RISE (Resilient Integration for Survivor Empowerment) for Removing Guilt of Suicide of Loved Ones

By Cecilia Lai Wan Chan, Ph.D.

Introduction
It is common for suicide-bereaved survivors to ask questions such as: “How come I didn’t notice any signs of it before? I should have stopped it! Did I say something wrong? It is all my fault! How come you abandoned the family and me? I am to be blamed. I am responsible for your death. I can do nothing, I have no hope! I can’t go on with my life…”

Doris suffered from depression for 10 years following her grandmother’s suicide. She cannot hold on to a job. She tried to run away from her home. She has no friends. She holds on to a boyfriend who is married. She refused an operation against medical advice after her discovery of breast lumps. Doris was referred by a friend to a counseling center for her anxiety about her breast lumps. When she arrived, she quickly shared her bereavement experience.

Doris had dinner in her grandmother’s home every evening since she was 20 years old. One evening, her grandmother held Doris’ hand and reminded her that she should put on more clothes as the weather was cold. Doris swung away grandmother’s hands and ignored her. Grandmother hung herself that evening. Doris learned about it and saw herself being fully responsible for her grandmother’s death.

WHY? WHY ? WHY?

Sense of guilt is common among bereaved persons due to suicide death of a loved one. These individuals might be consumed by a strong sense of self blame, guilt, self scolding, and exhausted by self-query of “Why have I not done something to prevent this suicide?” The tendency to self punish is common among survivors of bereavement due to suicide. Individuals may experience a strong impulse for fault finding of self, self battering, and set up an automatic filter of all positive thoughts. They regard themselves as not self-worthy.

Individuals would face a strong sense of isolation, silence, and stigmatization. It is common to hear self appraisals of “There is no meaning in life,” “This makes no sense,” “My life is not worth living,” “It is better that I be dead,” “I am good for nothing,” and, subtly, there is a hidden message of “I don’t deserve to be happy,” “I have no place in this earth,” “I am good for nothing,” and “I should be the one who died.”

Being haunted by guilt, bereaved persons suffer from symptoms of traumatic loss. There is a strong urge for sense making, fact finding, meaning making from the process of suicide on what exactly happened. The “Why? How? What happened in leading to the suicide? Is it a homicide? Who agitated him/her so much that he/she died by suicide?”

Bereaved individuals may be locked in a state of confusion. They may feel that “I don’t deserve to live, too.” Thus, individuals may mess up their lives by making wrong decisions, problematic relationships, engage in struggles, and lost confidence in self-efficacy.

The conventional saying of “forget and forgive” does not work for suicide bereavement. The sense of loss and grief, guilt over not being able to prevent the suicide may always stay, and yet the disabling impact of the pain can be different over time. The sense of guilt can lead to self-destructive impulse at the initial stage. Over a long run, individuals can forgive themselves while not forgetting their loved ones and the sense of guilt can be converted into constructive energy of helping others and altruistic action.

The unforgettable memory– it is easy for suicide survivors to be consumed by the rumination of the last contact with the deceased. Rumination in terms of the dispute and conflicts, the incidents of hurt and pain, the final touch, the final words, and final facial expression. These vivid memories with unresolved emotions can easily lead to prolonged self blame.

Strong Sense of Guilt

Three key areas of grief responses in suicide bereavement are: struggle over the meaning around death, carrying higher levels of guilt, more blame and responsibility of the death than other mourners, and heightened feelings of rejection or abandonment by the loved one, and anger towards the deceased (Jordan, 2001) The existing research on sense of guilt experienced by suicide survivors mainly focuses on studies with surviving spouses (Demi, 1984) and parents (Kovarsky, 1989; Miles & Demi, 1991-92). In fact, the suicide of any family member, particularly those with a close emotional bonding with the survivor before death, usually results in a tremendous sense of guilt. Then, they punish themselves through a process of self-stigmatization (Dunna and Morish-Vidners, 1987) which affects their self-perception; they are preoccupied with the assumption or fear that others are judging them negatively despite people around them who were showing true care and compassion and they tend to withdrawal or inhibit themselves from receiving social support.

Implications and questions to ask:

How do survivors comprehend the experience?
How do survivors make sense of the future under a different condition?
How can survivors move on from guilt and a sense of helplessness to regain their locus of control?
How to stop self-battering, physically, emotionally, socially, and spiritually?

Helping professionals cannot change the fact of suicide, their guilt, and definitely cannot answer their queries. Yet, professionals and suicide survivor support groups always can provide positive role models and support survivors in developing a sense of coherence and a coherent narrative. This can be done by enabling survivors to share stories, providing room for self reflection, helping one another, and, ultimately, being transformed into advocacy and suicide prevention as well as promoting a supportive society to make life worth living for all. Thus, the goal is to help survivors regain their sense of coherence. According to Antonovsky (1987), the sense of coherence can be described as a sense of manageability, comprehensibility, and meaningfulness. I would like to add a final form of transformation to this model of coherence.

Bereavement Support

To provide bereavement support for survivors, it is best to consider a four-piece time frame: the immediate incident, the short term, the intermediate term, and the long run. Unfortunately, most of the suffering from complicated and problematic bereavement cases is often identified when it is many years later. Many bereaved persons manifest their grief through long-term depression and somatic illnesses.

In the immediate term of digesting the bad news which is impossible to swallow, survivors will have to keep children at school, continue to go to work, and maintain daily routines. It is easier said than done. The immediate term can be so traumatic and shocking that survivors can break down emotionally and physically. Thus, it is important to call in help to manage the situation, to prepare for the legal procedures and funeral arrangements during the initial few days. In a short term, survivors will have to break bad news to relatives and friends. They need to comprehend the situation before they can share with the others what happened. Thus, comprehensibility of a reason for suicide and knowledge of what will happen next, information on what needs to be done, and support with resources would be required at this stage.

After the funeral, it may take months or even years to mourn the loss. It is essential to focus on the continuing bond of how to create a space where the deceased can continue his or her living legacy in the minds of loved ones. The meaningfulness of the suicide and the benefit that it brings, such as ending suffering of depression and pulling the family together, will help to bring a full closure to the loss. In a long run, the whole painful experience of the loss of a loved one through suicide can be transformed into new strength for helping other people. Like growing new teeth, the suffering can open new horizons and broaden our spiritual compassion for people in pain.

Table 1 Primary Focus in working with suicide-survivors over the immediate, short, medium and long term

Immediate	Short tetm	Medium term	Long term
Manageability	Manageability	Manageability	Manageability
Comprehensibility	Comprehensibility	Comprehensibility	Comprehensibility
Meaningfulness	Meaningfulness	Meaningfulness	Meaningfulness
Cope with shock and sudden changes	Carry on and living their life without the deceased	Creating meanings of life and continue legacy of deceased	Long term goal of Transformation in advocacy and change

Immediately after the completion of suicide (in the first few days), it is best that friends and bereavement support organizations send staff to help, to be a shoulder for the bereaved to cry on, provide relevant information on practical issues, provide socio-emotional support, assist in the establishment of a daily routine in the crisis situations (especially with provision of food and baths for children and elderly persons), and listen to the bereaved as there is a strong need to ask why and tell about the bereaved persons. The way to get out of the conspiracy of silence is fundamental to the mental health of bereaved persons. Listen to fault finding of oneself, such as “Why could I miss the signs of suicide? Why did I scold him/her” as it is a necessary process of meaning making.

From the first week to the first three months, the return to normalcy is the goal within the short term. Individuals can suffer from problems of concentration, intrusive thoughts, sleep disturbance, poor concentration, cognitive impairment, somatic pain, and loss of appetite. It is crucial to have someone help with tasks to maintain a regular and predictable daily routine, exercise, meals organized so that the family can eat, rest, sleep, and maintain personal hygiene.

At the intermediate level of the first 18-24 months, bereaved persons will have to relearn the daily routine especially for anniversaries, birthdays, Christmas, New Year’s, and major festivals where families get together. Probate, insurance, making sense of the suicide will often take more than a year or two to settle; the intermediate terms can range from the first months to two years.

Owing to strong sense of guilt, individuals impose a strong sense of self-stigmatization on themselves. They may feel that there are people judging them for their neglect of their loved ones such that the suicide happened. Individuals can suffer from traumatic symptoms of rumination, loss of meaning, find life meaningless, total loss of joy and happiness in life, low energy and find oneself totally incompetent in tackling daily activities and in problem solving. It will be crucial for individuals to develop skills in coping with the pain and suffering of grief and loss to endure a prolonged sense of grief and shame, as well as to regain a sense of self competence in handling issues of everyday life.

In the process of establishing a return to normalcy, it is important that individuals develop a coherent narrative on the suicide of their loved ones. The meaning reconstruction process involves sense making, fact finding, life review, and through the establishment of a continuing bond.

Over a long run, if bereaved persons can turn their grief and loss into compassion for others in the same shoe, and mobilize themselves to provide help to others, it can be regarded as a personal transformation. There are studies on how bereaved persons report post-traumatic growth through articulating their suffering and rewriting their stories to help other people through writing books; journaling; composing music and songs; creative art work and play. The active search of meaning, telling and retelling of stories of their loss, can help individuals develop a coherent narrative. Many of the bereaved due to suicide actively contribute to suicide prevention because they personally experienced how painful it can be if suicide is not prevented.

RISE Model for Suicide Bereavement Survivors

In order to cope with the traumatic shock, loss, grief, self-blame, guilt, and anger, it is important for bereaved persons to RISE again. The following proposal of the RISE model represents a new focus on Resilient Integration for Survivor Empowerment. The goal of this empowerment model is for suicide survivors to appreciate that from the pain of loss, there is a bigger plan for us in Transformation.

“There is no suffering that the soul does not profit by.” Unknown Author

The important concept of growth pain: Children and adolescents often report discomfort or pain in the leg as they grow tall. There also is blood and pain involved in growing of new teeth as well as childbirth. Behind the suffering, there is hope for new life and personal capacities.

The Chinese word for “Compassion” consists of two words, “Chi-Bei.” “Chi” meaning loving-kindness. “Bei” means suffering and sadness. It is through personal pain and suffering that individuals develop capacity to be compassionate. With the experience of a deep pain and hurt through suicide of loved ones, bereaved persons know how it hurts. Parents who lost a child through suicide would be committed to teenage mental health and suicide ideation, drug use, and adulthood depression. Adult children of parents who complete suicide pay more attention to isolation, sense of burden, physical pain, and chronic illness as well as geriatric depression. The guilt can be turned into constructive energy for social transformation of social activism.

Through sharing of transformative stories, survivors can find meaning to the suffering. From witnessing growth in support groups and mutual help activities, survivors can be convinced that this is a growth pain that can result in growing of new wings in our personal strength so that we can all take the mission of building a better world for all and fly.

Families set up charitable foundations and associations in memory of their loved ones. Individuals establish trusts to help disadvantaged children or older adults. Parents print paintings of their deceased children into books so that their talents can be appreciated by more people. Bereaved spouses contribute by joining charities for HIV-AIDS affected areas and hospice movements. There are endless lists of how survivors can RISE into becoming more resilient, passionate, caring, peaceful, and more humane people with broader visions in life and an appreciation of the vulnerability of life.

The author promotes a model called Integrative Body-Mind-Spirit approach of bodily care, emotional strength focus, and spiritual growth process of searching for peace and ultimate meaning (Lee, et al., 2009). There also are examples of how individuals can be transformed through various kinds of pain. Practices of meditation, exercise, sharing, and artistic expression all can contribute to the sense making, meaning search, and benefit finding process of Transformation. I look forward to reading more of your transformative stories in the days ahead.

References
Antonovsky, A. (1987). Unraveling the mystery of health: How people manage stress and stay well. London: Jossey-Bass.
Chan, C.L.W. (2006). An eastern body-mind-spirit approach: A training manual with one-second technique (2nd ed.). Department of Social Work & Social Administration, The University of Hong Kong.
Chow, A. Y. M. (2006). The day after: Experiences of bereaved suicide survivors. In C. L. W. Chan, A. Y. M Chow (Eds.), Death, Dying and bereavement: A Hong Kong Chinese experience (pp. 293-310). Hong Kong: Hong Kong University Press.
Demi, A. S. (1984). Social adjustment of widows after a sudden death: Suicide and non-suicide survivors compared. Death Education, 8, 91-111.
Dunn, R. G., & Morrish-Vidners, D. (1987-1988). The psychological and social experience of suicide survivors. Omega, 18, 175-215.
Jordan, J. R. (2001). Is suicide bereavement different? A reassessment of the literature. Suicide and Life-Threatening Behavior, 31(1), 91–102.
Kovarsky, R. S. (1989). Loneliness and disturbed grief: A comparison of parents who lost a child to suicide or accidental death. Archives of Psychiatric Nursing, 3, 86-96.
Lee, M. Y., Ng, S. M., Leung, P. Y., & Chan, C. L. W. (2009). Integrative body-mind-spirit social work: An empirically based approach to assessment and treatment. New York: The Oxford University Press.
Miles, M. S., & Demi, A. S. (1991-92). A comparison of guilt in bereaved parents whose children died by suicide, accident, or chronic disease. Omega, 24, 203-215.

About the Author

Cecilia L. W. Chan, Ph.D., is a Si Yuan Professor in the Health & Social Work, Department of Social Work & Social Administration, and, Director, Centre on Behavioral Health, University of Hong Kong. She is renowned for her creative innovations of integrating eastern concepts into her integrative therapy as well as her work on psychosocial oncology, end-of-life care, death, and bereavement studies. Her e-mail is: cecichan@hku.hk and web site: http://cbh.hku.hk/.