Survivors of Suicide, Those Left Behind When Someone Dies by Suicide
Abstract and Keywords
Suicide is a more prevalent cause of death in many countries than automobile accidents, homicide, and breast cancer. Despite this, the experience of people left behind after a suicide is not well understood. This entry provides a sociohistorical overview of suicide to place suicide death in a relevant cultural context, explores the bereavement experiences of those grieving a loss to suicide, and presents the debate about similarities and differences regarding suicide bereavement in relation to other forms of traumatic death. In addition, this entry examines the role of social workers in working with people bereaved by suicide.
Each year over one million people worldwide die by suicide. Suicide, the intentional taking of one’s own life, is the 11th leading cause of death in America. Approximately 38,000 people die by suicide each year in the United States, with a suicide occurring every 14.2 minutes, totaling over 100 deaths by suicide each day (McIntosh, 2012). Suicide in the early twenty-first century claims more American lives than breast cancer and automobile accidents and almost double the number of yearly homicides. Suicide is a leading cause of preventable death and occurs primarily in young people and during the middle ages, particularly for men. Similar trends exist in Australia (Australian Bureau of Statistics, 2013), the United Kingdom (Office for National Statistics, 2013), and Canada (Statistics Canada, 2012). When an individual dies by suicide, family members, friends, work colleagues, and other associates are left behind to grieve and try to understand why the person took his or her life. This entry will provide a brief sociohistorical overview of suicide to place suicide death in a relevant cultural context, explore the bereavement experiences of those grieving a loss to suicide, present the debate about similarities and differences regarding suicide bereavement in relation to other forms of traumatic death, and finally examine the role of social workers in working in the field of suicide bereavement, whether in specialized fields or in other settings.
Suicide has existed throughout human history, yet how such a death is viewed by society has changed over time and is shaped from within the cultural context in which the death occurs. In the past, reliable statistics of the number of suicide deaths were not kept. This remains the case in some (generally low- and middle-income) countries throughout the world. The historical literature that does report on suicide death examines the ways that society deals with suicide, rather than the number of people who die in this way. For example, in early societies, suicide death primarily occurred among the old, disabled, and humiliated. As society evolved, the reasons for suicide and the methods used have changed. In the early Middle Ages, suicide was generally seen as a cure for shame. Throughout history, suicide was seen as a criminal act, a type of murder, and a desperate, mortal sin in the opinion of some Christian churches. Suicide was punishable by the state through the reclaiming of personal possessions of the deceased and forbidding a church burial. During these times, the deceased’s loved ones suffered punishment for the suicidal actions of their relative, and civil law had the power to enact severe sanctions against surviving family members (Minios, 1999).
During industrialization of many countries, the growth of societies, and the emergence of large cities, the rate of suicide reached new heights, causing speculation that lonely people in cities became desperate and took their own lives. One early suicide theorist, Emile Durkheim, set out to try and explain suicide and why suicide occurs (Durkheim, 1857). Durkheim’s widely known and enduring analysis locates the causes of suicide in the social realm, suggesting there are three causes. The first cause, known as “egotistic suicide,” is said to occur when an individual lacks integration into society. The second, “altruistic suicide,” is said to occur when an individual is highly integrated into society and is governed by social customs and habits, yet perceives his or her suicide to be “commanded” by a higher power, either religious or political. Third is “anomic suicide,” when there is lack of regulation in society or when order is suddenly upset.
Durkheim’s focus in his theory of suicide was on the manner in which interaction between an individual and society takes place. Since the 1990s, parts of his theory have been brought into question, in particular the ways in which Durkheim viewed the protective features of marriage (Lehmann, 1995). Although this questioning is likely caused by the dominant culture of the time, his theory provides a social lens in which to consider suicide and suicide-related behaviors. In direct contrast, more recent theories of suicide focus on the medicalization of suicide (among other conditions and behaviors) and is driven by the view that suicide is a symptom of a lack of reason, related to mental illness or mental disorder. This theory has led to the fundamental premise underlying suicide prevention activities in the early twenty-first century, placing the emphasis on the individual and particular risk factors he or she may exhibit and on intervention strategies to promote positive mental health, rather than broader societal influences.
Religious prohibitions against suicide are still common to try to deter individuals from ending their lives. In the early twenty-first century, many religious groups condemn the act of suicide but not the individual who died by suicide. This leads to a situation for the family in which normal grieving rituals can take place and offers an understanding that the death was the result of mental illness. This attitude can help family members feel that the death was not their fault and can help with community support following the death. Nevertheless, the powerful influence of history cannot be underestimated, with suicide death continuing to be stigmatized and family members’ grieving affected. Importantly, most individuals working in the field supporting those bereaved by suicide, along with those bereaved, caution against use of the word “commit” when discussing someone who died by suicide because commit is related to the antiquated criminalization of suicide (Beaton, Forster, & Maple, 2013). Families bereaved by the suicide of a loved one react negatively when the word commit is used because they feel it is stigmatizing and more related to a crime or sin than to a hopeless person who saw no other solution to his or her problems.
Defining the Population
It has been estimated that there are 6 “survivors,” that is, those bereaved, for every death by suicide (Shneidman, 1972). However, this understanding of the number of people affected by a suicide death is based on an estimate created by Dr. Edwin Shneidman in the 1970s, which was meant to be comparable to the number of extended family members who were eligible to receive compensation following an airline disaster. Researchers, support service personnel, and bereaved people all report this figure to be a significant underestimation. Although determining the actual population is challenging, some examples exist. In a recent phone survey in a southern U.S. state, 66% of people stated they knew someone who had attempted or died by suicide, 40% knew someone who had died, and 20% of people indicated they were a survivor in that one or more suicides had a profound effect upon them (Cerel, Maple, Van de Venne, & Aldrich, 2013). In the only nationally representative sample of self-identifying suicide-bereaved individuals published to date, Crosby and Sacks (2002) found exposure to suicide (in the 12 months prior to the interview) among 7% of surveyed households in the United States. Extrapolating this finding to the whole population of the United States results in 1 in 14 Americans being exposed to suicide in the survey year. Of the 7% of households reporting exposure to suicide, 1.1% reported it was a family member who died and 5.4% reported exposure to suicide of another person they knew. Again, extending this conclusion to the whole of U.S. population results in 3.3 million Americans experiencing the suicide death of a family member in that year. If approximately 30,000 people in America died by suicide that year, then at least 10 family members were affected for each death. Crosby and Sacks also reported on suicide risk among the population in their study exposed to suicide and concluded that exposed individuals were 1.6 times more likely to report suicidal ideation, 2.9 times more likely to have suicidal plans, and 3.7 times more likely to have made an attempt than those not exposed to suicide. Therefore, early estimates of 6 people affected appear to be underestimates in that when a suicide occurs, entire families, neighborhoods, schools, and communities are impacted, as well as individuals. Further, the effect that a suicide death has on an individual appears also to influence poor morbidity and mortality outcomes associated with the experience.
To allow a broader and deeper understanding of who is affected by suicide, a definition is required that is usefully broad, but at the same time provides people with the ability to self-identify their bereavement status. Several authors have offered definitions, including Andreissen (2009), who suggests that “a survivor is usually regarded as a person who has lost a significant other (or loved one) by suicide, and whose life is changed because of this loss” (p. 43). However, this definition excludes a broad definition of relationships between the person now deceased and the person bereaved. Jordan and McIntosh (2011a) offer the following: “Someone who experiences a high level of self-perceived psychological, physical, and/or social distress for a considerable length of time after exposure to the suicide of another person” (p. 7). This definition is problematic because it relies first on symptomatology and the lack of any way to operationalize “a high level” of distress and second on a “considerable length of time,” not allowing the prediction of who will be a survivor among people who are exposed to suicide and experience immediate distress. A third useful definition is offered by Berman (2011), as follows: “survivors of suicide were defined as those believed to be intimately and directly affected by a suicide; that is, those who would self define as survivors after the suicide of another person” (p. 111, original italics). This definition is useful in that it relies on self-report for distress in the absence of knowing why some people are more distressed than others. It is also broad enough to capture those who may not be intimately related to the deceased, but are negatively affected nonetheless.
More research is needed to determine nomenclature that indicates a continuum through which people can be identified as being “exposed to suicide” in the immediate aftermath of a suicide death; within those exposed, a proportion will be “affected by the suicide”; some of those affected will be “suicide bereaved, short term” and a smaller proportion will become “suicide bereaved, long term.” This nomenclature has been described in detail by Cerel and colleagues (Cerel, McIntosh, Neimeyer, Maple, & Marshall,2014).
In the proposed continuum of survivorship, Cerel et al. (in press) propose that those labeled as “exposed” would include those defined as suicide survivors by Jordan and McIntosh, but would also include those who “know of” or knew someone who died by suicide but did not experience (or would not likely experience) the severity of or longer term effects associated with this definition of survivors. Such reactions may represent typically more fleeting and shallow initial bereavement reactions, but likely indicates that a larger percentage of the population is exposed to suicide at some point in their lives.
Those identified as “affected” include people who are exposed to suicide who have a potential for the death to have a disruptive effect on their lives. These individuals might have some sort of reaction to the death, but not as much as someone thought to be suicide bereaved. People who are suicide bereaved are likely to experience posttraumatic stress disorder (PTSD), depression, or prolonged grief as a result of the death. Individuals who are suicide bereaved, long term, may experience suicidal ideation or behavior, may have the potential for posttraumatic growth as a result of the death, and, most importantly, identify the suicide as a defining experience in their lives. There is evidence to indicate that certain risk factors or mediators may exist that increase the likelihood of the bereaved individual experiencing the loss at different levels. These factors will most likely include kinship relationship and perceived emotional closeness to the deceased, previous experience with suicide, exposure to the trauma of the death, and demographics such as age and sex. Other variables that may play a role include perceived responsibility for the death and hostile social environments or stigma (real or perceived). Protective factors that are seen to play a role in the reaction of a suicide-bereaved individual include resources, support systems, and coping skills. These various groups may represent individuals of differing needs and reactions in their suicide bereavement and may help to lessen the inconsistencies of previous research findings and clinical experience. This will lead to better identification of those who would benefit from interventions and the kind of interventions most likely to assist them in their grief experience (Cerel et al., in press).
Although this discussion presents ideas on a definition to better identify the ways in which people are affected by a suicide, it is necessary for the community of researchers, clinicians, and people who are themselves affected by suicide to agree on a definition of who is bereaved following a suicide death. This will allow research to determine the full impact of the death and identify people at highest risk and most in need of clinical intervention, thus informing evidence-based interventions that provide support services that are timely and appropriate to need. In the field of suicidology, the term for services offering support to those bereaved is postvention.
Grief is the living response to loss. Grief usually follows the loss of certain primary relationships, but not when less intimate relationships are lost. Primary relationships may be defined as those that are close, face to face, emotionally important, or comprising a strong identification with the other person. The loss may be real or perceived, yet grief will still occur. Grief is a universally human phenomenon, yet it is experienced in a highly individualized and multidimensional manner. Grief encompasses sensory, behavioral, and cognitive systems showing emotional and often spiritual components. The type of death may influence the way in which the grief is experienced. Sudden, unexpected, or unnatural deaths may have elements of grief that differ from those experienced when a person dies in old age or after a long illness or when the death is anticipated. Culture and cultural norms also play a role in how grief is experienced. Some cultures have highly structured ways of demonstrating grief, sometimes with specific periods of time allocated for particular tasks. However, in many Western countries, the way in which grief is expressed is very personal.
Over time, many theorists have offered interpretations and explanations for the ways in which people grieve following a death. There are two theoretically derived frameworks for understanding grief, with many variations. The first framework is a stage-oriented model that has seen many evolutions and adaptations and continues to inform the social understanding of grief in both lay and professional circles. This framework was first noted by Freud (1917) in Mourning and Melancholia. Follow-up work by Bowlby (1980) extended the model to conceptualize death as a loss of attachment to the deceased. Bowlby argues that the bereaved person must adjust to this loss of attachment by detaching him- or herself from the deceased before being able to move forward from the bereaved state. Kubler-Ross (1969) suggests that this grief occurs in five stages. Although her research was based on the experiences of people anticipating their own death, rather than in response to the death of a loved one, these stages rapidly became the prominent and accepted model of grieving across the field of grief and bereavement. The stage framework, underpinned by a developmental process, is characterized by working through of a number of tasks associated with loss. Grief is assumed to be a linear process, with stages that will be moved through, in no particular order, before reaching the final goal of resolution. These stage models emphasize the breaking of bonds with the deceased, characterized by reaching a point of acceptance that he or she is gone.
Many, including Stroebe (2001), question some of the pivotal assumptions to stage-based models, indicating that there is little empirical evidence that working through grief is more effective for coming to terms with loss than not working through it. As a consequence of this critical analysis of the stage model, a newer framework in which the continuation of a bond with the deceased is acknowledged is now broadly recognized (Klass, Silverman, & Nickman, 1996). Although it does not completely discount aspects of the stages-and-phases framework, the continuing-bonds model acknowledges the presence of a continued connection with the deceased person once the physical bond is broken through death. Bauer and Bonanno (2001) propose that such continuing bonds enable the bereaved “to recognize the personal meaning of past goals and relationships and then to understand how those meanings can continue in the present” (p. 155).
The way in which grief is conceptualized is thought to be influenced by the manner in which the person died. Several factors are reported to be unique to bereavement through suicide because of the particular nature of the type of death (Jordan, 2001). In short, suicide death, along with accidental death, is viewed as a life cut short or a waste of life. Because suicide death is often sudden, there is little or no time to clear up any unfinished business with the deceased, which is particularly problematic when the prior relationship was ambivalent, antagonistic, or estranged (Ratnarajah, Maple, & Minichiello, in press).
Several factors are often reported as being different with suicide deaths, with the seven most common elements including shock, guilt, blame, shame, stigma, lack of social support, and, for some, relief that the deceased person is no longer in pain or suffering (Maple, Cerel, McKay, & Jordan, in press). Each is briefly described below.
On finding out about the death, the bereaved individual has questions of where and how the suicide occurred. There may be high levels of shock experienced in response to learning of the suicide death. Following the initial shock upon learning of the death, there are questions about why the person chose to take his or her own life. Although much of the literature reports a need to come to an acceptable answer for the question of “why” a person ended his or her life, which is clearly an important part of the grieving process for survivors of suicide, research has thus far failed to examine why survivors need to explain the act or what purpose this serves internally. Shock has also been linked to the development of posttraumatic stress reactions and complicated grief reactions in those bereaved by suicide (Young et al., 2012).
Nevertheless, for most bereaved individuals the rationale used by the person now deceased remains a mystery. This holds true for situations where a note was not left behind, as well as for many where a presuicide message was recorded. Notes have been found in around 10% to 40% of suicide deaths but notes are often also found to be inadequate in explaining why a life was ended (Callanan & Davis, 2009; De Leo, Milner, & Sveticic, 2012; Gunn, Lester, Haines, & Williams,, 2012; Leenaars, Girdhar, Dogra, Wenckstern, & Leenaars, 2010; Leenaars, Sayin, et al. 2010).
First and foremost, guilt experienced by survivors of suicide is thought to be caused by a perceived inability to prevent the suicide from occurring. Suicide is generally viewed as preventable; thus, by natural extension, those who are close to the person now deceased feel they should have been able to intervene in some way to stop the actions. Guilt experienced following a death by suicide has been linked to poor health and well-being outcomes in the survivor (Li, Stroebe, Chan, & Chow, 2014).
Many authors report survivors of suicide describing feelings of blame internally, within the family, or from the wider community (Jordan & McIntosh, 2011b). Horror may also be experienced upon realizing the pain the bereaved was experiencing before death that the survivor had not been aware of. There may be a tendency to blame the self, spouse, child, partner, or anyone who had been close to the deceased at the time of death. Blame also tends to increase stigma and decrease access to social support. In young people, this has been linked to self-imposed isolation from potential supports (Bartik, Maple, Edwards, & Keirnan, 2013).
A survivor of suicide may also experience feelings of shame. Shame appears to be elevated among this group when compared with people bereaved through other deaths. Feelings of shame can lead to social isolation. Shame is often related to the cause of death as a stigmatized one, blame from others in the social network, and guilt about not being able to prevent the death.
Because of the complex dynamic of suicide deaths throughout history, stigma is often associated with suicide. People bereaved through suicide often report feelings of being stigmatized by the death of their loved one. Stigma is not always easy to detect. Some have questioned whether stigma is real and whether survivors of suicide must deal with it or whether they are self-stigmatizing. Either way, the feeling of being stigmatized has been related to the difficulties some suicide survivors have in talking about their experience (Maple, Edwards, Plummer, & Minichiello, 2010). Regardless of whether stigma is real or perceived, it can result in people who are suicide bereaved being social isolated at a time when most need access to social support networks (de Groot, de Keijser, & Neeleman, 2006).
Because suicide appears to be taboo, talking about it is often discouraged. Campbell (1997) suggests that “society’s inability to deal with survivors in an honest and caring way remains a negative legacy of suicide” (p. 330). Public displays of grief are generally socially discouraged, and as such, survivors may feel awkward with previous social supports and find themselves drawn to support from people who have experienced similar losses.
Support for Those Bereaved Through Suicide.
The value of social support has been measured in many areas of personal distress, including suicide survivors. In general, social support networks have been found to facilitate the grieving process and at the same time lower separation anxiety, feelings of rejections, and depression (Reed, 1998). Initially, support appears to be available for the bereaved (for example, immediately postdeath following the funeral); however, it often weakens over time. Further, although people within support networks may offer support, the bereaved may not know how to ask for the assistance they require. To further complicate the issues relating to social support for survivors of suicide, supporters may hold unrealistic or undesirable attitudes or misconceptions about the ways in which people react to suicide, potentially resulting in support attempts being inappropriate or inaccessible to the bereaved person.
Relief for Some.
Suicide death is typically thought of as unexpected and sudden. However, some families may feel relief, especially when the suicide death ended a troubled, painful history. This is not to suggest that the person will not be greatly missed, but rather that the family may experience reduced stress and be relieved that the individual is now free from distress. The notion that suicide may not be sudden and unexpected has received little attention. However, when it has been studied it has been shown to influence the way in which the resultant grief is experienced and is therefore an important consideration (Maple, Plummer, Edwards, & Minichiello, 2007) in the range of emotions experienced by those bereaved by suicide.
Within the family setting it is most common for survivors to feel anger and feelings of social stigmatization and to experience familial dysfunction both prior to and after the death. Following the death, prior events in the family may be reviewed individually or among family members as they search for explanations as to why the deceased family member ended his or her life (Ratnarajah et al., in press). Cerel, Fristad, Weller, and Weller (2000) suggested three types of families in which the suicide of a parent had occurred: functional families, which are characterized by no evidence of preexisting family conflict or psychopathology, with the suicide often taking place in the context of chronic physical illness; encapsulated families, in which psychopathology and conflict were generally observed only in the deceased, not in other family members; and chaotic families, in which clear evidence of psychopathology in multiple family members or turmoil prior to suicide was present. Although research has not examined whether these three categories represent all families in which a suicide occurs, it is helpful to think about the variety of families who experience suicide.
In short, some aspects of the bereavement process appear to be unique to suicide. Suicide bereavement appears to cause an existential crisis in the bereaved as they struggle to find meaning in a world that feels meaningless while suffering feelings of blame, guilt, and responsibility for the death. Given that more than 38,000 people die by suicide each year in the United States and using the often quoted, yet extremely conservative estimate of 6 people affected by each suicide death, at least 198, 000 Americans are newly bereaved by suicide each year. In Australia, around 2,500 people die by suicide. Again, using this calculation of 6 people affected, these deaths result in at least 15,000 Australians newly bereaved. It is important to note that this is an annual addition to an already large population continuing to grieve prior deaths—because suicide bereavement affects individuals for a long time after the event and in profound ways.
Psychological Outcomes for Suicide-Bereaved Individuals.
With the multitude of complex emotions suddenly confronting suicide-bereaved individuals, the trauma of the event may lead to additional psychopathology. Although there is limited evidence about how suicide bereavement differs from bereavement from other types of sudden traumatic deaths (Jordan, 2001; Jordan & McIntosh, 2011b), attention to the longer term morbidity associated with this experience is an important consideration.
Complicated or prolonged grief may be common for those bereaved by suicide, as for those survivors of other types of sudden and traumatic death. Prolonged grief disorder shares features of PTSD and depression and also involves intrusive yearning, longing for, or searching for the deceased (Prigerson et al., 2009). Symptoms of trauma that may be present include avoidance of reminders of the person who died, a feeling of purposelessness or futility, difficulty imagining life without the deceased, numbness, detachment, feelings of being stunned, dazed, or shocked, feeling like life is empty or meaningless, feeling like part of oneself has died, disbelief, excessive death-related bitterness or anger, and identification with symptoms or harmful behaviors resembling the behaviors experienced by the person who died before his or her death. Complicated grief has been shown to occur following the suicide of a family member and to increase the risk of suicidal ideation for those bereaved by a suicide; in addition, it appears to be related to the onset of depression, a prolonged course of depression, and PTSD. Complicated grief appears to be highest in those with the closest ties to the deceased, perhaps because suicide-related bereavement differs from other bereavements in regard to its nature, including the deceased’s choice to end his or her life, the cultural and historical perceptions of suicide, and the involvement of officialdom based on legislative requirements to determine cause of death.
No overall difference in suicidal behavior and diagnosable depression in children bereaved from a suicide compared to children bereaved from other types of death has been found in the few studies focused on outcomes for children. However, compared to children bereaved from other types of death, children bereaved by suicide have been shown to experience increased levels of psychopathology, especially behavior problems, prior to the death, as well as increased behavioral and anxiety symptoms after the initial few months following the death (Ratnarajah & Schofield, 2008). This is an area worthy of future research attention.
Differences in Suicide Bereavement Compared With Other Deaths.
In a comprehensive review of previously reported research, Jordan (2001) suggests three important differences evident in a person bereaved by suicide when assessing the research literature. These differences are that suicide survivors struggle to find meaning in the death, experience high levels of guilt at not being able to prevent the death, and experience higher levels of abandonment by the deceased. However, while recognizing that there are many similarities, Jordan maintains there are also important differences that must be acknowledged in the suicide bereaved. Thus, he concludes that the thematic content of the grief, the social processes the survivors must face, and the impact the death has on the family system are unique to this form of death.
The difference between suicide bereavement and bereavement following other deaths may appear less distinct based on the nature of the deaths to which suicide is often compared. The available literature compares suicide bereavement with other sudden and traumatic deaths such as death through homicide or motor-vehicle accident. Such comparisons may potentially dilute the difference and effects of sudden or traumatic bereavement from suicide by obscuring feelings of responsibility held by others toward the suicide victim, particularly in the case of young adults. These comparisons also obscure the inevitably confronting nature of suicide, that is, that the individual did not die by accident but purposely chose to take his or her own life. As Jordan (2001) proposes, it is important to understand whether significant differences exist because this will affect service delivery and planning. An approach focusing on understanding how grief affects individuals, rather than the manner in which the deceased died, to illuminate diversity in bereavement may be a critical step to designing effective policies and practices to support suicide survivors.
There is evidence that a person is more likely to die by suicide if a family member has died by suicide or has a history of psychiatric illness (Runeson & Asberg, 2003). Suicide survivors seem to be at risk for their own suicidal behavior, even where no familial relationship exists. In families, the mechanism of this transmission is both genetic/biological and cognitive/learned. Suicide rates have been shown to be twice as high in families where suicide death has occurred compared with families in which a suicide has not occurred (Roy & Segal, 2001; Statham et al., 1998). It also is possible that exposure to suicide in family members may sensitize people to the idea of suicide as a coping mechanism. This also can apply to others outside the immediate family who are at increased risk of suicide following exposure. This process, described by Joiner (Joiner, 2002; Van Orden et al., 2010), includes cognitive sensitization and opponent process theory. These processes sensitize people to suicide-related thoughts and behaviors, making these thoughts and behaviors more cognitively available as coping mechanisms. Further, as one becomes sensitized, emotion around the idea of suicide diminishes as it is repeated. The idea of suicide is primed, that is, more cognitively available, and perhaps less taboo for the family member, which then could be seen as a potential coping strategy when problems arise. The similarity of suicidal behavior over generations within a family or broader kinship group is evidence to support this model.
The interpersonal–psychological theory of suicidal behavior (Joiner, 2005) posits that for someone to end his or her life, he or she must experience a combination of perceived burdensomeness, thwarted belongingness, and acquired capacity for suicidal behavior. This acquired capacity may be especially primed by the experience of a loved one dying by suicide, which puts suicide survivors at special risk given their exposure. Although some will be affected in this way, others will not. Why some survivors are resilient whereas others are vulnerable is not yet understood.
Supporting Those Bereaved by Suicide
The needs of the bereaved are typically of concern to mental-health and counseling practitioners, including social workers in a variety of settings. Social workers must be aware of the issues outlined in this entry because they will come across clients who are bereaved by suicides—whether or not these clients seek services for that loss. The total cost of unmet needs of those bereaved in terms of suffering, health problems, and economic losses is unknown and currently incalculable. The literature on effective interventions for those bereaved suicide is sparse. Most survivors do not seek out mental-health treatment or formal or informal interventions. Yet given the high level of exposure to suicide, with some conservatively estimating that 1 in every 65 Americans will have been exposed (McIntosh, 2012) and research showing that over 40% of people know someone who has died by suicide (Cerel et al., 2013), a social worker in any field can assume that many clients will have been exposed to a suicide death at some time. This experience will have significantly affected the lives of some clients—even if it is not the presenting issue for service provision. Therefore, exploring a history of suicide bereavement should form part of any comprehensive social-work assessment. Although generalist service providers may come across people bereaved by suicide in their day-to-day work, services are emerging that directly respond to the needs of people bereaved by suicide. These services are known as postvention and refer to interventions that take place after a suicide for the surviving family, school, or community.
Postvention has been seen as a type of prevention in that survivors are at risk of future problems, including their own suicidal behavior. Historically, attempts to reach survivors for support following a suicide have been passive, often occurring weeks or months after the death. When postvention is passive, survivors themselves must find out about resources that might be available in their community. These resources include postings on agency websites, brochures or flyers at funeral homes, or newspaper advertisements for bereavement groups. Because most people bereaved immediately following a suicide do not know the term survivor, it may be difficult for people to find appropriate sources of help.
Barriers to people getting help include stigma about suicide and not knowing about available resources or where to turn for help. A new type of postvention, called the active postvention model, was devised by Dr. Frank Campbell (2004) and has been disseminated across the United States and internationally. Active postvention allows services to occur as close to the time as death as possible, which can better help identify and assist survivors. There is an emerging evidence base that indicates that accessing support in close proximity to the time of the death appears to reduce the long-term morbidity and mortality associated with being bereaved by suicide. A similar model in several locations in Australia, offering support early following the suicide death, has been economically evaluated. Not only do these active postvention models offer timely support, but also the Australian StandBy Model appears to indicate that providing such a service is cost-effective. Unfortunately, these services are provided only in some localities and are not available to everyone who may benefit.
Traditional psychotherapy, both in individual and in family format, is preferred by some individuals and may be helpful. Where therapy is viewed most positively, it is often attributed to the therapist’s knowledge and understanding of suicide bereavement as a unique form of grief and loss. If the therapist does not have this experience and knowledge base, therapy can be a negative experience. In some countries, including the United States, insurance coverage of mental-health care and the perceived stigma of being in therapy may prevent many survivors from accessing psychotherapy.
Peer-led or professional-led support groups, often called Survivor of Suicide groups, are the most common form of intervention received by people bereaved by suicide. Many view participation in support groups as an essential part of working through bereavement following suicide. Support groups are thought to be preferred because there is low or no cost and because they are convenient and less stigmatizing than formal mental-health treatments. Further, these groups are most often run by group leaders who are themselves bereaved by loss through suicide. In some instances, professional leadership occurs alongside lay leadership. There are over 400 support groups for survivors in America, with at least 1 group in each state. There are also online support groups available for people who prefer the anonymity and convenience of online support. A similar proportion of services are found in other countries, with more online support groups commencing. Online support groups are particularly useful for people who live in rural areas, who may be inhibited from attending support groups by distance and time. Support groups may be helpful because they allow members to feel a sense of identification with other group members who may have experienced similar situations. People in support groups can feel like they are benefitting both themselves and others from sharing their experiences and listening and providing advice to people newer to the process. Over time, people who have been in the group and who have been bereaved for a longer period of time can help newer members as they describe how they made it through especially difficult times or handled sensitive topics. This becomes a form of social support, which often extends to friendships outside the group. This social support may be helpful for survivors dealing with depression, loneliness, or life stress. Support groups can be located through the websites of the American Association of Suicidology (http://www.suicidology.org) and the American Foundation for Suicide Prevention (http://www.afsp.org). There is a limited research base to draw from to determine who is most helped by these support groups, which group practices are the most helpful, or how long survivors should continue to attend a group (Cerel, Padgett, Conwell, & Reed, 2009). Although reports that do provide information regarding participants’ experiences are often positive, a lack of information from those who do not attend or only attend support groups for a short period and do not find them helpful makes it difficult to contextualize these reports.
Advocacy has been a source of support for some survivors, either on its own or in combination with individual or group therapy. Using their grief to advocate for local, regional, or national change, survivors have been at the forefront of the suicide prevention movement. In some instances, these efforts have resulted in a variety of policy and legislative successes. For example, during the 1990s in the United States, the introduction of congressional resolutions recognized suicide as a serious public-health challenge, which led to the passage of the Garrett Lee Smith Memorial Act in 2004. The Garrett Lee Smith Memorial Act, named after the son of Senator Smith of Oregon who died by suicide, was the first-ever authorization and appropriation for youth suicide prevention. The Garrett Lee Smith Act authorized $82 million over three years for youth suicide prevention programs, including grants to states, American Indian tribes, and colleges to support suicide prevention efforts. Services for survivors are part of these funds. Some survivors have reported that the act of creating political will and seeing change becomes a part of their healing experience. Other survivors use their grief to work in suicide prevention with the hope that other families will not have to experience the pain of losing a family member to suicide. There has been no research to date about the effect of survivors engaging in advocacy or prevention work.
Although the challenges for survivors are multifaceted and complex, some family members may experience what has been termed posttraumatic growth. Posttraumatic growth, a concept that has grown out of the positive psychology movement, has been described as psychological change that occurs as the result of a person’s struggle with a stressful and traumatic event. This area requires further research to determine which survivors or what situations might be most associated with growth following a suicide. Social workers involved with supporting survivors must acknowledge the wide variation in experience and the needs of the individual client to support where they are in their bereavement and not assume that particular experiences, events, or situations will lead to expected outcomes.
The tendency to regard suicide survivors as a homogenous group overlooks the diversity of experiences and responses to suicide and the accompanying grief. In the early twenty-first century, it appears responses to those bereaved through suicide may be too limited. Recognizing the different needs of suicide-bereaved people is important in determining the appropriateness of the services delivered. Neimeyer (2000) suggests that for those experiencing an unproblematic reaction to the death of their loved one, conventional therapy is not indicated. Indeed, he suggests there are potential negative consequences from engaging an individual in therapy when it is not needed. In contrast, for individuals suffering an extreme grief reaction to a sudden and unexpected death, therapy can be useful.
It is likely that social workers, especially those in direct clinical practice, will be impacted by client suicide. Research indicates that 55% of social workers will experience at least one client suicide attempt and 31% will experience a client suicide completion during the course of their career (Ting, Sanders, Jacobson, & Power, 2006). Social workers who lose clients to suicide can experience reactions related to their professional identity as well as the personal experience of loss. A loss of a client to suicide can be related to feelings of professional incompetence and is an occasion in which it is appropriate to seek peer supervision or actual therapy (Clark, 2009). The American Association of Suicidology maintains a clinician/survivor task force that has a listserv on which clinicians can discuss their experiences as well as information about how to get help following a client suicide (http://www.suicidology.org/c/document_library/get_file?folderId=236&name=DLFE-275.pdf).
Those bereaved by suicide are the individuals left behind when a person dies by suicide. Suicide is no longer a criminalized act and many religious groups are moving toward helping those family members left behind by condemning the act of suicide, but not the individual who died. Up to a third of the population may feel the profound impact of a suicide in their social network within their lifetime. Postvention, the interventions that take place following a suicide, is becoming more active, including reaching out so survivors can get the help they need. Suicide survivors are at risk for their own suicidal behavior, depression, posttraumatic stress, and complicated grief. The most common form of treatment for suicide survivors is support groups. Advocacy and working for suicide prevention are other common sources of support.
Given the complex political and policy environments in which services are provided, along with funding and health-care provision costs, it is timely to provide a broad overview of the issues related to this complex grief and aftermath of a suicide death. Social workers are required to work in ethical and meaningful ways with those affected by suicide and self-harm and contribute to reducing stigma experienced by these individuals, families, and communities. With much of the social-work literature in the suicide domain focused on suicide prevention and intervention, it is timely to acknowledge both the full range of activities that must be addressed by the social-work profession and that suicide prevention and postvention are both issues central to social work.
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Suicide Prevention Resource Center. After a suicide: A toolkit for schools: http://www.sprc.org/sites/sprc.org/files/library/AfteraSuicideToolkitforSchools.pdf. There are a number of programs in place for postvention, including a free toolkit for school personnel to utilize following a suicide in a school. This toolkit addresses crisis response in the immediate aftermath of the suicide and how to help students cope, including expressing their emotions and identifying strategies for managing them. It also discusses the issues of memorialization of the deceased student. The toolkit describes how it is important for schools to treat all deaths the same way in terms of memorialization because there is a balance between how to appropriately memorialize the student who has died and the risk of suicide contagion among at-risk surviving students. Despite this comprehensive resource, no existing research examines how postvention within a school impacts affected children.