What is suicide bereavement?
Can counselling help with health issues?
How can healthcare workers cope with stress?
Bereavement by suicide is not like other forms of loss. It can bring an intensity and range of emotions and physical reactions which may be unfamiliar, frightening and uncontrollable.
We are all different. You may have some, all or none of the emotional or physical feelings described. Do not worry that you are not reacting in the “right way” – there is no right or wrong way and we all respond differently to a death by suicide.
You may experience disturbances in your thinking and behaviour, as well as the following emotions:
Shock and Disbelief
These will often be the first reactions. In many cases the suicide was not expected or there was little warning. You may feel dazed and numb and you may have nightmares. These are normal results of shock.
Anguish, longing and searching
You may have a desperate longing, not just to see the person again but to sort out whatever problems they were having and change the outcome for them. You find yourself searching for them and thinking that you see or hear them. You may find yourself behaving in ways which appear odd to outsiders but which help you to feel close to the person who died.
This is a common response to bereavement. You may be angry with yourself because you feel that you should have realised there was a problem or that you could have acted differently. You may be angry with others and this can take the form of blame – there is a danger of tormenting yourself if you pursue this. You may also feel angry with the person who died.
You may feel guilty about things you believe that you could or should have done, or about your feelings about the death. Those bereaved by suicide are plagued by thoughts of “if only…” Very often it can be some time before we realise that the decision the person made was a result of many factors and that the apparent reason for their decision was just the last in a long series of events.
When the person who died was known to have had a troubled or unhappy life, or made repeated suicide attempts, it is common for relief to be mixed in with other emotions that we feel. It can be difficult to admit this to ourselves and, when we do, we feel guilty about it. It is however a natural reaction. We are relieved not that the person’s life is over but that they are no longer suffering and perhaps that constant threats of suicide or other destructive acts will not happen again.
Some survivors feel ashamed because they feel that the suicide has branded them as, say, a bad parent, sister or partner in eyes of the community. This feeling of shame is often made worse by the stigma still attached to suicide and may be intensified if we isolate ourselves from people who we fear will blame or judge us.
Fear and anxiety
You may be worrying about the welfare of other family members and terrified about the consequences for vulnerable relatives. How will you and others cope? What will the future be like? These are normal concerns.
Despair and depression
Following a bereavement by suicide, the constant swings of emotion, the never ending questioning, the physical pain and lack of sleep all have an effect and you may need to consult your doctor. The pain you experience may be so intense that you find yourself having thoughts about taking your own life – you must seek help if you have these thoughts, get support from your Doctor. Don’t delay.
This is one of the most common feelings. It is natural to cry but it is also quite normal for some of us not to do this as we were brought up not to show our feelings. Men typically cry less than women but this is not always the case.
Grief can also affect sexual feelings and this can become a source of conflict between partners and lead to a greater sense of isolation.
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You may experience some or all of the following physical sensations:
You should be aware of any physical symptoms and consult with your doctor if they persist over a long period of time as they may lead to a more serious physical condition.
The death of another person by suicide can be traumatic. If you discovered the body or witnessed the death you may find yourself experiencing recurring nightmares or flashbacks. You may even be imagining what happened. Flashbacks are very distressing and can be symptoms of post traumatic stress.
Post Traumatic Stress Disorder (PTSD)
PTSD is an anxiety disorder caused by very stressful, frightening or distressing events. You should speak with your Doctor if you are experiencing symptoms of post traumatic stress. Whilst anti-depressant medication may be prescribed, you may feel that these are not appropriate to your needs and you may want to consider counselling.
Health issues affect almost everyone at some point in their lives. People may develop an illness themselves or indirectly experience illness through a friend or family’s condition.
Illness can be classified as acute, chronic, and/or terminal diseases. Acute illnesses often appear suddenly and last a short time (Example: a flu episode). Chronic illnesses are conditions that last a long time and often require ongoing medical care (Example: epilepsy). Terminal illnesses have no cure and will likely cause death within several months or years (Example: late-stage cancer).
The onset of medical health issues may contribute to feelings of sadness, anxiety, depression, and/or anger. Counselling may be able to help individuals cope with any challenges that arise as they face a difficult or debilitating illness.
SOCIAL DETERMINANTS OF HEALTH
No person is an island. Everyone exists in a wider social and cultural structure that affects their health. Some of the many ways social factors affect health include:
Access to health care. Some people have access to better health care than others. Preventative care and early treatment can reduce the risk of developing or dying from serious illnesses. People who cannot afford health insurance tend to have worse health. People who live in regions with poor access to quality providers may not receive good care. Some people may not seek health care because of fears about the quality of care they will receive.
Access to lifestyle factors that promote good health. People who live in food deserts may struggle to eat nutritious food. Families with limited finances may not be able to afford quality food. A person with limited time may be unable to exercise.
Exposure to dangerous substances. Toxic substances such as lead, air pollution, and asbestos can cause serious health issues. People in poor communities tend to be exposed to more pollution and other contaminants.
Bias in healthcare. Health care providers may have unconscious biases that can affect treatment quality and outcomes. For example, research shows that doctors tend to dismiss women’s pain. Women wait longer to see doctors in emergency rooms, and they are less likely than men to have their case classified as urgent.
Cultural norms and attitudes about medical care. Communities can have different understandings of which symptoms are normal and how best to treat them. For instance, a devoutly religious community may recommend praying about a symptom before seeking health care. Some communities are inherently distrustful of medical providers. A parent who has not vaccinated their child, for instance, may be reluctant to admit that fact to a health care provider.
The impact of oppression. Members of marginalized communities tend to receive lower quality health care and thus have worse health. The daily stress of racism can also have long-term effects on the health of communities of color. Exposure to discrimination can increase levels of the stress hormone cortisol. In turn, high cortisol levels can erode one’s health.
MIND-BODY CONNECTION: HOW EMOTIONS CAN AFFECT PHYSICAL HEALTH
Psychological challenges can directly and indirectly affect health. For example, research consistently shows a link between post traumatic stress (PTSD), depression, and chronic pain. People with co-occurring physical and mental health issues may report more emotional symptoms and have worse health outcomes.
Stress is often a large mediating factor between emotional and physical health. It can weaken the immune system, making it more difficult for the body to fight illnesses and infections. Stress can also render the body more vulnerable to chronic ailments. For example, a 2009 study found that early-life stress changed the gut microbiome of rats, making them more vulnerable to conditions such as irritable bowel syndrome.
Psychological stress can also make it difficult to adopt a healthy lifestyle. Exercise can improve symptoms of a wide variety of health issues. It may even prevent health problems such as cardiovascular disease. Yet a person who is stressed may feel too overwhelmed or tired to exercise or try other lifestyle changes.
Psychological pain can even change how a person perceives physical pain. Research shows the higher a person’s stress levels, the less their bodies can regulate pain. In individuals with fibromyalgia and other chronic pain conditions, trauma can strongly affect how they experience pain.
The fact that pain can have psychological components does not mean a person is faking or exaggerating their pain. Instead, this pattern points to the many ways that the mind and body interact with one another. When the mind is in pain, the body often experiences pain too. Healing the mind can often bring some relief to the body.
HOW MEDICAL ISSUES CAN AFFECT YOUR EMOTIONS
A disease or injury may alter a person’s daily life in many ways. For example:
A person may be unable to attend school or work for an inconvenient length of time. This can cause stress related to academic performance, job security, or finances.
A person used to an active lifestyle may find it difficult to adapt to enforced inactivity. They may have elevated anxiety or irritability, especially if they use exercise as a coping mechanism.
An illness or injury may leave a person confined in bed or to one room. This confinement may cause boredom or loneliness, especially when mental processes are not affected by the health issue.
A person may require intensive or long-term care to survive. Some people may feel shame or regret around losing their independence.
If a health issue has permanently restricted their activities, an individual may struggle to adjust to their new lives. They may have to rebuild an identity outside of the jobs or hobbies that used to define them.
Health issues can cause a person to feel helpless, hopeless, and frustrated. Emotions may run especially high if the prognosis is uncertain. This stress may cause a person to lash out at family and friends, which can put strain on relationships. Some individuals who are prescribed painkillers to cope with the illness may also experience dependency or addiction.
Any long-term illness can be difficult to cope with, but a terminal illness may be particularly challenging to face. In addition to the stress caused by present symptoms, a person will need to come to terms with what their future holds. Some may be paralysed with grief. Others may hide or repress their feelings to avoid worrying friends and family.
A therapist can offer emotional support as a person prepares for the end of their life. They can also help families discuss difficult subjects such as finances and palliative care.
HOW ILLNESS CAN AFFECT CHILDREN
Children who are coping with a serious illness or a disability are twice as likely to experience emotional concerns or behavioral disturbances. It can be difficult for children to understand how their illness affects them or why they are sick. Young children will likely need help making lifestyle changes. They may cooperate with certain activities, such as physical therapy exercises, but resist other measures like insulin shots.
Health issues can also cause indirect effects. Ill children may face insensitive questions, bullying, or exclusion from peers. Children who miss school repeatedly due to illness or injury might also fall behind in class. If children need to repeat a grade, they may lose access to their peer group and develop low self-esteem.
CARING FOR A LOVED ONE WHO IS ILL
Sometimes family members need to provide long-term care for an ill loved one. Whether it is a temporary or permanent situation, caregiving can be a stressful job. When the responsibility of caregiving falls on one person, the job can be isolating and exhausting as well. Some caregivers develop complicated feelings of guilt, resentment, and depression. Caregiving can be especially challenging when a person is looking after both their adult parents and their children.
Families affected by one member’s chronic or serious illness often face financial issues. Health care can be expensive, especially if the former breadwinner is now unable to work. Family members can also feel intense anxiety, stress, and grief. As members attempt to cope, conflict may result.
Family conflict can often be reduced with the help of a mental health professional. Therapy may contribute to a better quality of life for the caregiver, the person who is sick, and any family members also involved.
Stress is something that everyone feels at times. Specifically, work-related stress is defined as 'the adverse reaction people have to excessive pressures or other types of demand placed on them’. It is more prevalent in public service occupations, such as health and social care.
The 2020 NHS annual survey results revealed that 44 per cent of staff report feeling unwell as the result of work-related stress (up from 40 per cent in 2019). The NHS has been identified as having a higher-than-average level of stress-related sickness absence of all job sectors across the country, and so it is integral to address how stress experienced both in and outside of work can be damaging to our NHS people and their organisation, so that we can best support colleagues to be happy, healthy and offer excellent patient care.
The We Are the NHS: People Plan for 2020/2021 focuses on ‘looking after our people’ to ensure people are safe and healthy at work, prioritising the wellbeing of NHS staff to deliver safe and high-quality patient care. Stress, alongside anxiety and other psychiatric illnesses, is consistently the most reported reason for sickness absence in the NHS, accounting for over 511,000 full time equivalent days lost, (NHS Digital Statistics, 2020) and so it is essential that NHS provider organisations are well informed and equipped to support those experiencing stress.
Detecting early signs of stress
It is both important and beneficial that initial indicators of stress are detected. It is also important to intervene at the early stages, before an employee becomes unwell and the pressures feel unmanageable. The best way to detect whether an individual might be experiencing stress is by being alert and aware. Knowing and listening to your staff members is essential, considering them as a whole and recognising what may be out of character for them, as reactions to stress are individual in nature.
Changes in behaviour and/or performance that could be initial indicators that employees are suffering from excess pressure, caused directly or indirectly from the workplace. These could be:
work performance - inconsistent performance, uncharacteristic errors, lack of motivation, working longer hours, skipping breaks
emotional signs - overreactions, crying, undue sensitivity
aggressive behaviour - malicious gossip, temper outburst, bullying
withdrawal - absenteeism, limited social contact, leaving early
physical signs - nervous speech, sweating, reporting/increase of headaches.
Other signs can include increased alcohol intake, smoking, lack of interest in appearance, accidents at home/work.
Different types of stress
There are several different types of stress that can contribute to an individual feeling like they are unable to cope with the pressures and demands whilst at work, caused by circumstances inside and outside of work.
Whilst not exhaustive, the following list notes some of stressors that contribute to an individual feeling stressed:
homelife-related stress (including family and childcare responsibilities)
changes to workload
significant life events (e.g. moving home, marriage, divorce)
financial wellbeing and changes
Burnout refers to an emotional, mental and physical state of exhaustion, caused by excessive and prolonged periods of stress. In an Our NHS people article, burnout is described as a feeling of ‘not enough’, be that not enough energy, time, enthusiasm or ability. Common in health and social care occupations, it can result in a poorer physical state, mental health problems, reduced job satisfaction, absenteeism and professional errors.
Whilst burnout is a type of stress with overlaps in symptoms, the main difference is that stress is associated with a feeling of ’too much’, whereas burnout relates to a feeling of ’not enough’.
Signs and symptoms of burn out:
physical - feeling tired and drained, lowered immunity, change in appetite
emotional - sense of failure and self-doubt, decreased satsifcation and sense of accomplishment, loss of motivation
behavioural - isolating from others, procrastination, withdrawing from responsibilities.
Caring for patients during the pandemic has taken a significant toll on health and social care staff, impacting on their wellbeing and contributing to feelings of stress and burn out. The NHS Reset campaign outlines how the pressures of the COVID-19 pandemic have inevitably exacerbated the prevalence of burn out in our NHS people due to the intensity of workload, pressures and circumstances. In a recent survey, NHS Providers found that 92 per cent of staff agreed with the statement ‘I am concerned about staff wellbeing, stress and burnout following the pandemic’, reinforcing the need to focus on staff wellbeing surrounding burn out when restoring NHS services.
COVID-related workplace stress
The pandemic has resulted in some NHS staff feeling particularly worried and anxious. COVID-related workplace stress is an overwhelmed, yet essential, area to consider during the ever-evolving and uncertain times. People react differently, but some common fears, anxieties and stressors about COVID-19 related to work are:
Exposure to the virus either during the commute to or at their workplace
Bringing the virus home and infecting family members
Changes in work role practices
Dealing with changing work patterns/shifts
Loss of control over usual working routine
The impact of the crisis on job performance/future career
Due to the pandemic, there has been a significant increase in the number of NHS colleagues working from home, meaning usual face-to-face meetings take place virtually through a laptop of onscreen device. This can have a negative impact on an individual and may experience symptoms of screen fatigue (eye strain), which include symptoms such as blurred vision, neck and shoulder pain and trouble concentrating, all of which can contribute to heightened feelings of stress. Managers should promote taking regular breaks where possible, as well as encourage teams to consider and continually review the length and frequency of meetings.
Some employees may experience stress as a result of having previously contracted the virus, and could be living with long COVID symptoms.
Broadly speaking, trauma refers to the emotional response of a stressful, frightening or distressing event. It is normal to have an emotional reaction to a stressful and traumatic situation, but in some cases the effects can be long-lasting and severely impact on an individual’s life. Employers should be mindful that our NHS people may have experienced trauma from events stemming both inside and/or outside of work, with the psychological response impacting on their job role. This reiterates the importance of ensuring managers really know their colleagues and take the time to really see how they are feeling.
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by a traumatic event. It is especially challenging for people experiencing it and can impact on how a person feels they are able to cope with the demands of their work. They may experience feelings of irritability, isolation and guilt, often reliving the event through flashbacks and nightmares. PTSD symptoms may occur soon after exposure to a traumatic event, or may be delayed by months or years, and is particularly common in occupations with a high risk if trauma exposure, such as those responding to emergency medical situations.
In relation to the NHS workplace, a large-scale survey launched by the Nursing Times in April 2020 revealed that one in seven NHS people respondents reported having PTSD symptoms. Recent research by Neil Greenberg looked at NHS staff working in critical care, who reported twice the rate of PTSD typically found in military veterans, highlighting the relevance and importance of knowing how to support staff suffering from PTSD.
Moral injury is defined as ‘psychological distress which results from actions, or lack of them, that violate someone’s moral or ethical code’. In traumatic or unusually stressful situations, people may witness or fail to prevent unforeseen events that contradict their deeply held beliefs and morals. Someone experiencing moral injury may have feelings of anger, guilt, shame or disgust, which can lead to PTSD, depression and possibly suicidal thoughts. The COVID-19 pandemic has meant NHS practitioners have been required to make very difficult decisions, at times compromising their professional values which can lead to moral injury and distress. Given the ongoing pandemic, it is therefore now more important than ever to raise awareness of the risks of moral injury, and encourage people to discuss their feelings openly.
To support employees who may be experiencing moral injury, it would be beneficial to ensure professional psychological support is readily available so that line managers can direct colleagues, provide informal support by trained peer supporters and tailor the support to address feelings of guilty and/or shame.