The necessary attention for people who have lost someone to suicide

In 2020 , almost four thousand people died in Spain due to suicide . Furthermore, since 2008, death due to suicide has been the leading cause of unnatural death, and is currently almost triple the number of deaths due to traffic accidents.

The World Health Organization establishes that the level of impact in the immediate environment of a person who dies by suicide is around six people, but it also clarifies that if this suicide occurs in an educational or work environment, it can affect hundreds of people. If we do the calculation, the number of people affected by a loss by suicide is terrifying: around 20,000 people each year.

Despite this data, at present in Spain there is not a single program of care for people who have lost a loved one due to suicide. We know of only one exception to this abandonment: the program of care for victims of a loss by suicide that is carried out at the Hospital de la Santa Creu i Sant Pau (Barcelona) in agreement with our association DSAS, Després del Suïcidi, Associació de Supervivents . Our association is a pioneer in the care for this type of loss.

Factors that aggravate the grieving process for a death by suicide

Dr. Catherine Le Galès-Camus, WHO Assistant Director-General, sums it up this way: “Every suicide causes emotional, social and economic devastation for numerous family members and friends.”

People who have suffered a loss of this type will have to deal with the difficult psychological management of two devastating events:

• Very often, the news is unexpected and unpredictable .
• Reason about the reason for this death.

We must keep in mind that suicide involves:

• Extreme aggression towards oneself and towards those closest to one.
• The impossibility of carrying out a normal farewell process.
• The acceptance of an irreversible action.
• The fact of having to assume it in adverse social circumstances, almost in solitude.
• The coexistence with the social qualification of suicide pejoratively labeled as brave or cowardly, which feeds the mythology about the true causes of suicide.
• The suffering of the public display that death by suicide entails, the participation of the police, judicial, emergency services... They subject us to a situation of exposure and judgment of the conduct of the deceased, but also of those around them, as possible collaborators or involuntary instigators.

It is necessary to consider as an element that aggravates this tragic situation the fact that it is an unnatural death with considerable violence, like other traumatic deaths (accidents, attacks, wars, murders), which also adds an element of difficult management in the environment, especially if it involves children.

We also need to understand that “cultural, religious and social taboos surrounding the fact can make the path even more difficult” (WHO, 2008).

Grieving a suicide is a process of serious complexity

We know that grief is a biopsychosocial adaptive process that all human beings go through at some point in our lives. Its duration will depend on the magnitude of our loss, each person will experience it individually and with a process that is not transferable.

Measuring this process by time will be a mistake, as Robert Neimeyer points out: "Time does not heal. It does not matter what time does to the grieving person. What is important is what the grieving person does with time."

Likewise, it would not be entirely correct to place the grieving process in a series of chronological stages: "Talking about stages of grieving can lead to error, as it can be implied that all grieving people must follow the same itinerary in their painful personal recovery" (Neimeyer, 2007).

The trauma of the news propels us into the past. Biographical reconstruction will often become obsessive: "Why? What if I had...? What could I have done differently...?" This question becomes a differentiating factor compared to other griefs: what influence could I have had on his death?

Likewise, the influence of people around them, especially therapists, medical, psychiatric or psychological professionals, will be judged very harshly. "How come you didn't see it?", "Why did you discharge him?" or "Did you change his medication?" will be very common questions and can mean a real desire to punish the professionals who have intervened (Ward et al., 2014).

In the case of this type of grief, its evolution can be much more complicated , with a longer duration and with a very significant risk that the evolution will not be favorable, and it will be difficult to guide the person who has suffered the loss towards a reconstruction process.

Signs that you should seek help during grief

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During the most acute phase of grief, which can last between six and twelve months (Worden, 2016), people's narrative is oriented towards what has been experienced. Emotions seriously overwhelm us, they fluctuate and dominate our behavior. We settle into thoughts that return again and again without control and that send us to this obsessive review of what happened.

It is important to keep in mind that people who have suffered a loss by suicide increase their own risk of suicide in the days immediately following the loss, as well as on the days of birthday celebrations (Barker et al. Omega, 2014).

Loss becomes a debilitating factor in the life process :

• It makes us rethink our own beliefs, especially about suicide and who has died from this cause.
• A profound distortion occurs in the vision we had of the person who died: how could they do this to me, how could they abandon me...
• We review our entire relationship with that person: we punish the photographs, the memories, or we feel irremediably linked to them.
• In some cases, when the disease has accompanied the person for many years, profound relief can occur.

Along this path, as we have already said, some questions will appear that are difficult to answer and that also imply the need to work on the most powerful emotions during this process:

These feelings are very powerful and their consequences must be faced to prevent them from becoming elements of evolution towards a traumatic grieving process.

Guilt can become an adaptive process that helps us move forward (Rocamora, 2021).

Adaptive guilt:

• It helps to process the loss.
• It helps to forgive and forgive yourself.

Maladaptive or toxic guilt:

• It is incapacitating.
• It can be a driving factor for suicide.

​​​​​​The shame and taboo that accompanies this type of death means:

• Not being able to talk about the circumstances of death.
• Avoid the word "suicide".
• Consider it a "outlawed" and "marginal" death.

The most important risks to consider in a loss by suicide

As we have been pointing out, attention to loss by suicide poses the challenge of attending to and making visible a group of people much more important than might be assumed , but also with a high risk of developing processes that compromise their health.

• After suffering a loss by suicide, the risk of developing a complicated (traumatic) grief process is 40% higher than in other groups.
• There is a high probability of chronicity in the evolution of grief.
• It increases the occurrence of major physical illnesses.
• Addictive behaviors increase (Pitman et al., 2014).
• The risk of depression and the risk of suicide is 5.5 times higher than in other people (De Groot and Kollen, 2013, and Barker et al., 2014).

It is therefore necessary to consider resources for caring for people who have suffered this type of loss.

“94% of survivors grieving suicide indicated the need for help to manage their grief as a priority, although only 44% received support” (Wilson and Marshall, 2010).

This disappointing figure does not correspond to the situation in our country, given that, as noted at the beginning of this article, this support is almost non-existent in our country.

The characteristics that a suicide bereavement care program should have far exceed the intent of this article, but I would like to conclude with some brief guidelines on how to approach suicide bereavement care.

The Rules of Grief of a Suicide Loss

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I want to take advantage of these lines to remind you that our association provides care to survivors from all over Catalonia and Spain through the resources of individual care and group work, and that we maintain numerous contacts with professionals in the world of health to advise, train and inform about this need.

Most people who come to us complain about the difficulty of establishing a bond of trust with their therapist . They usually state that they do not achieve the necessary climate to feel authorized to work on their grief.

Supporting grief due to suicide requires the ability to stand by each other and listen actively and compassionately.

As Joan Carles Mèlich points out, "compassion means accompanying, welcoming, standing next to the one who suffers. An ethic of compassion emphasizes that no one can avoid suffering and that the ethical response does not consist of putting oneself in the other's place but at their side."

Therefore, we will need to deploy resources around:

• Receptiveness : while recognizing the need to listen, putting aside preconceived ideas and prejudices about a death so stigmatized that it confuses health professionals themselves with myths and half-truths; clearly placing the fear of one's own exposure to work on the grief of the person who asks us for help; designing solutions for their concerns and, above all, responding to their concerns and fears.
• Trust : "I want to accompany you." I accept your rhythms and your perceptions as a starting point to work with you on the path of reconstruction. I do not shy away from appropriate physical contact, nor the resource of humor.
• The ability to ask the right questions : we avoid the Because they torture us so much, questions encourage the evocation and reformulation of pain and fear, questions pave the way and do not imply a preconceived solution.
• The return of what we perceive : we avoid evaluation that implies judgment; the feed back is the work we do with the person we help. The tasks we propose are reviewed from this point of view.

The path of accompaniment in grief seeks to help us find a path again. To feel authorized to recover our lives.