By Julie Cerel, Ph.D.
Sept. 28, 2020

U.S. Army photo

Approximately 48,000 people died by suicide in the United States in 2018. Each of those deaths is mourned by a wide range of people. In fact, recent research finds that each suicide leaves behind about 135 people who have varying degrees of exposure to the loss. Within the veteran community, it is estimated that approximately half of all veterans have known an individual who died by suicide.

When a suicide happens in military settings, many types of people can be affected. Close family members and friends will often experience significant bereavement. Service members who lived or worked in close proximity with the decedent — such as military leaders, unit members, and roommates — can be left sad, angry, and/or confused. Health care workers, chaplains, and other professionals in supportive or caregiving relationships with the decedent may have questions about what they could have done to stop the suicide or may question their professional acumen. In addition, people who may not have known the decedent personally but who interact with a family or unit after the death (e.g., clergy, grief counselors, casualty assistance personnel) may be impacted in various ways by the suicide.

No matter the relationship to the deceased, exposure to a suicide death has been associated with increased risk of depression, anxiety, and suicidal ideation in veterans. Additionally, increased risk of PTSD and prolonged grief has been found in survivors who perceive themselves as having had a close relationship with the deceased. This last point is especially important for military and veteran clinicians to know — with respect to psychological health difficulties, an individual's perception of closeness with the deceased matters more than the level of closeness implied by a relationship label (e.g., unit member, commander). Hence, clinicians are encouraged to assess the level of closeness the survivor feels in order to be more attuned to the possible impacts they may experience secondary to their loss.

In terms of the broader picture, the term "postvention" is often used to describe any activity that takes place after a suicide to help those left behind. One goal of postvention is to reduce suicide risk in those exposed to a suicide death. A Department of Defense study on active duty postvention showed that members of units in which a suicide occurred experienced more shame and stigma, and had less satisfaction with unit leadership and funeral and memorial services than unit members who experienced other types of sudden and traumatic deaths. This again illustrates how suicide losses may be experienced differently than other deaths and is important information for clinicians to know. Although more research is needed to determine how best to respond following a suicide and who to target in such a response, it is clear that organizational responses such as leadership responsiveness, unit cohesion, and social support can help individuals at risk in military settings.

In present times, social distancing practices related to COVID-19 may be hampering our normal grieving rituals and associated supportive activities. In addition to changes to funerals and memorial services, people may be coping with many types of losses at the same time, which can increase their risk for adverse outcomes following suicide exposure. Fortunately, there are a number of online postvention resources available to service members, veterans, and their families as well as clinicians serving those populations. If you, your patient, or your service member or veteran needs help coping with a suicide death, please consult the list below:

• Tragedy Assistance Program for Survivors: Offers resources such as a peer-based Survivor Care Team, grief and community counseling, military-related organizations, funeral resources, and networks for health care professionals
• Uniting for Suicide Postvention (Department of Veterans Affairs): Provides resources and support for everyone touched by suicide loss, with a section specifically for providers
• Postvention Toolkit for a Military Suicide Loss (Defense Suicide Prevention Office): Contains education and guidance for unit commanders and leaders, chaplains, casualty assistance officers, first responders, military investigators, non-clinical providers, suicide prevention program managers, and long-term casualty support coordinators
• Clinician Survivor Task Force (American Association of Suicidology): Provides consultation, support, and education to mental health professionals about the suicide loss of a patient/client and/or family member

Dr. Cerel, is a licensed psychologist and professor, interim associate dean for research, and director of the Suicide Prevention & Exposure Lab at the University of Kentucky.