Lessons Learned Working with Survivors of Suicide Loss
We all know how it feels when someone you love dies suddenly or in an unexpected way. There is numbness and overwhelm. And then the mind struggles to make sense of the loss. It wrestles with the frailty of life in the face of disease and accidents. It brings up memories and images of the loved one as if to comfort. Even an act of violence allows survivors to trace, step by step, the events which led to the loved one’s passing.
There is Just Something Different About Losing Someone to Suicide
The mind leans in to make sense of what’s happened, but there may be few answers. There’s a feeling of being blindsided. How this tragedy unfolded and what the final straw was are often not clear. That lack of information about everything that led up to this death invites debilitating narratives about the deceased and opens the door to the survivor’s sense of guilt, failure, shame and regret. And then there is speculation about the "should halves" and "could halves.” Survivors dissect past interactions in minute detail. They struggle to create meaning where none is to be found.
There is an inherent violence to the act of ending one’s life. Add that to the survivor’s pain, confusion, emotional extremes and guilt and you have the risk of secondary traumatization and the possibility of a survivor’s own suicidal ideation.
In an attempt to better understand the mind of a person who died by suicide, many loved ones try to “walk in the shoes” of the person who died. It’s a way of trying to make sense of the "why" behind the decision to die. It may reflect a desire to be reconnected with the lost loved one. And then there is the wish to find relief from the pain of loss. These are just three common ways of coping that feed the risk of increased suicidality among survivors.
A True Story
As I was beginning to set up a new client’s first reprocessing session following the death of his brother to suicide, he was expressing deep loneliness, but nothing about his brother or his suicide. When I asked him what emotions he was feeling, he looked up at me with incredible sadness in his eyes and surprise in his voice and he said, “I’m feeling incredibly suicidal!”
I had a choice to make in that moment as to whether or not to pull him out of the reprocessing and engage in creating a safety plan or to recognize that what he was feeling was an “attachment cry” for his brother. We continued on with the reprocessing session, and his SUD, which had been a 10 at the outset, ended at a 4 by the end of that session. He was no longer feeling suicidal as he left my office and was relieved that the acute pain he was experiencing had shifted.
Of course, I had been anxious during the session. After he left, I took time to reflect on what had actually happened as I was a little in shock myself. Was it the fear of “what happens if I walk him through this and it doesn't go well?” Was it a deep compassion that I felt for another human’s devastating pain in that moment? Was I questioning my own ability to hold space for the pain? Maybe it was a combination of all of those things, but I also knew that he felt safe enough to tell me how he was feeling. So, I’m glad I trusted the relationship I had with him as well as my own intuition to make the decision to move ahead and offer him the relief he desperately needed.
I mention this only because it’s important to recognize that for us as therapists, suicide and suicidality can be particularly frightening. And we may or may not be able to tell the difference between the client’s experience in the moment and our fears. But that’s the part we’re responsible for. For me, I have to slow myself down long enough to go inside and check my own system. And when I’m scared, that means it’s too much about my fear and not enough about the client. That’s when it’s time to seek support and to do our own work, whether it’s around the lack of control or the uncertainty of what can happen.
Keeping a Tab on Suicidal Ideation
I think one of the easiest ways to understand and track suicidal ideation is with this simple red light, yellow light, green light categorization which considers the elements of intent, plan, action steps and means. I use this for risk assessment.
Green Light: Throughout the course of a lifetime, most people have painful circumstances which cause them to question whether life would be easier if they were gone. Would anyone miss me if I were gone? These are scary thoughts, but without intent, plan, action steps or means behind them. They are low urgency, with no intervention required. I think of these as green light thoughts. They are just difficult thoughts and feelings that are shared with a therapist, and that feel less intense for the client for having shared them in a safe space.
Yellow Light: This is when the painful thoughts are accompanied by behaviors that point towards action. Language about emotional, psychological and/or physical pain becomes more specific. The client may reference a vague plan, but it’s not yet clearly formed. There’s no clear intent, action steps or means, so this remains a situation of moderate risk. Of course, when in doubt lean on the side of safety and intervention.
- Red Light: When there is a clear plan, there is intent and there are means. The client is being specific about what their plans are which puts us in a situation requiring us to intervene right away in order to keep our client safe. A red light situation requires a clearly elaborated safety plan that requires external supports such as family and friends to ensure the client’s safety.
One way that we can make sure we're keeping a pulse, particularly with clients who have lost a loved one on this is to ask whether they are having thoughts of suicide from time to time or having feelings of no longer wanting to live. Use the words that feel right for you with your client. Keep it low-key but ask.
A Red Light Moment
I had been working with a client for some time who had lost her older sister to suicide 40 years before. I began to see a shift in her language and in how she was dodging certain topics that we'd always been able to discuss before. I was really concerned that perhaps some of the work we were doing to better understand the family dynamics at the time of her sister's death had triggered her own suicidal thoughts. As I began to ask her some more direct questions, she eventually disclosed that not only was she having distinct suicidal thoughts, but she had also begun to stockpile some of her psychotropic medication, the exact lethal method her sister had used to end her life when my client was 14. This was definitely a “red light” moment and I needed to intervene in order to keep her safe. We named and identified people that she could specifically share her painful thoughts and feelings with more openly, and particularly a plan of action with her spouse. We set up more frequent intervals to touch base briefly between sessions just to make sure that she was feeling safe and grounded. Thankfully, it was a short-lived period in our journey together, but it began with recognizing the shift in our relationship which prompted me to ask that simple question.
Know Where We Are on Suicide Ourselves
We can only respond with clarity and centeredness if we have taken the opportunity to apply some self-examination. How would you feel if your client shared with you their suicidal thoughts? Can you be present to their pain long enough to figure out how much they are at risk before we respond? We have to resolve any shame or discomfort we may have talking about suicide, because if we're not settled with it our clients will be uncomfortable. Perhaps we can ask ourselves questions like these: When you were growing up, was suicide considered morally wrong? Was it considered a sign of weakness? Or, have you lost a client to suicide or know of a colleague who has and are fearful because it’s so close to home?
We have to notice what’s coming up for us in the moment during the session as well. Perhaps the client’s grief feels "too big" for our internal system, or we worry about the consequences if we don't handle it the "right way." In order to do this work and do it well we always want to seek consultation and support from our peers. I consult with my colleagues on a regular basis because I believe that how we show up for a client following the loss of someone to suicide can mean the difference between life and death.
In addition, this work will personally impact you. It will stir up your past. It certainly did mine and on one occasion, I experienced some secondary traumatization which got me back into therapy to address my own unprocessed experiences of powerlessness. As George Bernard Shaw said, “If we cannot get rid of the family skeleton, we might as well make it dance.”
As relational psychotherapists, we rely on curiosity, clarity, and compassion. For me, it’s a constant reminder to be humble as well as be brave. The territory before us is vast and unmarked. Paving a way for healing in the darkness is our biggest task and our greatest reward.