What If? The Haunting Question in Suicide Loss
What if I had come home from work five minutes earlier? What if I had called more often? What if we hadn’t gotten into that fight? What if I had insisted on taking him/her to the hospital?
Suicide ranks among the top three causes of death for adolescents and young adults, and an estimated 1 million people worldwide die by suicide yearly. This means that there are many millions of individuals who are grieving for someone who has died in this manner. An intensely painful and devastating experience, losing a loved one to suicide has a unique constellation of features that is not necessarily present in other kinds of losses.
One factor in suicide loss is that there often is a traumatic component to the way the person died. Even if you did not witness the trauma firsthand, you may have created a story in your mind about what the death scene looked like (which can be just as traumatizing). You may find yourself struggling with intense fear, horror, intrusive images, nightmares, hypervigilance, difficulty concentrating, negative mood, and other symptoms of post-traumatic stress disorder (PTSD). Survivors of suicide loss are at increased risk of developing suicidal thoughts, mental health issues like PTSD, complicated grief (a prolonged grief that does not change in intensity even years after the death), and major depressive disorder. These intense reactions can be quite debilitating and impact your ability to function at home with your families, at work, at school, and with friends.
Mixed feelings are common with every type of loss and can include feelings of sadness, anger, guilt, relief, shame, shock, etc. When someone is the victim of a homicide, it’s understandable to feel rage toward the perpetrator of the violence. When someone has died in a car accident, you are likely to feel angry with the driver of the other vehicle. With suicide loss however, the person you are often most angry with is your loved one, which can be a very hard feeling to have and reconcile. “How could you have done this to us?” Occasionally the person may leave a message or a note, which may provide some insight into why the person chose to die, but even so can leave many unanswered questions. There also can be a palpable feeling of abandonment, raising the questions of “Why did you leave me?” and “Was I not enough for you to want to live?” These painful thoughts, combined with the societal stigma and isolation around suicide loss can make the mixed feelings even more confusing.
If you have had a loved one die by suicide, you most certainly have asked yourself some variation of the “What if...?” questions above, if not asked these questions in many forms. Referred to as counterfactual thoughts - or the tendency to invent alternative outcomes for real life events that have already happened - these “What if...?” questions or “If only…” statements are a hallmark of the suicide loss grief process. “If only I canceled my plans that night, then they wouldn’t have been alone and wouldn’t have died.” Counterfactual thoughts serve the psychological function of envisioning how the future could be altered if you made different choices, and ultimately, allow you to imagine a scenario in which the person would still be alive.
When someone dies by suicide, there is a tendency to look for a concrete explanation to help make sense of why the person decided to end his or her life. The 1998 Gwyneth Paltrow movie Sliding Doors offered a glimpse into how a woman’s life would have been different had she either missed or made a particular subway train, and oftentimes people wonder if the same could be said for the lives of those they care about. Many people reference this movie to me when imagining how certain decision inflection points would have prevented an outcome. In looking for an explanation for a loved one’s suicide, people tend to ruminate on these counterfactual thoughts as a way to find answers and gain control of the death story.
Sometimes counterfactual thoughts represent regret for real wrongdoing, such as when someone dies from a medical error you made. Usually however, the “What if…?” thinking tends to overestimate your own responsibility in your loved one’s death and increase your emotional suffering. It is said that hindsight is 20/20, meaning it is easier to look back and see potential warning signs or to wish you taken a specific action to actively prevent the suicide. There are often many factors that lead to someone choosing to die by suicide, rather than one triggering event or decision point, which are not always readily apparent.
It has been documented that about 90% of the people who have died by suicide meet the criteria for a mental health or substance-abuse disorder, however they may not have ever been diagnosed. These individuals may have been suffering greatly before deciding to die because of their psychiatric illness. Survivors of suicide loss tend to relate to their loved ones more, find compassion for them, make sense of the death better, and experience decreased self-blame when there is more understanding about the impact of mental illness. You may find yourself understanding your loved one’s choice more if there is a notion of how much they were hurting when alive. In the case of persistent mental illness there can be a feeling of inevitability, that the person was determined to end their life and if it had not happened in that moment it would have happened in another. This can help decrease the blame you might feel about failing to prevent the death.
While easier said than done, the haunting I could have, I should have, I would have statements can take on a life of their own if not addressed and challenged. A therapist with experience working with suicide loss is one way to go about working with these intrusive thoughts. Another suggestion would be to make a list of all the things you did for the person (titled “I did…”) to help balance out the beliefs of what you feel you did not do. You may surprise yourself to remember all the ways you showed up for the person and positively contributed to their life over the course of your relationship. If there are mistakes that you genuinely are responsible for, a therapist can also help you to examine them, work through them, and find a sense of peace around them.
Suicide loss support groups can also be an invaluable part of the healing process, particularly for the connection it creates with others who have experienced a similar loss. They can help decrease isolation and make you feel that you have a place to share and be understood. If you are looking for a support group for yourself, some great resources are the American Foundation for Suicide Prevention (AFSP) and the American Association of Suicidology (AAS) which have searchable directories of over 400 suicide support groups throughout the United States.
AFSP support group finder: https://afsp.org/find-a-support-group
AAS support group finder: https://suicidology.org/resources/support-groups/
References:
Tal Young, I., Iglewicz, A., Glorioso, D., Lanouette, N., Seay, K., Ilapakurti, M., & Zisook, S. (2012). Suicide bereavement and complicated grief. Dialogues in clinical neuroscience, 14(2), 177–186. https://doi.org/10.31887/DCNS.2012.14.2/iyoung
