Abstract
Bereavement by suicide is a unique form of grief characterized by features such as stigma, shame, and rejection that may complicate the grieving process and place people at heightened risk for specific mental health disorders, suicide attempts, and dying by suicide. To better understand the unique support needs of the suicide-bereaved and how these can be met, this Australian study qualitatively explored the experiences of people bereaved by suicide. Fifteen individuals who had lost a spouse or partner or a family member to suicide formed three focus groups across different locations in Queensland, Australia. Analysis identified four dominant themes: changing support needs, difficulties navigating services, experiences of stigma and social isolation, and connecting with others. The results from this study provide a powerful insight into the experiences and specific needs of the suicide-bereaved and could inform further development of suicide bereavement support services.
Introduction
The impact of suicide is devastating and far-reaching, with those left behind often the ultimate victims (McKinnon & Chonody, 2014). Estimates from the United States have indicated that on average 5 family members, 15 extended family members, 20 friends, and 20 class or workmates could be affected, suggesting approximately 60 people are directly and intimately affected by each suicide death (Berman, 2011). Moreover, more recent research by Cerel et al. (2018) indicates that 135 people may be directly exposed to each suicide death. Based on World Health Organization (2014) estimates that 800,000 people die by suicide each year, approximately 48 million people may be impacted by suicide bereavement annually.
In addition to common grief reactions such as confusion, sadness, anger, loneliness, depression, and anxiety, research indicates that the suicide-bereaved experience higher levels of shame, stigma, responsibility, and rejection (Kõlves & De Leo, 2014; Pitman, Osborn, King, & Erlangsen, 2014; Sveen & Walby, 2008). Compared with other types of bereavement, people bereaved by suicide are at heightened risk for specific mental health disorders, suicide attempts, and dying by suicide (de Groot & Kollen, 2013; Erlangsen et al., 2017; Kõlves & De Leo, 2014; Pitman et al., 2014; Sveen & Walby, 2008). It is therefore vital to understand more about the unique support needs of the suicide-bereaved and how these can best be met.
Rather than the application of a top-down treatment approach, where mental health professionals design the services they believe will be helpful, researchers have advocated for a bottom-up approach, informed by the experience of the suicide-bereaved (Jordan, Feigelman, McMenamy, & Mitchell, 2011; Myers & Fine, 2007). Existing knowledge about effective postvention strategies is poor, and to date, little research has been conducted on the support needs of the suicide-bereaved (Dyregrov, 2011). This study aimed to qualitatively examine the experiences and support needs of the suicide-bereaved with the goal of informing future postvention efforts. The study was set in Queensland, Australia, where the age standardized suicide rates for 2012 to 2016 were 14.4 per 100,000, higher than the Australian national rate of 11.7 per 100,000 (Australian Bureau of Statistics, 2017).
Method
People bereaved by suicide were invited to participate in focus groups via advertisements placed with local postvention support services and networks, social media, and the Griffith University online news. Inclusion criteria were those older than 18 years who were bereaved by suicide between one and years. The specified bereavement period was to exclude those experiencing acute grief in the first year of bereavement and those bereaved over 10 years ago to minimize recall bias. The advertisements described the purpose of the study and explained that the focus groups would involve discussion of their expectations and experiences of bereavement support. No specific kinships were excluded, and due to small numbers due to geographic and time factors, it was not possible to balance demographic variables between groups.
The focus groups were conducted in July to September 2016 by two experienced female facilitators with relevant master’s degree qualifications. Both facilitators were trained in responding to distressed individuals and provided assurance to participants that support was available for them at all times before, during, and after the focus groups. The facilitators alternated roles for each focus group so that one facilitated and the other was available to provide support if necessary. Prior relationships had been established between the facilitators and some participants, as some had previously participated in telephone interviews as a component of a wider study.
Two of the focus groups were conducted in the Queensland capital of Brisbane and one on the nearby Gold Coast. The topic guide was developed by the researchers to facilitate discussion on the support needs of the suicide-bereaved based on issues identified in the existing literature (Dyregrov, 2011; Jordan, McIntosh, et al., 2011). Participants’ experiences in accessing support, their awareness of available supports, the types of support accessed and whether these were helpful, their expectations of support, and specific support needs were explored. Each focus group took approximately 90 minutes, and was digitally recorded and professionally transcribed. Field notes were taken immediately after the focus groups to provide context for the transcripts.
Participants
A total of 26 individuals who had lost a spouse or partner or a family member to suicide responded to the advertisements. Of these, 11 people dropped out, leaving a total of 15 participants (12 females and 3 males) who formed three focus groups. Their ages ranged from 31 to 73 years, and the length of bereavement they had experienced ranged from 1 year and 3 months to 5 years. One participant attended with a friend as a support person.
As per Australian human research ethics requirements, participants were provided with written information, which included the identity and affiliation of the facilitators and researchers, aims of the research, and confidentiality and informed consent issues, including the right to withdraw voluntarily. All participants were required to provide written consent prior to taking part in the focus groups. The study was reported according to the Consolidated criteria for reporting qualitative research checklist criteria for reporting qualitative research (Tong, Sainsbury, & Craig, 2007). Interpretive phenomenological analysis (IPA) was used to gain an in-depth understanding of participants’ experiences after a suicide. As IPA is concerned with gaining insight into individual’s subjective experiences, rather than the formulation of objective accounts, it was chosen as the most appropriate method to explore the experiences and needs of people bereaved by suicide (Brocki & Wearden, 2006). The inductive and iterative procedures of IPA assist researchers to develop an “insider’s perspective” on the topic and provide an interpretative account of the participants’ experiences (Reid, Flowers, & Larkin, 2005). While IPA has traditionally been conducted through individual interviews, focus groups have also been successfully used in IPA research; however, care must be taken to pay attention to both group patterns and dynamics and individual accounts (Palmer, Larkin, de Visser, & Fadden, 2010; Smith, 2004).
In the first phase of the analysis, two researchers, V.R. (PhD), a social psychologist, and K. K. (PhD), a sociologist, worked independently, reading and rereading the focus group transcripts, note-taking, and manually coding the data to create a preliminary list of codes. The researchers then worked together, discarding or expanding codes and looking for connections and clusters between codes to identify and create a list of themes. The themes were subsequently reviewed by both researchers, ensuring that consideration had been paid to both individual and group data, with any discrepancies negotiated until consensus was reached. This iterative revision process was used to create a master list of themes and subthemes with supporting verbatim examples from the transcripts.
Results
Four dominant themes were identified: (a) changing support needs, (b) difficulties navigating services, (c) experiences of stigma and social isolation, and (d) connecting with others.
Changing Support Needs
A need for proactive and practical support
Participants described how their support needs changed considerably over time and their subsequent needs for different support services at different stages of their bereavement. There were marked inconsistencies in experiences with the provision of initial support, with some participants describing receiving little initial assistance, resulting in significant delays in finding appropriate support. When recounting their experiences, some participants viewed themselves as simply being “lucky” as to whether they found help when they needed it. In most cases, police were first responders and were generally described as being compassionate. However, after the departure of the police, several people spoke of feeling bewildered and not knowing what to do next. One survivor described having no one to turn to for help after the departure of police and having to clean up the death scene unaided. In contrast, other focus group members shared positive experiences of receiving initial support and guidance. When the police came to my place they weren’t armed with any information for me there and then. That would be something that would have been really good because I just looked at them and said “What do I do now? What do I do?” They said, “Oh, can we call a friend over?” (Female) When the counsellors came they said “. . . . we can run you through what we know you will be experiencing based on our experience . . .” They talked a lot about what we would be sure to experience and the kinds of things we ought to be careful we don’t fall into; certain ways of thinking. We still reflect on the things that the counsellors told us as such potent, valuable pieces of advice. I would say they were utterly instrumental in setting me personally on a good path. (Male) You absolutely have no idea what you need . . . because I certainly didn’t and you just need somebody to start you . . . (Male) You’re not in your own mind . . . you’re not thinking straight . . . But there’s nobody there to guide you along those lines either. There’s no guidance on “Okay, this is possibly what’s going to happen to you.” (Female)
Flexibility in timeliness and approaches to support
Some participants described feeling “too raw” to seek emotional assistance early in their grief, but once their feelings of numbness and confusion had subsided, they benefited from support such as counseling and support groups. There was considerable variation in the time period where participants felt emotionally ready to engage in support, ranging from several months to well over a year after the suicide. Several participants suggested that it would be beneficial to provide people with information on grief processes after a suicide to help understand their own changing support needs. Participants also emphasized the importance of understanding the ongoing nature of suicide bereavement and the subsequent need for continuing support in the long term. The need for a flexible approach to the provision of support services was identified as crucial. This was in terms of both flexibility to allow participants time to feel ready to seek support and flexibility in the approach to supporting the bereaved. The first time I went I told (the counsellor) my situation, I walked out going “Oh, he’s no help. He doesn’t understand.” But 6 months later I was talking to somebody and they said “You really do need help. Could you please just go and see somebody?” When I went and saw the psychologist the next time and I did all the sessions. He helped greatly . . . I’m more aware now of what happened, why it happened, why I couldn’t help it and why I couldn’t save this man. (Female) By the end of 6 months . . . people just expect there’s an expiration date on grief and you’re supposed to just get over it. It’s actually now where you start needing that support, because you’re thinking a bit more clearly. You know what you want to do and how to approach things a little bit better, but yet everything (support services) has gone. (Female)
Difficulties Navigating Services
A need to be guided through services and systems
Participants described their difficulties in navigating their way through available support services while struggling with their grief. Many reported not knowing where to find services, while those who were provided with contact numbers of services described feeling confused over which service to contact. Although several people said they found support services relatively easily, many others spoke of not knowing where to look for services and searching the Internet with little success.
Participants also spoke of their difficulties in attempting to navigate the numerous services relating to the suicide (e.g., coronial, funeral, insurance, legal, financial). Several individuals suggested that guidance in their navigation would be a much-needed and valuable service for those bereaved by suicide. For some participants, funeral directors had played an important role in providing support and guidance. Other survivors revealed examples of seeking suicide-bereavement support through unconventional channels (e.g., attempting to visit the deceased’s psychiatrist or connecting with a support group unrelated to suicide-bereavement), resulting in delays in finding support. A strong need was identified for the provision of proactive guidance in directing people to appropriate services. There is a need to be guided in navigating the available services, because there’s a list of things . . . “Well which one do I call?” But if somebody sits down with you … and says, “Look how are you actually going? What do you think would help you now? There’s these things. Do you think that might help you?” Just a conversation and engage you. (Female) Whether she (the psychiatrist) was afraid that I was going to accuse her of not caring for him properly—eventually I got an answer back from a person in the office. She said, “The doctor’s not taking on new patients.” I said, “That wasn’t what I exactly wanted. I just wanted to talk to her. I didn’t want to become one of her patients.” (Female)
Challenges in locating appropriate general practitioner (GP) and counsellors
Locating an understanding GP or appropriate counsellors with suicide-bereavement skills was also difficult. Several participants pointed out that good GPs and counsellors are usually in high demand, making it difficult to obtain an appointment. Discussions indicated that there was a lack of counsellors with an understanding of suicide-bereavement as well as the need for assistance for the suicide-bereaved in locating appropriate counsellors. Participants experienced feelings of distress and discomfort in having to retell their painful stories to strangers, and several described negative help-seeking experiences, where they found therapy unhelpful or even making them feel more distressed. A number of participants also stressed that grieving is not the same as depression and indicated that they believed GPs and psychiatrists were too hasty to offer antidepressants. I was told to try and find a counsellor who was specific in grief counselling or suicide counselling. So my doctor took 8 months before she found somebody who I could go and see. (Female) It takes time for you to grieve. Some people get through real quick. For others it goes on for years and years and years. It takes what it takes. That’s what I’ve learnt. It’s your pace and you just go at your own pace. But first thing they offer you is antidepressants. I just said “No, I don’t want to go on antidepressants. I’m actually grieving.” (Female)
Experiences of Stigma and Social Isolation
Shame, rejection, and loss of social support
Participants described feelings of shame, guilt, and self-blame in relation to their loved one’s suicide. They felt uncomfortable about talking about the suicide and found social interactions to be difficult and painful, leading to social withdrawal and self-isolation. Participants also expressed hurt and anger at the way family and friends seemed embarrassed talking about the suicide and made comments that were perceived as insensitive. Some survivors spoke of having quarrels with families and friends which led to ongoing estrangements. As a consequence of this loss of contact and social support from family and friends, survivors described their feelings of rejection, loneliness, and isolation. They (friends) don’t want to talk about it and . . . they just don’t feel comfortable around you talking about suicide or anything. So I found that really hard because I started to internalize that a little bit and I felt a little bit rejected and a bit isolated. (Female) I found (my family’s) grieving process . . . ended up resulting in being a very negative experience for me, which resulted in me cutting off all ties with family. (Female)
Stigma and avoidance in the workplace
Accounts of stigma and insensitive attitudes from others were described in participants’ experiences of returning to the workplace after the suicide. Participants described how other coworkers avoided acknowledging the suicide as well as attempting to physically avoid them. Several people expressed the wish for work colleagues to acknowledge their loved one’s life and suicide, rather than avoiding the topic. Avoidance and insensitive comments from staff at management level were also experienced by some participants. The need was highlighted to develop workplace education on mental health issues and suicide, including guidelines on how to on how to respond appropriately to suicide-bereaved staff members. It was suggested that at the very least, training should be provided for managers. Yeah, they avoid you like the plague . . . You go into in the kitchen and people come in and then suddenly turn the other way. (Female) My boss was an “I don’t want to know” sort of person. So as long as it didn’t affect my work and as long as I didn’t talk about it and we just pretended nothing happened everything was fine. So when it came to support and feedback I don’t recall one of those places ever ringing me back and saying “Hey, how are you going? Is there anything we can do?” (Female)
Connecting With Others
The Internet as both useful and distressing
Some participants described how they found Internet-based groups such as Facebook groups and some online forums to be a useful way to connect with other suicide-bereaved persons. While a number of participants described the useful role of online forums in connecting and identifying with others, some found these to be less helpful after some time. Others highlighted the negative aspects of online forums on suicide loss, saying that these tended to be too intense and they found it distressing to read other stories of loss. Facebook groups and online forums and things (were helpful) . . . because initially hearing people’s stories and identifying similarities and—I found that really comforting. But then after a while, you hear the stories of the loss and everything and it was just more upsetting . . . (Female) It’s a dangerous thing to be sitting, trolling through all these sites late at night, because it can be very depressing. Then I think you need to know when to think, “Now cut that off. Get out of that.” (Female)
Comfort in talking to others with similar loss experiences
Participants also discussed their experiences in connecting with others bereaved by suicide through face-to-face suicide-bereavement support groups. Although there were mixed opinions on the value of support groups, most participants spoke of the positive experience of connecting with others; in particular, the value of talking with others who have lived through similar experiences. These shared experiences were not only in relation to their grief and loss but also the strain of the caregiver burden (i.e., being on “suicide watch” in the lead-up to the suicide, as described by a number of participants). It sort of moves you a little bit and helps you to understand that you’re not alone. You’re not the only person that’s going through this. There’s other people out there going through exactly what you’re going through. There’s strength in that—knowing that someone else is suffering the way you’re suffering . . . (Female) I’ve made new friends and they seem to—they understand how you’re feeling more than your other friends you’ve had before. So they know where you’re coming from. (Female)
A need for professional facilitation of support groups
Although participants generally spoke positively about suicide-bereavement support groups, an example was given where the group facilitator dominated the group with personal stories of loss. Participants described difficulties when boundaries become blurred and bereaved people attempt to take on the role of a counsellor to others. The need was highlighted for professional guidelines for running support groups. There was general agreement that although people bereaved by suicide have much to offer through their experiences, roles such as counsellor or support group facilitator should be conducted by trained professionals. People want to find each other and they want support, and problems happen when it’s people that are bereaved and are just coming from their own place of loss and trying to help and counsel each other and they really don’t know what they’re doing. That’s when it can get dangerous and just some groups aren’t helpful. (Female)
Discussion
This study qualitatively examined the support needs of the suicide-bereaved and identified four key themes of changing support needs, difficulties navigating services, experiences of stigma and social isolation, and connecting with others. Participants’ descriptions of feeling too overwhelmed to seek help and the subsequent need for proactive support are consistent previous literature (Dyregrov, 2011; Jordan, Feigelman et al., 2011; McMenamy, Jordan, & Mitchell, 2008). Clear consideration should be given to a proactive approach to support such as the active postvention model developed by Campbell (1997). In contrast to traditional passive models of postvention where the bereaved have to find resources themselves, active postvention provides proactive support to suicide-bereaved individuals and facilitates access to services when they need them (Cerel & Campbell, 2008; Jordan, McIntosh et al., 2011; McMenamy et al., 2008). Given the difficulties participants also experienced in identifying and locating support services, a proactive support model would facilitate timely access to essential information and appropriate services.
The provision of postvention support is further complicated by the different support needs of the suicide-bereaved at different stages of their grieving process. Participants highlighted the critical need for flexible and long-term support during the course of their bereavement. To address different needs during bereavement trajectories, Jordan, McIntosh, et al. (2011) advocate for a program of support services, which would allow for multiple points of access to multiple types of services. Jordan and colleagues recommend that information about available services should be offered on more than one occasion as the suicide bereaved are often too traumatized to retain this information or to know what they may need later in their grieving process. Jordan, Feigelman, et al. (2011) also highlight the need for long-term service provision as well as short-term and crisis-orientated responses.
Results also indicated a need for more counsellors with skills in suicide-bereavement. Sanford, Cerel, McGann, and Maple (2016) point out that many therapists do not have specialized training in suicide loss, and that current understanding of how therapists can help suicide-bereaved individuals is limited. Consistent with the available literature, participants recounted how stigma and insensitive attitudes from family and friends led to feelings of rejection and social isolation (Kõlves & De Leo, 2014; Young et al., 2012). Participants also experienced these attitudes in the workplace from colleagues and even managers and emphasized the need for workplace education on mental health issues and suicide, including guidelines on how to talk to a person bereaved by suicide. Pitman, Osborn, Rantell, and King (2016) stress the critical need for employers to be aware of the impact of suicide-bereavement on occupational functioning and to take action to promote mental health. There are currently several resources that been developed in the United Kingdom and the United States for managers to respond to suicide-bereaved individuals (e.g., Business in the Community, 2017; Carson J Spencer Foundation, Crisis Care Network, National Action Alliance for Suicide Prevention, & American Association of Suicidology, 2013).
Participants described the benefits of connecting with others through suicide-bereavement support groups. Given the experiences of stigma and social isolation on the suicide-bereaved, there appears to be great value in attending support groups with those who share similar experiences and offer understanding and support (Young et al., 2012). However, despite anecdotal evidence for the benefits of support groups, there is little research evidence available to determine their efficacy (Cerel, Padgett, Conwell, & Reed, 2009; Gall, Henneberry, & Eyre, 2014). Empirical research evaluating the impact of suicide-bereavement support groups is clearly needed. Participants raised the issue of blurred boundaries when a bereaved person attempts to take on the role of a counsellor, highlighting the need to ensure support groups follow professional guidelines, such as the World Health Organization and International Association for Suicide Prevention (2008) suicide bereavement support group guidelines. The results of this study have clear policy implications for the provision of support and professional guidelines for suicide-bereavement support groups.
Strengths and Limitations
A key strength of this study was the ability to obtain an in-depth understanding of the experiences and needs of the suicide-bereaved across several intimate small-group settings. A clear limitation, however, was that the sample was composed of those whom had responded to the advertisement, thus missing the opportunity to allocate individuals purposively (e.g., balanced numbers of those whom had, or had not, attended bereavement support groups), which may have resulted in sampling bias. There was also the potential for self-selection bias from participants (e.g., a bias toward those whom may have felt comfortable in attending a focus group, rather than those who were not). Consistent with similar research studies, female participants outnumbered males in this study. Future research would benefit from purposive sampling, additional data collection methods such as online surveys, and attempts to examine gender and cultural differences in postvention support needs.
Footnotes
Acknowledgments
The authors would like to acknowledge the focus group participants who generously provided their time and insights into this important research. The authors also acknowledge the contributions of Ms. Rosemary Spencer and Ms. Jessica Daly who facilitated the three focus groups for this study.
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.
Ethical Approval
The study was approved by the Griffith University’s Human Research Ethics Committee (GU Reference number CSR/04/11/HREC).
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by an Australian Research Council Discovery grant DP140102567 and the Commonwealth Department of Health.