In psychiatric wards, death by suicide is not unusual. I have been involved in the aftermath of several such cases. Based on my research and experience, this article discusses what is important to family members who lose a close one by suicide, and how we, as healthcare professionals, can support them. As a chaplain for 21 years, and as a former center leader for Kirkens SOS (KSOS – a help line) for seven years, I have talked with several thousand patients and family members before and after death, be it death by accident, illness, or suicide.
In this article, I present a case – case 1, where parents lost their daughter in suicide. I will discuss the case considering my research findings in palliative care, where I found that the most important support from healthcare professionals according to family caregivers, is:
A trustful relationship to healthcare professionals.
Available healthcare professionals.
Information and communication about illness, prognosis, and death.
Help with the relationship to the patient.
I will also discuss the case from my clinical experience from both psychiatric and somatic wards. Thereafter, I will present another case - case 2 and compare it with the first case.
Case 1
The mother was referred to me by her family doctor. Later, after advice from his wife, the father too had therapy with me. Here is a short version of what the bereaved mother told me:
My daughter, who was 20 when she committed suicide, grew up active and well-functioning, but started having psychological problems in her late teens. Turning 19, she changed. Having talked openly with us earlier, she now did not want to talk to us. She inflicted herself with self-harm and was destructive. The psychiatrist advised us not to tolerate that she harmed herself at home, and we followed the advice, which turned out to be harmful. It broke the relationship we had, and it took a long time to rebuild it. She was diagnosed with unstable emotional personality disorder, but did not get the help she needed. Only when she harmed herself, she was hospitalized for some hours. Several instances said afterwards that they did not take her self-harm and suicide warnings seriously. We were very worried and feared suicide, and I called the psychiatric ward and other instances in the healthcare system that dealt with our daughter. Every single time I called, and I called several times weekly, the answer was: ‘I cannot say anything due to confidentiality’. But yes, they could! They did not have to talk to us about her, but they could have said something about the diagnosis, and they could have shared their eventual experiences with that diagnosis’. I was desperate! A year before she died, she tried to commit suicide. I sat by her bedside in the intensive ward for three days. She survived but said: ‘If I am not well in a year from now, I will commit suicide’. That was on the 14th of November. When the date came, I called all instances. No help! Two days later, she was dead.
Afterwards, no one has ever contacted us, and we have been offered no help. I called myself and asked for a meeting, and got a meeting with the different instances, but they only said “blablabla”. The first time I was to meet with the therapist, I was met by the communication adviser. No one has ever said they are sorry. On the contrary, they said she received the right help.
My research in palliative care
My research is among primary family caregivers in cancer palliative care, focusing on how healthcare professionals can support them. In a study, I interviewed 14 primary caregivers of patients with advanced cancer about what support from healthcare professionals they thought important. Their answers were grouped in four themes, as mentioned earlier in the bullet points.
A trustful relationship to healthcare professionals
The most important support from healthcare professionals was, according to the primary family caregivers of patients with advanced cancer, a trustful relationship with the healthcare professionals (1) (This was supported by the healthcare professionals themselves in another interview study. The family caregivers said: “It feels so safe. They know who we are. The fact that she [nurse] comes and talks with me, makes me feel taken care of.” The family caregivers described the relationship to healthcare professionals as support in itself. Interestingly, that differed from the healthcare professionals’ way of talking about the importance of a trustful relationship in another study. For them, the relationship seemed to be more of a tool that enabled them to provide better support, and not support by itself.
Availability of healthcare professionals
Availability of healthcare professionals was another priority for the family caregivers, preferably someone who knew them and their situation. The caregivers had received information about healthcare professional whom they could contact 24/7 if they needed it. One said: “That’s a safe reference point.” Another said: “When you need it, they are there.” A third said about their GP: “She knows the family in and out. So, she’s fantastic.”
Information and communication about illness, prognosis, and death
The third of four support priorities for caregivers was Information and communication about illness, prognosis, and death. One said: “They must be clear and honest and say how things are. I find that important! It was never said in a way that made me understand how serious it was. I wasn’t at all prepared for her to die. We haven’t talked about death, for example […] And not having had those kinds of talks has affected our relationship.”
Help with their relationship to the patient
The last of four support priorities for the caregivers was help with their relationship to the patient. Some wanted such help because they as partners were so different. “She’s a pessimist and I’m an optimist.” A husband would have wanted healthcare professionals to invite them to a talk and say “which road you have chosen? What have you chosen, which model do you seem to be choosing now? Let us talk a little about the advantages and disadvantages with it”. A wife could not forget how her husband had looked at her in a scary and hateful way. “He looked at me with horrible eyes […] as if I were a troll.” A husband had a bad conscience because he had not been there for her. “I was on sick leave for a year after she got worse, and it was very hard to start working again, ‘because I felt I had to leave her alone, because she was still pretty ill, but I had no choice!
Case 1 discussed on the background of the four themes
A trustful relationship
The relationship between the patient/confidant and the psychologist or psychiatrist is known to be the most important factor for the outcome of therapy. The parents in the case referred to, tried to come in position to those responsible for the treatment of their daughter, or lack of such. They never felt that they were met with trust or got in a position where they were heard as to what help their daughter needed. A trustful relationship to healthcare professionals had hence not been established at the time of the suicide. This has complicated their grieving process considerably.
To my experience, family caregivers in somatic and psychiatric ward seek healthcare professionals who can stand together with them, side by side, as partners. In another case where I was involved several years ago, a woman around 50 hospitalized in a psychiatric ward, with suicidal impulses, committed suicide while going for a walk. The journal seemed to show a lack of therapeutic consultations, and a lack of healthcare professionals who bonded with her. After a short time in the ward, where she felt alone and abandoned and that nothing was helpful, electroshock was suggested. She was terrified. It seemed to me that there was a lack of therapeutic alliance or partnership with the patient and the family, and that this was hard to handle for both the deceased and the family.
It is well known that health professionals in psychiatry easily suspect that the family of origin may be the problem, or part of the problem, which is of course sometimes true. We also know that families who receive help to communicate and interact better through e.g. family therapy, may become part of the solution. Parents who change their way of interacting with the patient to the better, and perhaps ask for pardon, may have a formidable role in the patient’s healing.
The family caregivers are often the closest, most stable and strongest support for the patients. If this resource is not administered and employed in a good way, an important resource for healing is lost. Also, family members who are extremely concerned about their patient, afraid that their patient does not receive the help necessary, and perhaps fearing for the patient’s health and life, may become angry, accuse the staff of neglect, and be hard to relate to. Establishing a good and trusting relationship as early as possible is hence important also in psychiatry. Meeting the family after the suicide may also contribute to better grief outcomes.
Often, family caregivers I meet after suicide, are ashamed, feeling that others suspect that they are part of the reason for the suicide. Parents are especially vulnerable to feelings om shame, since their most important task in life is to protect their child, which they did not manage to do. Talking with us also about shame may hence be part of what they need.
Availability of healthcare professionals
Primary family caregivers interviewed in my study cherished available healthcare professionals when they needed support. The parents in case 1 were disappointed and upset when those responsible for their daughter´s treatment did not agree to meet them, and felt abandoned, as they needed very much to meet and communicate with them. Suicidal danger over time is a heavy burden for the family and is worsened if they feel that they are not taken seriously or supported.
When a person dies suddenly by suicide, the family needs to be taken seriously. I am often involved in tragic events, such as sudden death by accident or illness. The bereaved often report the lack of professional helpers contacting them to offer support and say that such proactive offer of support from professionals would mean very much to them. The parents in case 1 are discontent with the way the situation has been handled in the aftermath of the suicide, health personnel not accepting any responsibility, and saying that they could not have prevented the suicide.
Information and communication about illness, prognosis, and death
The parents in the case above, did not know what they talked about in therapy, how the therapists reflected or tried to help. They felt that they did not get help, and that their daughter´s suicide could and should have been avoided.
As in the interview study I referred to, the patients’ families in somatic ward in the Nordic countries normally want open and honest information about the diagnosis and prognosis. Adult patients of course must consent to sharing information about the diagnosis and treatment and can also deny us talking with the family. Confidentiality should, however, not become a pretext for not talking with the family about the situation. In palliative care, we encourage patients to let us inform their closest ones. To my mind, one should do the same in psychiatric wards. If we are allowed to talk with a family member, but not inform about the diagnosis, it is still possible to talk in general about being the family of a patient in psychiatric ward. If the diagnosis is already known to them, we can also on a general basis say something about that and how it often is like to be the family of a patient with such a diagnosis. It is possible also, and recommended in all cases, to ask how they are doing, and to let them share their anxiety and despair before and after a suicide. One can also ask them how they see the patient and what they think the patient needs and ask them to describe their own situation. We can furthermore, when the patient is still alive, talk with them about how it will be for them if we, together, fail in hindering the suicide. In that way, it may be possible to establish a trusting relationship.
Help with their relationship to the patient
Is the wish for help with the relationship to the patient among family caregivers in palliative care, also relevant in psychiatry? Many who are threatened by suicidal impulses and risk ending their own life, experience that the close ones are so worried and burdened that they have bad consciousness for being a problem and find it difficult to inflict even more pain on them. This may result in the focus changing from the patient to the parent if they share their difficulties. Helping parents process their own problems, may enable them to become parents who stand firm when their son or daughter need them and share their despair, keeping the focus on the son/daughter. Some parents or other close ones are invited to consultations together with the patient. Some patients, whose parents are violent or abusers and have an extremely negative impact on them, may need help to keep distance to their parents or break the relationship.
How to provide therapy?
Existential therapy and grief
As a chaplain with a PhD on primary family caregivers within palliative care, I am drawing on the palliative care concept of total pain (physical, psychological, social, and spiritual/existential), and my family therapy and counselling competence. Existential therapy is my method and approach. I use the insight I have into psychiatric diagnosis if the family member has got one, but do not have the authority to give diagnoses, and am looking for the sound and sane in the person, more than the sick. Persons with a psychiatric diagnosis do also have resources and sound sides that may be used in our therapy with them. Grief is a sound, normal and necessary reaction, even though it in some cases may become complicated grief which has now become a diagnosis. For 25 years, the most prominent grief theory used has been the Dual Process Model (2;3). Different from Kubler-Ross’ grief theory of four stages, grief is now seen as individual, lifelong, and is best handled by oscillating between facing the loss and facing the future. Furthermore, grief in seen as oscillating between facing/working with the loss, and having breaks from it, and between facing/working with the future, and having breaks from it. Also, grief is no longer understood to end with a break of relationship to the deceased, but an altered relationship. For example, talking with the dead on the graveyard for years after the death is no longer seen as wrong.
Express emotions and thoughts, including physical reactions
Parents of persons who have committed suicide are often surrounded by silence. Not knowing how to address the situation, judging the parents or simply thinking that not talking about it is best for the parents, may be reasons for the silence. Although cautious and securing that the family member feels safe and cared for in the therapy relation, I am not afraid of inflicting extra pain by asking about difficult things. The pain and suffering are already there, and it is helpful to talk about it in a safe and caring context. I regularly get comments like “this is difficult to talk about, but it’s good that somebody dears to ask about it.” Guilt is, to my experience, often prominent, which should not be surprising to us, since a person has been murdered. When the delinquent is a stranger or outsider, the guilt is easier to place and handle. In suicide, the person who killed my loved one, is the same loved one. I often share this way of looking at the suicide with the bereaved and mean to see that it helps them understand why the death by suicide is so desperately hard to process. Also, we should not take their responsibility from them, but for example say that it was not their fault that he/she committed suicide, but that it is still possible to take responsibility for and even regret the choices they made in the relationship to the deceased.
Relational stress
Living with the suicide of a close person, is of course extremely demanding, which does not apply only to the individual, but also the relationships within the family. Often, harsh words have fallen right after the incident, accusing words that are hard to forget and that have created or strengthened a conflict. Also, grieving in totally different ways may result in disappointment and accusing the other for not grieving, or mere loneliness, due to each being in place in life where they feel that nobody understands them. In therapy, feeling understood is essential. Drawing on group counselling and systemic thinking used in family therapy, I explore the relational challenges within the family, including the relationship to the deceased. If the relationship to the deceased was complicated, grief is normally also more complicated. If there were already family conflicts, they often worsen. Also, the last words exchanged before the suicide are crucial. If it was a quarrel and hard words, it usually generates guilt and regret.
Guilt, anger and shame are in the therapy room
After suicide, guilt is in play in the therapy room, and search for an explanation. Guilt, anger, and wish for retribution may hinder a good grief process. It is therefore important to help them share these thoughts and emotions, also anger towards the deceased. Why didn’t he come to them for support before he took his own life? If a farewell letter has been written, assuring that the bereaved is loved, it helps handle the feeling of guilt. Also, typically, the deceased search their memory for expressions of love for them. Many blame the help or lack of such that the deceased received in psychiatry. I often hear that he only was medicated and receiving no or insufficient therapy. I think it is crucial that the healthcare professionals responsible for the treatment meet with the grieving family members to listen to their complaints, and to explain what has been done to help. This is not only important to the family, but also for the healthcare professionals. Losing a patient in suicide is not easily forgotten, and often associated by feeling guilty, or being angry at the patient or the family. In debriefings of the staff that I have conducted at psychiatric wards after suicide, I have observed that it is very hard and rare to be critical to the wards handling. This is understandable since those who have been in some way responsible for the deceased will need to be reassured of not being guilty by their colleagues, which normally happens. These mechanisms contribute to my mind to reduce the learning after suicide. Whether the therapy was good or not, it may obviously be said to have failed to keep the person alive. I think I it would be of great help if the responsible sat down with the bereaved, listened to the complaints or accusations, explained how they did their best, admitting that it obviously was not good enough to make him/her capable to live, and sharing their deep sorrow because of that. Again, shame may be in the room and talking about it face to face may contribute to healing it.
Family caregivers in psychiatric ward probably need more support than caregivers in somatic ward, but normally receive less support. Hospital chaplain colleagues of mine offer supportive, existential groups to family caregivers. Here are some quotes from the participants.
What groups for family caregivers in psychiatric ward have meant to them.
I’m not alone, and I’m less ashamed.
It means a lot to meet others who are in similar situations
It helps me understand myself and my own and others’ reactions.
The group is a room where I’m allowed to say anything, and it helps.
I get support, understanding and new perspectives from the other group participants.
I receive support and understanding also from the leaders of the group, who do also share their experiences.
Case 2
The mother in case 2, who lost her son in suicide in his twenties, is back in full time work, and is to a large extent at terms with what happened. Here is a shortened version of what she told me.
My son changed from a well-functioning, social young man with many friends to an altered person, withdrawing from the world, tending to isolate himself. He had a good education and job, but became a man who did not recognize himself, and who was in constant psychological pain. It was something physical that happened to him. He started suffering mentally and got a schizophrenia diagnosis. He understood his own situation and was good at explaining it to me. I learnt a lot from him. He asked for admission to a psychiatric ward and was admitted. He wanted very much to live but suffered from inner torture. He knew how it was to be a normal, sound person. He was a long-time inward patient, but we went for a walk together every day. He told me everything about how his life and pain was, including suicidal thoughts. He sent a text message: ‘You are the light in my life’. I understand that he took his life, but I wish he would have tried a little longer. I had many consultations with the therapist and my son together, to try to find something that worked. One day I found him after he attempted suicide. He was in intensive care for some days, then he became an organ donor. When we saw him afterwards, somebody had put flowers in the window and lighted a candle. That was so wonderful. The therapist called me immediately when my son had committed suicide. We have met for several talks afterwards also. The therapist is also shaken by the suicide. He knew him the same way as I knew him. I may think that they gave him a lot of medicines and little other help, but he tried to help him, and that was hard for both the therapist and me and my son himself, because he suffered so intensely. The funeral was so fine, with a lot of his friends present. After some time, I got a letter inviting us to a national gathering for family members of organ donors, saying that his heart had given life to a young person. He became a lifesaver. That means a lot to me. When I look out at the scenery a sunny day, I say to myself: ‘You are out there’. I hope somebody cares for him.
Case 2 compared with case 1
How were then the four themes in palliative care taken care of in case 2?
Much of what was lacking in case 1, was in place in case 2.
Firstly, the relationship with the therapist was in place, and still is. The therapist knew her son the same way as she did. She looked upon the therapist as someone who cared for her son and who cares for her. Even though she was not totally content with the treatment, she acknowledged that they had tried to help him. Contrary to case 1, this is an example of healthcare professionals being there as a support in difficult times.
Secondly, the therapist made himself available by calling her the day of the suicide. This proactive way of being there for the family after the suicide is important for the bereaved. The talks they had afterward to process the death were probably important for both the healthcare professionals and the family.
Thirdly, the mother in case 2 was well informed about diagnosis and treatment, by the therapist as well as her son. She knew under ways and afterwards how the healthcare professionals understood her son’s problems and how they tried to help him. The family of a patient in psychiatric ward often struggle with helplessness and powerlessness and have to trust the professional helpers. In somatic as in psychiatric care, I have seen how much it means to be confident that the patient receives the best treatment possible. “They are doing their very best, and they are so competent!” Then, living with death becomes easier.
Fourthly, the healthcare professionals had invited the mother and her son to consultations together. This may have had several good outcomes. It probably helped mother and son maintain a good and open relationship, obtain a common understanding of his diagnosis and treatment and find their way together. Also, healthcare professionals meeting the mother with openness and confidence, and treating her as a resource for the treatment, probably contributed to building a trustful relationship between family caregiver and patient on the one hand and healthcare professionals on the other. The relationship between mother and son remained good till the end, and she felt that she had done everything she could for her son and contributed to a better life for him. They went for a daily walk together and talked openly, and he had also given her strong tokens of his affection for her. It is well known that the grief process is facilitated if the bereaved feels that he/she contributed to a better life for the deceased, and if the relationship was good.
Conclusion
This article has, in the light of two deaths by suicide, discussed the relevance of four themes that family caregivers in palliative care reported as the most important support from healthcare professionals: 1) A trustful relationship to healthcare professional, 2) Available healthcare professionals, 3) Information and communication about illness, prognosis, and death, and 4) Help with the relationship to the patient. The discussion has shown that all four themes are highly relevant also in psychiatric care. The most important seems also here to be the relationship.
If patient, caregiver and healthcare providers feel that they stand together as a team, shoulder to shoulder, having confidence in each other, the most important factor according to family caregivers and healthcare professionals in palliative care is in place: A trustful relationship. □
References by request
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