumstance, now is the moment to help those bereaved by suicide. There may be other times when it is enough to simply to sit quietly or to pray: whether the bereaved has a faith or not, treat their beliefs with respect.

Most important of all, be there for the long haul. This grief after suicide is not just “a bad flu”; it’s not just going to be over in a few days. There will be times ahead in weeks and months - maybe even years - when the pain is more acute. Birthdays and anniversaries will be harder than before. It’s best to acknowledge these.

As the bereaved return to work and as daily life moves on, it is easy for others to pretend or to forget. Don’t be afraid to bring up the subject. If the bereaved don’t want to talk about it, they will quickly say so.

Support networks

Support groups for the bereaved are helpful. Dedicated support groups for those bereaved by suicide are particularly useful; Pieta House, for example, provides a free support network.[x] Suicide bereavement support in Ireland is poorly researched, but we know that access to these supports is vital for those surviving suicide: a guide to some of these supports is linked below[xi]. It’s essential to know that help is at hand so building awareness and access to appropriate support is key.[xii]

Some of the bereaved will subsequently become ill themselves. It’s a mistake to dismiss or rationalise every distress after a bereavement as a normal part of the grieving process. Be prepared to help someone to seek professional help, particularly if depression or post-traumatic stress disorder (PTSD) deepens.

In the immediate aftermath, it may be impossible to concentrate, but, in time, the ability to read becomes a source of great solace. I have found a work of CS Lewis titled ‘A Grief Observed’ an invaluable support.[xiii] So also is Thomas Lynch’s essay on death, entitled ‘The Undertaking’; this beautiful, humane and hopeful book is my favourite work on mourning. I read it and re-read it every year.[xiv]

If you need further support or information, please call our dedicated Support and Information Line on 01 249 33 33.

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[i] Griffin E, McMahon E (2019) ‘Suicide Bereavement Support: A Literature Review’. National Suicide Research Foundation and Health Service Executive (HSE)

[ii] Young IT et al (2012) ‘Suicide Bereavement and Complicated Grief’. Dialogues in Clinical Neuroscience (14). Pages 177-185

[iii] Young IT et al

[iv] Young IT et al

[v] United Kingdom Survivors of Bereavement by Suicide (UKSOBS) ‘How Suicide Bereavement is Different’

[vi] Young IT et al

[vii] Begley M, Quale E (2007) ‘The Lived Experience of Adults Bereaved by Suicide. A Phenomenological Study’. Crisis (28). Pages 26-34

[viii] Young IT et al (2012) ‘Suicide Bereavement and Complicated Grief’. Dialogues in Clinical Neuroscience (14). Pages 177-185

[ix] Harvard Women’s Health Watch (2018) ‘Suicide Survivors Face Grief, Questions and Challenges’

[x] Pieta House (2018) ‘I’ve Been Bereaved By Suicide’

[xi] HSE (2014) ‘You Are Not Alone: A Guide for Survivors in Managing the Aftermath of a Suicide’

[xii] Public Health England (2019) ‘National Suicide Prevention Alliance. Help is at Hand: Support After Someone May Have Died by Suicide’

[xiii] Lewis CS (2013) ‘A Grief Observed’. Faber and Faber.