A Qualitative Study on Traumatic Experiences of Suicide Survivors

Abstract

The suicide of a loved one can be a traumatic experience. The objective of this study was to investigate trauma-related experiences of suicide survivors. This is a qualitative study with people who had recently lost a family member or a close one to suicide, conducted at least two months after the event. Forty-one participants agreed to take part in the study and were interviewed. The interviewees' perception was that suicide brought harm, symptoms, and suffering. Traumatic experiences can begin immediately after the event, with many reporting symptoms lasting many months and persistent impact, both personal and to the family. Postvention models after suicide should incorporate such findings, and investigate trauma consistently.

Keywords

trauma suicide qualitative study

Introduction

Exposure to the suicide of a close one is a relatively frequent life event. Three to five percent of people are estimated to have experienced suicide in the family, with 1% exposed in the previous year (Andriessen et al., 2017). Suicide can be traumatic due to the violent and unpredictable quality of the death, with many survivors going on to suffer from a form of traumatic grief (Andriessen & Krysinska, 2012; Public Health England, 2015).

The grief experienced by suicide survivors can be qualitatively distinct; guilt, confusion, rejection, shame, and anger can add to the bereavement process. Suicide and other violent deaths can cause more post-traumatic symptoms and depression than unexpected natural deaths (Kaltman & Bonanno, 2003), although there is significant variability owing to sampling and methodology (Sveen & Walby, 2008). There are suggestions that violent loss can lead to prolonged grief and post-traumatic symptoms, and that this is not always reported or treated. Perceived unexpectedness and shock have been shown to lead to distress and dissociation, which can lead to grief and trauma symptoms (Boelen, 2015; Jordan, 2020; Sanford et al., 2016).

Family members report difficulty communicating the pain they feel about the loss (Castelli Dransart, 2017; Dutra et al., 2018; Peters et al., 2016; Ross et al., 2019). Suicide is stigmatized, and the feeling of being unable to talk about it can be a barrier towards the healing process. Family members also often struggle with understanding reasons for suicide (Jordan, 2009). There may be perceived abandonment and rejection, as they may see themselves responsible, and the suicide an act that could potentially have been prevented (Tal Young et al., 2012).

While there is a debate on how distinct the grief process is following a suicide, qualitative studies can help in the understanding of underlying themes and processes. Qualitative studies on grief related to suicide are sparse, usually not focusing on traumatic aspects of the death (Shields et al., 2017). The objective of this research was to investigate the trauma experiences of family members of people who died by suicide in depth. We sought to investigate those experiences related to trauma, with emphases on experiences related to the initial reaction to the trauma, perceptions of the trauma, aroused feelings, and consequences for the social environment resulting from the suicide.

Methods

Design

This is a qualitative study; semi-structured in-depth interviews were used to gather information, a method widely used to understand the experience of suicide survivors (Lee et al., 2019; Peters et al., 2016; Ross et al., 2018).

Data Collection

We employed semi-structured interviews to investigate traumatic experiences of family members exposed to the suicide of a loved one. The interview was semi-structured to allow the participants to express themselves, while the researcher also looked for relevant issues (Minayo, 2010). We explored exposure to suicide as a traumatic phenomenon, especially the experience of physical and psychological reactions to the exposure, impact on the individual, perception, feelings, and changes aroused by the experience. Interviewers used an interview guide designed by the authors, containing prompts to the themes described above.

The data presented here is a section of a broader protocol. Female psychologists (JCC and CSP) with training at master’s or doctoral level and clinical experience conducted all interviews. Interviewers underwent training designed by bioethics and mental health advisors and have been working closely with bereaved families since 2012. Interviewers had to subject their practice to a critical examination of values and posture to help unpack assumptions they could have brought to the field, identifying how personal contexts might shape results and interactions. The data presented here were collected between 2013 and 2019.

Sampling

This paper reports on family members and close relatives of people who died by suicide and were approached to consent to donate the deceased person’s brain tissue for neurobiological research. Briefly, participants were approached immediately after the suicide and invited to participate in the study; they were invited to participate in a psychological autopsy and qualitative research protocol at least 2 months after the initial approach, irrespective of their consent to brain tissue donation (Longaray et al., 2017; Padoan et al., 2017, 2020). There was no prespecified degree of kinship to the deceased, although the people we approached had to able to conduct the legal procedures required for both the release of the body for the funeral and to give consent for donation. In many cases, relatives were encouraged to discuss the decision to donate between themselves, and this provided opportunities for identifying a family member or close one who would be interested in participating in the study. There were no further inclusion or exclusion criteria other than those of the brain donation protocol. All participants had a close relationship with those who died by suicide and thus were in principle the most likely to have an intense experience and vulnerable to suffering significant trauma (Table 1). Those who had died by suicide were required to be between 18 and 60 and without brain lesions due to the trauma at the time of death.

Table 1.

Characteristics of Included Participants.

Participant	Gender	Age	Months since suicide	Kinship
1	Woman	58	6	Mother
2	Man	58	4	Father
3	Woman	16	4	Sister
4	Woman	30	14	Daughter
5	Man	75	4	Grandfather
6	Woman	50	13	Mother
7	Man	55	12	Father
8	Woman	47	6	Niece
9	Woman	48	7	Wife
10	Woman	53	13	Wife
11	Woman	56	14	Mother
12	Woman	32	12	Daughter-in-law
13	Woman	25	6	Granddaughter
14	Man	39	2	Ex-husband
15	Woman	23	11	Daughter
16	Man	60	3	Father
17	Woman	33	12	Daughter-in-law
18	Woman	63	3	Wife
19	Woman	53	3	Sister
20	Man	52	3	Father
21	Woman	19	3	Sister
22	Woman	50	5	Sister
23	Woman	59	2	Mother
24	Woman	57	6	Niece
25	Woman	52	12	Girlfriend
26	Woman	55	7	Wife
27	Man	61	12	Son
28	Woman	32	12	Granddaughter
29	Man	44	3	Ex-husband
30	Woman	67	10	Mother
31	Woman	27	12	Cousin
32	Woman	46	12	Aunt
33	Woman	28	3	Sister
34	Woman	47	12	Sister
35	Woman	33	5	Niece
36	Woman	47	4	Wife
37	Woman	38	8	Daughter
38	Man	43	8	Son
39	Woman	53	2	Aunt
40	Woman	28	2	Sister
41	Woman	34	3	Wife

Procedure

Family members were first approached to participate in the project at the coroner’s office (Instituto Geral de Perícias – IGP/RS). Those who agreed to participate were invited to the interviews a minimum of two months after the suicide. We had access to 71 families that were approached for the larger study into suicide and agreed to receive a telephone call to schedule this research interview. From those 71 families, 37 completed the qualitative research interview protocol.

The interviews were preferably conducted in person (21 of 37), but some were conducted by telephone at the request of family members. In-person interviews occurred at a specialized clinical research facility at the University Hospital. We conducted the interviews within one single appointment of about 150 minutes face-to-face and about 80 minutes when we used telephone calls.

Analysis

We employ Bardin's content analysis to explore the data (Bardin, 2009). The method proposed by this author offers a clear framework for categorizing emerging themes from the discourse, often allowing the researcher to understand the structures behind relevant fragments. The analysis suited the use of interviews as the method for collecting data, as well as the process of exploring themes related to trauma, our initial objective.

The interviews were recorded and transcribed. Interviewers had a research protocol into which they were able to take field notes on impressions and feelings aroused by the conversation and emotional state of the informants. The analysis was conducted by a pair of researchers (CP; JCC) and coding matrices were discussed in group meetings in all phases of the coding process.

The analysis was performed with the help of the NVivo program (QSR International Pty LTD, 2020); this kind of software can assist in avoiding coding errors, speeding up the process, and allowing the researcher in reflecting in depth by reducing operational activities. The material was organized for analysis through the following steps: pre-analysis; exploration of the material; inference and interpretation of results (Bardin, 2009). After this process, the material was explored through coding. Next, experiences were categorized; from the categories, elements with similar characteristics were gathered. After classifying the categories and according to study objectives, inferences and interpretations were made. The meaning of the trauma experiences was assigned according to the categories provided by thematic analysis (Bardin, 2009). Data saturation was the criterion employed to end data collection and no further interviews were conducted (Guest et al., 2006). We report the findings according to current COREQ guidelines.

Ethical Aspects

All participants signed an informed consent form and verbally confirmed consent after the interview ended. The institution’s Research Ethics Committee approved the project. Due to the delicate situation of mourning and possible trauma, specialized trauma-focused treatment was offered at no cost for families whenever necessary at the institution’s outpatient clinic. This was available to the family member independently of consent to participate in the research protocol.

Results

We conducted 37 interviews; four interviews were conducted with two family members at the same appointment (that is, 41 participants). Interviews took place a median of 6 months after the suicide; seventy-eight percent of interviewees were women (see Table 1). The experience of trauma associated with suicide was present in the discourse of many of the interviewees. We found six categories in the data, termed immediate reactions; memories and avoidance; impact on the individual; physical health; social and family impact; and coping and meaning-making.

Immediate Reactions

Regarding the initial reaction to the suicide, there were feelings like shock, anger, shame, and guilt. It becomes difficult to accept the event and whether the death is real.

“It is very difficult to receive this news. When it happened, my brother and I took care of all the errands, paperwork, and I was still having a hard time believing he had done it. And I was in disbelief until we were at the coroner’s office when we had to identify the body. That was when I realized it. I can't describe it, it's a very bad situation.” – report of a daughter.

“Even if you know it happened, you think it will be … It's like I told you about the impact, the shock … For you to accept it like this on the spot … In my whole life, I’ll think it's unacceptable. But being hit with this news like that, right on the spot. It is much worse!”- report of a sister.

“I still do not believe it somehow. It’s like he's alive, out there. So, this is something that worries you.”- report of a wife.

Memories and Avoidance

Family members report having persistent intrusive memories and thoughts about the deceased. They also report experiencing the dead loved one, such as seeing them, hearing them, talking, and having dreams about the person coming back to life. Consequently, they describe all kinds of efforts to avoid those disturbing experiences, trying very hard not to think about the death and the deceased, as well as avoiding places and routines that are associated with the deceased. The memories are described as sad and painful.

“I want to see if I can get a medical leave due to these persisting memories. It is not something fleeting for me, it is very much present in my day-to-day routine … It’s like all the time, you know? It comes all the time, all the time, all the time, all the time. Every hour, every second, you know? When I go to the bathroom sometimes, I get scared to go to the bathroom alone, you know? Then my hands get all sweaty, my feet sweat … ” - report of a sister.

“Because of the trauma, I am always very anxious … Because it is something that cannot be forgotten, right? You keep on having these thoughts about him, about his death, and all this keeps on coming back to you … ”- report of a sister.

Impact on the Individual—Grief and Depressive Symptoms

After the suicide, family members describe loss of interest, negative beliefs about themselves and the world, suicidal thoughts, depression, anxiety, isolation, crying, panic, anger, and guilt.

“I don't feel like getting out of bed anymore. I don't feel like working anymore. I come to work counting the hours for me to go home. I lost the joy in things. I don't celebrate anything else. I don't feel like celebrating birthdays, Christmas, new year. Nothing. Nothing else interests me, nothing more. I don't like to go out, I don't like to talk. People irritate me. It's like I hate life. I fret about everything. I get irritated by everything. Sometimes I don't even want to be talked to, I just want to be quiet. I just want to be in a corner alone. Isolated.”- report of a mother.

“But several times it crossed my mind that I could do the same crazy thing as him. I won't deny it. I go out on the streets and look at cars and think ”if I throw myself there in front of a car, I will be with him.” - report of a niece.

“Well, it's about mixed feelings. We feel guilty because we should have done more. We feel frustrated because what we did was not enough to keep her here with us. You even have a feeling of anger towards the person: why did you do that? It is a very complicated thing to express, everything that happens, everything that afflicts us. In fact, I can compare it to an earthquake that happens within your life, and you have to rebuild so many things after that. It is very heartbreaking.”- report of a sister.

Physical Health

Participants report that, after the suicide, they noticed changes in general health. In the first days after the event, there is insomnia, hypertension, nausea, shortness of breath, and palpitations. Among the symptoms that persist, there are difficulties in sleep and weight control.

“I gained 22 lb. I lost focus on things like that, mainly in relation to my weight and such.” - report of a sister

“I got really sick … I got sick, I used to pass out, feel dizzy, couldn’t eat, vomiting a lot … Early on, I couldn't eat and vomited a lot. But now I'm anxious so I eat a lot.” - report of a granddaughter.

“On the day she died, I took about 20 pills of valium. And I didn't even fell asleep. I didn't sleep for two days. Everyone says they don't know how I made it. That valium makes you sleep for days. Not to me. It just calmed me down, made me dazed. As if … As if it wasn’t quite happening. Like it was a dream. And I was going to wake up. Many, many times I say to myself: ”This is just a nightmare.” I'm going to wake up. And none of this really happened.”- report of a mother.

Social and Family Impact

Family members describe stigma and prejudice. There is difficulty talking about the form of death and the feeling of lack of understanding and empathy concerning the event. Among the survivors, quarrels, disagreements, disunity, guilt as an attempt to blame someone in the family for the suicide, concern for other family members after the event, and threats of suicide are common.

“Because we feel ashamed, you know, to tell what happened. At first, when asked about how my brother died, I used to tell people that it was sudden death. Because people get horrified, you know. And then I wonder … The priest from our town, when he heard it was suicide, he said: ”Oh, what a horror.” Just like that, right to my face. He didn't know that I was his sister. ”Oh, what a horror, why did he do that?” Yes, I also ask myself why he did it. But you know what? He did it, and that’s not what I wanted for him. That’s not what I wanted to hear from him also. You know?” - report of a sister.

“Well, working also upset me because people didn't ask me anything, but they looked at me in a certain way. They changed their way around me. I felt I had to smile, I had to appreciate it. If they said “hi”, then I had to respond. But all I wanted was to be left alone … And even today it still bothers me. So much so that today it happened there at work and I couldn't stand it, you know, I cried all day. Bad luck.” - report of a sister.

“I can't go to their house. No way I will go there. Every time I see my sister and my brother-in-law … Because from my point of view, they were the main culprits for this to have happened.” - report of an ex-husband.

“Only 28 days after my brother died by suicide, my other brother also tried to kill himself. The family was very upset after the suicide, very shaken. ( … ) So I don't know what went on in his head. But after that one was found dead, everybody retreated from family gatherings. So he kind of convinced himself about a conspiracy theory against him.” - report of a sister.

Coping and Meaning-Making

Participants discussed how life changed after suicide. Pain, suffering, and the search for reasons for suicide accompany the family members' daily lives. Families bring up how much more painful it is to lose someone by suicide than by any other form of death. Over time, the thoughts of family members remain the same, as if it were not possible to elaborate on the sadness of losing a loved one by suicide. There are many unanswered questions about the suicide that torment survivors.

“My mother died seven months ago and I haven't yet absorbed this story, I haven't digested it … I don't know how to live without her … I miss her so much because she listened to me, she took care of me … ” - report of a daughter.

“And now I very much miss him, miss him a lot and I practically do not to believe what happened. It is very difficult. Very difficult. Unbelievable. Sometimes I stop and I ponder about it and it still seems that it did not happen. I thought that a year later I’ll be better. I think it may never come to terms.” - report of an ex-husband.

“What most revolts me is not the suicide itself, it is not knowing why. Because she did not have depression, she was a very happy person, who loved helping others. But a suicide will stay with us for the rest of our lives! And our lives became hell after that.” - report of a mother.

Discussion

Participants in this study reported a range of trauma-related experiences after suicide. Among the themes emerging from their discourse, there was an immediate reaction of shock and disbelief, distressing re-experiencing and avoidance and sadness, anger, and guilt. There was a perception of stigma and increasing difficulty counting on others for support and attempts to hide the manner of death. Traumatic experiences can begin immediately after the event, with many reporting symptoms lasting months and persistent impact, both personal and to the family.

A recent systematic review was only able to unearth 11 studies on the general experience of suicide grief. They suggest three common themes from these studies, feelings, meaning, and context of bereavement (Shields et al., 2017). Our analysis certainly touches on the first theme. We confirm that themes related to intense distress related to trauma appear in the first months after suicide. After the suicide, participants reported a wide range of symptoms, such as loss of interest, negative beliefs about themselves and the world, suicidal thoughts and attempts, symptoms such as depression, anxiety, isolation, crying, panic, anger, and remorse.

We add to these findings the presence of traumatic elements (disturbing intrusive memories, guilt, negative feelings, avoidance, anger), that can act to perpetuate this pathological cycle. The immediate moment after death was reported as the most difficult and painful for family members. Case studies on the experience of survivors have reported the presence of traumatic symptoms, such as flashbacks, depressed mood, anxiety attack, guilt, and intense suffering (Kawashima & Kawano, 2017; Padoan et al., 2020; Roston, 2017). People close to the deceased can carry emotions such as shock, guilt, flashbacks, nightmares, avoidance, hypervigilance, repetitive memories, and the feeling of reliving the event that becomes common in these people's lives, as we report here. The fear that suicide could reoccur in the family was another disturbing consequence for survivors, associated with hypervigilance, anxiety, and difficulty in having positive feelings.

While we were not investigating traumatic grief per se, the phenomenology described here appears similar to that syndrome, characterized by separation distress and traumatic stress (Shear et al., 2001). In this form of grief, symptoms at the interface between PTSD and depression add to the mourning over the loss. In this study, immediate reactions after the suicide of a relative were despair, shock, confusion, pain, guilt, anger, and denial, with doubts about the reasons for the suicide and the form of death, as previously described (Adams et al., 2019; Dutra et al., 2018; Lindqvist et al., 2008; Ross et al., 2019). Neurovegetative and somatic symptoms were also frequently reported, with insomnia most prominent in the first days after the suicide. Other studies corroborate psychosomatic complications for family members after exposure to suicide. Loss of energy, persistent chest pain, shortness of breath, physical pain, hypertension, diabetes, and diverticulitis appeared in physical health (Spillane et al., 2018). As a result, survivors of a suicide loss end up seeking general practitioners. Thus, it is essential for health professionals - and not just mental health professionals - to be able to identify the demands and appropriate treatment for this population (Nic an Fhailí et al., 2016).

The participants reported their experience of pain related to the search for the reasons for suicide, which does not resolve over time. Other qualitative studies highlight similar findings of the state of shock and negative surprise with which the survivor is immediately faced (Dutra et al., 2018). A reconstruction of the deceased life trajectory occurs, in an attempt to better understand the meaning of the event (Castelli Dransart, 2017; Pritchard & Buckle, 2018). The closer the relationship with the deceased, the greater the feeling of guilt, related to not perceiving signs related to suicide and not being able to prevent it (Pritchard & Buckle, 2018; Ratnarajah et al., 2014).

Qualitative studies reveal that survivor families perceive the support network as weak and find it difficult to talk openly about feelings (Azorina et al., 2019; Peters et al., 2016; Ross et al., 2019). This creates difficulties for family members to discuss the matter and seek treatment when necessary (Ross et al., 2019). Telling other family members and society about suicide is difficult, and families report feeling the necessity to omit the manner of death, which can cause difficulties at the time of the farewell (Tzeng et al., 2010). Different types of need for social assistance are perceived, such as initial help, guidance on services, practical support, support groups, information, locating clinical assistance for the grieving process, and support from people close to the grieving process (Ross et al., 2019).

This study aimed to explore trauma-related phenomena after exposure to suicide. The research did not aim to assess the diagnosis of PTSD or other psychiatric disorders, but rather to capture the experience of exposure to this form of trauma. Qualitative studies are also not intended to generate results that are generalizable to the entire population, but thematic analyses such as the one presented here can explore themes that must be further developed. The population of origin for the study was the one that originally participated in a study of brain tissue donation for research. Whether those who were not approached or did not want to participate in any way in the study would bring different or contradictory themes is not possible to define. These results need to be tested in the general population, to expand knowledge and determine whether these traumatic phenomena after suicide exposure can occur on a larger scale. Through this, it is possible to identify the needs of this population to formulate treatment strategies that are issue targeted.

While there has been some qualitative investigation on suicide grief, the specific focus on trauma is novel in this report. Among the themes explored here, surprise and shock related to receiving the news of a family member’s suicide are vividly reported. These are reports of experiences that are can be symptoms related to trauma and are reported as traumatic by the survivors interviewed. Postvention models after suicide should incorporate such findings, and investigate trauma consistently.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPQ), Brazil. Professor Magalhães is supported by a National Council for Scientific and Technological Development – CNPq productivity fellowship.

ORCID iD

Pedro V. S. Magalhães

Author Biographies

Júlia Camargo Contessa, MSc, is a clinical psychologist who investigated the impact of suicide on families in her graduate studies.

Carolina Stopinski Padoan, MSc, is a clinical psychologist who is currently undertaking her doctoral degree studying families bereaved by suicide and brain tissue donation for research.

Jéssica Leandra Gonçalves da Silva is a psychology undergraduate student with an interest in studying families bereaved by suicide.

Pedro V. S. Magalhães, PhD, is a professor of psychiatry who leads the research group on suicide and severe mental illness. His research focus is on suicide and research methodology.

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