What Underlying Processes Facilitate Suicide Loss Survivor Outcomes?

BACKGROUND:

Healing after losing someone to suicide is a challenging and complex journey that can lead to a variety of outcomes. Research has shown that — though suicide rates are low for this group — people who are bereaved by suicide (individuals also known as survivors of suicide loss) are at an elevated risk for depression, anxiety disorders, PTSD, and suicidal ideation and behaviors. For some survivors, grief may progress into complicated grief, a type of grief in which an individual feels “stuck” at the same level of emotional intensity in response to the loss for a prolonged period, leading to extended disruption of their daily functioning. Previous studies have found that beyond being associated with major health problems such as sleep disturbance and substance abuse, complicated grief is associated with heightened rates of suicidal ideation and behavior in loss survivors.

However, we also know that in addition to grappling with difficult emotions, many suicide loss survivors can also experience positive psychological changes as a result of struggling with, and processing, traumatic loss. This is referred to as post-traumatic growth (PTG) and encompasses the idea that, alongside the suffering that comes with bereavement, survivors can develop a higher capacity for coping with challenges in their day-to-day lives, and deepen their appreciation of life.

The next step for researchers is to develop an even deeper understanding of what facilitates outcomes, such as complicated grief and PTG, by studying their underlying processes. In psychological research, one type of underlying element is called a moderator, which affects the strength and direction (i.e., whether an outcome will be positive or negative) of a relationship between two variables (e.g., suicide loss bereavement and complicated grief). And one cognitive process (i.e., way of thinking) that has recently been identified as a potential moderator for grief among loss survivors is mentalization.

Mentalization refers to the processes by which we make sense of the internal and external experience (e.g., needs, desires, feelings, beliefs, goals, purposes, and reasons) of ourselves and others. For example, when a person wonders whether a distressed loved one is angrily acting out in response to overwhelm at work rather than something between the two of them, they are displaying mentalizing ability. Several studies have found that strong mentalizing functioning may be a protective factor against the effects of trauma. However, difficulties with mentalization have been shown to play a key role in various mental health disorders, such as depression and personality disorders.

Given these findings, it has been suggested that mentalizing difficulties could play a part in complicated grief by dampening a suicide loss survivor’s ability to process their own thoughts and emotions surrounding their loss, along with the internal experience of the person who died by suicide. In turn, this could make it more challenging to engage in processes that have been shown to help facilitate healing and PTG, such as self-disclosure and self-forgiveness. Research has shown that sharing your story and receiving support from others are outgrowths of positive mentalization that can facilitate post-traumatic growth.

With this in mind, Dr. Yossi Lev-Belz set out to examine the role that difficulties with mentalization may play in suicide loss survivors experiencing complicated grief and suicidal ideation.

STUDY:

As part of a four-year study investigating potential predictors of complicated grief and suicide ideation, Dr. Levi-Belz and his team at Ruppin Academic Center in Israel recruited 152 suicide-loss survivors to report on their experience. The sample was recruited from both Israel’s largest agency for suicide loss survivors, The Path to Life, and an Israeli Facebook group for survivors. A wide range of relationships to the deceased was accounted for in the sample:

• Parents of deceased (18.6%)
• Children of deceased (16.7%)
• Siblings of deceased (27.6%)
• Spouses of deceased (10.3%)
• Other family member (8.4%)
• Best friends of deceased (18.6%)

The participants completed assessments at the beginning of the study and were administered three questionnaires during a 40-month follow-up to measure complicated grief (Inventory of Complicated Grief-Revised), suicidal ideation (Suicide Behaviors Questionnaire-Revised), and mentalization (Reflective Functioning Questionnaire). Dr. Levi-Belz and his colleagues then analyzed the data to see if there were significant associations among the three variables.

RESULTS:

Dr. Levi-Belz and his colleagues found that difficulties with mentalization were significantly associated with complicated grief and suicidal ideation. This association also had a positive correlation, which means that when the mentalization deficits were greater, complicated grief’s contribution to suicide ideation was stronger, making the case that mentalization may have a critical role in moderating grief.

A few possible explanations were offered by Dr. Levi-Belz for how the role of mentalization may work as a moderator in the suicide bereavement process. Since it can be thought of as a means of self-communication, survivors who experience difficulties with mentalization (which is wholly natural and understandable after a traumatic loss), may find it harder to decipher and explain their thoughts and feelings to themselves and to others, which could preclude them from the prospect of receiving help and alleviating pain. Additionally, these difficulties may hinder a survivor’s capacity for recognizing their own negative thoughts and feelings, which could, in turn, fester and lead to suicide ideation. Lastly, mentalization deficits in understanding the person who died may affect the ability for survivors to grasp the context surrounding the death, which could lead to shame, anger, and feelings of culpability.

One intervention Dr. Levi-Belz highlights as potentially promising for helping strengthen mentalization in suicide-loss survivors suffering from complicated grief is Mentalization-Based Therapy (MBT), which is designed to improve the ability to examine, recognize, and name an individual’s own thoughts, feelings, behaviors, and intent, as well as those of other people. By doing this, loss survivors can help elevate their own self-compassion, forgiveness, and emotional regulation which can then alleviate complicated grief and suicidal ideation. Beyond this, reflecting on the potential intentions, emotions, and actions of a loved one who died by suicide can help with feeling more empathy and compassion toward a behavior that may seem unexplainable.

Another hope in treating suicide loss survivors suffering from complicated grief with MBT is to eventually get them on a path to healing by engaging in behaviors that facilitate post-traumatic growth. This approach is rooted in tailoring mentalization’s moderating role towards a positive outcome by helping suicide loss survivors share their experience with others, an act that research has shown can, as Dr. Levi-Belz has put it, “change a personal tragedy into a triumph with a little help from my friends.”  

TAKEAWAYS:

• Healing after suicide loss is a complex and difficult journey with a wide range of potential outcomes (e.g., complicated grief, post-traumatic growth, and suicidal ideation).
• Research has unveiled much knowledge about the different pathways to healing along with what may contribute to survivors experiencing complicated grief and suicidal ideation.
• Learning more about the underlying processes (e.g., moderators) that affect these outcomes can help with understanding the ways to support survivors as they heal.
• Difficulties with mentalization may be a core component of complicated grief and suicide ideation in suicide loss survivors.
• Interventions that can address difficulties with mentalization, such as MBT, may help offset the development of complicated grief and suicide ideation in survivors.
• As difficult as suicide loss is, healing can lead to post-traumatic growth as exemplified by suicide prevention efforts from people with lived experience.

Yossi Levi-Belz, Ph.D.

Grant Type: 2015 Pilot Research Grant – $29,781

Grant Page: Post Traumatic Growth among Suicide Survivors: Longitudinal Effects of Interpersonal Characteristics

Grant Related Publication:

1. Levi-Belz, Y., & Lev-Ari, L. (2023). Thinking for healing: The role of mentalization deficits as moderator in the link between complicated grief and suicide ideation among suicide-loss survivors. Death Studies, 47(3), 360-369, https://doi.org/10.1080/07481187.2022.2065707
2. Levi-Belz, Y. (2023). Growing together: Longitudinal trajectory of posttraumatic growth among suicide-loss survivors and its interpersonal predictors. European Psychiatry, 66(S1), S1118-S1118. https://doi.org/10.1192/j.eurpsy.2023.2378
3. Levi-Belz, Y., & Hamdan, S. (2023). Shame, depression, and complicated grief among suicide loss-survivors: the moderating role of self-disclosure. Eur J Psychotraumatol, 14(1), 2182820. https://doi.org/10.1080/20008066.2023.2182820
4. Levi-Belz, Y., & Ben-Yaish, T. (2022). Prolonged Grief Symptoms among Suicide-Loss Survivors: The Contribution of Intrapersonal and Interpersonal Characteristics. International journal of environmental research and public health, 19(17), 10545. https://doi.org/10.3390/ijerph191710545
5. Levi-Belz, Y. (2019). With a little help from my friends: A follow-up study on the contribution of interpersonal characteristics to posttraumatic growth among suicide-loss survivors. Psychological trauma : theory, research, practice and policy, 11(8), 895-904. https://doi.org/10.1037/tra0000456