Book Review-Suicide and Its Aftermath

They don’t know what to say.  My friends, colleagues, and acquaintances are at a loss for words when I tell them of our son’s death by suicide.  While suicide ends the suffering of the person completing the act, it transfers that pain to those who survive.  Suicide and Its Aftermath isn’t focused on assessment and prevention of suicide.  Instead, it focuses on the impact to those left behind and their experience.

Blame

With any tragic situation, there are natural tendencies.  The first, and one we experienced, was a curiosity about what happened.  Even as open as we’ve been with our loss and how it happened, we paused before sharing some of the details.  Some of that was for us to make sense of it, and some was to try to find a way to honor the situation.  The second tendency is to try to find people to blame.  We fought back our own thoughts of blaming people.  Often in the case of a suicide, the family themselves is blamed for the loss of a friend, a colleague, or acquaintance.

While we’ve not heard directly from anyone that they blame us for our son’s death, we’ve heard from others for whom the story is different.  They meet with extended family or friends and find themselves attacked as people lash out, because they’re hurting in their own grief experience.

This is tragic.  The people who are hurting the most are being attacked, because others are in pain and don’t know what to do with it.  There are two things that my suicide research has made crystal clear.  First, there’s no one path to suicide.  Rarely is there something that is done that causes someone to decide suicide is the answer.  In The Savage God, A. Alverez blames himself for Sylvia Plath’s final successful attempt.  He felt he failed her in some final way – but this is after she had a long career of attempts.  Because there’s no known ways to cause it, it’s impossible to know how to prevent it.  In fact, it’s generally accepted that if someone wants to die by suicide, we’re powerless to stop it.  In Suicide Inside and Out, we hear the opportunities that were presented to someone who was in an inpatient program, and they’re ample.

Second, blame is pointless.  What are we going to do?  How could we possibly punish the survivors any more than losing their loved one?  While as a society we attempted to discourage suicide by desecrating the body and denying families inheritance, we’ve largely realized that this is cruel and unnecessary.  It only causes more suffering, and we’ve all had enough of that.

The truth is that the only person to blame for a suicide is the person themselves.  It was their decision.

Put Out the Fire

Postvention

Shneidman in his work with the Los Angeles Suicide Prevention Center discovered something important when working with survivors (to perform psychological autopsies).  That is, survivors had a need to discuss their grief.  They needed a way to connect about their experience so they could process it.  (For more on psychological autopsy, see Review of Suicidology, 2000.)

“Postvention” was thus devised as a word to speak about the care for the survivors, which critically reduced suffering – and was supposed to prevent additional suicides triggered by the first.  Once suicide is experienced, it becomes somehow more real and acceptable.  This makes it more likely that someone close to another who has suicided will consider or attempt it.

It Can’t Be

Perhaps the most challenging aspect of surviving a suicide is to survive the cognitive restructuring that happens.  When we lose someone close to us – particularly in an unexpected or tragic way – we have to change our perspective on the world.  Something that could never happen has just happened, and it means that we must reconsider our perspective on the world.

The recurring thought is that “it just can’t be.”  Our experience of the world keeps fighting back the reality of the situation.  The thought is so incompatible that as we try to reorganize our perspectives on reality, we continue to question the fact that we know all too well.  We know it to be truth and simultaneously can’t bring ourselves to fully accept it.  We’ll get there.  We know it’s true.  But accepting it emotionally is more than can be borne initially.  It will take time.

The Silence

Those around the family are at a loss for words – appropriately so.  However, for some, their own discomfort disconnects them from the people they most want to support.  Most survivors experience material support – often in the form of meals.  However, one of the curious things that happens is how some people can’t bring themselves to reach out and communicate their care and concern.

Countless folks have responded to my messages by saying that they didn’t know what to say – so they didn’t reach out.  The disconnection from friends and colleagues may not take the form of a complete lack of communication – it may be much more focused.  They’ll connect, but only in a superficial way that avoids the elephant in the room.  They’ll not bring up the suicide for fear of triggering more pain.  For many, this results in an awkward conversation as everyone seems to be craning their neck around the obvious barrier to real connection.

My simple advice for those who have friends or acquaintances suffering from loss is don’t be afraid to bring up the topic.  Creating space for the conversation is sufficient.  You don’t need to be eloquent or witty.  You don’t have to find the “right” words – because they don’t exist.  Something as simple as “I don’t want to bring up ‘the situation’ if you don’t want to talk about it, but we can if you want to.”  This creates space for the survivor to engage at the level that is appropriate for them.  Of course, this presumes that you’re willing to walk through uncomfortable conversations if that’s what they need.

Acceptable Anger

Somewhere, we got this idea that we shouldn’t “speak ill of the dead.”  Our ability to be angry with the person who deserted and abandoned us is harmed if we can’t express it.  Desertion and abandonment are the feelings that many people have as they face the cold reality of the suicide.  They didn’t “have to” do it.  No one “has to” die by suicide; it’s a choice.

As The Grief Recovery Handbook explains, grief isn’t a linear process – but anger is often a part of it.  Elizabeth Kübler-Ross in On Death and Dying predicts that anger is a part of the process as well.  We shouldn’t be surprised that we’re angry with the person who chose suicide.  The feelings of desertion and abandonment are predictable.

Suppressing the feelings of anger because others can’t accept that you’re angry with someone has died causes more suffering.

But, why?

Another natural question that follows a suicide is “Why?”  There is very rarely any one reason.  While suicide can be reasoned, it’s not likely to be rational to others.  Like many things in life, suicide rarely follows a cause-effect pattern.  Instead, there are countless factors that pull people away from suicide and some that push them precariously close to the cliff of suicide.

We want to understand the why, because, for most survivors, the suicide answer was never an expectation.  The person who died violated our expectations, so we want to correct our mental models.  (See Resilient.)  The problem is that some things have no “why.”  In the case of suicide, even when a psychological autopsy has been performed, we may not know the real reason.  We may never know the final straw that broke the camel’s back and caused the person to decide death was the best option.

While it’s absolutely expected and natural that you’ll try to find the “why” for the situation, it’s important to accept that there may be no reason that you can understand or that you’ll find a mixture of psychological forces that moved the person to both life and death.  (See Principles of Topological Psychology for more on psychological forces.)

What Next?

Loss of a loved one is such a disruptive process it often lifts people up from their social moorings and makes them question their worlds.  Like any death, one is forced to confront their own mortality.  (See The Worm at the Core for more about confronting our mortality.)  This alone encourages people to reevaluate their world.  If they watch a friend fall victim to a heart attack before they retire, they’ll wonder if they’re putting off their retirement too long.  After all, what good is a savings when you’re dead?

However, the challenges with suicide are more complex.  One must also invite the question about what it is they really want out of life.  Not only must we consider whether it’s time to take it easy, but we also must question what we’d do if we were taking it easy.  The grief of the loss may be short in comparison with the existential crisis it triggers.

Out of Order

Because of the bimodal distribution of suicide – having a peak in the twenties and then much later in life – there’s the very real possibility that the person who dies by suicide will be much younger than those who survive.  This creates a more intense feeling of reorientation, as it violates the natural order of things.  We accept that old people die.  We think that they’ve lived their life, and it’s their time – even if they die by their own hand.  However, when someone younger than you – particularly a child – dies, it shakes your belief in the way that things should be.

Tragedy strikes everyone in different ways, and while most of the time it’s older people dying before younger people, we can’t eliminate the occasional situation where someone significantly younger does die.  We do, however, need to cope with the reality that they did, and it “isn’t right.”

Tell the Truth

In the case of an adult who is close to a child dying by suicide, there’s a natural inclination to protect the child from the truth.  The idea that it’s too painful for a child to process the fact that their loved one abandoned them is pervasive.  However, the research shows that those children who are told the truth – in a caring way – have fewer problems in adulthood.  It seems that the lying about the situation sets them up to have a general distrust of everyone when they discover the truth.  That isn’t healthy for them as an adult.

Additionally, the lie which must be kept creates further distance between the child and the remaining loved ones due to the need to suppress the thoughts of sharing the truth.  (See White Bears and Other Unwanted Thoughts for more.)

Magical Thinking

Magical thinking has a role to play in survivors just like it does in suicide itself.  (See Comprehensive Textbook of Suicidology for more on magical thinking in suicide.)  Some children (and adults) believe that somehow their thoughts and feelings may have caused the death.  While this occurs in any kind of death, it’s particularly frightening when combined with the sense of rejection that can be felt when someone close commits suicide.

Despite evidence or any indication, children (and adults) feel guilty for their feelings and thoughts, somehow believing that they are responsible.  While we can rationally argue that this could not be the case, the feelings are often persistent as people feel that they “had” to have some role in what happened.

While this may seem narcissistic – even for a child – our general tendency is to ascribe more belief about the circumstances we find ourselves in are a result of something we did or did not do rather than recognizing them as the randomness that happens.

Sibling Survivors

Siblings are often considered the forgotten survivors.  The attention and resources are focused on the parents coping with the loss, but too often, siblings are left feeling left out and perceived to be unimportant in the recovery process.  This process doesn’t require that others are unkind or tease them.  There’s no additional pain needed than the pain of losing a sibling.

In addition to the loss of future associated with a suicide, siblings can feel as if they’ve been deprived of a part of their childhood.  They can feel as if their memories of the happy times with their now departed sibling were untrue, or not enough, or unimportant.  These feelings don’t quiet quickly.

The Decision

Survivors get no choice in having their lives changed.  They do, however, get to choose how they respond.  (See Choice Theory for more on the importance of decisions.)  The choice can be to remain stuck and a victim or to decide that victimhood is a poor place to build a house.  (See Hostage at the Table for more.)

If the decision is made to move forward, it will require that emotions and the grief process is allowed to fully express itself rather than being suppressed, hidden, or accelerated.  The process takes its own time and attempts to suppress it or accelerate it can backfire and make the process messier, longer, and more severe.  However, actively looking for ways to heal, grow, and change are healthy.  (See Antifragile for more on growth.)

Helping Others

In Being Mortal, Atul Gawande explains that mortality of people in senior care drops when they are responsible for something as simple as a plant.  Helping others is wired into our DNA, and as we seek to help others in their struggles with surviving suicide, we help ourselves.  This creates a positive cycle that helps all those who are suffering – not just those being helped.  Gawande’s not alone.  Flourish and The Dalai Lama’s Big Book of Happiness also express that we’ll find the most joy when we’re helping others.

We won’t have to hide, drown, or attempt to compartmentalize our feelings of sorrow if we’re completely immersed in our desire to help others.  However, this presumes that you’re giving to others and that they’re not trying to take solace through you.  (See Give and Take for more on giving and taking.)

Others Using You

Others struggle with their feelings and may attempt to become closer to you to assuage their own feelings – and it ends up making you feel used.  It doesn’t help you and is of limited use to them.  Unfortunately, there is little to be done in these situations except to establish appropriate boundaries.  (See Boundaries for more.)

First Responders

Suicides don’t just impact just those who make the choice and their loved ones.  There’s another group that is impacted by suicides.  First responders – police, fire, and paramedics – are often the first to find the bodies and must face their own struggles.  Invariably, the suicide will resemble a friend, child, parent, or sibling from time to time.  First responders are remarkably adept at encountering the situations that others wouldn’t be able to tolerate.  They are, however, often restricted in their ability to communicate about their feelings; thus, while they have a higher tolerance for such events, the events build over time and lead to their psychological distress.

We have to find ways to make it safer for first responders to talk through their feelings and release the psychic pain that others’ suicides inflict upon them.

Prescription Pads

While first responders are also often the first people who must speak with the survivors, physicians often must support their patients who are survivors.  The natural impacts of stress, anxiety, trouble sleeping, and other health problems – including broken heart syndrome – lead patients to physicians for help.

Physicians have the power to prescribe and thereby relieve their patients’ pain.  While tempting – and invariably what the patients ask for – it’s likely not the right answer.  Survivors need to cope with their pain – and that’s not always possible when medicated.  (See Warning: Psychiatry Can Be Hazardous to Your Mental Health.)

Physicians should remain in contact with their patients and opt for more frequent interactions and evaluation before defaulting to a medical answer to a psychological problem.

Warning Signs

One of the nagging thoughts that suicide survivors must face is whether there were warning signs and what they should or could have done to prevent the suicide.  In some cases, there were warning signs, but in others, there are none to be found.  Even if there were warning signs, it’s not possible to stop someone who is intent on the act.  While we all want to do as much as possible – as we should do – sometimes there is nothing to be done.  Sometimes all we can do is live in Suicide and Its Aftermath.