Suicide survivors

Interpersonal Psychotherapy for suicide survivors


The Bulletin of The International Society
for Interpersonal Psychotherapy.

November , 2005


It is estimated that, on average, every suicide leaves at least six people profoundly affected by the death of a loved one (1). Family, friends, co-workers and even therapists left in the aftermath of suicide are commonly referred to as suicide survivors. This expression does, however, refer to a blurred category of people whose features remain to be defined. Well-designed epidemiological studies are clearly warranted to determine how many survivors there are, their characteristics, and their needs. Is the status of survivor better defined by specific characteristics as kinship ties or by the nature and quality of the relationship shared with the deceased? Can passing time modify survivors’ needs?
Some studies hold that people bereaved by suicide present more similarities than differences compared with those bereaved by other kinds of death i.e. accidental or sudden death (2). Other research work has suggested that people who have lost a significant person to suicide can present slower recovery (3) because they have to deal not just with the loss, but also with shame, fear, rejection, anger and a sense of guilt (4).
Other aspects specific to this type of bereavement are the social stigma confronting survivors and the different impact suicide has on the family system compared with other types of death (5). All these elements seem to corroborate the hypothesis that survivors who were close to the deceased are at heightened risk for complicated grief or other psychosocial consequences (6; 7).
The term postvention was coined by Shneidman in 1971 to indicate the support given to those who have lost a significant person. It can also be understood as an opportunity to provide professional intervention to people bereaved by suicide. Interpersonal psychotherapy (IPT; 8) can play an important role in facilitating the recovery of survivors because of its overt interest in the problems facing these individuals. Alternatively, these clients can be offered Crisis Intervention (9) to help them overcome the emotional impasse experienced after the suicide.
Survivors usually seek professional help for problems related to loss, but not infrequently they have to deal with other types of psychological distress, such as role dispute or interpersonal deficits. These problem areas represent ideal foci for Interpersonal Psychotherapy. In this brief report we will present two cases of suicide survivors treated with IPT, within a broader postvention protocol specifically designed to meet the unique needs of this type of patient. [read more=”Read more” less=”Read less”]

Considering that in the Veneto Region (North-East of Italy) there are over 300 suicides per year (336 in 2001; ISTAT, 2002), yielding a substantial population of potential clients, we have developed a research-intervention scheme named SOPRoxi, in response to the lack of postvention schemes in area. The term SOPRoxi is derived from survivors (in Italian SOPRavvissuti) and proximity, to define the closeness of the relationship (10).
Once the survivors have been identified, it is important to evaluate those who need support and/or treatment and those who are coping with the grieving process by themselves through informal support from the social network.
The scheme envisages two assessment sessions to obtain more information and identify both psychiatric disorders and unspecified psychological pain. In addition to a clinical interview, subjects are administered tests for the purpose of categorial and dimensional assessment. Evaluation centers on:
•Axis I and II diagnoses (Mini International Neuropsychiatric Interview, Brief Symptom Inventory and SCID-II);
•level of depression and other psychopathological conditions (Hamilton Rating Scale for Depression; Brief Symptoms Inventory);
•interpersonal distress area (Interpersonal Questionnaire);
•suicidality (Interview of Suicidal Feelings; Reasons for Living Inventory);
•perceived stigma (Link Stigma Scale);
•complicated grief (Inventory of Complicated Grief)
•suicide-related feelings.
Scocco P, Frasson A, Costacurta A, Frank E, Corinto B, Drago A, Pavan L.
Finally, outcome is discussed by the clinical/research team which then draws up a program that is presented to and shared with the client.
Some clients benefit from a counseling approach, lasting a few sessions, on how to appropriately deal with their feelings; others benefit from participation in self-help groups (the SOPRoxi scheme is promoting the creation of these groups). However, some clients may need a more profound approach to help them overcome the emotional turmoil triggered by the suicide of a significant person. Such clients are invited to undertake either Crisis Intervention (for people grieving for less than 6 months) or Interpersonal Psychotherapy (for people grieving for 6 months or longer). All psychotherapy sessions are videotaped and the therapist is supervised on a weekly basis.

Clinical Vignette 1
Initial phase
Mrs. V, a 65-year-old housewife, separated, mother of two married children, was referred to the SOPRoxi group by her general practitioner (GP). Mrs. V. had been to her GP complaining of initial insomnia and depressed mood, with frequent crying bouts and occasional night-time binge eating. This picture, which had gradually worsened, had lasted since the death of her husband by suicide (Mr. A) some 9 months beforehand.
Mrs. V. was legally separated from Mr. A. During their thirty-year marriage, Mr. A. had subjected his wife to every form of physical and verbal abuse while under the effects of alcohol. Even during their 2-year engagement, Mr. A. had been violent towards the patient, but his immediate apologies had always managed to dissuade Mrs. V. from leaving him.
After the marriage, events had rapidly come to a head: Mr. A. began to constantly abuse alcohol and use violence against Mrs. V., who was admitted to hospital on several occasions with contusions and fractures in various parts of the body. The situation would temporarily return to normal when Mrs. V. threatened to leave home, but when it became clear that this was not the case, her husband would resume his usual behavior.
Mrs. V. brought up two children in this setting. They, too, had often been the target of their father’s fury. The family’s social circle had been restricted to the husband’s friends who made Mrs. V. feel uneasy. She had been forbidden from seeing anyone else, including her own relatives.
The patient had always had a precarious financial situation. Her elder son, who had partially contributed to the family budget, married at an early age and left his parents’ home. The younger son had continued to live with his mother until two years previously.
Mrs. V. filed for separation in 1989 but had continued to live with her husband and endure violence for two more years. After the actual separation, the husband had abused alcohol to an even greater extent, accumulating debt. Yet Mrs. V. had continued to help him with the housework,
Scocco P, Frasson A, Costacurta A, Frank E, Corinto B, Drago A, Pavan L.
though avoided meeting him or being near him whenever possible since it caused her great anxiety.
The day before the suicide, Mr. A. had telephoned his ex-wife asking her to tell their sons not to go and see him on that day because he had a few matters to deal with and informing her that should something happen to him, she would find a letter addressed to the family in a box. Mrs. V. said that at the time she had not thought her husband had wanted to tell her of his intention to take his own life and she consequently felt very guilty.
At initial evaluation, Mrs. met the criteria for dysthymia, with a HDRS score of 22, but scored below the cut-off on the Inventory of Complicated Grief (11). In addition to grief for her husband’s suicide, an interpersonal dispute with the sons was identified as the interpersonal focus.

Intermediate phase
In the fourth session, Mrs. V. continued to complain of repeated thoughts about her husband’s death and a sense of guilt and responsibility for failing to understand his intentions. She reported thinking of suicide at times but had not made any precise plans. Her relational style led her to mask the pain and anxiety related to her experience and avoid significant contact with others.
At the fifth session Mrs. V.’s depressive state and death thoughts had worsened. Her account of marital relations and her husband’s death was resumed and further investigated. Since she found it hard to spontaneously express her feelings of anger, the therapist sought to facilitate contact with this emotion through role playing and affect clarification techniques.
At the sixth session, her sons’ behaviour was identified as another source of distress. Mrs. V. felt her sons were unaware of her needs and were not sufficiently available. Yet she did not wish to inform her sons of her needs because she was afraid of “bothering them”, of preventing them from looking after their own families, and of irking her daughters-in-law. By exploring these potential interpersonal disputes and analysing communications the therapist sought to highlight her communicatory problem with her sons. To avoid the risk of vexing others, the patient often put aside her own wishes, hiding her distress behind a “mask”. In an attempt to break this vicious circle of missed opportunity for communication alternative behaviour options were discussed.
At the seventh and eighth session, the discussion centered on Mrs. V.’s feeling of solitude. She was unable to develop satisfactory friendships, believing she did not measure up socially: “I have nothing interesting to say; what I have to say is of no importance”. Hypothesizing that this might also be reflected in the psychotherapeutic setting, the therapist verbally stressed the importance of communications, proposing the psychotherapeutic space as a place where the patient’s thoughts and feelings were highly valued and where even anger and aggressiveness could be expressed without fear, as different from her husband’s years of physical violence.
Mrs. V. still found it hard to let her sons know she needed attention. Through a communications analysis procedure, the therapist sought to help the patient identify her specific communicatory pattern and see how it contributed to communicatory difficulties. During subsequent sessions, the patient reported progressive improvement in her relations with her sons.
Scocco P, Frasson A, Costacurta A, Frank E, Corinto B, Drago A, Pavan L.
The patient’s traumatic married life was re-examined in detail at the tenth and eleventh sessions, providing a source of empathetic listening and helping Mrs. V. accept and express feelings of hostility towards her husband. Current interpersonal difficulties were linked to painful past experiences and the patient was asked to find a meaning for her behaviour and symptoms (e.g. night-time binge eating caused physical pain that she found more familiar than the psychological distress linked to her husband’s memory). The time leading up to and immediately after the suicide were re-examined to foster the expression of associated thoughts and feelings, particularly those related to the sense of guilt initially reported by the patient.
During the final sessions, the patient showed gradual, progressive improvement in symptoms, particularly in mood. The opportunity to openly and unrestrictedly discuss the relationship with her husband and his recent death helped alleviate the suffering associated with past memories and led to a reappraisal of the suicide-related guilt. This simultaneously promoted reconciliation with her sons and helped overcome relational difficulties, enabling Mrs. V. to express previously unpronounceable needs and desires to her sons.

Conclusive phase
The final sessions were used to discuss future plans and to analyse progress achieved. The opportunity to openly and unrestrictedly confront her own aggressive and guilt feelings and recount the relationship with her husband and his recent suicide also enabled the patient to tackle her relational problems with her sons, motivating her to come to terms with interpersonal needs that had lain dormant for years. At the end of the cycle of psychotherapy, Mrs. V. had no difficulty separating from the therapist and showed an appropriate sense of gratitude.
Clinical Vignette 2
Mr L. was a 30-year-old man, referred to the SOPRoxi group by a psychiatrist who had seen him in an emergency setting following the onset of depressive and anxious symptoms and suicidal ideation, which the patient openly associated with the death by suicide of a co-worker one month previously. The interpersonal relationship with the co-worker was of moderate duration but involved no affective relationship or particular affinity. Yet he had been particularly struck by his colleague’s suicide which, for the first time in his life, had triggered intrusive self-destructive ideation.
The patient met the criteria for a diagnosis of depressive disorder not otherwise specified with a history of major depressive disorder; HDRS and ICG scores were 18 and 15, respectively. The suicide method and circumstances had upset him deeply and were the subject of discussion for most of the first session. It had been a “dyadic” death: the colleague and his fiancée had made a suicide pact involving death by car exhaust fumes. The image of the suicide of two lovers “joined in life and death” greatly disturbed him (although Mr. L did not see the bodies nor take part in any way in their discovery).
In the initial phase it emerged that Mr. L. was part of a very close family, although verbal and affective communications were highly constrained. His interpersonal network outside the family was extensive, but lacked significant others. Mr. L. had had brief, uninvolved romantic experiences. In the very first sessions, the survivor experience clearly proved to be an epiphenomenon that had triggered and brought to light the interpersonal deficit that was to become the key focus of IPT.
Scocco P, Frasson A, Costacurta A, Frank E, Corinto B, Drago A, Pavan L.

These two vignettes describe two clinical presentations rather frequently found among survivors of suicide who are unable to autonomously work through the grief process. The first case describes a survivor unable to deal with feelings of isolation, self-stigmatisation and fear of being negatively judged by others. This caused her to withdraw and act in such a way as to inhibit social and family support.
The loss of Mr. A. had a major impact on the functioning of the entire family system which, prior to his the suicide, had been close and mutually supportive in response to the role of (physical and psychological) persecutor played by the husband/father during his life. However, rather than real conflict, this family system was experiencing a communicatory and affective block related to the bereavement. This convinced us to propose individual treatment for the patient without any direct contribution, in any session, by the sons.
In other similar cases, the suicide triggers open and at times durable conflict within the family unit. This is particularly frequent among married couples when the suicide involves a child, but may also be encountered between a parent and children when the victim is the other parent. In these cases, although the person unable to work through the grief process or the patient “designated” by the family unit is generally the spouse, it is essential to intervene with family or couples treatment, since working with only the “identified” patient does not seem to achieve very positive results.
The case of Mrs. V. stresses how IPT with suicide survivors often requires a dual focus, even in the acute setting: grief associated with the suicide and interpersonal disputes. With respect to the grief focus the aim of therapy is to promote the expression of feelings (e.g. anger, hostility, guilt, etc.). With respect to the disputes focus, the purpose is to solve communication problems with other significant survivors, through clarification, communication analysis, problem-solving, use of affect etc., and to help the patient towards gradual, adequate expression of his or her own needs and feelings.
The second clinical vignette addresses another group of survivors, in which the suicide uncovers latent distress. However, the different type of relationship between the victim and the survivor (in the case in point they were colleagues) probably has a profound effect on grief management strategies (12), the resulting psychopathological and relational manifestations, and short- and longterm outcomes.
Scocco P, Frasson A, Costacurta A, Frank E, Corinto B, Drago A, Pavan L.
On the basis of current experience, we feel that individual, couples, family (and probably group) interpersonal psychotherapy is a beneficial therapeutic tool that lends itself very well to this particular population. Efficacy studies that compare IPT with other therapeutic methods and longitudinal assessment of untreated suicide survivors are warranted to confirm this hypothesis. Correspondence: Paolo Scocco email:

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10. Scocco P., Frasson A., Pavan L. SOPRoxi: a research-intervention project for suicide survivors.
Submitted for publication.
11. Prigerson HG, Maciejewski PK, Reynolds CF III, Bierhals AJ, Newsom JT, Fasiczka A, Frank E, Doman J, Miller M (1995). Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss. Psychiatry Res. 59, 65-79.
12. Reed, M., Greenwald, J. (1991). Survivor-victim status: attachment and sudden death bereavement. Suicide and Life-Threatening Behavior. 21, 385-401. [/read]

LINK: The Bulletin of The International Society for Interpersonal Psychotherapy