Parental Grief After Offspring Suicide and Adaptation to the Loss in Japan

Abstract

Several reports have indicated that grief and mental health outcomes of people bereaved by suicide vary by their relationship to the deceased. Parents who have lost offspring experience higher levels of distress than those with other relationships to the deceased. However, there are limited studies investigating the experience of parental bereavement by suicide, and further research is needed. The present study aimed to clarify the differences in grief reactions between bereaved parents and those with other relationships to the deceased in Japan and explore a statistical model of adaptation to the loss. In total, 105 bereaved participants completed a questionnaire covering grief reaction, meaning reconstruction, mental health, social context, and demographic variables. Parents scored higher on several grief reaction items and lower in sense-making than those with other relationships. In addition, path analysis showed that sense-making acted as a moderator in the experience of loss of offspring and grief reaction.

Keywords

suicide grief parent bereavement adaptation

Suicide is a critical public health issue in today’s society. It has been estimated that worldwide, over 800,000 people die by suicide annually. The resulting impact on families, friends, and communities is devastating and far-reaching and can persist long after an individual has taken their own life (World Health Organization, 2014). It has been reported that more than six people are impacted per suicide (Cerel, Maple, Aldrich, & van de Venne, 2013; Shneidman, 1969); therefore, at least 4,800,000 people become bereaved by suicide annually worldwide. In Japan, there are almost 25,000 suicide deaths annually. Although the suicide rate in Japan has declined from a peak of 27 per 100,000 people (over 34,000 people per year), it remains one of the higher rates among developed countries (World Health Organization, 2014). Further, given the moderate estimate of six people impacted per suicide (Shneidman, 1969), at least 150,000 people are affected by suicide each year in Japan.

Bereavement experienced by suicide causes psychological distress and increases the risk for mental health problems (Bolton et al., 2013; Sveen & Walby, 2008), social dysfunction and mortality (Pitman, Osborn, King, & Erlangsen, 2014), and suicide attempts (Agerbo, 2005). Research and strategies to support suicide survivors/suicide bereaved¹ have focused on diverse topics, such as the efficacy of interventions (Jordan & McMenamy, 2004; McDaid, Trowman, Golder, Hawton, & Sowden, 2008), and the need for support (Cerel & Campbell, 2008; de Groot, de Keijser, & Neeleman, 2006; McMenamy, Jordan, & Mitchell, 2008). Several investigations also have been conducted in Japan; for example, Cho (2006) reported on the mental health of suicide survivors. Kawashima and colleagues (Kawashima & Kawano, 2017a; Kawashima, Kawano, Koyama, & Ito, 2010) investigated the aftermath of suicide and adaptation to loss in Japan and found that 78% of their participants had possible mood or anxiety disorders.

Previous studies also pointed out that the grief reactions of suicide survivors differs from that of other bereaved (Jordan, 2001; Jordan & McIntosh, 2011; Sveen & Walby, 2008). For example, Sveen and Walby (2008) reviewed existing research findings and revealed that, for specific aspects of grief, such as rejection, shame, and stigma, there were significant differences between suicide survivors and those bereaved by other causes. Jordan (2001) also demonstrated the thematic aspects of suicide bereavement, proposing three broad dimensions of suicide survivors’ grief process: struggling to find meaning in the loss, guilt, or blame and rejection or abandonment along with anger toward the deceased. In Japan, there are few studies regarding the differences in the grief process between suicide survivors and those bereaved by other causes, but Hirayama (2004) described the grief reactions of suicide survivors, which include self-blaming, feeling pain, anger toward the deceased, and longing for the loved one. These studies influenced the development of the scale we used in the current study; from these studies, we extracted the seven aspects of grief reaction after suicide, that is, pain, yearning, nonacceptance, disbelief, feeling alone, anger, and self-blame. The detail of the scale will be explained in the Method section.

Meaning-Making of Suicide Survivors

The importance of meaning-making has been pointed out elsewhere in bereavement studies; people are driven by a psychological need to find or create a sense of meaning and purpose in their lives, even with respect to the most horrific experiences (Gillies & Neimeyer, 2006). Further, from a constructivist viewpoint, experiencing the loss of a loved one can shake or break one’s assumptive world (Janoff-Bulman, 1992) or meaning structures (Gillies & Neimeyer, 2006), and thus the central process in grieving is meaning reconstruction in response to a loss (Neimeyer, 2001). Therefore, we should pay careful attention to the active aspects of the grief process, rather than merely focusing on the passive aspects, such as grief reactions (Kawashima, 2008).

Meaning reconstruction comprises two major activities: sense-making and benefit-finding (Davis, Nolen-Hoeksema & Larson, 1998; Gillies & Neimeyer, 2006, Kawashima, 2008). Sense-making, or meaning as comprehensibility (Janoff-Bulman & Frantz, 1997), is an activity that involves questioning, finding, and gaining a sense of comprehension about the bereavement. Benefit-finding, or meaning as significance (Janoff-Bulman & Frantz, 1997), involves building new meaning structures and finding positive implications of the loss. Previous reports have shown that bereaved individuals face many difficulties when attempting to make sense of the loss of their loved ones by violent death, such as accident or homicide (Davis et al., 1998; Lehman, Wortman, & Williams, 1987; Murphy, Johnson, & Lohan, 2003).

The experience of suicide bereavement is a challenge to survivors’ assumptive worlds or meaning structures because most of the bereaved were blindsided by the suicide, that is, they had no awareness that their loved one was considering ending his or her life, and the shock effects are usually most prominent among survivors (Sands, Jordan, & Neimeyer, 2011). Thus, searching for the meaning of the loss is central theme among the survivors (Jordan, 2001). Based on the above knowledge, Kawashima and colleagues (Kawashima & Kawano, 2017a; Kawashima et al., 2010) conducted empirical studies on Japanese suicide survivors. Their results indicated that suicide bereaved faced many difficulties in making sense of their loss and that sense-making activities predicted adaptation to loss from suicide. Despite increasing research evidence, there is insufficient knowledge, and further study is needed.

Parental Grief After Suicide

The relationship to the deceased is a primary factor in survivors’ adaptation to loss by suicide (McIntosh & Jordan, 2011). Previous reports have indicated that closely related survivors of suicide show higher distress (Cleiren, Diekstra, Kerkhof, & van der Wal, 1994). For example, Mitchell, Kim, Prigerson, and Mortimer-Stephens (2004) reported that bereaved who lost a spouse, partner, or children showed significantly higher scores for complicated grief than those with other relationships (in-laws and friends/coworkers). A literature review by Pitman et al. (2014) showed the experience of suicide was associated with several negative health and social outcomes for the bereaved, and these depended on the individual’s relationship to the deceased.

Further, among the bereavements of loved ones, losing a child is the most devastating experience because “the death of a child, even if the latter is already an adult, is almost always felt as unnatural by the parents” (Cleiren et al., 1994, p. 27). Therefore, the parental grief process after the loss of a child is reported to be more intensive and longer than for those with other types of loss (Middleton, Raphael, Burnett, & Martinek, 1998; Sanders, 1979–1980).

The experience of losing offspring to suicide has also been explored, and several qualitative reports (Kawashima & Kawano, 2017b; Maple, Edwards, Minichiello, & Plummer, 2012; Maple, Edwards, Plummer, & Minichiello, 2010; Sugrue, McGilloway, & Keegan, 2014) have indicated that parents who lost offspring by suicide faced distress and difficulties, and the parental experience of this loss differed from that of other relationships to the deceased (e.g., children, partners, etc.). For example, Maple et al. (2010) described the difficulties faced by parents who lost offspring given the contemporary social and cultural context of grief and suicide. Kawashima and Kawano (2017b) reported that a Japanese mother who lost her son to suicide strongly felt responsibility for her son’s death and searched for the meaning of the loss. Further, some quantitative studies with control groups have also been conducted (e.g., Feigelman, Feigelman, Jordan, & McIntosh, 2012; Miyabayashi & Yasuda, 2007), and parents who lost their children by suicide more often reported being blamed, held accountable, and disliked than other surviving parents (McIntosh & Jordan, 2011).

Despite these findings, it is unclear why parental grief is so devastating and prolonged. From the constructivist viewpoint, losing children is an unnatural experience, and thus, it causes a major shock to one’s assumptive world or meaning structures. Further, a report by Currier, Holland, and Neimeyer (2006) shows that those bereaved by violent death experienced more complications in grieving than those bereaved by natural, sudden causes of death, and that sense-making perfectly explained this difference. Therefore, we hypothesized that the relationship between loss of a child and the devastating parental grief reactions might be also mediated by meaning-making.

To investigate the above hypothesis, we should consider the limitations of the previous studies: First, studies have examined meaning-making in a variety of populations, but exploration of meaning-making processes among parents who experienced loss of a child to any cause of death has been limited (Lichtenthal, Neimeyer, Currier, Roberts, & Jordan, 2013). In particular, parental grief after offspring suicide and its relationship to meaning-making have not been sufficiently considered (Kawashima & Kawano, 2017a), and further study is needed to test the above hypothesis. Second, most previous studies have focused on only one kinship category (e.g., parents only, widows only) or on comparisons with other surviving parents. Although we should pay careful attention to the notion that “each specific relationship potentially involves its own aspects of grief and bereavement” (McIntosh & Jordan, 2011, p. 43), the differences between parental grief processes and those of other relationships remain unclear. Therefore, a comparative study of the differences between parental grief after offspring suicide and that of people with other relationships to the deceased is necessary. Third, in supporting suicide survivors, social contexts such as social support and care should be targeted to each grief process, particularly if they differ by relationship to the deceased. In addition, previous reports show that negative social contexts, such as secondary wounding,² a psychological scar that occurs postsuicide, were frequently reported by suicide survivors (Hirayama, 2004; Shimizu, 2009) and affected their adaptation (Kawashima & Kawano, 2017a). Therefore, a model of the parental grief process including both facilitative and complicating factors, especially social contexts, should be explored.

This study aimed to clarify the differences in the grief reactions between bereaved parents and those with other relationships and to explore a model of adaptation to loss, including factors related to their distress.

Method

Participants

The current study was conducted during the period from December 2007 to June 2008. We contacted 32 known support groups for suicide survivors in Japan to ask for assistance; 23 groups agreed to cooperate. Then, we sent 461 questionnaires to these groups and asked them to circulate the questionnaires among their members and contacts. Completed questionnaires were received from 111 suicide bereaved. We also asked an Internet-based support group for suicide survivors to post a request for participation. Five survivors contacted us to express interest in our study. We sent briefing paper about the study and consent form to these five survivors by e-mail, and all five agreed to participate in our study. We received three completed questionnaires from this group. In total, we received 114 completed questionnaires. Of these, 105 indicated their relationship to the deceased (response rate: 22.5%) and were included in our analysis.

Overall, 49 participants (46.7%) had lost a child, 23 (21.9%) had lost a parent, 22 (20.9%) had lost a partner, and 11 (10.5%) had lost a sibling. We conducted a preliminary investigation of the differences among participants who lost a parent, partner, or sibling and found significant differences in age distribution (χ²= 25.08, p < .05), mental health as scored by the Kessler Psychological Distress Scale (K6), F(2, 51) = 3.69, p < .05, and perceived social support, F(2, 46) = 4.58, p < .05. However, we did not find any differences in grief process (i.e., grief reaction and meaning reconstruction), which were the primary research targets in our study. Therefore, for the purpose of the present study, we combined participants who lost parents, partners, or siblings into a single group (n = 56; 53.3%).

All participants gave informed consent before participating and were involved in this study on a voluntary basis. This study was part of a larger study of Japanese suicide survivors who use support groups and was approved by the institutional review board of the Japanese National Center of Neurology and Psychiatry.

Questionnaire

The questionnaire comprised items covering grief reaction, meaning reconstruction (sense-making and benefit-finding), mental health status (assessed with the K6), social context (social support and secondary wounding), and demographic variables (age, sex, relationship to the deceased, deceased’s age and sex, and information about how many months ago the death occurred).

Grief reaction

We developed an original scale to assess the grief reaction of suicide survivors. First, we collected items from the Inventory of Complicated Grief (Prigerson et al., 1995) and narratives from Japanese suicide bereaved around topics such as feeling pain and longing for the deceased (Hirayama, 2004; Jishi Iji Henshu Iinkai & Ashinaga Ikueikai, 2005). Next, we elaborated these from the perspective of the unique features of grief following suicide, such as self-blame, anger, and disbelief (Jordan & McIntosh, 2011). However, searching for the reason of the death, a primary feature of suicide grief (Jordan, 2001) is an activity rather than passive reaction from the constructivism viewpoint (Gillies & Neimeyer, 2006). Therefore, we did not include sense-making as a grief reaction. Finally, we constructed seven items covering specific themes: pain (“I cannot help anguish about his or her death”), yearning (“I feel myself longing for the person who died”), nonacceptance (“I cannot accept the death of the person who died”), disbelief (“I feel disbelief over the death”), alone (“I feel lonely a great deal of the time ever since he or she died”), anger (“I feel angry about his or her death”), and self-blame (“I blame myself for his or her death”). Participants were asked to answer each question on a scale from 1 (none of the time) to 5 (all of the time). We assumed a one-factor model for the scale, and principal-component analysis yielded one factor that included all seven items. The Cronbach’s α for the scale was .84 in the present study. Further, the total score of the grief reaction was significantly correlated with mental health scored by K6 (r = .498, p < .001), consistent with previous reports that addressed psychometric properties of grief scales (Neimeyer, Hogan, & Laurie, 2008). These show a certain level of validity and reliability of the scale; thus, the sum of each response was calculated and used in the analysis. Total grief reaction scores ranged from 7 to 35.

Meaning reconstruction

This comprised two components of meaning—sense-making and benefit-finding. Meaning reconstruction was assessed using single-item questions (Currier et al., 2006; Davis et al., 1998; Holland, Currier, & Neimeyer, 2006; Lehman et al., 1987). We measured sense-making with the question “Do you feel that you have been able to make sense of the death?” Benefit-finding was measured with the question: “Sometimes people who lose a loved one find some positive aspect in the experience. For example, some people feel they learn something about themselves or others. Do you feel that you have found anything positive in your experience?” These questions corresponded closely to the single-item questions used by other researchers to measure these components of meaning for quantitative purposes (Currier et al., 2006; Davis et al., 1998; Holland et al., 2006; Lehman et al., 1987). Participants were asked to answer each question on a scale from 1 (not at all) to 4 (strongly felt).

Mental health

To assess participants’ mental health status, we used the K6 (Furukawa et al., 2008; Kessler et al., 2003). The K6 Scale consists of six items preceded by the following instruction: “The following questions ask about how you have been feeling during the past 30 days. For each question, please circle the number that best describes how often you had this feeling.” Participants were asked to answer each question regarding their feelings (e.g., nervous, hopeless, and worthless) on a scale from 1 (none of the time) to 4 (all of the time). Possible K6 scores range from 0 to 24, with scores of 5 or above indicating the possibility of psychological distress (e.g., mood or anxiety disorders) in a Japanese population (Sakurai, Nishi, Kondo, Yanagida, & Kawakami, 2011). In this study, the Cronbach’s α for the scale was .87. We used the total score as the index of mental health rather than the cutoff point.

Social context

Participants answered questions about social support and secondary wounding. Based on previous research with Japanese suicide bereaved (Kawashima & Kawano, 2017a; Kawashima et al., 2010), participants indicated the extent of their experience of support and wounding from other people, including other family members, relatives, friends, neighbors, colleagues, teachers, police officers, emergency service workers, health professionals, lawyers, monks or clergy, local government officers, support group staff, other suicide bereaved, the media, and others. Support and wounding experiences were reported on a scale from 0 (none) to 4 (felt strongly). In this study, the sum of each response (with the exception of “others”) was calculated and used in the analysis. Total scores for social support and secondary wounding ranged from 0 to 60, and the Cronbach’s αs for the scale were .68 (social support) and 76 (secondary wounding).

Statistical Analysis

First, we assessed the demographic differences between the sample of parents and others. We used Fisher’s exact tests to examine the differences between participants’ sex and that of the deceased. We used χ² tests to examine the differences in participants’ age and age of the deceased between parents and those with other relationships to the deceased. We conducted t tests to examine differences in the relationship to the deceased with respect to the time since the loss occurred. Second, we considered differences between parents and those with other relationships to the deceased on the study variables: grief reaction, meaning reconstruction, mental health status (K6 score), and social context (social support and secondary wounding). For these analyses, we used t tests (with the Bonferoni correction for grief reaction items). Third, we conducted path analysis based on structural equation modeling to identify the statistical model that best explained the grief process and related factors of parents bereaved by suicide. We first input grief reaction and K6 scores as outcome variables and input the other variables (including meaning reconstruction, social context, and demographic variables) as predictor variables. Then, we removed nonsignificant variables and modified the model until it showed high goodness-of-fit indices. The full information maximum likelihood method (Enders & Bandalos, 2001) was used to deal with the missing data in our analyses.

All statistical analyses were performed with IBM SPSS Statistics version 22 and IBM Amos version 20.

Results

Participants’ demographic characteristics are shown in Table 1.
Table 1.
Participants’ Demographic Variables.

Parents (n = 49)
Others^a (n = 56)
Total

n % n % n %

Sex

Male 6 12.2 18 32.1 24 22.9

Female 43 87.8 38 67.9 81 77.1

Age (years)

10–19 0 0.0 1 1.8 1 1.0

20–29 1 2.0 6 10.7 7 6.7

30–39 0 0.0 14 25.0 14 13.3

40–49 4 8.2 14 25.0 18 17.1

50–59 27 55.1 11 19.6 38 36.2

>60 17 34.7 10 17.9 27 25.7

Sex of the deceased

Male 33 67.3 33 58.9 66 62.9

Female 16 32.7 23 41.1 39 37.1

Age of the deceased (years)

10–19 11 22.4 3 5.4 14 13.3

20–29 25 51.0 5 8.4 30 28.6

30–39 10 20.4 10 17.9 20 19.0

40–49 2 4.1 14 25.0 16 15.2

50–59 1 2.0 11 19.6 12 11.4

>60 0 0.0 13 23.2 13 12.4

Mean SD Mean SD Mean SD

Months since the loss^b 51.71 53.00 103.39 120.64 79.07 98.06

Note. N = 105. SD = standard deviation.

a
Participants who lost a parent, partner, or sibling. ^bn = 102.

There were several significant differences between the parent sample (participants who had lost a child) and participants with other relationships to the deceased. In the parent sample, there were 6 males and 43 females, and in the other relationship sample, there were 18 males and 38 females. Almost 90% of parents were aged over 50 years, but most participants in the other relationships group were in their 30s and 40s. We found significant differences in the male to female ratio (Fisher’s exact test, p < .05) and in age distribution (χ²= 32.63, p < .001). In the parent sample, 33 of the deceased were male and 16 were female, and in the other relationships group, 33 of the deceased were male and 23 were female. In the parent sample, over half of the deceased were in their 20s (55.1%). In contrast, the ages of the deceased among those who had lost parents, partners, and siblings were widely distributed. We did not find a significant difference in the male to female ratio (Fisher’s exact test, ns), but there was a significant difference in age distribution (χ²= 47.99, p < .001). The average number of months since the loss occurred was 51.71 (SD = 53.00) in the parent sample and 103.39 (SD = 120.64) in the other relationships sample. There was a significant difference in the months since the loss occurred between the parent sample and those with other relationships to the deceased, t(75) = −2.85, p < .01.

As shown in Table 2, parents scored higher on several grief reaction items: pain, t(96) = 3.63, p < .001; yearning, t(95) = 2.90, p < .01; nonacceptance, t(96) = 4.98, p < .001; disbelief, t(97) = 4.59, p < .001; and total grief reaction score, t(92) = 3.91, p < .001. However, there were no significant differences for the items alone, anger, and self-blame.
Table 2.
Descriptive Information for Grief Reaction Items and t Test Results.

Variables Groups Mean SD t p Value^a

Pain Parents 4.49 0.86 3.63 ***

Others 3.73 1.25

Yearning Parents 4.30 1.11 2.90 *

Others 3.57 1.37

Nonacceptance Parents 3.91 1.24 4.98 *

Others 2.64 1.27

Disbelief Parents 3.62 1.40 4.59 *

Others 2.37 1.31

Alone Parents 2.93 1.47 0.26

Others 2.85 1.51

Anger Parents 2.30 1.23 0.14

Others 2.26 1.38

Self-blame Parents 4.24 1.09 2.60

Others 3.63 1.31

Sum of the items Parents 25.62 5.52 3.91 ***

Others 20.63 6.61

a
When we conducted t test for each grief reaction item, we applied Bonfferoni corrections.

*
p < .05. p < .001.

Table 3.
Results of t Tests for Meaning Reconstruction, Mental Health, and Social Context.

Variables Groups Mean SD t p Value

Meaning reconstruction

Sense-making Parents 2.41 0.88 −3.21

Others 2.98 0.78

Benefit-finding Parents 3.17 0.92 −1.65

Others 3.46 0.78

Mental health (K6) Parents 10.39 6.07 1.15

Others 8.98 5.98

Social context

Social support Parents 14.49 6.30 −0.29

Others 14.96 8.36

Secondary wounding Parents 7.57 6.65 −0.37

Others 8.12 7.55

Note.* K6 = Kessler Psychological Distress Scale.

**
p < .01.

Parents scored lower in sense-making than those with other relationships to the deceased, t(89) = − 3.27, p < .01. However, no significant differences were found in other variables, including K6 scores and social context (social support and secondary wounding) (Table 3).

The path analysis yielded a model that best explained parental adaptation to suicide bereavement (Figure 1). After controlling the effects of demographic variables on grief reaction, the direct path from the relationship to the deceased to grief reaction was not significant, but the association was significantly intermediated by sense-making activity. In other words, sense-making activity acted as a moderator in the experience of loss of offspring and grief reaction. We also explored factors related to parents’ adaptation to loss and found secondary wounding negatively affected grief and mental health. In addition, benefit-finding activity independently affected mental health. In contrast, the deceased’s sex, time since the loss occurred, and social support were not significantly related to mental health or grief reaction.
Figure 1.
Path model for parental grief and adaptation to the loss.^a,b,c ^aInformation on standard error was removed from the figure.

Discussion

Bereaved parents showed higher levels of distress, particularly in grief reaction and sense-making activity than those with other relationships to the deceased. More precisely, parents reported higher scores for pain, yearning, nonacceptance, disbelief, and sense-making, which may characterize parental grief after offspring suicide in Japan. Further, consistent with our findings, previous reports (Maple et al., 2010, 2012; Sugrue et al., 2014) noted the difficulties of parental grief and importance of meaning-making after the loss of offspring. In contrast, we found no significant differences in K6 scores, suggesting that mental health may not always be affected by relationship to the deceased. However, as we previously noted, participants who lost offspring were older than those who lost parents, partners, or siblings. In addition, there were significant differences in participants’ sex and the time since the loss occurred. Thus, we conducted the path analysis, and the results revealed that the association between experiencing the loss of offspring and parental adaptation was strongly mediated by sense-making activity. More precisely, the experience of losing one’s offspring causes difficulties for sense-making activity, leading to elevated grief reactions and deterioration of mental health. As mentioned previously, sense-making has been shown to explain why those bereaved by violent death experience more complications in grieving compared with those bereaved by natural, sudden causes of death (Currier et al., 2006). The current study showed that sense-making activity also accounted for the differences in adaptation to loss between those who experience loss of offspring to and those with other relationships to the deceased.

In addition, benefit-finding activity and secondary wounding affected the adaptation of suicide survivors. Previous reports (Hirayama, 2004; Shimizu, 2009) also highlighted the negative effects of secondary wounding on adaptation to loss, which is consistent with our results. It should be remembered that it is important to support suicide survivors’ meaning reconstruction to assuage their distress and secondary wounding experiences.

Although we found participants’ sense-making activity was affected by kinship, other variables such as grief reaction, mental health scored by K6, secondary wounding, and benefit-finding activity were not in the path analysis. Further, time since the loss, an important component in parents’ adaptation to the violent death of a child in the previous studies (e.g., Feigelman et al., 2012; Murphy, Johnson, Wu, Fan, & Lohan, 2003) did not have a significant effect on mental health or grief reactions in the present study. These results may represent parental grief after suicide in Japan; however, it should be noted that there were significant differences between the parent and nonparent bereavement groups with respect to those variables, and these differences might have affected our findings. Therefore, we should reexamine the findings of the present study after accumulating empirical findings through further investigations.

Clinical Implications

Sense-making activity plays an important role in parental adaptation after the suicide loss of offspring, consistent with findings of previous reports (Kawashima & Kawano, 2017b; Maple et al., 2010, 2012; Murphy et al., 2003; Sugrue et al., 2014). Therefore, professionals who support suicide survivors should support engagement in a meaning construction process. In contrast, benefit-finding activity only affected survivors’ mental health. Further, secondary wounding and benefit-finding activity independently affected survivors’ adaptation. Therefore, we should pay careful attention to survivors’ social context and continue postvention efforts, including educational training for health professionals, accumulating research findings, and destigmatizing suicide.

Previous reports have noted that the meaning-making process is affected by factors such as optimism and religious belief (Gillies & Neimeyer, 2006; Kawashima, 2008). For example, Kawashima and Kawano (2017b) reported the meaning reconstruction process of a Japanese mother who lost her son to suicide and described how the symbolic bonds between mother and son were narrated within a cultural–spiritual context. In our study, we could not find factors that promoted meaning reconstruction, with the exception of relationship to the deceased. However, we should continue to search for key points to help suicide survivors’ adaptation and use these as scaffolding to support the meaning reconstruction process.

Limitations and Further Directions

Our study has several limitations. First, we did not sufficiently consider parents’ sex differences in adaptation to loss of offspring, and the experience of bereavement and adaptation to loss might differ between fathers and mothers. In particular, previous reports suggest that the mother–child bond may be stronger than the father–child bond (Kawashima & Kawano, 2017b; Sugrue et al., 2015). In addition, we did not consider differences in relationships to the deceased among those in the other relationships group; that is, parents, partners, and siblings, as the sample size for each group was too small. We found significant differences in age distribution, mental health status, and social support among the other relationship group; therefore, the experiences of bereavement might differ in several ways (Mitchell et al., 2004). The variety of relationships to the deceased was not fully covered by the relationship categories we used, and future studies should consider the social functioning of the family system (Cerel, Jordan, & Duberstein, 2008). Further studies should be conducted to gain deeper understanding of parental adaptation to loss. Second, we did not compare parental grief by suicide in Japan with that in other countries. Therefore, future studies should consider this issue to show any cross-cultural differences in parental adaptation to loss by suicide. Third, we did not perform a longitudinal study. This is particularly important because the meaning of loss changes over time (Davis et al., 1998). We should follow the meaning reconstruction process longitudinally in a future study and reconsider the adaptation model of parental bereavement after offspring suicide. Fourth, we have distributed the questionnaire through support groups for suicide survivors, but those survivors who do not participate in such groups may experience their grief in different ways. In addition, social treatment of suicide survivors has changed drastically over the last 10 years in Japan (Kawashima & Kawano, 2017a): Japanese survivor support groups have greatly increased in number during the past decade, and peer-led suicide survivor support groups have been more widely available and acceptable throughout the country. The grief of Japanese suicide survivors might change in the coming years, and thus, future research will be needed to reconsider the findings of the current study.

Despite these limitations, we should also consider the current status of suicide postvention in Japan. As noted, few studies in Japan have focused on adaptation to loss by suicide (Kawashima & Kawano, 2017a). Further, there are limited empirical reports of parental grief after offspring suicide. Therefore, the results of the present exploratory study are valuable, and future studies should consider this along with extending postvention efforts.

	Parents (n = 49)	Others^a (n = 56)	Total
Sex
Male	6	12.2	18	32.1	24	22.9
Female	43	87.8	38	67.9	81	77.1
Age (years)
10–19	0	0.0	1	1.8	1	1.0
20–29	1	2.0	6	10.7	7	6.7
30–39	0	0.0	14	25.0	14	13.3
40–49	4	8.2	14	25.0	18	17.1
50–59	27	55.1	11	19.6	38	36.2
>60	17	34.7	10	17.9	27	25.7
Sex of the deceased
Male	33	67.3	33	58.9	66	62.9
Female	16	32.7	23	41.1	39	37.1
Age of the deceased (years)
10–19	11	22.4	3	5.4	14	13.3
20–29	25	51.0	5	8.4	30	28.6
30–39	10	20.4	10	17.9	20	19.0
40–49	2	4.1	14	25.0	16	15.2
50–59	1	2.0	11	19.6	12	11.4
>60	0	0.0	13	23.2	13	12.4
	Mean	SD	Mean	SD	Mean	SD
Months since the loss^b	51.71	53.00	103.39	120.64	79.07	98.06

Variables	Groups	Mean	SD	t	p Value^a
Pain	Parents	4.49	0.86	3.63	***
	Others	3.73	1.25
Yearning	Parents	4.30	1.11	2.90	*
	Others	3.57	1.37
Nonacceptance	Parents	3.91	1.24	4.98	***
	Others	2.64	1.27
Disbelief	Parents	3.62	1.40	4.59	***
	Others	2.37	1.31
Alone	Parents	2.93	1.47	0.26
	Others	2.85	1.51
Anger	Parents	2.30	1.23	0.14
	Others	2.26	1.38
Self-blame	Parents	4.24	1.09	2.60
	Others	3.63	1.31
Sum of the items	Parents	25.62	5.52	3.91	***
	Others	20.63	6.61

Variables	Groups	Mean	SD	t	p Value
Meaning reconstruction
Sense-making	Parents	2.41	0.88	−3.21	**
	Others	2.98	0.78
Benefit-finding	Parents	3.17	0.92	−1.65
	Others	3.46	0.78
Mental health (K6)	Parents	10.39	6.07	1.15
	Others	8.98	5.98
Social context
Social support	Parents	14.49	6.30	−0.29
	Others	14.96	8.36
Secondary wounding	Parents	7.57	6.65	−0.37
	Others	8.12	7.55

Footnotes

Authors’ Note

A component of this study was presented at the 2015 International Summit on Suicide Research in New York, USA.

Acknowledgments

The authors appreciate all participants and support groups that cooperated in this research.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported in part by a Grant-in-Aid for Scientific Research (B) from the Japan Society for the Promotion of Science (25285196) and a Chukyo University Research Fund from Chukyo University.

Notes

Daisuke Kawashima, PhD, is an associate professor in the School of Psychology at Chukyo University. His research focuses on attitudes toward death, bereavement, and suicide prevention.

Kenji Kawano, PhD, is a professor in the College of Comprehensive Psychology at Ritsumeikan University. His research has focused on suicide prevention, community mental health, and aging.

References

Agerbo

(2005) Midlife suicide risk, partner’s psychiatric illness, spouse and child bereavement by suicide or other modes of death: A gender specific study. Journal of Epidemiology and Community Health 59(5): 407–412.

Bolton

J. M.

Leslie

W. D.

Martens

P. J.

Enns

M. W.

Roos

L. L

Sareen

(2013) Parents bereaved by offspring suicide: A population-based longitudinal case-control study. JAMA Psychiatry 70(2): 158–167.

Cerel

Campbell

F. R.

(2008) Suicide survivors seeking mental health services: A preliminary examination of the role of an active postvention model. Suicide and Life-Threatening Behavior 38(1): 30–34.

Cerel

Jordan

J. R.

Duberstein

P. R.

(2008) The impact of suicide on the family. Crisis: The Journal of Crisis Intervention and Suicide Prevention 29(1): 38–44.

Cerel

Maple

Aldrich

van de Venne

(2013) Exposure to suicide and identification as survivor. Crisis: The Journal of Crisis Intervention and Suicide Prevention 34(6): 413–419.

Cho

(2006) Hitowa naze jisatsu surunoka [Why do people die by suicide?], Tokyo, Japan: Bensei.

Cleiren

Diekstra

R. F.

Kerkhof

A. J.

van der Wal

(1994) Mode of death and kinship in bereavement: Focusing on “who” rather than “how.”. Crisis: The Journal of Crisis Intervention and Suicide Prevention 15(1): 22–36.

Currier

J. M.

Holland

J. M.

Neimeyer

R. A.

(2006) Sense-making, grief, and the experience of violent loss: Toward a mediational model. Death Studies 30(5): 403–428.

Davis

C. G.

Nolen-Hoeksema

Larson

(1998) Making sense of loss and benefiting from the experience: Two construals of meaning. Journal of Personality and Social Psychology 75(2): 561–574.

10.

de Groot

de Keijser

Neeleman

(2006) Grief shortly after suicide and natural death: A comparative study among spouses and first-degree relatives. Suicide and Life-Threatening Behavior 36(4): 418–431.

11.

Enders

C. K.

Bandalos

D. L.

(2001) The relative performance of full information maximum likelihood estimation for missing data in structural equation models. Structural Equation Modeling 8(3): 430–457.

12.

Feigelman

Jordan

J. R.

McIntosh

J. L.

Feigelman

(2012) Devastating losses: How parents cope with the death of a child to suicide or drugs, New York, NY: Springer.

13.

Furukawa

T. A.

Kawakami

Saitoh

Ono

Nakane

Nakamura

Kikkawa

(2008) The performance of the Japanese version of the K6 and K10 in the World Mental Health Survey Japan. International Journal of Methods in Psychiatric Research 17(3): 152–158.

14.

Gillies

Neimeyer

R. A.

(2006) Loss, grief, and the search for significance: Toward a model of meaning reconstruction in bereavement. Journal of Constructivist Psychology 19(1): 31–65.

15.

Hirayama

(2004) Mizukara itta anata, nokosareta watashi: Kazoku no jishi to mukiau [You made away with yourself, and I bereaved], Tokyo, Japan: Asahi Shinbunsha.

16.

Holland

J. M.

Currier

J. M.

Neimeyer

R. A.

(2006) Meaning reconstruction in the first two years of bereavement: The role of sense-making and benefit-finding. Omega: Journal of Death and Dying 53(3): 175–191.

17.

Janoff-Bulman

(1992) Shattered assumptions: Towards a new psychology of trauma, New York, NY: Free Press.

18.

Janoff-Bulman

Frantz

C. M.

(1997) The impact of trauma on meaning: From meaningless world to meaningful life. In: Power

M. J.

Brewin

C. R.

(eds) The transformation of meaning in psychological therapies: Integrating theory and practice, New York, NY: Wiley, pp. 91–106.

19.

Jishi Iji Henshu Iinkai Ashinaga Ikueikai (2005) Jisatsu tte ienakatta [Can’t say “Jisatsu (Suicide)”], Tokyo, Japan: Sunmark.

20.

Jordan

J. R.

(2001) Is suicide bereavement different? A reassessment of the literature. Suicide and Life-Threatening Behavior 31(1): 91–102.

21.

Jordan

J. R.

McIntosh

J. L.

(2011) Suicide bereavement: Why study survivors of suicide loss? In: Jordan

J. R.

McIntosh

J. L.

(eds) Grief after suicide: Understanding the consequences and caring for the survivors, New York, NY: Routledge, pp. 3–17.

22.

Jordan

J. R.

McMenamy

(2004) Interventions for suicide survivors: A review of the literature. Suicide and Life-Threatening Behavior 34(4): 337–349.

23.

Kawashima

(2008) Meaning reconstruction theory: Perspectives and future approaches. Japanese Psychological Review 51(4): 485–499.

24.

Kawashima, D., & Kawano, K. (2017a). Japan Research-informed support for suicide survivors. In K. Andriessen, K. Krysinska, & O. T. Grad (Eds.), Postvention in action: The international handbook of suicide bereavement support (pp. 396–401). Boston, MA: Hogrefe Publishing Corporation.

25.

Kawashima, D., & Kawano, K. (2017b). Meaning reconstruction process after suicide: Life-story of a Japanese woman who lost her son to suicide. Omega: Journal of Death and Dying, 75(4), 360–375. doi:10.1177/0030222816652805.

26.

Kawashima

Kawano

Koyama

Ito

(2010) Exploring the variables related to mental health of suicide survivors. Journal of Mental Health 56: 55–63.

27.

Kessler

R. C.

Barker

P. R.

Colpe

L. J.

Epstein

J. F.

Gfroerer

J. C.

Hiripi

Zaslavsky

A. M.

(2003) Screening for serious mental illness in the general population. Archives of General Psychiatry 60(2): 184–189.

28.

Lehman

D. R.

Wortman

C. B.

Williams

A. F.

(1987) Long-term effects of losing a spouse or child in a motor vehicle crash. Journal of Personality and Social Psychology 52(1): 218–231.

29.

Lichtenthal

W. G.

Neimeyer

R. A.

Currier

J. M.

Roberts

Jordan

(2013) Cause of death and the quest for meaning after the loss of a child. Death Studies 37(4): 311–342.

30.

Maple

Edwards

H. E.

Minichiello

Plummer

(2012) Still part of the family: The importance of physical, emotional and spiritual memorial places and spaces for parents bereaved through the suicide death of their son or daughter. Mortality: Promoting the Interdisciplinary Study of Death and Dying 18(1): 54–71.

31.

Maple

Edwards

Plummer

Minichiello

(2010) Silenced voices: Hearing the stories of parents bereaved through the suicide death of a young adult child. Health and Social Care in the Community 18(3): 241–248.

32.

McDaid

Trowman

Golder

Hawton

Sowden

(2008) Interventions for people bereaved through suicide: Systematic review. The British Journal of Psychiatry 193(6): 438–443.

33.

McMenamy

J. M.

Jordan

J. R.

Mitchell

A. M.

(2008) What do suicide survivors tell us they need?: Results of a pilot study. Suicide and Life-Threatening Behavior, 38(4): 375–389.

34.

McIntosh

J. L.

Jordan

J. R.

(2011) The impact of suicide on adults. In: Jordan

J. R.

McIntosh

J. L.

(eds) Grief after suicide: Understanding the consequences and caring for the survivors, New York, NY: Routledge, pp. 43–79.

35.

Middleton

Raphael

Burnett

Martinek

(1998) A longitudinal study comparing bereavement phenomena in recently bereaved spouses, adult children and parents. Australian and New Zealand Journal of Psychiatry 32(2): 235–241.

36.

Mitchell

A. M.

Kim

Prigerson

H. G.

Mortimer-Stephens

(2004) Complicated grief in survivors of suicide. Crisis: The Journal of Crisis Intervention and Suicide Prevention 25(1): 12–18.

37.

Miyabayashi

Yasuda

(2007) Effects of loss from suicide, accidents, acute illness and chronic illness on bereaved spouses and parents in Japan: Their general health, depressive mood, and grief reaction. Psychiatry and Clinical Neurosciences 61(5): 502–508.

38.

Murphy

S. A.

Johnson

L. C.

Lohan

(2003) Finding meaning in a child’s violent death: A five-year prospective analysis of parents’ personal narratives and empirical data. Death Studies 27(5): 381–404.

39.

Murphy

S. A.

Johnson

L. C.

Fan

J. J.

Lohan

(2003) Bereaved parents' outcomes 4 to 60 months after their children's deaths by accident, suicide, or homicide: A comparative study demonstrating differences. Death Studies 27(1): 39–61.

40.

Neimeyer, R. A. (Ed.). (2001). Meaning reconstruction and the experience of loss. Washington, DC: American Psychological Association.

41.

Neimeyer

R. A.

Hogan

N. S.

Laurie

(2008) The measurement of grief: Psychometric considerations in the assessment of reactions to bereavement. In: Stroebe

M. S.

Hansson

R. O.

Schut

Stroebe

(eds) Handbook of bereavement research and practice: Advances in theory and intervention, Washington, DC: American Psychological Association, pp. 133–161.

42.

Pitman

Osborn

King

Erlangsen

(2014) Effects of suicide bereavement on mental health and suicide risk. The Lancet Psychiatry 1(1): 86–94.

43.

Prigerson

H. G.

Maciejewski

P. K.

Reynolds

C. F.

III Bierhals

A. J.

Newsom

J. T.

Fasiczka

Miller

(1995) The inventory of complicated grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research 59(1–2): 65–79.

44.

Sakurai

Nishi

Kondo

Yanagida

Kawakami

(2011) Screening performance of K6/K10 and other screening instruments for mood and anxiety disorders in Japan. Psychiatry and Clinical Neurosciences 65(5): 434–441.

45.

Sanders

C. M.

(1979–1980) A comparison of adult bereavement in the death of a spouse, child, and parent. Omega: Journal of Death and Dying 10(4): 303–322.

46.

Sands

D. C.

Jordan

J. R.

Neimeyer

R. A.

(2011) The meanings of suicide: A narrative approach to healing. In: Jordan

J. R.

McIntosh

J. L.

(eds) Grief after suicide: Understanding the consequences and caring for the survivors, New York, NY: Routledge, pp. 249–282.

47.

Shneidman

(1969) Prologue: Fifty-eight years. In: Shneidman

(ed.) On the nature of suicide, San Francisco, CA: Jossey-Bass, pp. 1–30.

48.

Shimizu, S. (Ed.). (2009). Fuuin sareta shi to jishi-izoku no shakaiteki shien [Sealed death and social support for suicide survivors”] L'esprit d'aujourd'hui 501. Tokyo, Japan: Shibundo.

49.

Sugrue

J. L.

McGilloway

Keegan

(2014) The experiences of mothers bereaved by suicide: An exploratory study. Death Studies 38(2): 118–124.

50.

Sveen

C. A.

Walby

F. A.

(2008) Suicide survivors’ mental health and grief reactions: A systematic review of controlled studies. Suicide and Life-Threatening Behavior 38(1): 13–29.

51.

World Health Organization (2014) Preventing suicide: A global imperative, Geneva, Switzerland: World Health Organization Press.