When survivors do seek mental health assistance, they often do so on their own or through encouragement of friends or family. When they come to counseling, they might have a feeling that they "should be doing better by now." The belief that grief ought to be over after a certain period is popular in Western society, and suicide survivors might be getting messages from their social network that something is abnormal about them and their grieving process. As we discussed earlier, the grieving process for suicide survivors is "abnormal" in comparison with other kinds of grief, but the process is "normal" for suicide survivors. For suicide survivors, it appears that certain grief symptoms (e.g., guilt, rejection, shame, stigma) that occur after a suicide death for survivors complicate the bereavement process (Harwood, Hawton, Hope, &Jacoby, 2002). Clinicians need to realize when working with bereaved suicide survivors that they might not recover as quickly as other types of survivors and might have some special issues that complicate therapy. Above all, the experience of these clients will most certainly not fall nicely into the discrete stages of a "normal" grief process.
The most salient aspects of suicide survivor bereavement that have been identified in the literature relate to extreme feelings of guilt and shame. A second theme that emerges is the need to make sense out of the death, to answer questions of "why?". Third is to cope with social stigma and resulting isolation. In addressing these issues, suicide survivors must avoid denial, social withdrawal, self-destructive behavior, failures to communicate, and developing enduring mental and physical health problems. Dunne (1992) stated these issues somewhat differently and listed the following as the dominant psychological themes for suicide survivors in counseling:
- Obsessive search for the why of suicide
- Sense of stigmatizations
- Incomplete or unusual grieving pattern
- An invasion of conscious thought by the idea of suicide
- Sense of helplessness and low self-esteem
- Reduction in size or complexity of social relationships
- Erosion in basic trust of others
Even after identifying useful themes for directing therapy from the literature, clinicians still must remember that clients have many individual differences. Age, gender, cultural background, and life experiences all affect the grieving process in general and suicide survivor grieving in particular. However, how these many identities and experiences interact to produce the grieving process is poorly understood. For example, some individuals might not exhibit any grief and, contrary to myth, might not have a delayed grief reaction. At present, there is no long-term study on outcomes of these cases. Others find comfort and meaning in suicide notes left behind, while some find these notes heart-wrenching and more complicating to the process. The relationship of the survivor to the victim and the characteristics of that relationship are important individual modifiers. The perceived closeness by the survivor to the victim might be more important than the actual genetic relationship.
Given the complexity of survivor grief, clinicians might become impatient or discouraged with treating these clients. Fortunately, there are some very real things that mental health professionals can do to help. Farberow (1992) offered the following list of activities that survivors have reported as helpful:
- Talking with friends and family (most helpful)
- Reviewing pictures and mementoes
- Visiting the grave
- Rearranging and storing the belongings
- Individual psychotherapy (50% thought it helpful)
- Group psychotherapy (22% thought it helpful)
Further, it has been suggested that a factor that is of crucial importance to the suicide survivor's recovery is resolving the meaninglessness of the suicide (Rudestam, 1992). Helping clients with the why of the suicide, letting them tell their stories, and helping them to reframe and make some sense out of their loss might be the most helpful thing that a therapist can do. Many survivors use their experiences to reach out and help others. Examples of this "making meaning" range from public legal advocacy such as the passage of the Garrett Lee Smith Memorial Act, the first federal appropriation to colleges and universities for suicide prevention, to private actions such as set-ting up a remembrance web page or donating to a suicide prevention cause, such as the Jed Foundation or American Suicide Prevention Foundation, or as in our case, to writing a book to help better prepare mental health providers.
Additionally, helping to work through the emotions of guilt, shame, and responsibility associated with the suicide is a task with which professional mental health providers can definitely assist survivors. Clinicians also should remember to monitor the survivor for suicidality, given that survivors are at increased risk themselves. Finally, a therapist can help clients with addressing the survivor's ability to function in their social network, given any stigma they may feel (Jordan, 2001). It is important for survivors not to withdraw and isolate themselves from friends and loved ones following the suicide.
In the United States, there has been a movement to provide support to suicide survivors in the form of groups that are often sponsored by local mental health agencies. Most frequently, these groups are called S.O.S. (Survivors of Suicide) groups, but they may also go by other names. S.O.S. groups are sometimes peer led and sometimes led by a professional and a peer cofacilitator (Faberow, 2001). There has been very little systematic research on these groups, and little is known about their effectiveness (Ruby & McIntosh, 1996. However, one recent study of postvention groups for widowed survivors of suicide revealed some positive outcomes regarding bereavement. The groups met for eight weeks for 1.5-hour sessions that focused on facilitating group discussion and encouraging socialization. The study indicated reduction in overall depression, psychological distress, and grief as well as an improvement in social adjustment (Constantino, Sekula, & Rubinstein, 2001).
A final point concerning clinicians' treatment of survivors is that it is commonly held that clinicians should not treat the survivors of one of their own client's suicides. This belief arises out of concerns that the clinician's own feelings are likely not to be objective and that forming positive therapeutic relationships with the survivors also may be complicated. It is considered best practice for clinicians to refer survivors who are related to one of their own clients to another colleague in the community (Pietila, 2002).
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Excerpt from Suicide: An Essential Guide for Helping Professionals and Educators, by D.H. Granello, P.F. Granello, 2007 edition, p. 284-286 .
© ______ 2007, Merrill, an imprint of Pearson Education Inc. Used by permission. All rights reserved. The reproduction, duplication, or distribution of this material by any means including but not limited to email and blogs is strictly prohibited without the explicit permission of the publisher.
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