Sarah marched into the room, followed by her slump-shouldered husband, Paul, and their 11-year-old daughter, Ally, who sort of shuffled to the couch, eyes on the floor, her long dark hair almost covering her face. They were coming in for family therapy because Ally was wetting the bed.
It was the first time I’d met then, but Sarah had mentioned over the phone that her son, Jason, had died by suicide his freshman year in college, just the year before.
During our first session, the room was thick with tension as Sarah told me about her intense frustration with Ally, who sat motionless, her legs pulled up and her arms wrapped tightly around them.
Sarah complained that Ally’s bedwetting was just an attempt to get attention. “She won’t even wash her sheets afterward! She’s so immature compared to how Jason was at her age.” Suddenly, Sarah bowed her head and began to cry.
Paul stepped in to explain, “My wife is still grieving the passing of our son last year,” he said. His voice was oddly robotic. And then Sarah took over, launching into a description of her wonderful, gifted son, whom she couldn’t believe had been desperate and impulsive enough to take his own life. He’d left no note or clues.
I found myself distracted, remembering how much it would’ve mattered to me if my mom had written a note before her suicide when I was in my 20s. Anything that would’ve let us know what she was feeling or thinking before she took the 30 Seconal tablets and got back into bed. I felt my heart contract.
Then Sarah brought me back in the room with a jolt. “Jason was so open,” she stated, “not at all like Ally, who’s always been standoffish and difficult.”
I winced on Ally’s behalf and glanced her way. She was sitting rigidly, looking off toward the window. I made a quick decision: I needed to reach Ally, but first I needed to reach Sarah. She’d lost her son, and she needed to feel heard with compassion and full attention.
I returned my gaze to Sarah. “All children are different, and it sounds like you and Jason had a very special bond,” I said.
With that, Sarah began to cry again. Paul crossed his arms, his face a blank. After a beat, he put his arm around his wife. I wondered if he had some difficulty with her harshness toward Ally, too. But I was trying to stay focused. Accepting and normalizing feelings without blame or shame is the first step in helping a person who has lost a loved one to suicide. Still, in that moment, it was difficult for me to connect with Sarah after she’d just disparaged her daughter. Ally was a survivor as well. She needed my care and attention just as much as her mother did.
I don’t usually meet with kids by themselves, but I had a feeling that Ally wouldn’t talk with her parents in the room, so I asked for a little time with her alone.
After Sarah and Paul had gone out into the waiting room, Ally’s shoulders relaxed slightly. When I asked about her relationship with brother, she began to tear up. In response, I said something kind and reassuring about her grief, but she stopped me cold. “You don’t know anything. I hated Jason,” she blurted. “He was Mr. Everything in our family.” Her face tightened. “And now he’ll be the center of attention forever.”
Startled by her fury, I sat still for a moment. “So, it sounds like your parents are still focused on him, even though he’s gone,” I said.
“Damn straight,” she said bitterly, and then burst into tears. “I shouldn’t feel like this. I shouldn’t be pissed off. He’s dead. What’s wrong with me?”
“I don’t think that there’s anything wrong with you, Ally. Your brother shattered your whole family, violently. That unleashes a firestorm of all kinds of feelings, even shitty ones.”
She looked startled, and then maybe a little relieved.
I wish someone had said something like that to me back then.
The night I got home after our mom died, I remember my sister Lauris lecturing me through her tears. “You don’t even look upset! How can you be so cold and heartless?” I didn’t know what to say; I didn’t have any feelings inside me to show. I concluded that I was a cold, heartless asshole.
I was startled by how close to the bone this session was bringing me. It had taken me years of therapy to discover that I wasn’t heartless after all: I was frozen. And it took a long time before I could shed tears for my mom and finally, for myself. I felt terrible for Ally and the anger, pain, and guilt she was feeling. I knew that we needed talk about her feelings about her mother’s harshness toward her. But we’d just met. I didn’t want to rush in as her knight in shining armor. We had to take our time.
Under different circumstances, I might’ve recommended individual treatment for Ally and couples therapy for her parents. But I felt it was important to stay connected to their presenting problem—Ally’s bedwetting—despite how off-base it sounded. It, not Jason’s suicide, was the reason they’d been able to mobilize to come to see me, and families organize around a presenting problem for a reason. Focusing on bedwetting was perhaps way easier for them as a starting place than focusing on their grief.
Once we’d reconvened in my office, I tried to acknowledge the larger family issues while staying connected to the reason they’d come to see me. “Given the intensity of all the dreadful feelings going on—hurt, guilt, anger, grief, shame, hopelessness, and even numbness at times—it’s no wonder there’s a lot of tension among you all,” I began. “And Ally, here’s the deal. Messing your bed will stop soon enough, but in the meantime, I think you should change the sheets. It’ll give you a little privacy. What do you think?”
I got a baleful look and a slight nod.
They agreed to come back. Sometimes the job of a first session is to simply make sure you get a second one.
- - - -
When a family faces suicide, one of three things tends to happen. One: families turn away from each other. Two: families turn on each other. Three: families turn toward each other. The first two reactions are the most common because separating or fighting helps distract from the overwhelming grief. It seemed clear that Sarah, Paul, and Ally were all having intense but quite different responses.
I thought it was likely that Ally’s bedwetting was in part a response to all of the raging, unprocessed feelings that had been unleashed by Jason’s suicide. It also seemed like Paul was pretty checked out emotionally and funneling his energies into managing Sarah. Neither parent conveyed much concern about their daughter’s feelings.
Ally’s bedwetting continued intermittently, but when it happened, she changed the sheets without making a fuss. In our sessions, she continued to say little, but when spoken to, she seemed more willing to engage. When I asked her what she’d said to friends about Jason’s suicide, she replied, “I’m not ready to talk with them about what happened. I just say it was an accident.”
Sarah jumped in. “I told her that she didn’t have to tell anyone if she didn’t want to. It’s not really anyone’s business.” She lifted her chin slightly, signaling “subject closed.”
The shame and stigma of suicide still silences families, but I was surprised that this one was quite so closed up. My first impulse was to explain that opening up to trusted others about suicide is a step toward healing, but I caught myself. This was one of the first times Sarah had said anything supportively parental to Ally, and I didn’t want to criticize or derail it.
Each step with this family felt loaded. Trying to understand and support each person’s emotions while intervening in their often explosive reactions to each other required every iota of my therapeutic skill—and then some. Many times, I felt inadequate. I tried to err on the side of caution.
Eventually, Sarah shifted her focus away from complaints about Ally and onto answerless questions: Why hadn’t Jason told them he was in trouble? Why hadn’t he asked for help? What could’ve possibly driven him over the edge? At this, Paul seemed to come to life a little, muttering his own regrets: Why hadn’t he noticed that anything was wrong? How could he have been that clueless? Both parents felt that they’d failed their son.
Blaming ourselves is the most common response we survivors have. Many of us remain stuck here for a long time. It took me decades to stop thinking about the ways that I’d turned my back on my mother in the years before her suicide, when she’d been mired in depression and addiction. Could I have tried harder? If I had, would it have changed anything? Haunting questions.
After several sessions of helping Ally and her parents contact and express some of their feelings, Ally’s bedwetting stopped. Here I gently pivoted, suggesting that each family member bring in a couple of pictures of happy times in the family before Jason had gone to college. I wanted to see if it might help them connect to the whole life of their son, and not just his ending. Was this too hokey? I wasn’t sure. But I put it out there and nobody groaned—at least not out loud.
At the very next session, Ally dug into her backpack and proudly produced a picture of herself as a beaming five-year-old on a pink bicycle. Her 11-year-old brother was leaning over her, holding the handlebars.
Studies have shown that almost one in five therapists will lose a client to suicide. All of us who practice therapy live with the underlying fear of that reality.
“I sucked at balancing,” she announced, “and Jason just kept gently telling me to keep trying.” At that, Ally broke down in tears, at which point her mother slid next to her and put her arm around her. Ally leaned into her and sobbed.
At the end of the session, I suggested that each of them keep a private journal in which they could write about Jason or even to him directly, expressing good feelings, bad feelings, questions, and perhaps even news of everyday life. “Even though Jason is gone, he’ll always be in your hearts,” I reminded them. “People die, but relationships don’t. If you write what’s in your heart, sometimes it helps to keep the connection alive.”
“That sounds lame,” Ally replied. “Do they teach this stuff in shrink school?”
Still, we all laughed a little, and—much to my surprise—two sessions later, both she and Sarah reported starting their own journals.
A few sessions after that, Sarah brought in a letter she’d written to Jason the night before. I suggested that she read it out loud. After a moment’s hesitation, she began.
“Sweet pea.” She looked up. “That’s what I called him when he was a baby.”
Sweet pea, I was holding you in my arms in the rocker and you were finally sound asleep. It had been a long night with you howling, and I felt so sorry about having been so mad at you. You were only six months old, and I was yelling at you for not sleeping, for God’s sake.
But there we were, rocking gently.
I’ll never forget that moment.
I so wish I could hold you in my arms in this moment.
She let loose a guttural wail, and Ally reached out and took her hand. Together, they cried.
I felt the sting of my own tears. Their healing had truly begun.
As we know, every family is unique, and this quality is particularly evident in the way members respond to a loved one’s suicide. There’s no one way, no right way.
“Persistent complex bereavement disorder” is how the current DSM describes what happens to many family members and friends who lose someone to suicide. But in my mind, being emotionally shredded by a loved one’s suicide and taking a lifetime to learn how to come to terms with it is not a disorder: it’s a normal response. After all, we survivors—parents, children, siblings, partners, friends, and even therapists—are often left feeling like helpless witnesses, devastated victims, and sometimes unwitting accomplices. Suicide isn’t simply the tragedy of someone taking their own life: it’s also the long, excruciating nightmare of being left behind.
It’s normal to feel profound sadness about the pain that drove a loved one to take their life, as well as to feel overwhelming anger at that person for what feels like an abandonment. Then there’s the guilt, the relentless list of would-haves, could-haves, and should-haves that torments us when we consider all we did—or didn’t do—in the time leading up to the fatal moment. And for some of us, what’s most distressing is the feeling of relief that can creep in, knowing that our loved one’s suffering has ended.
Sharon, my pastoral-care colleague, was overwhelmed by grief and guilt in the wake of her husband John’s suicide four years ago. “In the beginning, there was this ineffable heartsick feeling I carried around inside me that flattened all flavor and blackened the sun,” she told me. “I couldn’t follow a plot in a story. I found music with words to be overwhelming. The first spring and summer came and went, and I never noticed.”
But there was more. “I lost faith in my judgment and myself,” she said. “How could I have missed such a huge thing that was right in front of me? I felt guilty for not saving John in the midst of his depression, for fearing that I’d somehow contributed to his mental state, that I hadn’t been enough to keep him here.”
We survivors are left splintered, each in our own way. Some of us weep. Some of us blame ourselves. Some rage. Some drink. And some just shut down like a blown fuse: the lights go out.
As therapists, it’s critical that we accept as natural and appropriate the range of feelings and responses experienced by survivors of suicide, including the ones that may seem misguided to both us and our client. Every feeling matters and makes sense.
- - - -
On March 4th of this year, Mom would’ve been 104. She killed herself 66 years ago. I called Jim, my last surviving sibling, to share the moment with him.
“You know what I like to think, David?” Jim said. “Even though we were both messed up after the suicide, if she could see us now, I think she’d be proud of how we turned out.”
“Yup, I think that’s true.” I paused, thinking about it. “And it’s weirdly nice to simply be able to miss her, now, without all the rest of it—the guilt, anger, shame, coldness.”
“I didn’t feel any of that,” Jim said, sounding a bit surprised. “I’ve just been missing her all along.”
“It took me decades of therapy to get to the point of being able to miss her.”
“Good thing you like digging into that kind of stuff. Certainly not my cup of tea, bro.”
We both chuckled.
Later that week, I was discussing my survival journey with my colleague Sharon, and I told her about how long it had been since my mom had died.
“Sixty-six years,” she said, shaking her head. “Wow. It’s only been four years since John died, and I’m already trying to close that chapter of my life.” She looked uncertain. “Do you think that’s okay?”
“There’s no real right or wrong way of doing our journey,” I said. “You’ve worked hard to rebuild your life, and I think it’s really healthy for you to be stepping into your future. How much time we need is different for each of us.”
“Wow, you sound just like a therapist,” Sharon teased. She’s a petite person but a big personality. She’d nailed me.
“Sorry about that occupational hazard.” I said, and we laughed. “But I’d love to know a little more about how you got to where you are now.”
Sharon paused and looked down. “Well, I had to learn it wasn’t my fault,” she said. “Obviously, everyone told me that, but it was a long time before I could say that to myself. And I knew in my heart that John wouldn’t think it was my fault. So it was slow,” she continued. “Like you said, little steps. Starting to do the laundry and grocery shopping again. Making myself go to friends’ homes for dinner, but also telling the hostess that I might need to leave early. Stuff like that.”
“How long did it take to feel like you could make a new life?”
“Okay, Doctor,” she laughed. “It was when I finally accepted the old life was done with and there’d be no real ‘moving on.’ I hate that phrase! When I realized I was never going to truly get over it, I noticed that I could taste an orange again, laugh at a joke, even sing in the shower.”
“From what you’ve said about John, I’m guessing he’d be happy for you.”
Sharon nodded slowly. “Yes, I think he would be. I like that thought. Now it’s your turn. What helped you the most?”
I told her that I’d been lucky enough to have had a really good therapist, and that writing letters to my mom had helped a lot. “Reading them out loud to my therapist finally allowed my tears to flow—the ones that had been frozen for 25 years.”
- - - -
Helping our clients cope with the trauma of a loved one’s suicide is one thing; it’s entirely another when the client is the one who dies by suicide. Studies have shown that almost one in five therapists will lose a client to suicide. All of us who practice therapy live with the underlying fear of that phone call, the one that starts, “I’m sorry to have to tell you. . . .” I practiced family therapy for 45 years, and over the course of my career, I lost three clients to suicide. Each was uniquely devastating. Each haunting, in its own way.
I think of Emily, who I always knew was at risk for suicide. She came into treatment with me eight years ago, after having almost successfully killed herself. She’d been heartbroken by her partner Laura’s affair. I’d agreed to see them in couples therapy only if Emily was being followed by a psychiatrist and an individual therapist, and the three of us could operate as a team.
The reparative work with Emily and Laura went well, and Laura—long a problem drinker—joined Alcoholics Anonymous. But about a year after we’d started working together, Laura was diagnosed with advanced cancer and soon died. Emily was devastated, of course, but also seemed remarkably resilient. When her therapist retired, I agreed to be her ongoing individual therapist. By that time, she’d stopped her medication and was no longer being followed by a psychiatrist. She seemed to have a strong support system in Al-Anon, and, in my judgment, she mostly needed supportive counseling. We worked well together well for five years.
The last time I saw Emily was on an April morning in 2020. She arrived as she always did—on time and impeccably dressed, with a matching mask, no less. During the session, we discussed her concerns about the impact of the pandemic on her: how her social network had shrunk, several Al-Anon meetings had been canceled, church had become virtual, and a potential new relationship had fizzled. But in her usual indomitable way, Emily announced that she was handling the circumstances well. “Now don’t start worrying about me,” she chided. “Compared to what other folks are going through, my issues are just pimples.”
“So, I don’t have to worry about you hurting yourself?”
“It’s been eight years, Dr. T. Am I ever going to graduate from your suicide watch list?” She was smiling.
Two weeks later, she skipped her regular meeting and didn’t return my call. Then the call came.
“I’m so sorry to have to tell you that Emily took her life.” It was a close friend of hers at church. Ten days earlier, Emily had taken a handful of pills and had put a sign on her door to ward off potential visitors: “Steer clear. COVID here.”
I was stunned. Then heartsick. And then I realized, suddenly, that of course Emily knew I would’ve hospitalized her without hesitation had I known how desperate she’d become. So she’d headed me off at the pass. And I’d let her.
I’ve replayed our last session in my head a thousand times. Why hadn’t I seen the signs? In our last session, she’d been the first one to bring up hurting herself. Maybe it had been her way of asking for help. Why hadn’t I challenged her more? My family, friends, and colleagues tried to comfort me, but I was inconsolable. I couldn’t sleep. I poured myself extra wine every night. I was a mess. And people making excuses for me just pissed me off.
The only way I’ve ever learned to come to terms with a client’s suicide is by owning my mistakes. It was a mistake to agree to become her only therapist. It was a mistake not to regularly discuss her situation with a knowledgeable colleague or supervisor. And, during our final session, it was a mistake to drop the conversation about her being at risk so quickly.
I’ll never know whether I could’ve gotten through to her. I’ll always know I didn’t try hard enough.
I don’t write about Emily’s suicide to publicly flagellate myself. I write about it for all of us clinicians who have been, or will be, in my shoes. We’re good, competent, caring clinicians. We do our best, day in and day out. We’re also flawed human beings. We try to learn from our mistakes and endeavor not to make the same one twice; that’s our sacred duty, after all. But I still struggle with questions about my response to Emily, and I expect I always will.
Talking to a therapist helped a lot, but still, writing about Emily now floods me with feelings all over again. She’d had a traumatic childhood and had spent her whole life trying to find a safe place on the planet to be herself, to love, and to be loved. She was a brave woman. And in the end, she’d turned to a bottle of pills, just like Mom had.
It makes me so sad: for her, for all those who’ve taken their lives, and for all of us left behind who have to keep stepping into the present anyway and in any way—which is the only way.
Illustration @ Illustration Source/Todd Davidson
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