Deaths by suicide are unquestionably tragic by any measure, but considerably more so when considered in the context of their impact on surviving family members. Most public health initiatives have logically targeted individuals at risk of suicide and promoted prevention efforts accordingly; fewer have addressed the complexities of decedent-survivor relationships and variables that influence survivors’ grief responses. An emerging body of research aims to illuminate factors that influence survivors’ responses and predispose them to prolonged grief, the onset or exacerbation of existing mental health conditions, and risk of suicide.
Suicide is an exceptionally complex phenomenon and the subject of extensive analysis by clinicians, social scientists, philosophers, and theologians. The 19th Century sociologist Émile Durkheim’s seminal work on the subject was among the first to situate suicide in a social context whose causes and effects are not limited to individual temperament or psychopathology (Durkheim, 1897). Durkheim’s leading thesis that social connectedness serves as a protective factor for those who would otherwise be at risk of suicide is axiomatic when viewed in hindsight, but it opened avenues for subsequent investigations into the intricacies of human relations and how they might affect, and be affected by, the act of suicide. Research findings suggest innumerable factors influence the trajectory of a survivor’s response to a completed suicide that include the role of the decedent (e.g., father, mother, child, sibling, etc.) relative to the survivor; age and gender of the decedent and survivor; prior familial history of mental illness or emotional disturbance; race, ethnicity, culture, and nation of origin; and genetics, among many others. Some investigations have also explored the manner in which stigma that often attends the act of suicide might complicate a survivor’s coping mechanisms and undermine the recovery processes.
Researchers in South Korea examined risk factors among individuals who lost family members to suicide. Their investigation explored differential risks according to family role and factors that distinguish suicide survivors’ responses from those whose family members died by other means. This study found women whose husbands had completed suicide were at greatest risk of all family members (Jang et al., 2022). Men who lost their wives to suicide were also at significant, albeit slightly lesser, risk, as were mothers who lost children to suicide. The risk of completed suicide was lowest among sibling and child survivors. The foregoing risks also varied according to several factors. For instance, gender was implicated in the risk trajectory, as mothers who lost daughters to suicide were at greater risk than mothers who lost sons. A similar trend was observed among siblings insofar as women who lost sisters to suicide were at greater risk than women whose lost brothers to suicide. This investigation also found suicide survivors were at threefold greater risk than those who lost family members to traffic accidents, a result that suggests suicide produces especially complex and severe grief responses among surviving family members (Jang et al., 2022). It should be noted, however, that conclusions drawn from this study must be interpreted in the context of the environment in which it was conducted. Familial dynamics vary greatly across nations and cultures, and factors specific to South Korean society might not be as present or as influential in other regions.
Another investigation addressed risk factors specific to child survivors of suicide, an especially critical endeavor in consideration of the risks unique to children and adolescents as they navigate other developmental challenges. Pfeffer et al. (1997) examined various dimensions of children’s responses to the loss of a parent or sibling to suicide and explored an array of factors that might influence both their risk of suicide and the trajectory of their recovery process. These authors found child survivors were at elevated risk of depression, anxiety, posttraumatic stress, and social maladjustment, but this risk was not universally present among study participants. For instance, when surviving (caretaker) parents of child survivors exhibited profound grief, distress, or other indications of psychiatric illness in the wake of the suicide, their children were similarly affected. The authors hypothesized these parents were less emotionally available to their children or ill-equipped to aid them in modulating their grief responses. This investigation also addressed potentially confounding variables applicable to studies of this type that underscore the intricate and multifaceted nature of suicide and its impact on family members. For example, first-degree relatives of decedents with documented histories of mental illness or suicidality are more likely to exhibit similar conditions or predispositions (Pfeffer et al., 1994). Thus, children whose parents experienced mental illness prior to suicide might be more vulnerable to psychopathology and at risk of its adverse effects irrespective of their parents’ suicide. Moreover, an extensive body of literature suggests both environmental and genetic factors are implicated in mental illness and suicidality. One study of suicidality among monozygotic and dizygotic twins revealed a significantly higher correlation among the former (i.e., identical) twin pairs (Coon et al., 2020), and another found familial “dysfunction” (i.e., disorganization, divorce and estrangement, interfamily violence, etc.) was more common among families of suicide victims (Jordan, 2001). The foregoing investigations highlight some of the complexities that propel the suicidal act and belie a false dichotomy that has driven the “nature vs. nurture” debate since time immemorial.
Suicide remains enshrouded in a fog of stigma that further exacerbates survivors’ grief and increases their risk of adverse outcomes. Actual or perceived stigmatization by individuals within a survivor’s sphere of influence may be particularly insidious for child survivors for whom social validation is of critical importance. One study examined unwritten “rules” of bereavement and found participants who interacted with suicide survivors often felt more constrained by such unwritten rules and were therefore unable to convey empathetic support as freely as they would to individuals bereaved by other losses (Calhoun et al., 1986). This finding suggests, but does not confirm, suicide survivors who receive fewer expressions of support from friends and associates might erroneously view it as a manifestation of stigma and process it accordingly.
Risks specific to family members of suicide victims warrant further analysis, and future investigations should reveal additional factors to be considered in public education and prevention initiatives. Findings to date affirm what common sense and standard clinical practice have long understood. Suicide is neither a solitary act nor a phenomenon to be understood solely in the context of the individual. It is, in short, a family affair, and survivors of such a grievous loss deserve the utmost empathy and support.
Ashley Brody, MPA, CPRP, is Chief Executive Officer at Search for Change, Inc, and can be reached at (914) 428-5600 (x9228) or abrody@searchforchange.org.
References
Calhoun, L.G., Abernathy, C.B., & Selby, J.S. (1986). The rules of bereavement: are suicidal deaths different? Journal of Community Psychology, 14(2), 213-218. https://doi.org/10.1002/1520-6629(198604)14:2%3C213::AID-JCOP2290140212%3E3.0.CO;2-D
Coon, H., Darlington, T.M., DiBlasi, E., Callor, W.B., Ferris, E., Fraser, A., et al. (2020). Genome-wide significant regions in 43 Utah high-risk families implicate multiple genes involved in risk for completed suicide. Molecular Psychiatry, 25, 3077-3090. https://doi.org/10.1038/s41380-018-0282-3
Durkheim, É. (1897). Suicide: A study in sociology. The Free Press.
Jang, J., Park, S.Y., Kim, Y.Y., Kim, E.J., Lee, G., Seo, J., Na, E.J., Park, J-Y, & Jeon, H.J. (2022). Risks of suicide among family members of suicide victims: A nationwide sample of South Korea. Frontiers in Psychiatry, 13, 1-10. https://doi.org/10.3389/fpsyt.2022.995834
Jordan, J.R. (2001). Is suicide bereavement different? A reassessment of the literature. Suicide and Life-Threatening Behavior, 31(1), 91-102. https://doi.org/10.1521/suli.31.1.91.21310
Pfeffer, C.R., Martins, P., Mann, J., Sunkenberg, M., Ice, A., Damore, Jr., J.P., Gallo, C., Karpenos, I., & Jiang, H. (1997). Child survivors of suicide: Psychosocial characteristics. Journal of the American Academy of Child and Adolescent Psychiatry, 36(1), 65-74. https://doi.org/10.1097/00004583-199701000-00019
Pfeffer, C.R., Normandin, L., & Kakuma, T. (1994). Suicidal children grow up: suicidal behavior and psychiatric disorders among relatives. Journal of the American Academy of Child and Adolescent Psychiatry, 33(8), 1087-1097. https://doi.org/10.1097/00004583-199410000-00004
