In the Shadow of Suicide - Surviving Stigma and Shame
Social Work Today
By Kate Jackson
Vol. 4 No. 4 p. 36

Twelve women sit stiffly on folding chairs arranged in a circle. Uneasy and apprehensive, they tug at the boxes of tissues on the floor at their feet. A few talk nervously, while the rest stare at the walls, windows, and ceiling. When all the participants have arrived, the leader of this support group for recently widowed women asks each person in the circle to introduce herself and tell a little about how she lost her spouse. She invites the others to comment and share their perspectives.

The first woman chokes back tears to explain that her husband died suddenly of a heart attack on the tennis court. The second says her husband was killed by a careless motorist. The third explains that her spouse had suffered with cancer for several years, and the fourth breaks down as she tells the group that her husband, who’d been lost to her for some years as a result of Alzheimer’s disease, suffered a fatal stroke. The group members listen attentively and communicate their interest, understanding, and empathy through eye contact, body language, and inquisitiveness. They ask for more information and knowingly acknowledge the anger, disbelief, and shock they see mirrored in the other faces.

One woman becomes increasingly agitated as her turn approaches. She eyes the door, fidgets in her seat, and bites at her nails. She manages to stammer her name—Marjorie—and then freezes. The leader coaxes her gently to tell the group why she’s there. She mumbles something and begins to cry. A woman sitting next to her strokes her back and takes her hand to try to comfort her. Pressured by the leader, Marjorie, barely audible, says her husband killed himself six weeks ago. The others in the group look away. They can’t claim to know her feelings and are unsure what to say. The group leader merely expresses her sympathy and welcomes her to the group. At the next meeting, Marjorie is absent.

A Different Kind of Grief
According to John D. Weaver, LCSW, author and crisis intervention specialist, the circumstances of a suicide may determine the degree to which grieving is complicated, but all survivors will struggle not only with the shock of their loss but also with the quicksand of emotions that follow. “There’s going to be extra trauma if someone finds the person who has committed suicide or witnessed them doing the suicide, and there’s a greater potential for increased guilt or shame with a suicide over other types of death,” he says. Furthermore, some individuals grieving a loss by suicide may be so overwhelmed by their emotions that they are themselves at risk for suicide.

Everyone who grieves the loss of a loved one suffers a range of emotions—from anger to guilt. Family ties and social support are often enough to help individuals cope with such losses over time. Those who grieve for someone who commits suicide may be overwhelmed by the same emotions, but guilt plays a more prominent role and is often accompanied by shame. Suicide and these potentially devastating emotions that arise in its wake are generally difficult to talk about for survivors. For family, friends, and caregivers of the bereaved, it’s often excruciating to ask about the suicide or listen to the story.

Susan Powers, PhD, an experiential psychotherapist trained in gestalt therapy and psychodrama, knows from personal experience the ways in which grieving a suicide is different—and perhaps far more lonely an experience—than grieving other kinds of losses. Two and a half years ago, her husband died of kidney cancer, only six months after he had been diagnosed. “He died with hospice in a very healthy way—very complete, emotionally connected, and conscious,” says Powers. Less than three months later, she received word that her daughter, who had been addicted to heroin and homeless in California, died in the street of an overdose.

“It was so clear to me the difference between a healthy death and an unhealthy death,” says Powers. After the latter, she says, there’s no chance to say good-bye and, thus, no sense of completion. “I was shattered,” she recalls, “but what later became so interesting to me was the difference of grieving someone who dies in a more natural way and the special difficulties of grieving someone who dies from suicide or addiction.”

Guilt And Shame
Guilt and shame, which tend to go hand in hand for many survivors of suicide, may spring from a variety of issues. After a suicide, a loved one might experience guilt over the possibility that they contributed to the desire to die or that they could perhaps have prevented the suicide. These feelings of responsibility may be heightened if the suicide victim battled addictions. “Any time people are using drugs or alcohol, it disinhibits them, so it tends to make them more prone to act impulsively and to act in a way that might complete the suicide more so than a suicide attempt that might be attention-getting,” says Weaver.

When people die of addiction, says Powers, guilt and shame are magnified by the awareness that the person was complicit in their own death through their own self-destructive behavior. Very often, says Powers, “the person has been kind of disappearing from your life in many ways and there have been many difficult decisions that had to be made about how to get help, how much to intervene, how to know if it’s just depression or addiction, or both.” Usually, she says, it’s a very complicated relationship. “In my experience, after a suicide or an addictive death, all the people close to the person who died feel guilty in some way,” says Powers.

Guilt is common among all mourners, but in the case of suicide, she insists, the feelings are often extreme. “There’s a typical shock and numbness that happens, but after that, there’s a lot of shame and blame that goes around the family and friends, and there’s a great deal of alienation afterward as people blame each other. Everything is so much more complicated, and the personalizing of the death—in shame and blame—is so much greater.” Shame, says Powers, “is like a dark pit, and there’s no way out of it.” Guilty people, she observes, think they made a mistake. Shamed people, however, think they are a mistake. There may be so many feelings of worthlessness that they think they’re undeserving of help.

Social workers can best help survivors put feelings of guilt in a more rational perspective by listening and helping them talk and work through the emotions, suggests Weaver. Clients, he says, may need help accepting that while things may not have been as good as they could have been in a relationship, they can’t change that now. It’s helpful for them to acknowledge that they’re not likely to be entirely responsible, if responsible at all, for the deficiencies in the relationship. “Certainly, some of it was a result of the deceased’s issues,” says Weaver, “and either one of them could have made for a better relationship.”

Survivors who are plagued by guilt associated with failing to anticipate or prevent the suicide can be comforted through reassurance. Social workers, suggests Weaver, “can help clients refocus a little on the fact that we just don’t have good predictors of who will commit suicide. Nothing is a sure thing. People are extremely resilient in some aspects of life and other people are not.” Therefore, he indicates, it’s nearly impossible to predict in every case who will or will not take their own life. “Some people are hard-core suicidal, and no matter how good a support system you try to build around them, if they’re bent on taking their life, they have that option. Even if they’re in a locked psychiatric unit with 24-hour supervision, people can find a way.”

Lack of Support
Accompanying shame, another pitfall to the resolution of grief, says Powers, is isolation. “There’s a tendency in grieving to want to be alone. It’s a natural desire to go and be alone to lick your wounds,” she observes. “People grieve in different ways. Some need more alone time than others.” Still, she says, too much isolation only deepens and complicates grieving. “You don’t want to be alone and suffering. There’s a phrase in recovery that pain is necessary, but suffering is optional.” Suffering, she says, is the self-flagellation and self-hatred, and pain is just pain. “But pain shared is reduced, and to be able to talk about it is just what’s needed.” But paradoxically, just when you don’t want to talk about it is when you most need to talk about it, suggests Powers.

“Many people just withdraw as they so often do when dealing with mental illness in a family,” explains Weaver. “Because of the stigma associated with suicide,” he adds, “people just don’t tend to want to talk about it, so some of the natural caring and support that might go on were it a different kind of death is probably less likely to occur.” Even the most well-meaning people, he explains, may not want to further upset the grieving person by opening a door to conversation. In a sense, it’s another loss for the survivor because, says Weaver, “it can be helpful to talk it out and shift some of the memory focus to good times they might have had with the person they grieve for, not visions of them in death or in moving toward death if the person had been leading a reckless lifestyle.”

“People don’t know what to say or do,” agrees Powers, so they often say hurtful, unhelpful, or foolish things. Although it challenges their boundaries, she insists, grievers must be encouraged to reply to such statements by saying, “That’s not very helpful to me right now” or “I can’t hear that right now.” “There’s not much you can say,” she acknowledges, “but what the griever really needs is just to be heard and listened to.” Silence, maintains Powers, is what kills people. She refers, for example, to a colleague, another therapist, who killed herself just days after losing a child to a suicide by overdose. Powers understands the shame. “I worked as a therapist, too, and there was that feeling that I couldn’t help my own daughter. If she could die like that, how could I help people? So there was professional shame on top of codependent shame on top of family shame. But it did kill my friend, and I have the feeling that she really wasn’t able to face it and talk about what happened.” Sadly, says Powers, that’s not an uncommon reaction.

Breaking The Silence
The real solution to shame and blame, she says, is telling the story. “There’s so much secrecy about suicide or an addictive death,” says Powers. “So many suicides, for example, are related to a chemical addiction of some kind, and very often that’s not stated.” It’s talked about as if there were no connection to addiction because for some people, that’s seen as more shameful.

Social workers who wish to help their clients cope in the aftermath of suicide can encourage them to share their experiences and feelings. It’s highly therapeutic for the bereaved to tell their story again and again to a compassionate listener. Following a suicide, however, the mourners may need to be drawn out. “If you can tap into their story and ask what happened, it often opens the floodgates. If you can push through their phobias about such questions—people welcome an empathetic listener,” says Powers. She advises grievers to be ruthless—to say, “This happened to me, and you’re going to be hearing about it.” They need to be equally ruthless, she stresses, in silencing people who are saying things that are hurtful.

Mending Relationships
One of the more difficult aspects of grieving after suicide is the lack of closure or inability to right relationships that have gone wrong. Social workers or other therapists can help survivors simulate closure and add dimension to the memory of the relationship. Caregivers can “help them get things said that they might have wanted to say to the individuals but didn’t get a chance because of the suicide,” says Weaver. This, he says, “might run the gamut of emotions—from anger at them for doing it to sadness at the loss.”

Powers brought her personal experience to bear upon her professional practice and began giving an experiential workshop called “Grieving the Unheroic Death” for those who lose loved ones to suicide or addiction. Because there’s so often a film of disgrace overlaying a suicide, Powers seeks in this workshop to both honor the life of those who have taken their own lives and stress that they deserve the same respect as those who have died from natural causes. “Very often, people need to experience a ritual that is loving and not shameful,” she notes, so participants are encouraged to bring a photograph and create an altar to their lost loved one. Powers encourages role playing—having someone stand in for the lost loved one and allowing the griever to talk to them, even get angry with them. Similarly, she advises people with these kinds of losses to write letters to the loved one to express feelings they were not able to express in life. “Letter writing is helpful,” she says, because it allows people to complete the relationship as much as possible. In another technique, she takes the correspondence a step further and asks the person to respond to the letter as the loved one might have. She reminds her clients that they knew the person very well and they’re capable of knowing how they might have responded. “I help them set up a writing dialogue, and it’s amazing what comes out of it,” she says. A surprising result of this is often an expression of wellwishing. “There’s often been so much anger in the family or in the relationships, especially when there’s addiction or severe depression, but the antagonism tends to fade away with death so that people are often able to get to a more loving place with each other.”

Contagion
Social workers who counsel individuals grieving loss by suicide must always be alert to the concept of contagion and be vigilant about suicide prevention. According to experts, suicide tends to beget suicide. Sometimes, observes Weaver, it can simply take away someone else’s will to live. This is especially likely to occur if the survivor’s mission has been to take care of a depressed family member and that person is suddenly gone. The person who’s been the caretaker may become suicidal.

A family history of suicide increases one’s risk of suicide, and highly publicized suicides can cause copycat behavior. According to the American Foundation for Suicide Prevention, an article in the newspaper about suicide often leads others to consider or commit suicide. Explains Weaver, “Suicide sometimes sets a sort of family standard. If you have a family in which many people have committed suicide, it becomes a learned violent behavior as a means of coping with stress.” Contagion, he suggests, may occur not only to family and close friends of suicides but even to complete strangers. “There’s contagion sometimes when famous people—either as a character in a movie or in real life—kill themselves.” It’s a phenomenon that occurs in schools as well, he explains, “where sometimes there’ll be a run of suicides.” Contagion is especially likely to happen when the person who commits suicide is very popular. “Other kids who are on the margins may think that if a popular kid who had everything going for him couldn’t hack life, why should they?” How the family or school system responds in the aftermath of a suicide, he adds, may increase the risk of contagion. Sometimes overmemorializing, he explains, “can make death look more attractive than life for people who don’t feel connected to life.”

Social workers, then, must be alert to the potential for suicide among those grieving a suicide. These clients, says Weaver, must be carefully monitored. Caregivers should encourage them to keep in close contact with other people and help them build a support system around them that might include family, friends, coworkers, spiritual leaders, or others they might turn to. “If a team of folks are watching, the person might avoid contagion,” he says.

To combat contagion and prevent suicides, social workers, says Weaver, must not be afraid to raise the subject. It’s crucial to reject the myths that lead people to believe that if you talk about something, you’ll cause it to happen. “That’s not the case,” reminds Weaver. “Generally, people who are suicidal have been thinking about it for a long time. It’s often a five-year process from the time suicidal people first thought the world would be better off without them to the point at which they take their own lives, and there may have been attempts along the way and efforts at improving the planning.”

Therefore, he suggests, therapists must encourage their clients to reveal suicidal feelings and take seriously any suspicions that a client may be so depressed that he or she might harm themselves or contemplate suicide. “Helping professionals especially must be comfortable using the word “suicide” in a sentence and not be afraid to ask if they’re getting a vibe that someone might be thinking of killing themselves and ask in plain language, ‘Are you thinking about that, and if you’re thinking about that, how would you do it, when would you do it?’” It’s crucial, Weaver insists, to find out whether or not the person has a plan and whether or not he or she has gotten that far, to take steps to work with crisis intervention to get an emergency commitment if necessary so everyone can help prevent an attempt.

It’s also important for social workers to encourage people in the survivor’s support system to take the risk and call the hotlines if they suspect that someone is suicidal. Help them understand that it’s better to err on the side of caution. “It’s better to have people mad at you because you tried to hospitalize them than have to live with the fact that you think you could have prevented something but didn’t try,” says Weaver.

In addition to close monitoring and contact, social workers, says Weaver, should employ a strategy of diffusing and debriefing. It may also be helpful to encourage clients to attend survivor groups, helping them focus on the positive aspects of life so the negative image of death doesn’t linger and overwhelm them. This is especially important for clients who witnessed the death or found or witnessed the body after the suicide. When a student commits suicide, says Weaver, the school can help by reaching out to the child or teenager’s closest friends so they can help avoid contagion. “School social workers may also want to help the students think about a memorial of their own by asking how they’re going to look back on the person’s life a year down the road and help them get ready for the anniversary reaction they may have year after year on the anniversary of the death.”

In the End
Suicide is an ending, but it never permits real closure. Concludes Weaver, “It’s generally something that families years and years later are still reflecting upon like other life traumas. It’s like people who survive a hurricane and never forget it. It changes their lives forever. It just tends to be a permanent memory that is troubling for years and years to come.”

— Kate Jackson is a staff writer for Social Work Today.

Resources

American Association for Suicidology
www.suicidology.org

Centers for Disease Control and Prevention
www.cdc.gov

National Institute of Mental Health
www.nimh.nih.gov

Substance Abuse and Mental Health Services Administration
www.samhsa.gov

Office of the Surgeon General National Strategy for Suicide Prevention
www.mentalhealth.org/suicideprevention

Suicide Prevention Advocacy Network USA, Inc.
www.spanusa.org