For all of us, the death of someone we loved and cared about can bring so many mixed-up emotions. When our friend or loved one dies by suicide, the emotions are even more complicated. We sometimes describe this as experiencing a cataclysm of emotions – shock, sadness, sorrow, confusion, guilt, shame, fear and even anger. 

Although these are common reactions following a suicide, it does not mean they are comfortable. Grief is not optional, nor is it pathological. As individuals allow themselves to name the reactions and to begin talking about the suicide, the healing process begins.

In many cultures, it is difficult to talk about death – no matter the cause. When a person dies by suicide, even our closest family and friends often do not have the words to say, and fear they will do or say the wrong thing.

There is frequently an internal conflict between the grief and loss experienced, and the confusion, anger and often perceived shame or guilt related to a suicide loss. Since death by suicide is most often unexpected, the person left behind must process the trauma (and reality) of the death before the actual grieving process can begin.

Grief is a natural healing process. No two people grieve in the same way or on the same timeline. How we grieve is affected by our past life experiences, personality, culture and family traditions. Contrary to popular opinion, there is no such thing as “closure” when someone you love dies by suicide. Grief may come in what we call "grief bursts" over our lifespan – which is common for all ages. The first year may be the toughest with all the “first” anniversaries, birthdays and holidays. Memories may surface, even years after the death, which allows us to both pause to remember and pause to grieve.

Respecting individual and cultural differences in grieving may make it seem hard to know how to support the person you care about during their grief. Remember the importance of social connectedness – we are social beings and even when we are hurting, having those we love reach out to us supports the healing process. Simple steps like sending cards or texts, using the name of the person who died in your conversations, and asking questions about specific tasks you can help with (for example, taking care of a child, grocery shopping, or just sitting with the individual) ensures the connections are there and no-one is grieving alone.

Having a family member or friend die by suicide is a risk factor for suicide. This can sound scary; however, risk factors do not predict suicide – they simply are defined as characteristics of the person or their environment that increase the likelihood that a person may die by suicide. Having a friend or family member die by suicide is a time to ensure support and conversation with our youth about suicide. 

On a national level, we have conducted a lot of public health education on the signs and symptoms of a heart attack or a stroke. What if we all were as knowledgeable about the warning signs and risk factors of suicide – also a leading public health concern?

Warning signs to watch for in our young people include:

• Talking about wanting to die or kill themselves

• Talking about wanting to sleep and not wake up

• Looking for ways to kill themselves, such as internet searches

• Increased anxiety or agitation

• Changes in sleep or appetite

• Feelings of hopelessness

• Extreme mood swings

• Any substance use

• Social isolation

Ask the question directly – suicide cannot be a taboo subject if we are going to decrease suicides in our country – in our own backyard. 

The two greatest fears we have around talking about suicide are:

1. We may give someone the idea of suicide. This is a common myth – in fact, we know that openly talking about suicide with those at risk will save lives.

2. They may say yes if asked directly and we will not know what to do or how to support the person.

Knowing the risk factors and warning signs will help you identify when there is a need to ask directly. Sometimes a soft question is a good place to start, such as “how bad has it gotten for you?” or “have you been feeling so bad that sometimes you wish that you were dead or could go to sleep and not wake up?” If someone you care about answers yes to these questions, then a more direct question is needed, for example, “sometimes when people are going through all the things you have been going through, they think about suicide. Have you had thoughts of suicide or killing yourself?”

The last consideration is to know your local resources. In the US, utilize the National Suicide Prevention Lifeline at 988 or the Crisis Text Line (text “Home” to 741741).

For schools and workplaces, postvention plans are a strong step toward suicide prevention. We have learned the importance of social connectedness and talking out loud about suicide as prevention strategies.

Since we now know that knowing someone who has died by suicide is a risk factor, we can more fully understand the importance of giving those who knew and cared about the person an opportunity to:

• Talk about what happened

• Learn about risk factors and warning signs

• Know where to go for additional support for themselves or those they may be concerned about

Many communities have local crisis response teams that can provide a structured response following a suicide death in a school or workplace. Other schools and organizations have developed their own internal teams, policies and procedures to support students and workers in the aftermath of a suicide death.

As a therapist or healthcare provider, when a person in our care dies by suicide, we become a suicide loss survivor. After a patient or client death by suicide, we may experience disenfranchised grief. Without structured support within the healthcare environment, the individual clinician or team member may struggle since they cannot reach out and talk to others in the same way we encourage family and friends to reach out. Concerns about patient confidentiality, workplace culture and fear of blame or liability can easily lead to personal stress, fear and anxiety about caring for others who may be experiencing suicidal thoughts or behaviors.

We can consider the twin tools of self-reflection and consultation as important steps in our professional healing process. Taking time to reflect on our own reactions to the suicide death and seeking support and supervision in the aftermath of a suicide death can aid in our healing process.    

Most healthcare organizations will conduct a critical incident review (which may include tools such as a root cause analysis) to understand and learn any lessons from the suicide death. It is imperative that this review is done in a just culture – one without seeking blame but rather to understand and improve the system. Experience has taught us that these reviews are best conducted after a staff support session has taken place to allow the staff and team involved to talk about what happened in a safe, structured space before the critical incident review.

PTSD is sometimes used as a catch-all phrase for stress after something traumatic has happened. While death by suicide is frequently experienced as trauma by those left behind, a diagnosis of PTSD is very complex and requires a set of criteria much broader than exposure to trauma.

Witnessing a death by suicide could lead to the development of PTSD symptoms and may require professional support and intervention.

One of our greatest concerns in helping suicide loss survivors is that we will say the wrong thing. The truth is that there are no words to make it stop hurting or to take the pain of loss away. A big heart and a compassionate presence are much more important than the words we say. Practice being a good listener – remember we have two ears and one mouth – perhaps we should use them proportionately.

Here are a few tips directly from those with lived experience:

• Avoid empty words of reassurance like “it’ll be okay” or cliches such as “I know just how you feel.”

• Don’t attempt to give false comfort, for example, “they’re in heaven now” or “in a better place.”

• Don’t look for a silver lining – comforting statements rarely start with “at least...”

The best gift you can give someone who is grieving is realizing you do not know how they feel, but you are open to listening and learning. When in doubt, sometimes it helps to say, “I don’t know what to say, except I am so very sorry.”

Reach out and stay connected to the loss survivor.

Don’t be afraid the use the person’s name who died. Memories play a significant role in the grieving process – being present and listening can help the survivor get in touch with their memories which will become a part of the narrative of their life.

Be specific in offering help. Remember that the survivor may not be thinking about what they need and many of us do not do a good job of asking for help. Ask if you can make a meal, go to the grocery store, run errands, or take the kids for a while so they can have a self-care break.