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Teen Suicide: Helping Survivors Make Sense of Sudden Loss
Teen Suicide continuing education psychology CEUs

Manual of Articles Sections 8 - 19
Section 8
Factors Affecting Family Responses to Suicide

CEU Question 8 | CEU Answer Booklet | Table of Contents | Grief
Counselor CEUs, Social Worker CEUs, Psychologist CEs, MFT CEUs

Introduction
Before the 1970s, systematic research on the aftermath of suicide was a neglected area of investigation. What studies did exist focused on the impact of suicide on individuals and less often on the impact on family system dynamics (Calhoun & Allen, 1991; McNeil, Hatcher, & Reubin, 1988). Current research indicates that the act of suicide intimately affects at least six other people and is a major mental health problem that affects a significant portion of the population--the survivors of suicide (Jobes, Luoma, Hustead, & Mann, 2000; Knieper, 1999). Survivors of suicide include family members, friends, acquaintances, and helping professionals.

Staying Alive: The Intersection of Individual and Family Dynamics
The personal struggles of individual survivors are now well understood and typically include a search for why survivors feel shame, guilt, anger, or rejection (Barlow & Morrison, 2002; Dunne & Morrish-Vidners, 1988; Van Dongen, 1991). While processing these emotions and attempting to create meaning from the suicide, the major personal challenge for survivors is to restore personal balance in the face of this devastating life event (Alexander, 1991).

Challenges for Survivors
After a completed suicide, survivors grapple with some basic life ironies. First, the suicide challenges survivors to recreate their self-images (a process that ideally occurs within a safe environment) at a time when their personal stability has been rocked. At the same time, survivors feel both powerful and powerless, often thinking, "I did and did not make a difference." In the process, their belief that personal destiny can be controlled is altered. Moreover, the tyranny of hindsight is a nagging companion. Personal acts of commission or omission are agonizingly reviewed, often leading to the same question, "Would it have made a difference?" (Alexander, 1991). A final irony is that "death ends a life, but it does not end a relationship, which struggles on in the survivor's mind toward some resolution which it never finds" (Anderson, 1974, p. 77). Many survivors strive to remain "in a relationship" with the deceased, despite the deceased's message signifying, "I don't want to be in a relationship with you." Further complicating their readjustment, survivors grapple with these confusing beliefs and emotions within a context where other surviving family members are going through similar personal struggles.

Suicide demands that surviving family members develop individual interpretations of the act as well as an understanding of the consequences of the act (Zinner, 1990). At the same time, survivors must renegotiate ongoing relationships with surviving family members. One important aspect of family reorganization after a suicide is the recognition of, and respect for, differences in grief reactions and coping styles among individual family members. Differences can create a lack of synchronicity in grieving, posing challenges to families. For example, a consistent thrust for adult survivors is to understand "why" (Van Dongen, 1990). Yet the search for meaning is only one element of children's grief and is not the central theme for child survivors (Demi & Howell, 1991). Hence, family members may find themselves out of step with one another as they seek to regain their balance. Interpersonal tension and marital discord may result from grief incongruence between the surviving adult partners (Oliver, 1999).

Communication
Some researchers claim that family communication following a suicide is essential for a positive bereavement outcome. Feelings of isolation often plague family members when discussion of the death is avoided, and the ensuing "conspiracy of silence" can lead to detachment from and hostility toward other family members (Lukas & Seiden, 1987; Reed, 1993). Some researchers note that reduction of grief symptomatology and a decrease in feelings of detachment can be dealt with through expressive support, sharing thoughts and feelings, ventilating frustrations, reaching understanding on issues and problems, and affirming the worth and dignity of self and others (Reed, 1993).

Other studies have found that communication within the family about the suicide is not a universal vehicle for grief resolution. Van Dongen (1991) noted that family communication immediately after the death is intense, as members cluster together in their attempt to understand the victim's behaviour. As time passes, however, family members tend to avoid expressing their thoughts and feelings for fear of upsetting other family members. When resources are limited, controlling the expression of grief can indeed facilitate family reorganization. In this way, an atmosphere of safety is created for easing into the expression of emotion. Grief, re-explored when the family is less fragile, can lead to an ever-evolving reintegration of the death into the family's history (Shapiro, 1994).
Suicide can sometimes precipitate an intense family crisis that can lead to either disengagement or greater cohesion. Family members may have difficulty sharing grief with one another because one member finds the loss too painful or embarrassing to talk about. Some children may withdraw out of fear that the surviving parent or siblings may also be provoked to "leave." A child's desire to protect surviving parent(s) and difficulty witnessing parental pain can intensify the child's withdrawal from the family.

Early clinical studies suggested that bereavement often leads to family conflict and mutual blaming (Danto, 1977; Hatten & Valente, 1981; Hewett, 1980). Parents were described as engaging in mutual blame, being overprotective of remaining children, or colluding to maintain silence about the suicide. Recent studies are more optimistic, suggesting that family ties are often unaffected or even strengthened after a suicide (Reed, 1993; Rudestam, 1977; Van Dongen, 1991). Nelson & Franz (1996), for example, reported that pre-suicide relationships of cohesion or conflict are positively correlated with post-suicide responses. In families where expressiveness and cohesion are high, parents felt closer to their deceased children. Families that become closer often would have shared, prior to the suicide, the stress and tension related to the deceased's psychological distress (Seguine, Lesage, & Kiely, 1995). Because family members had shared some of the deceased's. plight, the suicide acted as a catalyst for their re-examination of values, belief systems, philosophical concepts, and priorities (Trolley, 1993).

Factors Affecting Responses to Suicide
Bereavement outcomes vary due to the presence of mediating or moderating factors, including the characteristics of the bereaved, nature of their relationship with the deceased, social support networks, and the amount of stability in the home and the caretaking environments (Barlow & Morrison, 2002). However, survivors are likely to experience some social distance and feelings of isolation even from those who try to be supportive (Calhoun & Allen, 1991). Compared with accidental deaths and deaths by natural causes, suicides are more likely to be evaluated negatively by people outside the family.

Reed and Greenwald (1991) found that attachment, sex, and age are important in explaining differences in grief reactions. Survivors with an intense connection to the deceased tend to experience elevated guilt, shame, shock, and mental preoccupation. When attachment to the deceased is low, bereaved men and women report similar levels of separation distress. However, when attachment is high, bereaved women usually experience greater separation distress than bereaved men (Reed, 1998). As well, younger survivors tend to be more grief-stricken and depressed than older ones (Sherat & Reed, 1992). Thus, gender and age differences play a mediating role in suicide response.

Personal characteristics of the survivors also influence bereavement outcomes. A history of depression is an indicator of vulnerability to bereavement stress. On the other hand, high self-esteem acts as a mediator between grief and available resources. Grief symptomatology can be reduced by exercise and religious participation only insofar as they bolster survivors' self-esteem (Reed, 1993).

Family Reorganization
When suicide propels a family into an identity crisis, an initial response is to absorb the loss and re-establish stability. Grief challenges family members to manage emotions, reorganize family interactions and communication patterns, redefine social roles, and create a new family narrative that has a shared meaning (Shapiro, 1994). One of the first tasks is to establish stable family conditions that support daily functioning. As this is happening, family members must also develop mutual awareness of and responsiveness to one another's attempts to control overwhelming emotions, re-establish stable patterns of daily living, and reconstruct a sense of self.

Shapiro noted that as families reorganize, they restore a capacity for day-to-day functioning, a sense of emotional stability, a capacity for pleasure, and energy for living. In the process, the deceased moves from being external to internal, such that the relationship to the deceased individual exists in memory and emotion. The bond created then becomes spiritual and emotional. Because bereavement is not a psychological state from which one recovers, the concept of closure or letting go is less viable for the bereaved than the process of renegotiating the loss and its meaning over time (Silverman & Klass, 1996).

The Caretaking Environment
Child Survivors

A prevailing theme in the life of most children who have lost a parent by death is the fear of losing the other parent (Dalke, 1994). However, child survivors are themselves at risk. Indeed, children with one or more family member who has committed suicide have a greater risk of attempting suicide compared to other children with no suicide in the family (Gutierrez, King, & Ghaziuddin, 1996).

Childhood bereavement is not usually characterized by comorbid disorders. However, research findings indicate that comorbid depression and post-traumatic stress disorder (PTSD) can occur when death is due to murder or suicide because of the likelihood of traumatic images associated with witnessing the death or experiencing reports of it (Pfeifer, et al., 1997; Pynoos, 1992). Recurrent and intrusive thoughts about death, sleep disturbances, difficulty concentrating, emotional anesthesia, social detachment, and irritability are common symptoms of PTSD and grief after suicide. However, unlike typical sufferers of PTSD, who strive to avoid thoughts and stimuli related to their trauma, suicide survivors fixate on the suicide as they try to understand "why" (Van Dongen, 1991).

Research on childhood responses to suicide in the family identifies dynamics such as information and communication distortion, guilt, and identification (McNeil et al., 1988). It is not unusual for children to encounter an atmosphere of evasion or fabrication about the suicide of a parent that may continue long after the death. The child's age affects the information they are given. Children over 10 years of age are more likely to be told that the death was a suicide, while children under four are usually told nothing. This concealment is motivated by a desire to protect the children, a need for avoidance on the part of the caretaker, and a sense that silence will preserve the fragile emotional stability following a suicide. Surviving parents may forbid discussion of the death and even keep the children away from others who might talk about it. This dynamic leads to a conspiracy of silence and the creation of a family myth about the death, so that children are given different and conflicting accounts of it (McIntosh, 1987).

Children who survive parental suicide may also experience a heightened sense of guilt, partially due to this distorted communication, occurring in the form of denial, evasion, or closed discussion. Guilt may also arise out of hostile wishes and fantasies toward the parent before the suicide, a sense of feeling responsible for upsetting the parent, a perceived misconduct, and other specific behaviour before the suicide. Guilt may also stem from the child's belief that he or she could have done something to prevent the suicide or save the deceased (Cerel, 1999).

Sibling survivors may be neglected even though they are experiencing a double impact--the death of a sibling and having to cope with grieving and withdrawing parents. While most siblings' feelings of depression, fear, loneliness, and anger subside with time, for some, this crisis situation may remain in remission until a provoking incident once again brings these emotions to the surface. Anger toward the parents may be felt but suppressed to protect them (Cerel, 1999; Demi & Howell, 1991).
Demi and Howell (1991) examined the long-term effects of the suicide of a parent or sibling during childhood or young adulthood and noted three major themes: experiencing the pain, hiding the pain, and healing the pain. Pain is often expressed through anger that is directed toward the deceased and other family members as a response to a sense of family upheaval and loss of familiar patterns. Some children feel shame and blame other family members, particularly parents. Their lowered self-esteem leads to problems in social relationships. As well, surviving children may become fearful about the genetic origins of mental illness or the effects of stress on mental health.

Masking or hiding the pain occurs through denial, avoidance, secrecy, fleeing, working, and addictive behaviours. Survivors often reach adulthood with unresolved grief that they either continue to hide or seek to heal. Acknowledging the pain many years after a suicide is precipitated by work or interpersonal problems that motivate the survivor to seek counselling.

Parents play a crucial role in a child's bereavement outcome. Their mental health is an important mediating influence for their children (Dowdney et al., 1999; Pfeffer, et al., 1997). When the surviving parent experiences post-death psychological difficulties, the bereaved child must then deal with personal loss that is clouded by the grief and psychological issues of the parent.

Parents as Survivors
Parents who experience the death of a child by suicide face a particularly complex and intense grieving process marked by loss of their dreams and hopes, as well as feelings of guilt, self-blame, and social blame (Nelson & Frantz, 1996; Oliver, 1999). Surviving parents describe the painful uncertainty of responding to questions about how many children they have (Van Dongen, 1993). Their loss is exacerbated by the knowledge that suicide was the cause of death (Trolley, 1993).

Bereaved parents are confronted with a kaleidoscope of emotions. "The deliberateness of the act leaves a message of rejection and abandonment" (Trolley, 1993, p. 240). Guilt is perhaps the most overwhelming emotion for parent survivors of suicide. Parents may feel that they have failed their child, become preoccupied with guilt feelings, and then lose confidence in their parenting ability. Seguin, et al. (1995) noted that almost all of the parents in his study held the impression that they had failed in some way. They felt awkward within their families and with friends, no longer believed they were competent providers, and tended to isolate themselves more than other bereaved parents.
Stigma and the lack of validation for their loss exacerbate parents' sense of social isolation (Calhoun & Allen, 1991). When parents harbour resentment and hostility toward others, including professionals, for not saving their child, they may resist intervention. Thus, contact with professionals soon after the suicide may be less than satisfactory and can reduce the likelihood of accessing professional assistance later. Studies on perceptions of suicide survivors reveal that stepparents are considered less "close" to a child and therefore require less time to recover (Calhoun, & Allen, 1993).

Mothers, in particular, were found to experience prolonged depression (Brent, Moritz, Bridge, Perper, & Canobbio, 1996; Knieper, 1999). Speculated reasons include the possibility that women are more likely to self-report depression or that they feel closer to their children than do fathers (Cook, 1983). The social construction of mothering may offer additional insights. Mothers are assigned primary responsibility for their children's mental health, and this, combined with the propensity for helping professionals to blame mothers, adds to their grief (Barlow & Shimoni, 2000; Maushart, 1999; Swift, 1995). Caplan and Hall-McCorquodale (1984) reviewed major clinical journals and found that two-thirds of the articles attributed responsibility for 72 different types of psychopathology in children to their mothers. The tendency to blame mothers for the ills of their children continues today (Maushart, 1999).

Caplan (1989) noted that impossibly high standards of mothering are woven into the fabric of our society. Mothers experience guilt at not achieving these standards, the primary one being the production of a socially acceptable child. Consequently, women are motivated to invest vast amounts of energy into mothering to overcome their sense of guilt and failure. Thus, if a child commits suicide, the mother's negative feelings about herself are intensified.
- Barlow, Constance, & Heather Coleman; Suicide and families: considerations for therapy; Guidance & Counseling; Winter 2003; Vol. 18; Issue 2.
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 150 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information regarding considerations for therapy with family survivors of suicide.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 8
After a completed suicide, what is one challenge for survivors? Record the letter of the correct answer the CEU Answer Booklet

 
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