|Year : 2018 | Volume
| Issue : 2 | Page : 105-110
Psychological sequelae in suicide survivors: A brief overview
Sampurna Chakraborty, Susmita Halder
Department of Clinical Psychology, Institute of Psychiatry, Kolkata, West Bengal, India
|Date of Web Publication||29-Jun-2018|
Dr. Susmita Halder
Institute of Psychiatry, 7, D L Khan Road, Kolkata - 700 025, West Bengal
Source of Support: None, Conflict of Interest: None
Suicide survivor is a family member(s) or friend(s) who experiences the death of a loved one by suicide. Some existing literature shows the possible complications in them while some suggest on the management plans to address the reactions experienced by them. However, it is important to note here that added to the loss and grief, in suicide, there is an associated stigma that may dispose the person to fear, anger, self-blame, guilt, confusion, abandonment and may keep them away from the treatment procedures and reduce the process of ventilation and thwart the restoration of functioning. There may also be risk of suicide in the suicide survivors. The quantitative and qualitative difference in the experience of the emotional and cognitive experiences among suicide survivors require a specific plan for the intervention and more substantial research into this field.
Keywords: Grief, guilt, intervention, stigma, suicide survivors
|How to cite this article:|
Chakraborty S, Halder S. Psychological sequelae in suicide survivors: A brief overview. Indian J Soc Psychiatry 2018;34:105-10
| Introduction|| |
Suicide survivor is a family member(s) or friend(s) who experiences the death of a loved one by suicide. An existing literature review points to many possible complications for survivors, including heightened levels of guilt, shame, anger, family dysfunction, and social stigmatization. However, until recently, the survivors have been largely ignored within the field of psychiatry. Losing a loved one to suicide is one of the life's most painful experiences. The feelings of loss, sadness, and loneliness experienced after a close one's suicide is often magnified with feelings of guilt, self-blame, shame, confusion, fear, anger, and effects of stigma and trauma. These people are at a greater risk of developing serious medical and psychiatric conditions.
Nearly 1 million people die by suicide globally each year. Nearly 90% of all suicides are associated with a diagnosable mental condition. Suicide is an important public health concern as it affects not only the one who commits or attempts it but also affects the family members. Suicide has long been known to be associated with severe stress. While not everyone exposed to a suicide will be acutely affected by the death, individuals most closely related to the deceased are usually those most adversely affected by the death, especially mothers, twins, and spouses. India ranks 43rd in descending order of rates of suicide with a rate of 10.6/1,000,000 reported in 2009 (WHO suicide rates); the rates of suicide have greatly increased among youth, and youth are now the group at highest risk in one-third of the developed and developing countries. In 2010, the suicide rate increased up to 11.4%. In a study on suicide survivors of Indian farmers showed that female sex and being the spouse of the suicide victim were more prone to psychological distress that included manifestation in the form of depressive and/or somatic symptoms.
Relevant to the loss of a close one to suicide are the psychiatric conditions that may include major depression, posttraumatic stress disorder (PTSD), acute stress disorder, complicated grief reaction or acute and transient psychotic disorder. Added to the burden is the substantial stigma, which may subject the survivors to fear, confusion, shame, and guilt and may keep them away from the much-needed support and healing resources. Most tragically, evidence also suggests that suicide survivors may be at elevated risk for someday completing suicide themselves. Thus, the survivors may require substantial supportive measures and targeted treatment to cope with the loss and the resulting effects.
This is more important because the nature and quality of the distress experienced by the suicide survivors vary from the people who are depressed or are dysthymic. There is a difference in the quantity as the grief, self-blame, abandonment, and anger perceived and experienced are excessive, along with a difference in the nature of the symptoms. The presence of stigma and myths related to suicide being present in the society thwarts the expression and catharsis thereby worsening the grief reaction. Thus, the qualitative and quantitative difference in the experience and expression of the emotions and cognitions demand special emphasis and greater research into this field.
| The Emotional and Cognitive Reaction of the Suicide Survivors may be Understood in This Way|| |
Grief reaction and bereavement
Grief is the natural, universal, instinctual, and adaptive reaction to the loss of a loved one. It can be a state of acute grief or prolonged grief. Acute grief is the initial painful reaction to the loss. Immediately following the death, bereaved individuals often experience feelings of numbness, shock, and denial. This denial may be adaptive for some people as it provides a brief respite from the pain and helps the person to accept and deal with the loss. Shock, anger, regret, anxiety, intrusive images, feelings of depersonalization and overwhelming state and loneliness may be some of the associated feeling states. Prolonged grief is the persistent and intense reaction that may later develop into serious psychiatric and medical condition. Prolonged grief can again be understood as integrated grief or as complicated grief. Integrated grief is the ongoing, attenuated adaptation to the death of a loved one. This phase may be substantial extended for those who have lost a loved one to suicide. The healing process of death of a loved one is marked by the ability of the bereaved to recognize that they have grieved, returned to work and regular course of life, and to be able to seek the companionship of others. Complicated grief is labeled as prolonged unresolved reaction that may resemble the state of a trauma. The bereaved may feel traumatized that may interfere with their functioning. The bereaved may feel longing and yearning that does not substantially abate with time and may experience difficulty re-establishing a meaningful life without the person who died. Symptoms may include recurrent and intense pangs of grief, preoccupation with the person who died, and have recurrent intrusive images of the death. However, positive memories and experiences may be blocked or interpreted in a biased way. This may interfere with the daily functioning, occupational, and social functioning.,, They are also associated with poor health outcomes., Alternatively, the pain from the loss of the loved one may be so intense that this may lead to suicidal thoughts and ideas, thereby making them think that their own death may feel like the only possible outlet of relief.
Suicide bereavement is qualitatively different from bereavement of other causes of death. This difference may essentially prolong the state of acute or complicated grief as well as delay the process of recovery. Suicide bereavement is commonly linked with a state of confusion and disbelief, fear and anger, loneliness, rejection, shame, and all these states may further complicate the experience of guilt. These may also be accelerated by the outcomes of stigma and may eventually lead to a state of trauma.
As shown in [Figure 1], the complicated grief may result in perceived sense of abandonment. Survivors of suicide may experience feelings of rejection and abandonment as they see their close one choose to die. They are often left with an overwhelmed state and bewildered as to why their relationship with the person was not enough to prevent the self-inflicted death or where it failed to give the necessary support. Suicide-bereaved spouses often struggle with this perceived sense of abandonment as they perceive marriage as the most intimate relationship and the suicide as the ultimate form of rejection. Children who lose their parents to suicide feel handicapped as the person on whom they counted the most for basic needs has abandoned them.,
Anger is a common emotion among many survivors of suicide. It can be experienced towards the person who died for the feeling of abandonment, towards self for overestimation of responsibility and towards God and uncontrollable forces for the inability to explain the suicide.
Although there has been considerable amount of research, awareness, and attempts to destigmatize mental illness and suicide, it is still one of the most stigmatized individuals in the society. In the recent Mental Health Care Act, 2017, suicide has been perceived as no more a legal condition but essentially a mental condition, which conceives suicide as a result of some mental condition and that must be referred and intervened immediately than addressing it under Indian penal code. However, the stigma still remains among people which prevent the reporting of suicide attempts that identified at the right time probably could prevent a complete suicide in future. Stigma related to suicide is rampant in the rural areas and in the low socioeconomic status condition. The stigma attached to suicide often prevents the survivors to open up and discuss the grieved state which is very important for the survivors' recovery, thus restricting the catharsis process. Stigma also increases the state of over responsibility, anger, shame, and self-blame.
Trauma is the most common psychiatric condition recorded in suicide survivors. This can be understood as an inability to accept the loss. Many of the suicides involve considerable amount of bodily damage and injury. When the survivors witness the final act or are the first to discover the dead body are at a higher risk to trauma. In such circumstances, traumatic distress is often marked by fear, horror and vulnerability and thereafter, disintegration of cognitive assumptions may ensue. After witnessing a suicide or experiencing a loss by suicide, there are chances of terror-filled recollections, themes of violence and victimization, disbelief, despair, anxiety symptoms, preoccupation with the deceased and the circumstances of the death, withdrawal, hyperarousal, and dysphoria under traumatic conditions.
One of the systematic review studies done by Sveen and Walby in 2008 showed that there was no significant difference between survivors of suicide and other bereaved groups regarding general mental health, depression, PTSD symptoms, anxiety, and suicidal behavior.
The common psychiatric conditions related to suicide survivor are episodes of depression, dysthymia following the death of a closed one by suicide, obsessive-compulsive disorder, posttraumatic stress disorder, acute stress disorder, dissociative conversion disorder, acute transient disorder, schizophrenia, and substance abuse while the most common of the conditions being depression and PTSD.
The rate of PTSD in suicide survivors is almost 50% with flashbacks and terror-filled recollections. Another study reported that in suicide-bereaved individuals, the rate of recurrent as well as current episode of depression was found to be twice the rate of recurrent and current depression in other bereaved individuals.
From [Figure 1], we can see that the trauma and abandonment is linked to serious clinical conditions and that may also lead to increased risk of suicide in the survivors. Research studies suggest that suicide and mental illness run in families as a product of heritability and environmental factors. Survivors of suicide may be left to struggle with their own suicidal ideation and thoughts resulting from their guilt and anger. Suicide survivors are at a greater risk for suicidal ideation than any other state of bereavement. The intense state of grief, shame, self-blame, stigma, and anguish may make them believe that death is the only way to end this pain and may tend to induce pain to self. Some may also feel that death is the way that can unite with the lost person and the desire to join the loved one in death can be overwhelming.
| Understanding and Responsibility of the Suicide Survivor|| |
Most suicide survivors are burdened by the need to make sense of the death, understand why the person committed suicide, and attempt to explain and face the unanswered questions. They contextually feel they need to entangle the situation with their role in the sequence of events. When they commonly fail to understand the answers to the questions, mostly because of lack of information, their state of grief may negatively colour their perception and that may further accentuate the grief and shame. This leads to the other kind of common response to suicide that is an overestimation of one's own responsibility as well as guilt for not being able to control such an outcome. They may recall and replay events in search of cues and warnings and then blame themselves for not noticing or taking it seriously enough and may ruminate over it for prolonged period. The death of a child is arguably the most difficult type of loss one can experience, particularly when the death is by suicide. The state of confusion and need to understand and explain the suicide along with increased feelings of responsibility is found to be strongly correlated with parents who have lost a child to suicide, and therefore, the extent of guilt is also higher among parents of children who have committed suicide. This often leads to a state of self-blame. When the survivors are able to explain the suicide, for instance, by understanding that most suicide completers were battling a psychiatric condition when they died may help in decreasing the self-blame relatively.
Warning symptoms in suicide survivors
- Disturbed biological functioning such as decreased appetite and sleep
- Long absenteeism in workplace or inability to perform usual regular activities
- Withdrawal from friends, family, and society
- Increased use of tobacco, alcohol, or other substance dependency
- Frequent anger outburst, increased irritability, sudden and dramatic mood changes
- Recklessness and impulsiveness
- Verbalization of lack of purpose in life or hopelessness.
| Cultural and Societal Factors Delaying/hastening Recovery in Suicide Survivors|| |
The psychological reaction to suicide of a close person thus creates a risk and need for the intervention for the suicide survivor. Interestingly, some of the social and cultural families may be responsible in delaying the help-seeking behavior thereby aggravating the risk for the suicide survivor further. However, on the other hand, the sociocultural factors may also act beneficial in the form of understanding the need for help and provide adequate support. For instance, a collectivistic society like India or a joint family setup may shorten the grief period or provide support than a more individualistic or nuclear family setup. Furthermore, instances where suicide is considered a sin in few religions may bear greater responsibility and guilt in the survivor.
| Intervention for Suicide Survivors|| |
It is important to understand that grief is a natural, spontaneous, and adaptive response to loss; thus, other than complicated grief that may progress toward depression, there is not much a need for formal intervention for suicide survivors. However, there is a need for intervention keeping in light of the self-blame, complicated grief reaction, guilt, anger, and loneliness. To address all the emotional reactions and also importantly the suicide risk in the survivors itself, the following module may be used that integrates useful and effective principles and strategies from various therapies.
At this stage, immediately after the suicide loss has been experienced, it is necessary to provide support and strengthen skills in the individual to deal adaptively to the environment. The survivor(s) must be given reassurance about the event so as to remove the guilt and self-blame tendency. To allow the individual have an emotional catharsis is the second most important step. Thereafter, he/she may be guided and must be encouraged so as to foster the acceptance of the event and sustain through it.
The catharsis process may be continued as per the need of the patient and he/she must be encouraged. Here, it is important to address the biological functioning of the client. Sleep hygiene must be addressed and activity scheduling may be done to engage the individual into activity that in a way helps in distracting and at the same time targets the lowered interest and energy to work. The individual must be motivated for the engagement in the therapeutic setup and daily functioning.
This may be understood as the natural process of acute grief gradually changing into integrated grief if the complications of the grief are addressed and the natural mourning process is supported. Initial sessions may target at loss-focused grief that includes talking about the death and surrounding events, start taking pleasure in memories of the loved one, and trying to feel a connection with the person who committed suicide. Here, imageries may be used for exposure and can include cognitive restructuring.
This phase includes primarily allowing the acceptance of the event, gradually achieved through catharsis, mourning process, and encouragement. This must be followed by a commitment on the individual's part to continue living life and regularizing daily life and occupational activities. This commitment can be achieved through persistent encouragement, guidance, and restructuring the automatic negative thoughts leading to overestimation of responsibility into the suicidal act, self-blame, and guilt. The errors need to be challenged through Socratic dialogue, giving alternative rationale, using imagery and self-monitoring.
As mentioned in [Figure 2], in this phase using guided imagery, the therapist may use in vivo techniques to evaluate the efficacy of the skills learnt and prevent the relapse of the condition post the termination of the intervention process. This phase may be ended by generating future plans and goals.
Crisis intervention may be of significant importance here to address the suicide risk if present in the suicide survivor. The client needs to be comforted and brings into his/her acceptance of the acute distress and situation. This is followed by helping the person find the alternatives and the available options. The therapist has to take a directive yet supportive role and help the person see that the present distress is not endless. Overall, the therapist must try to identify the risk factors and try to reduce the risk factors in a supportive way to the person. The family and the associates must be informed about close supervision of the client and restrict the access to the suicidal means.
Suicide survivors tend to find relief and moderate help by attending support groups. Support groups have proved to be beneficial as they feel that it is their only access to people who can understand them, thus fostering emotional catharsis and reassurance. Support groups also help them get wider perspective to their problem and alternatives that may be beneficial in dealing adaptively. Through such supports, individuals may receive helpful suggestions for taking care of real-life obligations and setting realistic goals for one's own life. Support groups may thus be useful in providing accurate information, permission to grieve, normalization of affects, and most importantly conveying that they are not alone. Support groups that are relatively homogeneous that is the ones that consist of only suicide survivors are found to be more beneficial.
Some of the support groups working in India to help the suicide survivors include Sneha and Alliance of Hope.
| Emotional Buffer and Motivation|| |
The suicide survivors are usually so low on motivation that initially emotional catharsis and encouragement may be useful. However, once the motivation has been improved substantially, it is important to encourage the survivor(s) to engage in a task that acts as a prolonged catharsis and buffer for loneliness and perceived feeling of abandonment. For instance, the survivors may engage in religious or spiritual activities, may engage in music, traveling, teaching, or any other activities of their interest.,
Thus, suicide survivors face unique challenges that can impede the normal grieving process, putting them at an increased risk for developing complicated grief, PTSD, or serious psychiatric conditions such as depression or suicidal ideation or attempts. If these complications are left untreated, this can lead to prolonged suffering, impaired functioning, negative health outcomes and can even be fatal., The stigma related to suicide thwarts the normal grieving, catharsis, and perception of social support. Treatment hence should be inclusive of the best combination of education, psychotherapy, and pharmacotherapy often targeting the depression and PTSD. There is an immense need for more knowledge and research on the psychological sequelae of suicide bereavement and its treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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