Survivors of Suicides: Struggles with Complicated Grief and Approaches to Treatment

Anna H.
Sallie Foley
SW617- Death, Loss and Grief
Intellectual property of the writer. Do not use without express permission.

In his book on addressing grief from a clinical perspective, Grief Counseling and Grief Therapy, Worden (2009) reserves much of a particular chapter specifically to address the issues that arise when faced with a death due to suicide. It is, he notes, a particular type of grief which causes much trouble beyond the normal feelings of pain and loss at the death of a loved one: “Nearly 750,000 people a year are left to grieve the completed suicide of a family member or loved one, and they are left not only with a sense of loss, but with a legacy of shame, fear, rejection, anger and guilt,” (179). Out of all the different experiences throughout the western world, few evoke as complicated and visceral a reaction as surviving a loved one who has died due to suicide. Suicide has been criminalized in countries and been deemed a sin by many cultures; many people frequently continue to see it as the ultimate act of selfishness. It is a type of loss where people don’t send condolence cards, one that is often left unacknowledged, and for which there are few, if any, good explanations. Suicide causes so much disruption among families and communities beyond the normal scope of grief for the death of a loved one that many surviving friends and family struggle for years with loss that stigmatization, coupled with shame, rage, confusion and guilt makes more complicated than any other type of death we encounter. There are, however, many therapeutic means through which people can alleviate these complex and burdensome layers of grief, so that in time they may uncomplicated their grief enough to incorporate it into their love and memories of the person they have lost. This paper will discuss in greater depth the various types of struggles surviving loved ones face when they shoulder the complicated grief of a completed suicide, and several modes of therapy which have been found particularly helpful in mediating their pain.
Grief reactions to the death of a friend, loved one, or family member always include sadness and periods of pain in missing the person whose life has ended. When a the loss is due to suicide, however, these normal feelings can become terribly enmeshed with a myriad of other, often more destructive feelings caused by stigma associated with this particular type of death. “Suicide survivor” is term which has come into clinical parlance to describe anyone who experiences these significant, painful consequences for a suicide within their social network, and there is a recognition that this term is applicable to a significant percentage of the population—perhaps as many as 7% of people in the United States (Jordan, 2009). While not everyone exposed to suicide feels its impact in the same way, the grief experienced by survivors of suicide is most commonly characterized by the shame and guilt they carry with regards to their connection’s death, compounded by other tumultuous emotions such as anger, hurt, betrayal, confusion, and— frequently— shock at the unprepared-for loss. There are thoughts that for many, these complications for survivors of suicide, like those who survive the loss of a loved one to an accident, are suffering in large part due to the sudden, unexpected nature of the death, for in such losses there is no time to say goodbye, or prepare one’s self for the absence of the deceased (Lindqvist, Johansson, and Karlsson, 2008). However, Jordan observes that there are no “clear operational definitions” for a suicide survivor, along with a notable lack of longitudinal studies with regards to their integration of the loss, further indicating that, at least within Western culture, there remains a significant taboo when to dealing with suicide and all that it touches, even when it comes to helping treat those who suffer in its aftermath (Jordan, 2009).
Feigelman, Gorman and Jordan (2009) discuss in great detail both the ways in which stigma in response to suicide has developed in Western culture and the damaging effects it can have on the dead person’s survivors. In Europe, from as early as the Middle Ages the punishment for suicide from the Church and the State extended beyond the deceased to their family: property could be confiscated and held by governing agents, and all immediate relatives could be excommunicated from the Church (Feigelman, Gorman and Jordan, 2008). It is the continuation of this stigmatization, coupled with guilt, which appears to be the primary cause for complicating the grieving process for survivors of suicide up to the present day. In a survey conducted with grief support groups, Feigelman, Gorman and Jordan observed that, when comparing the effects of stigmatization responses in a group of 462 parents who had lost children to suicide with 54 whose children had died to traumatic death and 24 from natural causes, those parents who encountered stigmatizing responses from their peer, support and family groups had greater difficulties with their grief, including the development of depression and suicidal ideation on the part of the survivor, (Feigelman, Gorman and Jordan, 2009).
Distorted communicative perceptions based upon stigmatization within family and social systems in reaction to the suicide can have a significant impact on the ways in which the survivors cope. Families can experience, or themselves develop feelings of blame (or being blamed) for the death, feel the need to keep the nature of the death secrete from extended family or the larger community, and undergo a sense of social ostracism (Jordan, 2008). Even for those who do not encounter any outright negativity regarding their loss, the experience of ambiguity and lack of social protocol for how to be supportive of a family grieving for this sort of loss can lead to exacerbated feelings isolation, shame, and condemnation (Jordan, 2008; Worden, 2009). Worden describes a client who came into his office and lamented that “‘no one will talk with [me]… they act as if it never happened,’” (Worden, 2009). This is not to say that there is no social support for survivors of suicide, nor that all social interactions produce feelings of shame or stigma; there is evidence to suggest that near to half of the survivors of suicide may experience a strengthened feeling of closeness to their remaining living family members and friends or support structure (Feigelman, Gorman and Jordan, 2009). For the other half, however, it does underscore the complicated reactions both felt by the survivors for themselves and as members of the community in which they live. What may be of most import when considering the negative effects of stigma is the expectation— prevalent throughout the centuries, despite the growing recognition in our present time that suicide is almost always predicated on mental disorders and psychological illness— that there will be little support for the survivors, and that they are somehow to blame for their loss (Feigelman, Gorman and Jordan, 2009).
The other, perhaps most pronounced experience for survivors of suicide is the often overwhelming sense of guilt they feel: for not anticipating the actions which caused their loved one’s death, for not recognizing their pain, for not being able to somehow save him or her, and in turn, save themselves the pain they and others sharing their experience now feel. As with stigma, Pridmore and McArthur note that feelings of guilt have been associated with suicidal loss since antiquity in the West; going back as far as ancient Greece they see maladaptive feelings such as guilt, shame, anger, and sorrow (Pridmore and McArthur, 2009). Worden discusses that while guilt is frequently a feature of normal grief responses, the amount of guilt felt by survivors of suicide is inordinate and often overpowering (Worden, 2009). People who feel this amount of guilt can end up feeling themselves deserving of punishment, which can be very damaging to the survivor’s psyche and in turn can have physical consequences (Worden, 2009).
This sense of pervasive guilt may be especially the case for children and adolescent offspring of parents who have died from suicide: apart from the negative indications parental suicide has for child mental health outcomes in the future, the disruption of family functioning both before and after a parental death from suicide can have a significant impact on the psychosocial functioning of offspring (Kuramoto, Brent, and Wilcox , 2009). Worden discusses the ways in which reality testing when working with youth is particularly important, that families and clinicians be alerted to self-blaming and guilty feelings in children, as there is a correlation between being affected by suicide as a survivor and the survivor experiencing suicidal ideation in him or herself (Worden, 2009). Higher levels of shame, anxiety and anger have all been found in adolescent children whose parents died by suicide than in those whose parents were killed or died in other, less traumatic ways, and there is an increased risk for behavioral problems, well as possible decrease in overall functioning within the bereaved family unit (Cerel, Fristad, Weller and Weller (1999) in Kuramoto, Brent, and Wilcox , 2009). Jordan notes that many people incorporate their feelings of guilt and self-blaming into an ongoing analysis after their loved one’s suicide to determine if they were somehow the cause of it; unfortunately, these feelings, and the need to assuage them, can cloud the survivor’s recognition that their loved one, like up to 90% of suicide completers, had severe mental health disturbances, and these—not their actions or inactions—were what led the loved one to take their own life (Jordan, 2008).
All grief incorporates these elements or guilt and a wish to blame, and while the expectation of stigmatization appears to be particular to survivors of suicides, the social isolation felt by those who are grieving can cause additional pain beyond their initial loss; in the complex grief of survivors of suicide, there is another piece, comprised of anger and feelings of abandonment, which prolongs and further complicates the survivor’s ability to integrate their loss back into the tasks of living. Worden discusses the intensity of angry feelings survivors may experience when they perceive the death as a rejection; children and spouses may feel betrayed or as though their loved one’s death was a direct means of leaving them, and their grief may take on qualities of resentment or even rage (Worden, 2009; Kuramoto, Brent, and Wilcox , 2009). These mixes of emotions often feed into their guilt, and can have an impact on self esteem, that they feel as though their worth as the survivor is less because they were the ones who were left. There may also be questions in the survivor’s mind as to whether their deceased loved one was driven to death, which can be compounded by feeling of anger and hurt that they felt the need to kill themselves, or were not ‘strong enough’ to continue living (Jordan, 2008). Guilt and unworthiness at surviving often war with rage and immense pain at being left alone. Particularly in the case of teenage suicide, where there may be little sign of severe emotional distress disclosed before the act of suicide, surviving parents struggle with the unexpected nature of the death, their anger at being deceived by their children, their overwhelming pain at the loss of a child, and their guilt as seemingly failed parents (Lindqvist, Johansson, and Karlsson, 2008). Without intervention, such complicated grief, especially if coupled with post-traumatic stress if the survivor was a person who discovered their loved one’s death or body, can mix to cause grief so complicated that it overwhelms a person’s ability to work through their loss on their own such that they can continue living (Jordan, 2008).
In order to help intervene in complicated grief for survivors of suicide so that they are not wholly overrun with their feelings and cease to experience life themselves, it is of primary importance that the clinician acknowledge the death of their loved one and the entire spectrum of grief they feel because of that loss, to aid in overcoming the first hurdle of dealing with an unspeakable loss (Worden, 2009). The stigma of such a socially unacceptable behavior must be undermined in the eyes of the client, both so that the therapist may form an alliance with them and that they may feel that here is a safe place to begin coming to terms with all their feelings regarding their survivorship without being judged for any of them. Given that barriers to grief experience stemming from negative experiences regarding their loss can be linked to depression and suicidal thinking on the part of the survivor, it is paramount that a therapist acknowledge the reality of the loss along with the client, and bridge the loss of community they may have experienced (Feigelman, Gorman, and Jordan, 2009; Worden 2009). In surmounting the feelings of social and community isolation, it may be necessary for the clinician and client to take stock of what relationships are healthy and supportive to that client, and which may be more painful than they are worth currently (Feigelman, Gorman, and Jordan, 2009). This may even entail supporting the survivor in instructing their support system how to better work for them, which in turn will help destigmatize the association with the type of loss they are experiencing. Establishing this groundwork of support and belief for the client’s feeling, whatever they may be, is important in all cases, but all the more so when they are the survivor of a socially unacceptable loss.
While accepting the losses and the tumult of emotions the survivor has faced, however, it is important to keep in mind that the therapist needs to reality test a client’s feelings of guilt and blame, gently challenging or correcting distortions as they come up in conversation. Such gentle questioning can be highly appropriate for a client who feels excessive guilt, shame, or abandonment, as these feelings can stand in the way of Worden’s second task, processing the pain of grief. He gives the example, for instance, that it is acceptable for survivors to feel some level of relief that a person who had been experiencing such emotional anguish might no longer be in pain, even as they also feel anger at that person for leaving: such a jumble of emotions not only needs to normalized, but examined from an outside perspective, in order for a client to come to terms with all that they feel in association with their loved one’s actions (Worden, 2009). Similarly, while relieving the guilt many people feel for just having emotions which might be deemed somehow inappropriate, it is also necessary to give them the permission to feel as they do. These normalizing and giving permission tactics can be utilized either in one-on-one or group grief work settings with success, as individual attention and contact with other survivors are both beneficial in acknowledging the unique horror and relieving the isolation associated with suicide (Jordan, 2008). The best supports for survivors may come from other family members and close social connections, and it may be useful to incorporate them into a therapeutic situation, to act as witnesses and, in doing so, assuage some of the guilt and stigma of grief of this nature (Feigelman, Gorman, and Jordan, 2009).
Stepakoff (2009) suggests that, since suicide explicitly is a destructive act, a treatment of particular use for survivors of suicide involves active and willful countering of destruction, in the form of finding meaning and solace in creativity. To this end, she recognizes poetry therapy, the “utilization of poetry and related forms of literature and creative writing in order to improve psychological functioning” as a technique which is of great help to some survivors of suicide (Stepakoff, 2009). Lindqvist, Johansson, and Karlsson (2008) suggest that one of the hardest things to cope with is a survivor’s attempt to see a meaning in the actions their loved one has taken, and it can play a vital role in the ways in which survivors struggle with or accept their loss. Poetry therapy, therefore, is a means by which survivors can break their silence and express their struggles regarding the meaning of the suicide in an externalizing manner (Stepakoff, 2009). She outlines what she sees as the four primary tasks of for using poetry in working with survivors of suicide as:
“(a) to describe, in a fresh, creative manner, common aspects of the grieving process after a suicide, thereby helping participants feel less isolated; (b) to model exceptionally honest and brave self-expression, thereby freeing participants to express themselves more frankly and fully; (c) to give external form to internal, difficult-to-articulate emotions and perceptions, thereby helping participants contain their psychological pain; and (d) to serve as objects of aesthetic beauty, thereby instilling in participants renewed feelings of vitality and hope.”
(Stepakoff, 2009).
The approach is in keeping with Worden’s thoughts on helping survivors make meaning of their experiences of pain and grief by participating in the search for an answer for why this terrible even occurred, as well as work through task three, adjusting to a world without the deceased (Worden, 2009).
There are two forms of poetry therapy—receptive, which relies on the use of preexisting poetry, and expressive methods, which invites a survivor to use their own words, in poetry, or other creative writing form—either of which can be used on one’s own, or and especially to start out with, as facilitated by a therapist. Stepakoff outlines the use of receptive poetry as following one of two general methods: the survivor may pick a poem themselves in which they can find meaning and an echo of their feelings about the loss, and can read it aloud or to themselves; alternatively, the therapist can guide the survivor through the process where they facilitate the interaction and chose a poem which seems most appropriate. The former is more often utilized in the context of individual work, while the latter tends to be more in grief group settings, but either way constitutes classic poetry therapy, wherein the client’s task is to discern what they relate to in the body of work, and use it as a catalyst to discuss how they are experiencing their loss (Stepakoff, 2009). The expressive form of poetry therapy utilizes the client’s own words and thoughts to achieve what Worden discusses as the process of grieving; it includes the survivor’s writing down and often reading aloud the thoughts and feelings he or she experiences throughout the therapy, and at specific point in time, as they feel certain things. The theory behind this work is rooted in the idea of catharsis— that it is necessary to come to some resolution of powerful and often hurtful emotions through a purification or purging of the thoughts or feelings—and the practice of externalizing feelings, such as what is used in narrative therapy work, to separate out how a survivor feels from who that survivor is (Stepakoff, 2009). In doing so, the goal is to build in the client the ability to pick up, examine, and feel for a portion of time the overwhelming set of emotions he or she has been fraught with, without being overwhelmed by the constant presence of those aspects of grief within themselves.
It is not the resolution of the grief that is sought, but rather the rebuilding of the survivor’s life with their grief integrated into their future which therapists attempt to achieve when working with such clients (Jordan, 2008). Incorporating poetry therapy and other externalizing models into a framework where the therapist is present and accepting of the pain and grief the survivor brings into the room is a key to working with this population, and in doing so, we as therapists offer a means of easing the sorrow enough that a survivor can, in time, begin to remember their loved one while moving forward with their life.  
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