(“Intervention” refers to attempts to prevent suicide. “Postvention” refers to the efforts of caregivers to help survivors after suicide has occurred.)

It is estimated that there are about 3.68 million survivors of suicide in the United States. Every completed suicide will leave behind 6-11 “survivors” – people directly impacted by the death. Of all the “grief work” that caregivers will do, suicide intervention is among the most difficult. Survivors have been hit with a “one-two punch.” They must deal with the shock and grief of the sudden loss of a loved one, but they must also confront a host of accompanying issues because their loved one died at his/her own hands – issues that only survivors of suicide must face.

When death occurs, the depth of an individual’s grief depends upon a variety of factors: quality of relationship with the deceased; the support system that survivors have; the nature of the death, etc. But there is clear evidence that survivors of suicide are more likely to experience different and more complicated grief reactions than those who loved ones died from a natural or accidental death. The person who completes suicide dies once. Those left behind die a thousand deaths, trying to relive those terrible moments and understand WHY?

Caregivers must go beyond normal grief counseling to help survivors of suicide. Referrals to professional counselors and support groups for suicide survivors (such as S.O.S. – Survivors of Suicide) are an important part of suicide postvention. Included in this section are various articles and information to help acquaint caregivers with the unique concerns and needs of suicide survivors.

The Suicidal Process

Perhaps the most often asked question by suicide survivors is “why?” There is no easy answer to that question and no quick fixes. But an important key to helping SOS’s is to help them understand the nature of suicide. “Suicide does not just occur. Experience has shown that it is more often the end result of a process that has developed over a period of time” (N.L. Farberow). Suicide is the outcome of neurobiological and psychological breakdown. Becoming suicidal is a process that begins in severe stress and pain generated by a serious life crisis. Suicide is the end result of a process, not the process itself.

Stress and pain increase as the crisis, or the perception of it, worsens. As this happens, control and self-esteem deteriorate. Depression may be a cause or a side effect of the process.

Suicidality occurs when the stress induces psychological pain so unbearable that death is seen as the only relief. Prior to this point the individual is at risk of becoming suicidal. Beyond it the individual is at risk of completing suicide. Becoming suicidal is a crisis that causes traumatic stress.

Ingrained beliefs and values may cause an individual to be stigmatized by their own suicidality. This leads to shame and guilt. These cause alienation from self and withdrawal from others, which are also drivers.

Suicidality entails changes in brain chemistry and physiology. Suicidal individuals manifest various chemical imbalances. Most notable is depleted serotonin, a neurotransmitter that inhibits self-harm. This is a neurological threshold and those near or beyond it must be treated with medications.

Suicidal individuals are beset by suffering that is distracting and disabling. Suicidality is a state of total pain which limits options to enduring or ending utter agony.

The Suicide Loss Grief Process

Suicide grievers struggle with “why” and “what if.” We see the process in this way:

• Dissonance: Grieving opens with conflict among what is felt, believed, and heard.  Expectations about life are rocked. Lack of knowledge about suicide leads to seeking information.

• Debilitation: Efforts to make sense of the loss breakdown. Hopes of healing wither.  Pain worsens with holidays, birthdays, and the anniversary of the loss. Anger comes from seeing the loss may have been prevented.

• Depression: The enormity of the loss fosters disaffection and powerlessness. Severe stress and pain peak and plateau. Relationships become strained and some do not survive. Comfort is only achieved with other suicide grievers. Some interests are lost.

• Desensitization: Pain stops growing and gives way to an interminable ache.  Depression lifts somewhat; some energy is regained. Grief remains at a lesser level of acuity, and it is displayed less. Some interests return or emerge.

• Differentiation: Next comes self-realization of the consequence of the loss. Suicide grievers grasp a change in their core personal identity. Value and belief systems are recast. This is not healing. It is an accommodation involving a new sense of self.

A Pain Management Primer

“In almost every case, suicide is caused by pain, a certain kind of pain — psychological pain, which I call psychache” (Edwin Shneidman). Among those who are suicidal, pain is the problem.

Much of what has been learned about dealing with physical pain applies to psychache. Psychological pain is under assessed and undertreated. More attention is paid to the causes than to the pain itself. Suicidal individuals are left to contend with pain alone.

Severe pain has the same impact both physically and psychologically. Anxiety, sleeplessness, fatigue, depression, and anger set in. These modify and aggravate the pain. They elicit changes that increase stress which further drives pain. Severe pain is destructive. Worsening pain attacks self-control and self-esteem. It generates fear and powerlessness. It creates a sense of profound isolation.

Pain overwhelms coping and leaves helplessness in its wake. Any person has the potential to become suicidal when confronted with a situation that produces emotional pain and is believed to be inescapable, interminable, and intolerable (J. A. Chiles and K. Strosahl).

Pain travels in the company of suffering, which has been defined by Cassell as a state of severe distress induced by the loss of intactness of person or by a threat that the person believes will result in the loss of … intactness. Suffering is where pain and suicide meet.

Suicidal individuals and those with chronic pain share the same experience. Recurrent stress and intense pain decrease endorphin (natural substances that relieve pain) levels in the brain. This increases their vulnerability. This must be offset. This is the function of pain management. Time is critical with suicidal individuals. They are in jeopardy and may be within hours or days of succumbing to their condition. Immediately impacting their pain is the only way to save their lives.

Some Answers to Pressing Questions

Losing someone loved to suicide is one of the most devastating losses of all. Nothing in your life can prepare you for it. No one can ever be ready for it. These are some of the questions that may be on your mind:

1. Why did this happen? It happened because your loved one felt psychological pain so severe and unbearable that they believed could only be stopped if they died. The pain was caused by depression, which was caused by something in their life and/or in their brain. Drinking or using drugs make things much worst where they are present.

2. Why didn’t I know? Most don’t know the symptoms of depression or the warning signs of suicide. Many of those suffering depression hide it and some suicidal individuals don’t show any signs of their risk or danger. Even when there is some concern it is very hard to accept that someone you know so well is in mortal danger of suicide. Being life-affirming and non-suicidal makes it hard to recognize the opposite states in others.

3. Why didn’t my loved one tell me? Some may find it hard to ask for help when they are experiencing problems. Some may feel shame at being suicidal. Intense pain is distracting and consuming. It makes those suffering self-centered. It takes away the sense of control. It doesn’t mean that they didn’t care for or love those suffering because of the loss. Tunnel vision is part of being suicidal.

4. Why didn’t somebody do something? Even professionals sometimes have a hard time seeing that someone is suicidal. Misplaced concerns about privacy and confidentiality may deter warnings to others. There are warning signs but no reliable predictors of suicide.

5. Why do I feel like I’m going crazy? You have suffered the greatest and most horrible emotional shock of your life. Suicide is a severe traumatic loss – sudden, unexpected, and violent. You feel betrayed, out of control, disoriented, and hurt. This is what happens after a suicide. Nobody’s ever ready for it, and it overwhelms anyone whom it directly affects.

6. Why can’t I get over this? The loss is too fresh, and you are traumatized. The first weeks and months are very hard, and your emotions may be in turmoil for a long time. You never really “get over” your loss, but you eventually come to terms with it.

7. Why doesn’t anything help me? You can be helped. Start by seeing your doctor. She or he may be able to recommend services or medications that may help. You can go to a suicide loss support group or talk to a grief specialist, counselor, or clergy person. You can find information and people to talk to on-line. These may help you.

Factors in Suicide Survivorship

• Suicide is usually unexpected and sudden.
• Death by suicide is often violent.
• Suicide death often leaves unfinished and unresolvable issues.
• Suicide often occurs in “systems” already experiencing stress.
• Death by suicide can compromise usual mourning rituals.

Elements of Survivors’ Grief

• Grief is highly individualistic; there is no single way to grieve.
• Suicide bereavement most typically is not pathological, though complicated and sometimes problematic.
• A “survivor syndrome” often develops (see diagram on the next page).

Element of Survivor Grief Survivor’s Syndrome

• Shock and numbness
• Denial
• Search for the reason “why?”
• Shame
• Guilt and responsibility
• Blaming and scapegoating
• Anger towards self and the dead loved one
• Loneliness and social isolation
• Social support affected
• Difficulty trusting others
• Feelings of abandonment
• Family relationships effected negatively
• Depression
• High suicide risk
• Suicide ideation

High Risk Groups for Problematic Bereavement

• Parents.
• Those who find the body.
• Those who witnessed the suicide.
• Children and early loss.