Someone is to blame: the impact of suicide on the mind of the bereaved (including clinicians)

This paper presents an emerging understanding of the psychodynamics of suicide loss, derived from over 1500 accounts of suicide bereavement shared by families, friends and clinicians. It identifies clear patterns in the responses of the bereaved, particularly the formation of delusional narratives that often place them at the centre of blame for the death. These narratives have a profound impact on well-being, increase the risk of mental illness and elevate the likelihood of death by suicide. They not only cause harm to the bereaved but also permeate and distort our systemic and societal responses. Understanding why suicide unleashes such painful and dangerous forces helps mitigate the widespread harm and distress that often follows such a death. This knowledge also enables us to effectively and compassionately support those bereaved.

Sharing is Caring: A Realist Evaluation of a Social Support Group for Individuals Who Have Been Bereaved by Suicide

AIM

To understand the experiences and perceived impact on the wellbeing of individuals attending a suicide bereavement social support group.

DESIGN

A qualitative study guided by a realist evaluation framework.

METHODS

Data were collected from May-July 2020 using online semistructured individual interviews with participants (N = 6), from the North West of England recruited from a suicide bereavement support group's social media. Data were analysed using thematic analysis informed by the realist framework.

RESULTS

Effective social support includes the prioritisation of building meaningful connections with like-minded individuals, providing a safe space for authentic self-expression aiding personal relationship maintenance. Contextual factors included: Societal and cultural stigma of suicide, self-stigma and gender norms. Mechanisms influencing support seeking include: Not wanting to burden loved ones due to judgement, and a lack of understanding.

IMPACT

Policymakers can reduce demand on healthcare systems by developing tailored support groups to suit individual needs.

Impacts of suicide bereavement on men: a systematic review

Introduction

This systematic review examines the impacts of suicide bereavement on men's psychosocial outcomes relating to suicidality, mental health, substance use, grief, and social functioning. Given the high global incidence of suicide and the substantial number of individuals affected by each suicide, understanding the specific experiences and outcomes for men is crucial, particularly in the context of observed gender differences in suicide rates, grief coping styles and mental health outcomes.

Methods

Adhering to PRISMA guidelines, this review included peer-reviewed, English-language studies that involved men bereaved by suicide using quantitative, qualitative and mixed-methods designs. Searches were conducted in MEDLINE, Embase, Emcare, PsycINFO, and Scopus. Analysis used narrative synthesis methods due to the heterogeneity of findings. These were categorised based on comparison groups: non-bereaved men, or women bereaved by suicide. Prospero registration: CRD42023437034.

Results

The review included 35 studies (25 quantitative, 8 qualitative, 2 mixed-methods) published between 1995 and 2023. Compared to non-bereaved men, suicide-bereaved men are more likely to experience adverse psychosocial outcomes included increased suicide mortality, heightened susceptibility to mental health problems such as depression and posttraumatic stress disorder, and challenges in interpersonal relationships and social functioning. The review also identified gender differences in grief responses and coping strategies, with men often exhibiting more pronounced grief reactions and facing unique challenges due to societal expectations and norms regarding masculinity.

Discussion

The findings of this review underscore the elevated risk of adverse suicide- and mental-health related outcomes for suicide-bereaved men and the need for tailored postvention supports for this cohort. Gender-specific factors, including cultural norms and coping strategies, significantly influence men's experiences of suicide bereavement. Further qualitative and longitudinal quantitative exploration is needed to enhance understanding and effective support for men bereaved by suicide.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023437034.

What Are the Experiences of Mental Health Practitioners Involved in a Coroner's Inquest and Other Inquiry Processes after an Unexpected Death of a Patient? A Systematic Review and Thematic Synthesis of the Literature

Grief after suicide or patient-perpetrated homicide can be complex for those involved in the patient's care. Mental health practitioners with patients who die unexpectedly may be called to assist in the formal investigation processes that follow. The aim of this study was to examine the experience of mental health practitioners called to attend a coroner's inquest or other forms of formal inquiry. A protocol for a systematic review was prospectively registered on PROSPERO (CRD42023400310). A thematic synthesis of existing literature was conducted. We identified six articles for inclusion and constructed three themes from our analysis: Blame and enduring hostility, In the dark, and Limited learning. We found mental health practitioners may construct narratives of self-blame. These can be reinforced by the investigatory processes that follow. Feedback from inquiries is often delivered haphazardly and may not reflect the realities of clinical work. The support given to assist practitioners through inquiry processes varied-both in amount and how helpful it was. The research conducted on this topic is limited. More qualitative research should be conducted to understand the factors that make this experience more or less difficult as well as well as what support is needed for whom.

The role of depression and use of alcohol and other drugs after partner suicide in the association between suicide bereavement and suicide: cohort study in the Danish population

BACKGROUND

Although suicide bereavement is associated with suicide and self-harm, evidence regarding mechanisms is lacking. We investigated whether depression and substance use (alcohol and/or other drugs) explain the association between partner suicide bereavement and suicide.

METHODS

Linkage of nationwide, longitudinal data from Denmark for the period 1980-2016 facilitated a comparison of 22 668 individuals exposed to bereavement by a partner's suicide with 913 402 individuals bereaved by a partner's death due to other causes. Using causal mediation models, we estimated the degree to which depression and substance use (considered separately) mediated the association between suicide bereavement and suicide.

RESULTS

Suicide-bereaved partners were found to have a higher risk of suicide (HRadj = 1.59, 95% CI 1.36-1.86) and of depression (ORadj 1.16, 95% CI 1.09-1.25) when compared to other-bereaved partners, but a lower risk of substance use (ORadj 0.83; 95% CI 0.78-0.88). An increased risk of suicide was found among any bereaved individuals with a depression diagnosis recorded post-bereavement (ORadj 3.92, 95% CI 3.55-4.34). Mediation analysis revealed that depression mediated 2% (1.68%; 95% CI 0.23%-3.14%; p = 0.024) of the association between suicide bereavement and suicide in partners when using bereaved controls.

CONCLUSIONS

Depression is a partial mediator of the association between suicide bereavement and suicide. Efforts to prevent and optimize the treatment of depression in suicide-bereaved people could reduce their suicide risk. Our findings might be conservative because we did not include cases of depression diagnosed in primary care. Further work is needed to understand this and other mediators.

Suicide Attitudes Among Suicide Loss Survivors and Their Adaptation to Loss: A Cross-Cultural Study in Japan and the United States

Survivors' adaptation to a suicide loss is likely influenced by their attitudes toward suicide and their respective sociocultural contexts. Our study aimed to compare suicide attitudes and their association with depressive symptoms and sense of community safety in Japanese and American suicide loss survivors. A total of 193 Japanese survivors and 232 American survivors completed online surveys. The results show that Japanese survivors tended not to consider suicide as an illness or to recognize that others understood their experience but were more likely than American survivors to consider suicide as justifiable. Regression analyses indicated that taking suicide as a right was associated with depressive symptoms. Further, their sense of being understood by others was positively correlated with perceived community safety in both samples, but justifying suicide and considering it to be an illness was positively related to perceived community safety only among Japanese survivors.

Association of Sexual Orientation with Exposure to Suicide and Related Emotional Distress among US Adults

OBJECTIVE

Suicide bereavement is a significant public health concern. Using nationally representative survey data, we quantify sexual orientation differences in frequency of suicide exposure and suicide exposure-related emotional distress among US adults.

METHODS

We used cross-sectional data from the 2016 General Social Survey (GSS) and included sexual minority (i.e., lesbian, gay, bisexual; (n = 74, 5.3%) and heterosexual (n = 1,207, 94.7%) adults. The GSS asked several questions related to suicide exposure including number of lifetime suicide exposures, emotional distress related to suicide exposure, time elapsed since suicide exposure, and relationship(s) and perceived closeness to the person(s) who died. We use descriptive statistics to describe differences in suicide exposure characteristics across sexual orientation. Among those who were exposed to at least one suicide (n = 698, 51.1%), a weighted multivariable logistic regression model examined the association between sexual orientation and suicide exposure-related emotional distress adjusting for confounders.

RESULTS

Sexual minorities reported a similar number of lifetime suicide exposures and were not significantly different from heterosexuals on other suicide exposure characteristics. However, sexual minority, compared to heterosexual, respondents experienced 3.14 greater odds of severe emotional distress related to suicide exposure (95% CI = 1.42-6.94, p = .005).

CONCLUSION

Perhaps due to stigmatizing mourning experiences, sexual minority adults are particularly vulnerable to severe suicide exposure-related emotional distress. Future research to understand the scope of sexual minority-specific bereavement support services and public policies (e.g., bereavement leave) as well as intervention development to support sexual minority adults' coping in the wake of suicide exposure is warranted. HIGHLIGHTSApproximately half of sexual minority US adults report a lifetime suicide exposureSexual minority adults experience more severe suicide exposure-related emotional distressPostvention care should be tailored to meet the needs of sexual minority adults.

Predictors of Stigma, Guilt, and Shame among Adults Bereaved by Fatal Overdose

With the spectacular rise of US overdose deaths, bereavement for these affected families has become a matter of increasing concern. Qualitative research has highlighted the role of stigmatization as well as guilt and shame among this population. However, the magnitude and pre-death predictors of stigmatization, guilt, and shame have yet to be assessed quantitatively. In the current study, we assess the magnitude of stigmatization, guilt, and shame among 115 adults bereaved by overdose by drawing comparisons with 185 adults bereaved by suicide. Results revealed no significant differences regarding overall levels of stigmatization, guilt, and shame between the overdose and suicide bereaved. Among the overdose bereaved, regression models indicated a number of pre-death factors associated with stigmatization, guilt, and shame, such as the frequency of the decedent's drug use, family drug use severity, and interpersonal conflict between the bereaved and the decedent. Implications and future directions for research are discussed.

A Loss by Suicide: The Relationship Between Meaning-Making, Post-Traumatic Growth, and Complicated Grief

Meaning making has been found useful in processing grief, yet individuals who have experienced a loss by suicide may have difficulty with post-loss adjustment due to the traumatic nature of their loss. Through quantitative study, this article acts as an initial exploratory study and examines the relationship between meaning-making, post-traumatic growth, and complicated grief symptoms in 81 college students from a large university in the United States who have experienced the loss of a loved one to suicide. The results of this study indicated that meaning-making serves as a mediator in the relationship with post-traumatic growth and complicated grief. This finding sheds light on the importance of meaning-making as a possible avenue of interventions for clinical use in bereavement from loss by suicide to treat grief symptoms and lead to post-traumatic growth.

A Longitudinal Study of the Impact of a Suicide Bereavement Service on People Bereaved by Suicide

Whilst the body of research on the impacts of suicide bereavement interventions continues to grow, there is little understanding of the impact over time. This study measured changes in suicidality, levels of loneliness and grief reactions over time between those receiving support from a community-based suicide bereavement service (StandBy) compared with those that did not receive this support. Data were collected through an online survey with participation at baseline being varying times post loss, and three-months post-baseline (StandBy n = 174, Comparison n = 322). Statistical analysis included linear mixed-effects modelling for repeated measures. Results were consistent with earlier studies showing the positive impact of StandBy on participants' grief responses, loneliness and suicidality, specifically within the first 12 months after their loss. However, these outcomes were not retained over time, with the exception of suicidality. Further longitudinal studies consisting of more than two time-points and a greater period between time-points is warranted.

Trying to keep alive a non-traumatizing memory of the deceased: A meta-synthesis on the interpretation of loss in suicide-bereaved family members, their coping strategies and the effects on them

WHAT IS KNOWN ON THE SUBJECT?: Losing a family member due to suicide has been described as a traumatic experience, as suicide-bereaved relatives grapple to accept the particular character of death and the core elements of guilt, self-criticism and stigma it inflicts. There are long-term consequences for those who bereave due to the suicide of their beloved on, a high risk for mental and physical health problems included. Feelings of guilt and self-stigma influence help-seeking behaviour among suicide-bereaved individuals. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Coping mechanisms adopted by suicide-bereaved individuals mediate the impact of suicide on their family, and especially on the quality of relationships among them. Supporting others in need can help alleviate guilt and self-blame for the suicide while it enables the bereaved to fulfil their need to keep a non-traumatizing, or even positive bond with the deceased. WHAT THE IMPLICATIONS FOR PRACTICE ARE?: Nursing interventions to facilitate suicide-bereaved family members' participation in self-help support groups and promote their engagement in supporting others in need are important. Mental health nurses need to facilitate the replacement of dysfunctional coping strategies, such as substance use or self-blame with more adaptive ones focused on the personal needs of the bereaved, in order to help them embrace a non-traumatizing memory of the deceased while being in peace with the social environment. Screening for mental health problems and management of shame, self-stigma and guilt during the grieving period needs to be a priority in nursing interventions.

ABSTRACT

INTRODUCTION: Losing a family member to suicide is a traumatic experience which includes guilt and self-stigma. Yet, there is lack of data synthesis on the survivors' experience.

AIM

A meta-synthesis of qualitative data on the interpretation of loss in suicide-bereaved family members, their coping strategies and the effects on family.

METHOD

A meta-ethnographic synthesis following a systematic literature search and evaluation of the methodological quality of the selected studies was applied.

RESULTS

The narratives of 326 individuals (parents/siblings/children/spouses) reported in sixteen studies were analysed. Trying to achieve a balance between keeping alive a non-traumatizing memory of the deceased, destigmatizing and liberating themselves from self-blame, self-criticism and guilt while being able to transform this experience into support towards others in need, was identified as the essence of the experience of the bereaved.

DISCUSSION

Although suicide within a family is a traumatic experience, spiritual and existential implications among the bereaved have been reported; their coping mechanisms mediate the impact of suicide on family sustainability.

IMPLICATIONS FOR PRACTICE

Nursing interventions to facilitate adoption of coping strategies centred on keeping a non-traumatizing memory of the deceased among the bereaved and promote their participation in self-help groups and activities to support others in need are important.

Longitudinal Changes in Suicide Bereavement Experiences: A Qualitative Study of Family Members over 18 Months after Loss

Family members bereaved by their loved ones' suicidal death normally undergo a complicated and lengthy bereavement process. In this qualitative case study, we explored longitudinal changes in the suicide bereavement process by applying assimilation analysis, based on the Assimilation Model (AM) and the Assimilation of Problematic Experiences Scale (APES), to longitudinal interview data collected from two Chinese suicide-bereaved individuals within the first 18 months after their loss. The results showed that over time the participants both progressed in adapting to their traumatic losses. Assimilation analysis both effectively elaborated the difference in the inner world of the bereaved and clearly demonstrated development in their adaptation to the loss. This study contributes new knowledge on the longitudinal changes in suicide bereavement experiences and demonstrates the applicability of assimilation analysis to suicide bereavement research. Professional help and resources need to be tailored and adapted to meet the changing needs of suicide-bereaved family members.

Growth and Hope after loss: How TAPS facilitates posttraumatic growth in those grieving military deaths

We examined posttraumatic growth for 691 participants of the Tragedy Assistance Program for Survivors (TAPS). Peer mentors of bereaved individuals experienced greater posttraumatic growth (PTG) and reported higher psychological health than those who were non-peer mentors. Active involvement in TAPS and resilience consistently and positively predicted all types of PTG. These prediction models were far stronger (R², AIC) for the suicide-bereaved sample than those bereaved by other causes, and post-hoc analyses suggest suicide-bereaved benefitted more than those bereaved by other causes from active participation in TAPS.

Psychiatrists' Experience of a Peer Support Group for Reflecting on Patient Suicide and Homicide: A Qualitative Study

There is a lack of support for mental health professionals who experience a patient suicide or homicide. This is despite a high likelihood of such an occurrence and the heavy professional and personal toll the experience can take. We conducted 15 interviews with members of a facilitated peer support group run for consultant psychiatrists who have experienced a patient homicide or suicide. Our interviews explored the trauma of the experience as well as the effectiveness of the group in helping the clinician heal. Our results echoed previous research that the experience can be profoundly traumatic. A professionally facilitated, consultant-only peer group specifically dedicated to suicide and homicide were the key components helping participants to process their grief. Mental health trusts should consider setting up facilitated peer support groups for clinicians who experience patient suicide or homicide.

Experiences With Suicide Loss: A Qualitative Study

To better understand suicide loss survivors' experiences and barriers to accessing support and mental health care, 28 (21 women and 7 men) suicide loss survivors were interviewed. Using qualitative analysis of 28 in-depth, semi-structured phone interviews data, three categories emerged: Life before Suicide, Life after Suicide, and Meaning of Life. This deeper understanding of suicide loss survivors along with inclusion of experiences of male and rural participants' suicide loss, fill previously identified research gaps. Our findings suggest importance in providing emotional support and mental health resources to those with suicide intent or experiences with suicide loss. Most importantly, the recognition of suicide loss survivors extends beyond the immediate family and includes cousins, friends, and work associates. Recognition of extended suicide loss survivors' bereavement will provide additional opportunities for healthcare providers to effectively intervene with this vulnerable population.

Loss-Related Characteristics and Symptoms of Depression, Prolonged Grief, and Posttraumatic Stress Following Suicide Bereavement

(1) Background: The aim of the present study was to examine symptom classes of major depressive disorder (MDD), prolonged grief disorder (PGD), and posttraumatic stress disorder (PTSD) in a sample of suicide-bereaved individuals, while accounting for loss-related characteristics. (2) Methods: A latent class analysis was conducted to identify classes of the suicide bereaved, sharing symptom profiles, in a German suicide-bereaved sample (N = 159). (3) Results: Our analyses revealed three main classes: a resilient class (16%), a class with high endorsement probability for PGD symptoms (50%), and a class with high endorsement probability for combined PGD/PTSD symptoms (34%). Prolonged grief and intrusive symptoms emerged across all classes, while MDD showed low endorsement probability. Our results indicate an association between class membership and time passed since the loss; however, this applies only to the comparison between the PGD and the resilient class, and not for the PGD/PTSD class. (4) Conclusions: Our results may provide information about the predictability of symptom clusters following suicide bereavement. The findings also represent a significant step towards tailoring treatments based on the needs of relevant suicide-bereaved subgroups through a symptom-level approach. Time passed since loss might explain differences between symptom clusters.

The Spaces of Peer-Led Support Groups for Suicide Bereaved in Denmark and the Republic of Ireland: A Focus Group Study

Research has shown that people bereaved by suicide have an increased risk of mental health problems, suicidality and associated stigma, as well as higher rates of sick leave and increased rates of receiving disability pensions. Peer-led suicide bereavement support groups are perceived to enhance people's recovery by enabling shared experiences with others who are bereaved in similar circumstances. The aim of the research was to explore the viewpoints of participants living in Denmark and the Republic of Ireland on these peer-led support groups. This study focused on how the participants experienced being part of the peer-led support and how the participation affected them. We conducted four focus groups, two in Denmark and two in the Republic of Ireland, and two individual interviews, involving a total of 27 people bereaved by suicide. Data were analyzed thematically. The participants' experiences in the peer-led support groups were in contrast to what they had experienced in their daily lives. They felt alienated in daily living, as they believed that people could not comprehend their situation, which in turn led participants to search for people with similar experiences and join the peer-led support groups. While peer-led support groups may not be helpful for everyone, they created 'supportive spaces' that potentially affected the participants' recovery processes, from which we generated three key themes: (i) 'A transformative space', describing how the peer-led support group created a place to embrace change, learning and knowledge about suicide and suicide bereavement and the making of new connections; (ii) 'An alternative space for belonging and grieving', describing how the participants felt allowed to and could give themselves permission to grieve; and (iii) 'A conflicted space' describing how it was troublesome to belong to and participate in the peer-led support groups. In conclusion, despite the two cultural settings and different organizational approaches, the experiences were comparable. Peer-led support groups can, despite being a conflicted space for some, provide supportive spaces aiding the participants' recovery process.

Initial-Stage Suicide Bereavement Experiences: A Case Study

This study aimed to shed light on the initial-stage bereavement experiences of an individual bereaved by suicide, at three months from the loss of his spouse to suicide. A semi-structured in-depth interview was conducted with the individual, a man in his thirties. The data were analyzed using qualitative assimilation analysis, based on the Assimilation Model and the Assimilation of Problematic Experiences Scale (APES). The APES ratings of the interview revealed that the individual's bereavement was associated with the earlier stages of APES (all scoring under 3.5). In addition, the swift and frequent fluctuations in the APES ratings gave indications that the bereavement was unstable and complicated. It is suggested that mental health professionals could use APES to evaluate suicide bereavement and take note of the APES evaluations in clinical interventions.

Experiences of Bereaved Families by Suicide in South Korea: A Phenomenological Study

When an individual commits suicide, family members frequently experience feeling of hurt, denial, shock and anger, resentment, shame, and guilt. These negative emotions experienced by family survivors make their life suffer and impede the grieving process. If left untreated, they become physically and psychologically vulnerable and the risk of suicidal ideation is high, so professional intervention is needed. This study aimed to explore the experiences of suicidally bereaved families in South Korea. This research was designed to a qualitative phenomenological study conducted by using Colaizzi’s methods. Participants were seven individuals who had lost a family member to suicide in Changwon City, South Korea. The Data were collected through in-depth and individual interviews with participants from June to December 2018, and the interviews took place 1 to 15 months after their loss. A total of 25 meaning units, 12 themes, and 5 theme clusters emerged from the analysis. The 5 themes of south Korean bereaved families’ experience were: (1) an absurd breakup that came without notice, (2) a life trapped in pain, (3) family isolation by themselves, (4) uncontrolled mind in daily life, and (5) liberating from the bondage of pain. The findings of this study provide insight regarding how suicide loss affects bereaved families and could inform the development of evidence-based programs to prevention suicide thought experienced by bereaved families.

Emerging Despite the Indelible Wound: A Grounded Theory of Family Transformation Following Adolescent Suicide

Family members of a person who has died by suicide are at an increased risk of experiencing depression, post-traumatic stress disorder, suicide ideation, and suicide. However, despite the experience of losing a family member to suicide, most families continue to function and even live well following this difficult experience. This study sought to understand and describe the transformation process that occurs in family member survivors using a grounded theory approach. Seven families, who experienced the loss of an adolescent in their family by suicide, participated in this qualitative study that used a grounded theory methodology. The results describe the transformation process experienced by the family, one of growth and learning, even though the wound from their tragic loss was still present. According to the grounded theory developed in this study, the suicide is a cataclysm, followed by a sinking period that is tempered by the presence of lifebuoys, which are supports that can be found within the families or from people around them. It is necessary for family nurses to understand this transformation process to better support surviving family members and improve suicide postvention care.

The Relationships Between Personality Traits and Public Stigma Attached to Families Bereaved Due To Suicide

Suicide is a serious global public-health issue that is perceived as the most stigmatizing of sudden losses. Most studies on this topic have examined how bereaved families perceive public stigma, paying less attention to the actual stigma experienced by those not directly bereaved. Therefore, this study examined the association between personality traits and the public stigma attached to families that have lost a member to suicide. Three hundred and eighty (N = 380) Israeli participants completed demographic, Big 5, and stigma questionnaires. The study findings demonstrate that neuroticism and openness to experience are associated with higher levels of public stigma, while conscientiousness is associated with lower levels of public stigma. In addition, Arab participants reported higher levels of public stigma than Jewish participants. These findings make an important contribution to our understanding of the relationship between personality traits and the public stigma attached to families that have lost a member to suicide.

Pulling Together - The Protective Role of Belongingness for Depression, Suicidal Ideation and Behavior Among Suicide-Bereaved Individuals

Background: While belongingness has frequently been investigated in the general population as an antidote to experiencing depression, suicidal thoughts, and suicidal behavior, it has rarely been evaluated as a protective factor among individuals bereaved by suicide. Aims: We examined whether perceived belongingness could moderate the differences between suicide-bereaved, suicide-exposed, and nonexposed respondents regarding depression, suicide ideation, and suicide attempts. Method: We conducted an online survey of the adult Israeli population (N = 806), with 203 suicide-bereaved, 266 suicide-exposed, and 377 nonexposed respondents. Participants completed several questionnaires tapping depression and suicidality as well as perceived belongingness levels. Results: Individuals bereaved by suicide reported the highest levels of depression, suicide ideation, and suicide attempts in comparison with suicide-exposed and nonexposed individuals. However, belongingness was found to moderate these distinctions concerning suicide ideation and suicide attempts. Limitations: Belongingness was assessed by only a single question, and the online survey suffered from a relatively high nonresponse rate. Conclusion: Our results suggest that belongingness may act as a potent antidote to the adverse mental health consequences among individuals bereaved by suicide. Clinicians should accord adequate attention to fostering social connectedness among their clients bereaved by suicide.

The relationship between guilt, depression, prolonged grief, and posttraumatic stress symptoms after suicide bereavement

OBJECTIVE

A profound feeling of guilt and its role in complicating psychological reactions are accepted as central issues in suicide bereavement. However, research examining the relationship of guilt with mental disorders commonly following suicide bereavement is still lacking. This study aimed to examine the association between guilt and symptoms of depression, prolonged grief disorder, and posttraumatic stress disorder (PTSD) after suicide bereavement, as well as its moderating role in the association between the time which elapsed since bereavement and psychopathological symptoms.

METHODS

154 self-selected adult German participants bereaved by suicide completed online questionnaires assessing sociodemographics, characteristics related to the loss, guilt, depression, prolonged grief, and PTSD.

RESULTS

Significant positive correlations were found between guilt and all assessed psychopathological symptoms. Further, guilt was a significant correlate with symptoms of depression, prolonged grief, PTSD over and above sociodemographic factors, and time that elapsed since the loss. Guilt furthermore moderated the link between the time which elapsed since bereavement and depressive symptoms, while this effect was not observed for prolonged grief and posttraumatic stress symptoms.

CONCLUSION

Our findings replicate theoretical frameworks linking feelings of guilt with mental disorders after suicide bereavement. Accordingly, they highlight the necessity to adapt psychotherapeutic interventions according to the specific needs of this population to maximize treatment effectiveness.

Live-Chat Support for People Bereaved by Suicide

Background: People bereaved by suicide often face isolation, complicated grief, and increased suicide risk. Aims: We aimed to explore how live-chat can support survivors in their bereavement process. Method: A thematic analysis was carried out on 30 live-chat conversations through the software ATLAS.ti8. Transcripts were retrieved from a major Italian association providing online support. The users had different ages (18-60 years), degrees of kinship with the deceased (blood-related and not), and time distance from the loss (between 48 hr and 10 years). Results: Five themes were identified: meaning-making, reactions to the loss, resources, needs, and interactions with the operator. Survivors used the live-chat as a safe space in which to disclose nonsocially desirable details and to make sense of suicide through the reconstruction of events and the deceased's motivations. Given the limited social resources and the dissatisfaction with the available formal support, users resorted to justification, rationalization, or faith and found support and reassurance in the live chats. Limitations: Some conversations were fragmented and lacked detailed information on the users. Conclusion: Because of their anonymity and accessibility, live-chats represent a valid first-line form of support, from which survivors may obtain useful information and start a meaning-making process.

Experiences of Parental Suicide-Bereavement: A Longitudinal Qualitative Analysis Over Two Years

Limited research exists on the experiences of parents bereaved by suicide. Our earlier qualitative analysis examined the experiences of parents’ suicide bereavement at 6 and 12 months after their loss. The current study aimed to extend the analysis over 24 months, outlining the key themes of parents’ suicide bereavement experience. In the frames of a longitudinal study of suicide bereavement in Queensland, Australia, parents were interviewed at 6, 12, and 24 months after their loss. Thematic analysis was used to further explore new themes and three key themes identified in earlier analyses: searching for answers and sense-making, coping strategies and support, and finding meaning and purpose. Results at 24 months revealed a clearer differentiation between strategies adopted by mothers and fathers. Anger and blame had changed towards feelings of depression. A polarization was observed between parents still oscillating in brooding rumination and those who have shifted towards sense-making. The former more frequently reported depression symptoms, and the latter reported a more positive attitude towards life and acceptance of their loss. Consistent with the dual-process model, parents managed to reach acceptance after oscillating between sense-making and meaning making. Findings provide insights how suicide loss affects parents, with implications for postvention.

Lessons Learned: Forty Years of Clinical Work With Suicide Loss Survivors

The author has been a grief therapist in private practice for almost 40 years. The largest percentage of his clients have been suicide loss survivors, and in this article, the author reflects on the “lessons learned” about how grief therapy with survivors is both the same as, and very different from, work with clients bereaved after other types of losses. After briefly reviewing some of the empirical literature about differences between suicide bereavement and grief after other modes of death, the author argues that perhaps the most distinguishing and difficult aspect of a suicide loss is the “perceived intentionality” of the death, and the related “perceived responsibility” for the death. The author goes on to identify a number of tasks of psychological reintegration after a suicide loss that can serve as a template for treatment goals for clinicians and clients alike. These include the cultivation of a very specific type of secure and nurturing therapeutic alliance; extensive psychoeducation about suicide, trauma, and grief; the need to help the client repair the psychological continuing bond with the deceased; and providing gentle support for the survivor in rebuilding an assumptive world that has been shattered by the suicide of a loved one. Finally, the article concludes with a discussion of the clinical implications of these differences for work with suicide loss survivors.

Feelings of Blameworthiness and Their Associations With the Grieving Process in Suicide Mourning

AIMS

This study focuses on identifying the correlates associated with the emergence of feelings of blameworthiness associated with a suicide or other traumatic death and its associations with grief complications.

METHODS

Based on a mailed questionnaire survey of 575 mostly white and economically advantaged bereaved parents, 462 who lost a child to suicide, 48 to a drug overdose, 37 to ordinary accidents, and 24 to natural causes, we utilized chi-square tests, correlations and multiple regression analysis to compare and contrast patterns in the data.

RESULTS

Findings showed feelings of blameworthiness associated with grief difficulties, complicated grief, PTSD, depression and other mental health difficulties among suicide bereaved parents. Results among suicide bereaved parents also showed that being stigmatized by socially significant others, having a mixed or negative relationship with the deceased child prior to the death and a less happy marriage, among those presently married couples, all contributed to higher feelings of blameworthiness among these bereaved.

CONCLUSION

Based on these findings, feelings of blameworthiness could serve as a good shorthand indicator of grief problems since it correlates so well with other grief difficulties and mental health problem measures. The importance of peer support is essential for avoiding the downward spiral associated with feelings of blameworthiness that can occur at any time during the grieving process.

'We're the First Port of Call' - Perspectives of Ambulance Staff on Responding to Deaths by Suicide: A Qualitative Study

Introduction

Exposure to suicide is a known risk factor for suicide. Ambulance staff are exposed to work-related stressors including attending suicides, which may elevate their risk for mental health problems/suicide. Little is known about ambulance staff’s perspectives on how they experience these events and whether they feel equipped to respond to bereaved families at the scene of death. This study explores the perspectives of ambulance staff about responding to deaths by suicide.

Materials and Methods

A convenience sample of ambulance staff recruited from one ambulance service in England. In-depth, qualitative, semi-structured face-to-face interviews conducted with nine ambulance staff (six male, three female) to explore experiences of responding to suicide. Data analyzed using thematic analysis.

Results

Participants reported the experience of job-related strain including exposure to the suicide/suicidal ideation of colleagues; they described suppressing their distress despite significant emotional impact. All participants had been personally bereaved by suicide and responding to suicide was a common part of their job. They were often the first professionals at the scene, and undertook varied and often conflicting roles: negotiating with patients in crisis; informing individuals of the death of a loved one; preserving the body/potential crime scene; dealing with the intense emotional reactions of bereaved individuals. Participants reported long-term, salient memories of these events; however, there was a reported lack of acknowledgment in the workplace that suicides may be traumatic and no guidance for staff on how to cope. Opportunities to debrief were reportedly rare, and there was reluctance to access work-based liaison services. Training in how to respond to individuals bereaved by suicide was also lacking.

Discussion

The study is the first to reveal the complex challenges faced by ambulance staff in responding to suicide without adequate training and support. It demonstrates the potential impact that responding to suicide can have personally and professionally on staff, and emphasizes the need for employers to support staff wellbeing in better ways. Training and postvention support could enable better coping among staff, more effective support for bereaved individuals and reduce the risk of death by suicide both in those bereaved by suicide and in ambulance staff.

Evaluation of the Impact of the PABBS Suicide Bereavement Training on Clinicians' Knowledge and Skills

Background: Health-care professionals do not routinely receive training on how best to support parents bereaved by suicide. Evidence-based training - Postvention Assisting Those Bereaved by Suicide (PABBS) - was designed to address this gap. Aims: The study aimed (a) to pilot PABBS training and evaluate its perceived effectiveness (impact on self-reported knowledge, skills and confidence) in managing suicide bereavement; and (b) to explore training acceptability. Method: A pre- and postevaluation design was used. Professionals attended intensive, structured 1-day PABBS training comprising: didactic/interactive teaching; practice-orientated activities supported with real-life materials and a manual/workbook. Evaluation forms completed immediately before and after training analyzed: (a) self-reported changes in knowledge, skills, and confidence (perceived effectiveness of training); and (b) the acceptability of training. Results: In total, 62 professionals completed training. Perceived knowledge, skills, and confidence improved after training as did self-reported understanding, motivation to learn more, and intention to change practice. Training was highly rated, particularly the evidence-based, real-life materials, with some suggestions for improvement. Limitations: Self-selected sample and reliance on self-report measures are the study's limitations. Conclusion: PABBS training may help address gaps in professionals' capacity to support parents bereaved by suicide. The evidence-based content was highly acceptable and appeared to be a key ingredient in effecting self-reported changes in attitudes/intentions.

Adapting Digital Social Prescribing for Suicide Bereavement Support: The Findings of a Consultation Exercise to Explore the Acceptability of Implementing Digital Social Prescribing within an Existing Postvention Service

This paper describes a consultation exercise to explore the acceptability of adapting digital social prescribing (DSP) for suicide bereavement support. Bereavement by suicide increases the risk of suicide and mental health issues. Social prescribing improves connectedness and empowerment and can provide digital outcomes-based reporting to improve the capacity for measuring the effectiveness of interventions. Our aim was to consult on the acceptability and potential value of DSP for addressing the complexities of suicide bereavement support. Our approach was underpinned by implementation science and a co-design ethos. We reviewed the literature and delivered DSP demonstrations as part of our engagement process with commissioners and service providers (marrying evidence and context) and identified key roles for stakeholders (facilitation). Stakeholders contributed to a co-designed workshop to establish consensus on the challenges of providing postvention support. We present findings on eight priority challenges, as well as roles and outcomes for testing the feasibility of DSP for support after suicide. There was a consensus that DSP could potentially improve access, reach, and monitoring of care and support. Stakeholders also recognised the potential for DSP to contribute substantially to the evidence base for postvention support. In conclusion, the consultation exercise identified challenges to facilitating DSP for support after suicide and parameters for feasibility testing to progress to the evaluation of this innovative approach to postvention.

What Is the Experience of Practitioners in Health, Education or Social Care Roles Following a Death by Suicide? A Qualitative Research Synthesis

Recent research has highlighted that the number of people impacted by a death by suicide is far greater than previously estimated and includes wider networks beyond close family members. It is important to understand the ways in which suicide impacts different groups within these wider networks so that safe and appropriate postvention support can be developed and delivered. A systematic review in the form of a qualitative research synthesis was undertaken with the aim of addressing the question ‘what are the features of the experiences of workers in health, education or social care roles following the death by suicide of a client, patient, student or service user?’ The analysis developed three categories of themes, ‘Horror, shock and trauma’, ‘Scrutiny, judgement and blame’, and ‘Support, learning and living with’. The mechanisms of absolution and incrimination were perceived to impact upon practitioners’ experiences within social and cultural contexts. Practitioners need to feel prepared for the potential impacts of a suicide and should be offered targeted postvention support to help them in processing their responses and in developing narratives that enable continued safe practice. Postvention responses need to be contextualised socially, culturally and organisationally so that they are sensitive to individual need.

Suicide and Accidental Death for Australia's Farming Families: How Context Influences Individual Response

This article presents qualitative data to explore the experience of farming family members faced with accidental or suicide death and understand how this is experienced within the farming context. Individual semistructured interviews were conducted with 25 members of Australian farming families bereaved by suicide or accidental death. Qualitative data was thematically analyzed. Three interconnected themes were identified: acceptance of risk, normalization of death, pragmatic behavior patterns and connection to place. Bereavement and reconstruction of meaning following suicide or accidental death for farming families is influenced by the cultural, social, geographical, and psychological contexts of farming families. This article challenges traditional conceptions of suicide and accidental death as necessarily experienced as "violent" or "traumatic," bereavement as experienced similarly across western cultures, and the reaction to suicide or accidental death as one that challenges people's understanding of their world and leaves them struggling to find a reason why the death occurred.

The Perceived Impact of Suicide Bereavement on Specific Interpersonal Relationships: A Qualitative Study of Survey Data

People bereaved by suicide have an increased risk of suicide and suicide attempt, yet report receiving less support than people bereaved by other sudden deaths. Reductions in support may contribute to suicide risk, yet their nature is unclear. We explored the impact of suicide bereavement on the interpersonal relationships of young adults in the UK using an online survey to collect qualitative data. We conducted thematic analysis of free-text responses from 499 adults to questions capturing the impact of bereavement on relationships with partners, close friends, close family, extended family, and other contacts. We identified four main themes describing the changes in relationships following the suicide: (1) Social discomfort over the death (stigma and taboo; painfulness for self or others to discuss; socially prescribed grief reactions); (2) social withdrawal (loss of social confidence; withdrawal as a coping mechanism); (3) shared bereavement experience creating closeness and avoidance; (4) attachments influenced by fear of further losses (overprotectiveness towards others; avoiding attachments as protective). These findings contribute to understanding deficits in support and pathways to suicidality after suicide bereavement. Such disrupted attachments add to the burden of grief and could be addressed by public education on how to support those bereaved by suicide.

Identifying the Social Demographic Correlates of Suicide Bereavement

We investigated the demographic correlates associated with suicide bereavement among a representative sample of U.S. adults from the 2016 General Social Survey. A secondary aim of this study was to use this representative data platform to cross-check official data findings of U.S. completed suicides. Questions on suicide bereavement were administered to 1,432 GSS 2016 respondents and these were cross-tabulated with various demographic and social activity variables included in this omnibus survey to investigate whether suicide bereaved respondents shared any distinctive demographic characteristics. Findings showed that friends of the suicide deceased person outnumbered the deceased's first degree relatives by at least 2 to 1. We also observed older, White, Non-Hispanic, and native born women were over-represented among the suicide bereaved. The suicide bereaved were also less likely to live in the Pacific region, and to live in the nation's largest cities, and were more likely to come from homes where a gun was owned by someone in the household. More of the suicide bereaved reported themselves to be in poorer physical health and bereaved women were more likely to be Facebook subscribers. These findings are consistent with other data on U.S. suicide patterns and the greater likelihood of firearms being utilized in suicide deaths. These revealed demographic correlates of suicide offer valuable information to helping agencies seeking to reach potential clients among the suicide bereaved.

Suicide Bereavement and Differences in Religiosity

Background: The trauma from experiencing a loved one's suicide is often seen as an instigator of change in a person's religious life. Aims: We sought to examine whether suicide-bereaved adults were any differently disposed to religious participation and observances compared with the nonbereaved and whether religiously involved bereaved had any better mental health compared with religiously disaffiliated bereaved. Method: The 2016 General Social Survey (GSS) presented 11 new questions identifying suicide bereavement status. We examined how the bereaved (n = 516) compared with the nonbereaved (n = 916) in terms of their religious beliefs and participation. We also investigated whether suicide bereaved religiously committed adherents, who prayed at least weekly (n = 372), showed any better mental health compared with bereaved who were religiously disaffiliated (n = 102). Results: Initially, results showed the bereaved more inclined to pray and to believe in an afterlife compared with the nonbereaved. However, after sex differences were controlled for, most of the remaining differences between these contrasted groups faded. Limitations: Caution is advised regarding generalizations from these data to all subgroups of suicide bereaved due to the modest number of respondents in many subpopulations. The GSS does not include potentially important grief-related indices, and importantly, most of the current sample were friends of the deceased and not first-degree relatives. Conclusion: We discuss the implications of these findings and the need for further research on the interconnections between religiosity and suicide bereavement.

What are the physical and psychological health effects of suicide bereavement on family members? An observational and interview mixed-methods study in Ireland

OBJECTIVES

Research focussing on the impact of suicide bereavement on family members' physical and psychological health is scarce. The aim of this study was to examine how family members have been physically and psychologically affected following suicide bereavement. A secondary objective of the study was to describe the needs of family members bereaved by suicide.

DESIGN

A mixed-methods study was conducted, using qualitative semistructured interviews and additional quantitative self-report measures of depression, anxiety and stress (DASS-21).

SETTING

Consecutive suicide cases and next-of-kin were identified by examining coroner's records in Cork City and County, Ireland from October 2014 to May 2016.

PARTICIPANTS

Eighteen family members bereaved by suicide took part in a qualitative interview. They were recruited from the Suicide Support and Information System: A Case-Control Study (SSIS-ACE), where family members bereaved by suicide (n=33) completed structured measures of their well-being.

RESULTS

Qualitative findings indicated three superordinate themes in relation to experiences following suicide bereavement: (1) co-occurrence of grief and health reactions; (2) disparity in supports after suicide and (3) reconstructing life after deceased's suicide. Initial feelings of guilt, blame, shame and anger often manifested in enduring physical, psychological and psychosomatic difficulties. Support needs were diverse and were often related to the availability or absence of informal support by family or friends. Quantitative results indicated that the proportion of respondents above the DASS-21 cut-offs respectively were 24% for depression, 18% for anxiety and 27% for stress.

CONCLUSIONS

Healthcare professionals' awareness of the adverse physical and psychosomatic health difficulties experienced by family members bereaved by suicide is essential. Proactively facilitating support for this group could help to reduce the negative health sequelae. The effects of suicide bereavement are wide-ranging, including high levels of stress, depression, anxiety and physical health difficulties.

Do Primary Care Physicians Help the Bereaved With Their Suicide Losses: Loss Survivor Perceptions of Helpfulness From Physicians

Several previous studies suggested that primary care physicians can provide important bereavement assistance to survivors of suicide, yet no study has investigated whether suicide-bereaved patients perceive their physicians as helpful. Contacting bereavement communities on social media, we collected online survey data from 146 bereaved respondents reporting suicides causing them severe emotional distress. Data analysis suggested that nearly half (48%) of the respondents encountered positive, help-offering responses from physicians, compared to 10% whose responses were deemed as negative. Analysis of our data suggested that loss survivors' perceptions of a physician's helping or reproachful responses were associated with differences in grief difficulties and mental health distress.

Liberating burdensomeness of suicide survivorship loss: A Critical Interpretive Synthesis

AIMS AND OBJECTIVES

What is an interpreted and synthesised understanding of responses of survivors to a suicide death of a close person?

BACKGROUND

It is well known that survivors of suicide loss who are in a close relationship with the deceased are at high risk for suicidality and health conditions. Nurses in various settings need evidenced-informed approaches to encounter these vulnerable persons and support their healing journey from postvention to prevention.

DESIGN

The design is reflexive and iterative.

METHOD

A Critical Interpretive Synthesis comprised of six phases: formulating the review question; searching literature; sampling; determining quality; extracting data; interpretive synthesis. Qualitative content analysis was also.

RESULTS

Based on a sample of 15 published full-text qualitative and quantitative nursing research studies published between 1990 and 2016, an aggregated, interpreted and synthesised understanding of responses of survivors of suicide loss to the suicide death of a close person emerged. Four synthesised concepts were: dreading burden of suicide risk and stigma; facing burdensomeness in the aftermath of suicide death; enduring being burdened-unburdened, striving to invest in living; and liberating burdensomeness, journeying toward healing.

CONCLUSIONS

Contextually, geo-cultural gaps exist in published nursing studies. Most studies were from North American and a few from Asia. The reported suicide deaths occurred over a wide range of time. Conceptually, four synthesised concepts can be viewed as a process of moving from burdensomeness to liberating burdensomeness. Methodologically, a small body of knowledge that met quality appraisal was interpreted and synthesised into an understanding of an evidenced-informed approach to guide nurses' encounters with survivors of suicide loss.

RELEVANCE TO CLINICAL PRACTICE

The results contribute to an evidenced-informed approach for nurses in practice to support survivors of suicide loss journeying from burdensomeness to liberating burdensomeness. Results also serve as a foundation for further research.

What are the physical and psychological health effects of suicide bereavement on family members? Protocol for an observational and interview mixed-methods study in Ireland

INTRODUCTION

Research indicates that experiencing the suicide of a relative can have a significant impact on family members' emotional health. However, research incorporating the impact of suicide bereavement on family members' physical health is sparse. This paper details the protocol for a mixed-methods study of suicide-bereaved family members. The study will primarily examine the physical and mental health needs of those bereaved by suicide. A secondary objective of the study is to describe the support service needs of family members bereaved by suicide.

METHODS AND ANALYSIS

A mixed-methods approach, using semistructured interviews and self-report questionnaires, will be used. Interviews will be conducted with a group of 15-20 relatives who experienced suicide bereavement. This protocol will follow the COREQ checklist criteria for the reporting of qualitative research interviews. Thematic analysis will be used to examine experiences and impact of bereavement on psychological and physical health. Self-report quantitative data on well-being will be analysed using descriptive statistics.

ETHICS AND DISSEMINATION

Ethical approval to conduct this study has been granted from the Clinical Research Ethics Committee of the Cork Teaching Hospitals. Pseudonyms will be given to participants to protect anonymity. It will be explained to participants that participation in the study is voluntary and they have to right to withdraw at any time. The findings of this research will be disseminated to regional, national and international audiences through publication in peer-reviewed international journals and presentations at scientific conferences. This research also forms part of a PhD thesis.

Fruits of trauma? Posttraumatic growth among suicide-bereaved parents

BACKGROUND

While there is evidence that suicide-bereaved individuals may be at higher risk for trauma-related outcomes, such as posttraumatic stress disorder or prolonged grief, positive psychology suggests that suicide bereavement may also promote personal growth within the confines of distress characterized as posttraumatic growth (PTG).

AIMS

The aim of this study was to investigate PTG and what variables, such as reflective rumination, resilience, personality variables, and mood states, contribute to PTG among suicide-bereaved parents.

METHOD

Online survey methods were employed using a convenience sample of 154 parents bereaved by the suicide death of their child within 2 years.

RESULTS

Multiple regression analyses revealed that resilience inversely predicted PTG scores, but reflective rumination did not predict PTG. PTG scores were in the low-moderate range and were lower than those of parents bereaved by other causes of death. Items endorsed most strongly corresponded to the PTG factors Relating to Others, Spiritual Change, and Appreciation of Life.

CONCLUSION

In this study, PTG manifests among suicide-bereaved parents, but may be complicated by the proximity to the death and by concurrent brooding and reflective rumination unique to answering the question of "why" in this population.

Helpful and unhelpful responses after suicide: Experiences of bereaved family members

Individuals who are bereaved by suicide and other traumatic natured deaths are thought to be at greater risk of psychological complications, than people bereaved by other means. While it is recognized that interventions can influence the bereavement process, there remains limited communications about both helpful responses and those that may adversely influence the grieving process for the suicide bereaved. This paper presents findings from a narrative study, which sought the experiences of family members after the loss of a loved one as a result of suicide. The study findings demonstrated that responses by agencies are often insensitive and not aligned with the needs of those bereaved. We argue that training is paramount for all services to increase awareness of the needs of people bereaved by suicide and available support services. Changes to organizational policies in relation to finance support would greatly support the bereaved during their time of grief and heightened distress.

Suicide bereavement and complicated grief

Losing a loved to suicide is one is one of life's most painful experiences. The feelings of loss, sadness, and loneliness experienced after any death of a loved one are often magnified in suicide survivors by feelings of quilt, confusion, rejection, shame, anger, and the effects of stigma and trauma. Furthermore, survivors of suicide loss are at higher risk of developing major depression, post-traumatic stress disorder, and suicidal behaviors, as well as a prolonged form of grief called complicated grief. Added to the burden is the substantial stigma, which can keep survivors away from much needed support and healing resources. Thus, survivors may require unique supportive measures and targeted treatment to cope with their loss. After a brief description of the epidemiology and circumstances of suicide, we review the current state of research on suicide bereavement, complicated grief in suicide survivors, and grief treatment for survivors of suicide.

Suicide bereavement and complicated grief

Losing a loved to suicide is one is one of life's most painful experiences. The feelings of loss, sadness, and loneliness experienced after any death of a loved one are often magnified in suicide survivors by feelings of quilt, confusion, rejection, shame, anger, and the effects of stigma and trauma. Furthermore, survivors of suicide loss are at higher risk of developing major depression, post-traumatic stress disorder, and suicidal behaviors, as well as a prolonged form of grief called complicated grief. Added to the burden is the substantial stigma, which can keep survivors away from much needed support and healing resources. Thus, survivors may require unique supportive measures and targeted treatment to cope with their loss. After a brief description of the epidemiology and circumstances of suicide, we review the current state of research on suicide bereavement, complicated grief in suicide survivors, and grief treatment for survivors of suicide.