Debra and Keith* were back in my office, still trying to decide what to do. She was highly distressed over their marriage; he was equally confused about her distress. After several agonizing months of back-and-forth in both individual and marital therapy, she concluded the only way to move forward was alone. The reasons she provided for the separation were not, at least on the surface, dissimilar from other clients: her chief complaints had been centered on communication breakdowns and lack of meaningful attention directed her way. One key piece, however, is not obvious: their teenage son committed suicide one year ago.
Clinically, neither Debra nor Keith led the sessions with this information or even revealed any such secret was in their hearts or minds. They looked like any couple in distress might look on the surface. They shared similar inflections and grievances as other couples. In fact, had they not mentioned it as part of our typical genogram work, I would not have known. And as articulate as each was about their relationship and the challenges in their marriage, I couldn’t help but wonder at how they each seemed to be critically unaware of the way in which the suicide affected them and informed the problems they were having.
The lack of awareness—while striking for those of us in the profession—is not an uncommon response to such a tragedy. There is still a stigma that follows along with being a suicide survivor (Hanschmidt et al., 2016). Even in a mental health professional’s presence, the stigma may be so great that it prevents the survivors from acknowledging the impact that the suicide has on them and their relationships. In the case described above, the stigma around having a child who had suicided was so pronounced that it prevented the client from even acknowledging that it was an issue in their relationships, and certainly prevented them from seeing the role it had in their current issues.
The stigma exists on two levels: public stigmas and self-stigmas (Hanschmidt et al., 2016). Public stigmas refer to the way in which the public might receive the information about the loved one’s manner of death. This often is experienced as the prevalence of negative stereotypes against suicide survivors. Self-stigma refers to the perception that one has about how they are treated in response to the suicide. The weight of the stigma seems to be a heavier burden for those victims of suicide who served in the military. The stigma of having mental health diagnoses is especially pronounced, thus amplifying the isolation and the likelihood of suicide attempts (Sokol et al., 2000). In addition, the stigma around seeking services for mental health issues is institutionalized within the military (Mackenie & Wegner, 2022), increasing the difficulty in receiving help for ideation and shuts off help for military personnel affected by the suicides of their peers.
Outside of the stigma of being a suicide survivor, the consequences are devastating. The immense pain may be an actor in the client’s decision to not focus on the suicide as a contributing factor to their distress. The result may be an avoidance of conversations where it might in fact be relevant to the therapeutic work. Survivors are often racked with guilt and shame about the manner of death, thus complicating the grief process (Hanschmidt et al., 2016). For young people, the consequences of suicide survivorship may be more pronounced. Left with the same loss but without the developmental capacity to process more effectively, young people are profoundly affected by the suicide of a loved one. Often this includes feelings and experiences that are not shared in the immediacy and are instead repressed. In short, their desire to protect others in the family from having to take care of them leaves them feeling overwhelmed, overburdened, and sets them up for poor consequences in the long term (Jackson et al., 2015).
Couple and family therapists, with specific skills in understanding the power of language paired with dedicated training to enhance relationships, can be a significant help to suicide survivors. There are a few key strategies that can support suicide survivors. First, it is important to work with families to identify their preferred language in terms of how they talk about the event. Families have a preference by which they describe what happened to their loved one (Ohayi, 2019). To demonstrate respect for this, therapists need to ask families what their language preference is. In fact, most people prefer “died by suicide” instead of “completed suicide” (Ohayi, 2019), but that is not a hard and fast rule. Check with your client and learn the language most comfortable to them. This might be something small, but it provides the therapist with a tool for increasing the likelihood that the suicide can be discussed in treatment.
Second, once language is identified that will be heard by the client, therapists should continue to work to reduce the stigma. Any therapeutic interventions targeted toward dealing with the survivors are first going to have to remove or address at least the stigma. Part of addressing the stigma means understanding the couple/family’s religious orientation and the ways in which people have responded to them after learning about the suicide. Therapists would be well advised to do an assessment that also includes some of these areas of investigation.
Therapists can help couple and family survivors by normalizing the emerging identities and working to manage (or even embrace) the new patterns and ways of being
Once stigma is removed (or at least reduced), therapists can help clients to map how the suicide has become woven into their lives, identities, and histories. Suicide survivorship means acknowledging that the event was not a piece of history; to be a suicide survivor means that this has changed even the fabric of who you are independently and in relation to others. Every interaction, decision, etc. is colored with that event. The new individual and relational identity forged after the tragedy needs to be identified, acknowledged, and incorporated into the already existing relationships. In many cases, if more than one person in the therapy room is a suicide survivor, there may be two people who, after the suicide, are in many ways unknown to each other, yet interacting with each other in the same way they did before the suicide. This mismatch will create frustration and confusion. Therapists can help couple and family survivors by normalizing the emerging identities and working to manage (or even embrace) the new patterns and ways of being.
Finally, couple and family therapists need to encourage clients to employ versatility in obtaining social support. Another thing that we find from suicide consistently in the literature is the role of social support. Those who experience suicide in their families view themselves as “contaminated” (Sheehan et al., 2018). This conceptualization leads to withdrawal, furthering isolation, and increasing likelihood of more distress and emotional difficulties for survivors (Sheehan et al., 2018). Social support can be obtained in several ways. Working with clients to understand they are not contaminated, their friends, peers, and other family will open these pathways for support. Another less-known avenue for support, however, is tied to another facet of one’s life: work. Suicide survivors may be more likely to have employment problems either because of shame or the time spent dealing with the tragedy. Without employment, they are also losing out on another opportunity to connect with others who can be supportive. Establishing a social network might include assisting clients with obtaining appropriate career guidance. In addition, consider recommending that suicide survivors connect to a group whose focus is on social support, which can be helpful for the survivor to learn more coping strategies and learn about the personal response from others in the group, thus destigmatizing their reactions (Supiano, 2012).
It is impossible to separate experiencing suicide and relegating it only to a historical fact on a timeline. While they might look and sound the same, suicide survivors are irrevocably changed. They are a different person: a different worker; a different student; a different lover; a different friend; a different aunt, uncle, cousin, sibling, parent, etc. Couple and family therapists will not be able to undo the shift in the survivor’s sense of identity and safety, but perhaps we can continue to help them become more comfortable with removing the blockages to obtaining the support they will need as they move through the pain.
*Names and some details have been altered to protect privacy.
Katherine M. Hertlein, PhD, is an AAMFT Professional Member holding the Clinical Fellow and Approved Supervisor designations, and is a professor in the Couple and Family Therapy Program in the Department of Psychiatry and Behavioral Health in the School of Medicine, University of Nevada, Las Vegas. Her scholarship addresses sexuality and sexual health in couples, couple therapy, and the effect of technology on couples and families. Her research interests also include infidelity, high-risk sexual behavior, child and adolescent therapy, and cyber issues in couple and family therapy. Hertlein’s research, publications (10 books, over 70 articles and over 40 chapters) and teaching have been recognized by multiple awards at UNLV and beyond, including being awarded an esteemed Fulbright Scholarship.
Hanschmidt, F., Lehnig, F., Riedel-Heller, S. G., & Kersting, A. (2016). The stigma of suicide survivorship and related consequences—A systematic review. PloS One, 11(9), e0162688–e0162688. https://doi.org/10.1371/journal.pone.0162688
Jackson, D., Peters, K., & Murphy, G. (2015). Suicide of a close family member through the eyes of a child. Journal of Child Health Care, 19(4), 495-503. https://doi.org/10.1177/1367493513519297
MacKenzie, M., & Wegner, N. (2022). War myths and the normalization of PTSD and military suicide: The military suicide equation. International Political Sociology, 16(2). https://doi.org/10.1093/ips/olab033
Ohayi, S. R. (2019). “Doctor, please don’t say he died by suicide”: Exploring the burden of suicide survivorship in a developing country. Egyptian Journal of Forensic Sciences, 9(1), 1-7. https://doi.org/10.1186/s41935-019-0153-3
Sheehan, L., Corrigan, P. W., Al-Khouja, M. A., Lewy, S. A., Major, D. R., Mead, J., Redmon, M., Rubey, C. T., & Weber, S. (2018). Behind closed doors. Omega: Journal of Death and Dying, 77(4), 330-349. https://doi.org/10.1177/0030222816674215
Sokol, Y., Gromatsky, M., Edwards, E. R., Greene, A. L., Geraci, J. C., Harris, R. E., & Goodman, M. (2021). The deadly gap: Understanding suicide among veterans transitioning out of the military. Psychiatry Research, 300, 113875-113875. https://doi.org/10.1016/j.psychres.2021.113875
Supiano, K. P. (2012). Sense-making in suicide survivorship: A qualitative study of the effect of grief support group participation. Journal of Loss & Trauma, 17(6), 489-507. https://doi.org/10.1080/15325024.2012.665298
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