Postvention in Action E-Book

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2019

Seitenzahl: 1142

Beschreibung

A unique and comprehensive handbook presenting the state of the art in suicide bereavement support Suicide is not merely the act of an individual; it always has an effect on others and can even increase the risk of suicide in the bereaved. The International Association for Suicide Prevention, the World Health Organisation, and others have recognized postvention as an important strategy for suicide prevention. This unique and comprehensive handbook, authored by nearly 100 international experts, including researchers, clinicians, support group facilitators, and survivors, presents the state of the art in suicide bereavement support. The first part examines the key concepts and the processes that the bereaved experience and illustrates them with illuminating clinical vignettes. The second and third parts look in detail at suicide bereavement support in all the relevant settings (including general practices, the workplace, online and many others) as well as in specific groups (such as health care workers). In the concluding section, the support provided for those bereaved by suicide in no less than 23 countries is explored in detail, showing that postvention is becoming a worldwide strategy for suicide prevention. These chapters provide useful lessons and inspiration for extending and improving postvention in new and existing areas. This unique handbook is thus essential reading for anyone involved in suicide prevention or postvention research and practice.

Leseprobe

Postvention in Action

The International Handbook of Suicide Bereavement Support

Edited by

Karl Andriessen

Karolina Krysinska

Onja T. Grad

About the Editors

Karl Andriessen, MSuicidology, BSW, has been working in suicide prevention and postvention for three decades and is currently pursuing a PhD at the School of Psychiatry, University of New South Wales, Sydney, Australia, supported by a research grant of the Anika Foundation for Adolescent Depression and Suicide. He has published many peer-reviewed articles, book chapters, and co-edited volumes. He is also an affiliated researcher with the Faculty of Psychology and Educational Sciences, KU Leuven–University of Leuven, Belgium. He has been Co-Chair of the Special Interest Group on Suicide Bereavement of the International Association for Suicide Prevention (IASP) for almost 15 years and received the 2005 IASP Farberow Award for outstanding contributions in the field of bereavement and survivors after suicide.

Karolina Krysinska, PhD, is a research fellow at the School of Psychiatry, University of New South Wales, Sydney, Australia, and is affiliated as a research fellow at the Faculty of Psychology and Educational Sciences, KU Leuven–University of Leuven, Belgium. Her research interests include risk and protective factors of suicide, suicide prevention, thanatology, psychology of trauma and bereavement, and psychology of religion. She is author and coauthor of peer-reviewed articles and book chapters on various aspects of suicide, trauma, and bereavement.

Onja T. Grad, PhD, is a clinical psychologist working as a psychotherapist and supervisor in the outpatient clinic at the University Psychiatric Hospital in Ljubljana, Slovenia, mainly with patients who have lost somebody close by suicide or other traumatic death. As a professor at the University of Ljubljana she has a long-standing interest in bereavement research. She has published in national and international journals and contributed to international textbooks on suicide and suicide bereavement. In 1997, she was the first recipient of the Farberow Award, given biannually by the IASP for outstanding contributions in the field of postvention.

Library of Congress Cataloging in Publicationinformation for the print version of this book is available via the Library of Congress Marc Database under the LC Control Number 2016956065

Library and Archives Canada Cataloguing in Publication

Postvention in action : the international handbook of suicide bereavement

support / edited by Karl Andriessen, Karolina Krysinska, Onja T. Grad.

Includes bibliographical references and index.

Issued in print and electronic formats.

ISBN 978-0-88937-493-5 (hardback).--ISBN 978-1-61676-493-7 (pdf).--

ISBN 978-1-61334-493-4 (epub)

1. Bereavement. 2. Bereavement--Psychological aspects. 3. Grief. 4. Grief

therapy. 5. Suicide. 6. Suicide victims--Family relationships. I. Andriessen, Karl,

1964-, editor II. Krysinska, Karolina, 1969-, editor III. TekavčičGrad, Onja, editor

BF575.G7P678 2017

155.9'37

C2016-906719-X

C2016-906720-3

The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.

Registered trademarks are not noted specifically in this publication. The omission of any such notice by no means implies that any trade names mentioned are free and unregistered.

©2017byHogrefe Publishing

http://www.hogrefe.com

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Format: EPUB

ISBN978-0-88937-493-5(print) • ISBN 978-1-61676-493-7 (PDF) • ISBN978-1-61334-493-4(EPUB)

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Contents

Overview of Tables

Overview of Figures

Overview of Boxes

Foreword

Preface

Postvention

Postvention in Action

Action

References

Part I Current Knowledge and Implications for Support

Chapter 1 Current Understandings of Suicide Bereavement

Introduction

Concepts and Definitions

Postvention

Survivor

Bereavement, Grief, Mourning

Complicated Grief

Lived Experience

How Many People Are Bereaved Through Suicide?

Is Suicide Bereavement Different From Other Bereavement?

Grief Models and Suicide Bereavement

Implications for Practice

References

Chapter 2 Effects of Suicide Bereavement on Mental and Physical Health

Introduction

Pathways of Psychological Stress

Review of Evidence

Mental Disorders

Suicidal Behavior

Physical Disorders

Relationships and Social Functioning

Methodological Considerations

Implications for Policy, Practice, and Research

Conclusion

References

Chapter 3 Suicide Bereavement and Postvention Among Adolescents

Introduction

Characteristics of Suicide Bereavement Among Adolescents

Grief Experience

Mental Health

At-Risk Behaviors

Suicidal Behavior

Preloss and Postloss Characteristics

Psychological Closeness Before the Loss

Mental Health History

Social Support After the Loss

Quality of Remaining Relationships

Dose-Response Effect

Suicide Bereavement Support

Counseling

Support Group Interventions

School Communities

Implications for Research and Practice

Acknowledgments

References

Chapter 4 Suicide Bereavement and Gender

Introduction

The Impact of Death on Men and Women

Expressing Grief: The Influence of Gender

Bereaved Women and Bereaved Men: Implications for Practice

Conclusions

References

Chapter 5 Posttraumatic Growth After Suicide

Introduction

Study 1: Posttraumatic Growth Among Families Following an Adolescent Suicide

The Cataclysm Period

The Wreck Period

The Emergence Period

Pathways to Growth

Study 2: Posttraumatic Growth Among Suicide-Bereaved Parents

Role of Cognitive Engagement in Posttraumatic Growth

Resilience and Posttraumatic Growth

Future Directions and Implications for Practice

References

Chapter 6 Feeling Responsible: Pathways From Guilt Toward Inner Peace

Introduction

Method

Facing Feelings of Guilt and Dealing With Stigma and Social Relations

Facing and Dealing With One’s Own Feelings of Responsibility

Dealing With Responsibilities Assigned by Others

Management of Information

Social Assignment of the Victim or Guilty Party Identity

Supporting the Bereaved in Clarifying Responsibility Issues

Conclusions

References

Chapter 7 Suicide Loss and the Quest for Meaning

Introduction

Mourning and Meaning

The Search for Meaning in Bereavement

Spiritual Struggle in the Wake of Loss

Suicide Loss and the Quest for Meaning

Posttraumatic Growth

Clinical Implications of a Meaning Reconstruction Approach

Meaning-Oriented Assessment

Intervening in Meaning

A Lingering Loss: Long-Term Reconstruction Following Suicide Loss

Conclusions

References

Chapter 8 The Growing Flower Model of Reintegration After Suicide

Introduction

Rituals in Bereavement

Reintegration After the Loss

Method

Sample

Instruments

Procedure

Results

Interpretation of the Model

a. The Event of Suicide

b. Funeral and Rituals

c. Emotions and Their Expression

d. Negative Reactions: Guilt, Blame, Condemnation, and Clichés

e. Looking for explanations

f. Support

g. Spirituality

h. Meaning Making, Personal Growth, and Identity Changes

Personal Growth: Attachment and Relationship With the Deceased

Implications for Practice

Acknowledgments

References

Part II Suicide Bereavement Support in Different Settings

Chapter 9 History of Survivor Support

Introduction

Survivors and Postvention

Support Groups

Outreach Approaches

Online Support Approaches

Quilts

Comprehensive Community Support Programs

Recognition of Survivors and Postvention Through Major Books

Recognition of Survivors Through Major Suicidology Organizations

Recognition of Survivors Through Other Organizations and Events

Conclusions

References

Chapter 10 Characteristics and Effectiveness of Suicide Survivor Support Groups

Introduction

Characteristics of Suicide Survivor Support Groups: Definitions and Differences

Characteristics of Suicide Survivor Support Groups: Common Features and Objectives

Characteristics of Suicide Survivor Support Groups: Surveys

Research on Suicide Support Group Effectiveness

Mixed Leadership: Professional and Peer

Peer Leadership

Trained Volunteer Leadership

Professional Leadership

Evaluation of an Outreach Approach: LOSS Team

Evaluation Conclusions

Conclusions

References

Chapter 11 Priorities for Suicide Survivor Support Groups in Japan and the United States

Introduction

Method

Instrument

The Survey in Japan

The Survey in the United States

Results

Discussion

Acknowledgments

References

Chapter 12 Peer Counseling in Suicide Bereavement: Characteristics and Pitfalls

Introduction: Peer Counseling as a Form of Postvention

Peer Counseling in Suicide Postvention

Peer Counseling for Different Groups of Survivors: Some Words of Caution

Exploring Peer Counseling: Who Are These Suicide Survivors–Peer Counselors?

Research With Survivors of Suicide Who Went on to Become Peer Counselors

The Study: From Suicide Survivor to Peer Counselor

Participant Characteristics

Deciding to Volunteer in Suicide Postvention

Describing the Experience of Providing Peer Counseling

The Meaning of Providing Peer Counseling

Discussion

References

Chapter 13 After Suicide – Roles of the General Practitioner

Introduction

The Roles of General Practitioners in Postvention

Immediate Outreach

Subsequent Care

Long-Term Care

Family and Community Care

Counseling and Psychoeducation

Dilemmas in Providing Care

Medical “Failure”

Ethical Dilemmas

Expertise of the General Practitioner

Recommendations and Implications for Practice

GP–Postvention Pathway to Care

Establishing a Practice Postvention Protocol

References

Chapter 14 Supporting Families Through the Forensic and Coronial Process After a Death From Suicide

Introduction

Death Investigation and the Role of the Coroner

Social Work Role and Support After Suicide at the DOFM Sydney

Support and Information After a Suicide

Viewing the Body

Referral to the Support After Suicide Program

The Support After Suicide Group

Anniversary Card and SASP Newsletter

Discussion and Implications

Conclusions

References

Chapter 15 Workplaces and the Aftermath of Suicide

Introduction

Conceptualizing Grief at Work

Grief in the Workplace

Tensions in Postvention in the Workplace

The Suicide Postvention Process

Immediate: Acute Phase

Short-Term: Recovery Phase

Longer-Term: Reconstructing Phase

Conclusions

References

Chapter 16 The Roles of Religion and Spirituality in Suicide Bereavement and Postvention

Introduction

After Suicide

Spirituality and Religiosity After a Loss Through Suicide

Religion and Spirituality in Online Suicide Memorials

Role of Faith Communities

Implications for Practice

Conclusions

References

Chapter 17 Online Suicide Bereavement and Support

Introduction

Categories of Online Resources

Online Resources Available to Suicide Survivors

Online Support Groups

Online Memorials

Social Networks

Helpfulness of Online Interventions in Coping With Loss and Bereavement

Helpfulness of Social Media

Ensuring Quality of Online Information and Support for the Bereaved

Implications for Practice

Conclusions

Acknowledgments

References

Chapter 18 A Vibrant Living Process: Art Making and the Storying of Suicide

Mic

Ghosts From the Past

The Art of Understanding

Storying Through Art

Touching the Senses

The Right Fit

Mic and Erminia

Erminia

Conclusions

References

Part III Suicide Bereavement Support in Different Populations

Chapter 19 Emerging Survivor Populations: Support After Suicide Clusters and Murder–Suicide Events

Introduction

Support After Suicide Clusters

Suicide Clusters Identified by the Irish Suicide Support and Information System

Identifying the Survivors and Meeting Their Needs

Responding to Potential Suicide Clusters

Support After Murder–Suicide Events

Impact on Survivors

Traumatic Aftermath

Stigma and Isolation

Mixed Emotions

Impact on Communities

Impact of Media Reporting of Murder–Suicide

Responding to Murder–Suicide and Recommended Interventions

Conclusions and Implications for Research and Practice

References

Chapter 20 Lack of Trust in the Health Care System by Suicide-Bereaved Parents

Introduction

Trust in the Health Care System

Why the Study of Trust in the Health Care System Matters

What Predicts Lack of Trust in the Health Care System?

Lack of Trust in the Health Care System in Suicide-Bereaved Populations

Lack of Trust as a Criterion for Complicated Grief

Restoring Trust in the Health Care System in the Suicide-Bereaved

Recommendations for Future Research

Implications for Practice

References

Chapter 21 Impact of Client Suicide on Health and Mental Health Professionals

Introduction

Emotional Impact

Stress and Traumatic Reactions

Grief After a Client Suicide

Impact on Professional Practice and Professional Competence

Work Context

Support for Health and Mental Health Professionals

Institutional Postvention Procedures

Implications for Practice

Conclusions

References

Chapter 22 Promoting a Way of Life to Prevent Premature Death: Ojibway First Nation (Anishinaabe) Healing Practices

Introduction: Suicide Among Indigenous People

A First Nations Worldview

Culturally Competent Care

The Anishinaabe People

Send Off

Prelife

Life

Postlife

The Premature Unnatural Deaths

The Time of Healing

Conclusions

References

Part IV Help for the Bereaved by Suicide in Different Countries

Part IV.1: The Americas

Chapter 23 Brazil – The Development of Suicide Postvention

Introduction

Suicide in Brazil

Suicide Postvention in Brazil

Implications for Support and Research

Conclusions

References

Chapter 24 Canada – Hope After Loss: Suicide Bereavement and Postvention Services of Suicide Action Montréal

Introduction

First Contact and Assessment

Individual Sessions

Group Meetings

Postvention Services for the Community

Conclusions

References

Chapter 25 Uruguay – Working With Suicide Survivors

Introduction

Suicide as a Crisis

The Experience of Suicide Survivors

Postvention Groups

Postvention Groups in Uruguay

Conclusions

References

Chapter 26 USA – Suicide Bereavement Support and Postvention

Past Postvention Efforts in the United States

Current Postvention Efforts in the United States

Future Directions for Postvention in the United States

Conclusions

References

Chapter 27 USA – National Postvention Guidelines

Introduction

Development and Organization of the Guidelines

Goals and Objectives

Implications of the Guidelines

Conclusions

References

Chapter 28 USA – The American Foundation for Suicide Prevention’s Support of People Bereaved by Suicide

Introduction: Becoming Part of a Community

Gaining a New Perspective: International Survivors of Suicide Loss Day

Peer-to-Peer Support: Survivor Outreach Program

Putting a Face on Suicide: Memory Quilts

Resources: Current and Future

References

Chapter 29 USA – Collaboration of Volunteers and Professionals in Suicide Bereavement Support: The EMPACT Experience

Introduction

Volunteer Involvement

Components of the Model

Innovations in Support Formats

Meeting the Needs of the Bereaved

Conclusions

References

Part IV.2: Europe

Chapter 30 Austria – Suicide Postvention

Introduction

Development of Postvention in Austria

Integration of Postvention in the National Suicide Prevention Program

Postvention for Specific Groups: Workplace, Schools, Health Clinics

Conclusions

References

Chapter 31 Belgium – Support Groups for Children and Adolescents Bereaved by Suicide

Introduction

Characteristics of the Support Program

Bringing Traumatically Bereaved Families Together

A Flexible Program

Commitment of Parents

Strength of Rituals and Symbols

Beneficial Effects of Group Participation

Breaking the Isolation and Providing Emotional Support

Sharing the Story in the Group Helps to Construct Meaning

Reconnecting With Family Members

A Positive Experience With Mental Health Professionals

Conclusions

References

Chapter 32 Denmark – Support for the Bereaved by Suicide

Introduction

Psychotherapy

Volunteer Organizations

National Association for the Bereaved by Suicide

Network for the Affected by Suicidal Behaviour (NEFOS)

Books

Media Reporting

Research on Suicide Bereavement

Conclusions

References

Chapter 33 England – Help for People Bereaved by Suicide

Introduction

Developing Infrastructure, Leadership, and Resources

Suicide Surveillance

Research Into Practice

Dissemination

Conclusions

References

Chapter 34 France – Suicide Postvention

Introduction

Postvention in the Workplace

Medical and Psychological Support

Support Through Suicide Bereavement Associations

Conclusions

References

Chapter 35 Italy – Postvention Initiatives

Introduction

Local Postvention Initiatives

Suicide Prevention Center

Self-Help Groups for Suicide Survivors

National Postvention Initiatives

SOPRoxi Project

De Leo Fund

Conclusions

References

Chapter 36 Italy – Support After a Traumatic Death: The Work of the De Leo Fund

Services Offered by the De Leo Fund

Psychological Assistance

Support Groups

Helpline

Online Resources: Chats and Forums

Art Workshop, Events, and Publications

Conclusions

References

Chapter 37 Lithuania – Suicide Bereavement Support Beyond Cultural Trauma

Introduction

Suicide Bereavement Support

A Qualitative Study of the Experiences and Needs of Those Bereaved by Suicide

Previous Experiences and Unrealistic Expectations Regarding Help Providers

Experiences of Others With Help Providers

Stereotypes About Mental Health Professionals and Suicide

Tendency Not to Speak About Suicide and Grief

Implications for Postvention Research and Practice

References

Chapter 38 Norway – Networking and Participation Among Young Suicide Bereaved

Introduction

Consolidation of a New Platform for the Young Bereaved

The Organization

Activities and Participation Today

External Relations

Implications for the Future

Conclusions

References

Chapter 39 Portugal – First Steps of Postvention Practice and Research

Introduction

Postvention in Schools

Families Bereaved by Suicide

Impact of a Patient Suicide on Health Professionals

Conclusions

References

Chapter 40 Slovenia – Development of Postvention

Introduction

Postvention in Slovenia Over the Decades

The First Suicide Survivors Group

The Slovenian Hospice

The Slovenian Centre for Suicide Research

Further Development of Postvention

Postvention Research in Slovenia

Conclusions

References

Chapter 41 The Netherlands – Support After Suicide on the Railways

Introduction

Support for Passengers

Support for the Bereaved Family

Support for Train Drivers and Other Railway Staff

Gatekeeper Training

Policy Concerning Memorials on the Railways

National Monument for Railway Fatalities

Conclusions

References

Part IV.3: Africa

Chapter 42 South-Africa – Experiences of Suicide Survivor Support

Introduction

Role of Depression and Other Considerations

Survivor Support Groups

Prevention Initiatives as Postvention

Conclusions

References

Part IV.4: Asia-Pacific

Chapter 43 Australia – Postvention Australia: National Association for the Bereaved by Suicide

Introduction

Why Does Australia Need a National Postvention Organization?

Postvention Australia: Genesis, Vision, and Aims

Activities

National Postvention Conference

Website and Newsletter

Partnerships

Development of Quality Standards and Other Initiatives

Conclusions

References

Chapter 44 Hong-Kong – Support for People Bereaved by Suicide: Evidence-Based Practices

Introduction

Historical Review of Suicide Bereavement Care in Hong Kong

Pilot Suicide Bereavement Study at the University of Hong Kong

Current Suicide Bereavement Support by Nongovernmental Organizations in Hong Kong

Challenges and the Way Ahead

References

Chapter 45 Japan – Research-Informed Support for Suicide Survivors

Introduction: Sociocultural Context of Postvention in Japan

Mental Health and Social Contexts of Japanese Suicide Survivors: Empirical Findings

Postvention in Action: Future Directions

References

Chapter 46 New Zealand – Development of Postvention Guidelines for Pacific Communities

Introduction

The Pacific Postvention Study

Findings and Recommendations

Conclusions

References

Chapter 47 Thailand – Suicide Bereavement Support

Introduction

Families

Psychiatrists

The PRAKARN Model of Group Psychotherapy

Conclusions

References

Contributors

Subject Index

|IX|Overview of Tables

Table 7.1Assessment instruments for evaluating meaning making in thewake of loss 77

Table 7.2 Representative techniques for intervening in meaning  77

Table 9.1 Early suicide support groups and services, North America  103

Table 9.2 International suicide support groups and services  105

Table 9.3 Suicide support and response outreach teams  107

Table 11.1 Mean frequency ratings among Japanese and US support group facilitators  135

Table 11.2 Mean importance ratings among Japanese and US support group facilitators  136

Table 16.1 Religious affiliations of study participants  189

Table 16.2 References to religion and/or spirituality in online suicide memorials  191

Table 17.1 Recommended design for grief-related websites  206

Table 17.2 Tasks of mourning, traditional customs, and advantages and disadvantages of grieving online  207

Table 45.1 Results of regression analysis  399

Overview of Figures

Figure 1.1 Aspects of bereavement related to the mode of death  9

Figure 8.1 Levels of reintegration after suicide  89

Figure 8.2 Levels and themes of reintegration process  89

Figure 8.3 Growing flower model representing suicide survivors’ reintegration over time  93

Figure 8.4 Growing flower model in a leaflet for the lay public (in Slovene)  95

Figure 11.1 Frequency of 10 principles of mutual aid in support groups for suicide bereaved in the United States and Japan  134

Figure 11.2 Importance of 10 principles of mutual aid in support groups for suicide bereaved in the United States and Japan  135

Figure 15.1Balancing act of bereaved employees 178

Figure 15.2 Priorities of a healthy workplace  179

Figure 18.1 Too Few Ladders, 2008 (artwork)  214

Figure 18.2Paper Shadows, 2010 (artwork) 216

Figure 18.3 Columbus Cubes, 2009 (artwork)  218

Figure 19.1 Service delivery model  228

Figure 23.1 Suicide postvention center model  274

Figure 41.1 Landelijk Monument Spoorwegongevallen (National Monument for Railway Fatalities), The Netherlands  371

Figure 45.1 Social support and secondary wounding of Japanese suicide survivors  398

Overview of Boxes

Box 10.1 Common and beneficial elements of suicide survivor support groups  120

Box 10.2 Resources for developing and facilitating suicide support groups  123

Box 13.1 Resources for general practitioners  158

Box 19.1 Responding to suicide clusters  229

Box 29.1Feedback about program services 304

Box 31.1 Rituals and symbols  317

Box 33.1 Available resources  326

|XI|Dedication

This book is dedicated to Dr. Norman L. Farberow (1918–2015).

|XIII|Foreword

It is an honor and a pleasure to have been invited by such a distinguished group of researchers and clinicians to contribute a Foreword to this important publication.

In the mid-20th century, there were usually only veiled references to suicide, let alone any suggestion that those who were bereaved through suicide should be considered worthy of study or indeed support. Furthermore, any references were usually in stigmatizing terms, as in many countries, suicide was considered not only a legal offence, but a sin against one’s religion.

How this has changed has been quite remarkable, something that is comprehensively documented in this timely overview. It is timely in at least two ways: It’s publication is on the 50th anniversary of Edwin Shneidman’s having coined the termpostventionin 1967; and there is now a considerable body of research that has been undertaken in the ensuing years, research which has benefitted from the introspective scrutiny which characterizes this volume.

The editors of this volume have each been leading figures in this research for several decades, and have gathered together all of the contemporary significant contributors to the field. There is no doubt that the early influential pioneers in this field, who are no longer with us, would be delighted with the result. This would particularly be the case with Norman Farberow, to whom this book is dedicated.

I have been privileged to have had a working life that has encompassed these changes. As a new graduate in the late 1960s, I was unprepared for the realities of the emergency room, where suicide attempts were increasingly prevalent, and where those who had died by suicide were brought for certification of death. These were also usually accompanied by distraught relatives or friends in both scenarios.

Pursuing the literature at that time was easy, notwithstanding the absence of computer retrieval assistance, as there had been so little written. It quickly became evident that Norman Farberow and Edwin Shneidman of the Los Angeles Suicide Prevention Center were leaders in the nascent field of suicide prevention, and they were not ignoring those who were bereaved by suicide.

I am delighted to say that I was one of a steady stream of young researchers, not the least of whom was Onja Grad, one of the editors of this work, who travelled to Los Angeles and sat at the feet of those early pioneers. Furthermore, because of the longevity of both Norman Farberow and Edwin Shneidman, both Karl Andriessen and Karolina Krysinska have also had the privilege of contact with them, thereby providing a unique editorial experience in being able to document this important area of clinical practice.

The book is divided into four logical sections: current knowledge and implications for support, suicide bereavement support in different settings, suicide bereavement support in different populations, and help for the bereaved by suicide in different countries.

In the first part, a useful introduction, which clarifies the concepts and definitions to be used and which sets the scene for the book, is followed by chapters delineating current demographic and clinical issues which are to be pursued.

The second part offers a succinct historical overview of survivor support, and then a range of different settings is described. These include family practitioner and peer counseling, and the role of religion and spirituality is not forgotten, as commonly occurs. As one would anticipate in the 21st century, the place of online suicide bereavement supports is also explored. More traditionally, but until relatively recently often overlooked, the importance of supporting families through the forensic and coronial process is addressed, a process which is almost always a harrowing experience for all involved.

|XIV|The third part contains fewer chapters than the others, but each is of critical importance. The impact of cluster suicides and murder–suicide should not be underestimated; the lack of trust in the health care system is of major concern; the effect on health professionals can be a determinant of whether or not one continues in clinical work; and a description of healing practices in First Nation peoples in Canada is a good illustration of a challenge facing many other countries as well.

The final part provides a synopsis of the services for those bereaved by suicide in over 20 different countries. Not unexpectedly, most are situated in the United States and Europe. It could be argued that the number may not reflect the work that is undoubtedly being conducted in a number of other countries, as organizations such as the International Association for Suicide Prevention have many more member countries whose representatives would be familiar with the need for such services, even if they have not been formalized.

This book will be valuable as a reference for researchers and as a practical guide for clinicians who practice in this challenging but rewarding area. Much has changed in the last 50 years, and we are indebted to the editors for collating such a comprehensive overview of this previously ignored area.

Robert D. Goldney, AO, MD, FRCPsych, FRANZCP

Emeritus Professor of Psychiatry, University of Adelaide, Australia

Past-President of the International Association for Suicide Prevention

|XV|Preface

Postvention

Every year, more than 800,000 people die by suicide; that is one suicide every 40 seconds (World Health Organization [WHO], 2014). Though suicide is an individual act, it happens within a sociocultural environment and a relational context. Hence, feelings of abandonment, rejection, and being a part of the “decision” for suicide are frequent among the bereaved by suicide. The bereaved may face a long and painful process of acknowledging and expressing their feelings of shock, guilt, shame, anger, and/or relief. They often struggle with thoughts, doubts, and agonizing questions related to “why this has happened,” and “if I had done – or not done – this or that,itwould not have happened.” The bereaved cope with the loss, sometimes on their own, sometimes with the help of family or friends. Some turn to support groups or seek advice or therapy from professionals. Given that suicide bereavement is a risk factor for adverse mental health outcomes and suicidal behavior, there is a need for adequate suicide bereavement support.

Fifty years ago Edwin Shneidman coined the termpostvention,referring to the support for those left behind after a suicide (Shneidman, 1969). At that time, suicidology was a young discipline, and there was neither support for the bereaved nor postvention research. Currently, postvention integrates a dual aim of facilitating recovery after suicide, and preventing adverse health outcomes among the bereaved (Andriessen, 2009). Suicide bereavement support has become available in many countries and has been recognized by the WHO (2014) as an important strategy for suicide prevention. The WHO stipulates that communities can provide support to those bereaved by suicide (WHO, 2014, p. 9), that interventions should be offered to grieving individuals (WHO, 2014, p. 37), and national suicide prevention objectives should include support for the bereaved by suicide (WHO, 2014, p. 54). It suffices to say that the evolutions of the past few decades have been truly impressive. Importantly, in many countries, survivor support has been initiated by the bereaved themselves, and clinicians and researchers have followed. In many countries, still, those bereaved by suicide are actively involved in suicide bereavement support, as well as in suicide prevention activities and research. Indeed, the days are over when postvention was looked upon as the poor counterpart of prevention: This handbookevidences the global research and clinical interest in survivor support. Postvention has become an integral and indispensable part of any comprehensive suicide prevention program. Suicidology and suicide prevention without the active involvement of survivors would be poor suicidology. Postvention is prevention. Postvention is action.

Postvention in Action

Experiences with suicide loss, working with people bereaved by suicide, involvement in postvention research and development of support programs have inspired the three editors of this handbook. It has been written for clinicians and researchers, as well as for support group facilitators and survivors involved in community activities. 94 experts from all over the world have contributed to this book. The authors have generously shared their knowledge, experience, and insights into implications for the practice of suicide survivor support. The editors of the handbook and many contributing authors are members of the International Association for Suicide |XVI|Prevention (IASP), and specifically of the IASP Special Interest Group (SIG) on Suicide Bereavement and Postvention, which has become a major platform for the exchange of research and clinical expertise related to suicide bereavement support. Interestingly, the awareness of suicide bereavement support within the IASP has been raised due to the advocacy of dedicated survivors–researchersand survivors–clinicians, especially in the 1990s, which resulted in the first plenary presentations on postvention at IASP world congresses, and the establishment by Professor Norman L. Farberow of a Taskforce on Postvention in 1999, the taskforce being the forerunner of the current SIG.

This handbook aims to present a comprehensive overview of the state of the art of postvention, and demonstrates the evidence and practice base of suicide survivor support. All chapters are based on thorough reviews of the literature and/or original research of the authors. The book is organized into four parts.Part I is an in-depth and comprehensive presentation of current knowledge of suicide bereavement. This includes a discussion of concepts and definitions, and the age- and gender-related effects of suicide loss, especially in adults and adolescents. The following chapters focus on the grief process and on how the bereaved deal with the loss. These chapters, illustrated with vignettes, will be highly informative for clinicians, and present novel insights regarding posttraumatic growth after suicide loss, trajectories of dealing with feelings of responsibility and guilt, challenges regarding meaning making, and the process of reintegration after experiencing a suicide.

Starting with a scholarly overview of the history of survivor support, Part II of the handbook discusses suicide bereavement support in a variety of settings, including underresearched areas that may be more challenging or may require special attention regarding provision of services and support. Chapters in this part have been written by clinicians and/or researchers with ample practical experience. These chapters present a review of the effectiveness of support groups (the best-known format of survivor support), and differences in priorities of support groups between countries (Japan and the United States). Other chapters explore the suitability and pitfalls of peer counseling, and provide insights regarding the roles that general practitioners may have in survivor support. Other chapters address how bereaved families can be supported through the forensic and coronial services, discuss how workplaces may provide survivor support, and examine the roles of religion and spirituality in suicide bereavement support. Part II concludes with an overview of the fast-growing field of online suicide bereavement support, and a presentation of how personal experiences and artistic expressions can be used for the benefit of those bereaved by suicide.

Part III focuses on suicide bereavement support in specific populations. While cluster-suicide and murder–suicide events may be rare, their traumatic aftermath warrants dedicated aftercare. Suicide-bereaved parents may be in need of survivor support; however, they may have lost trust in the health care system. Health professionals who have lost a client by suicide also have to deal with the impact of the loss, and may do so in a variety of ways. Little is known about the Indigenous peoples’ experience with a suicide loss, and the elders of Ojibway First Nation have shared their knowledge of healing practices involving family and the community, and the important roles of rituals and spirituality.

Part IV presents an overview of postvention practice and research in no less than 23 countries. Besides chapters covering the “usual suspects” such as the United States and western European countries, this part includes chapters presenting postvention in South America, the Asia-Pacific, and Africa. Obviously a wide variety of suicide survivor support has been developed and implemented across the world. Many countries included in this part of the handbook report on the availability of support groups; however, it is also clear that support groups may have a variety of formats and goals. For example, authors from Uruguay and Thailand report on the availability of therapeutic, professionally led groups, whereas in other countries peer-led |XVII|groups are also available. Other countries, such as Denmark and France, report wide availability of individual psychotherapy. Most of the survivor organizations are volunteer-based or involve a collaboration of professionals and peers (e.g., Canada and Italy). Typically, these organizations provide one point of access, such as a helpline, involve counselors, who may provide assessment, and offer individual or group support. Sometimes the face-to-face support is extended to online support (e.g., in Brazil), or to community awareness-raising activities, such as a national survivor day or a “walk out of darkness. Alternatively, survivor support may also be professionally based – for example, through a forensic department or coroner’s office (e.g., in Australia and Hong Kong).

Support may be targeted at specific groups in society. Several countries report activities specifically for children and adolescents through support groups (Belgium), youth camps (Norway and Slovenia), or interventions at schools (Portugal). Postvention support in workplaces has become available through community organizations (Canada and the United States) or occupational health services (France), as well as support for health care professionals (e.g., from peers, supervisors, or through training; in Austria, Portugal, Slovenia, Thailand, and the United States). Some countries have developed specific support for the aftermath of suicides on the railways (e.g., Austria, The Netherlands, and the United Kingdom), and several countries offer postvention training and resources, such as websites (Australia, Slovenia, etc). Importantly, a number of countries (Ireland, the United States) have integrated postvention in national suicide postvention standards, which certainly is one way to go.

Action

It is the first time that such a vast overview of country reports has been compiled, demonstrating how postvention has become a worldwide strategy for suicide prevention. Nevertheless, this attempt at an overview also reveals serious gaps in the knowledge and practice of postvention. While there is a reasonable representation of the North American and European region, far fewer chapters could be solicited from Asia-Pacific and South American countries, and especially from Africa. Given that the majority of suicides occur outside the Westernized world, this poses challenges to the global understanding of suicide grief and mourning.

The book is dedicated to the ones we have lost through suicide, and their friends, families, and clinicians. More, the handbook is dedicated to the memory of Professor Norman L. Farberow (1918–2015), a founding father of the International Association for Suicide Prevention, who died on September 10, 2015, the World Suicide Prevention Day. Professor Farberow was a pioneer of postvention, a mentor, and a friend, and he will be remembered for his inspiring lifelong commitment to suicide prevention and postvention. It is hoped that this handbook will be a landmark resource for researchers, clinicians, and all those involved in survivor support. It is a testimony of how far and strongly the field has evolved, and it is hoped that the book may inspire further discussions and exchanges of expertise, which is essential to ensure the ongoing progress of postvention.

Postvention in action!

Karl Andriessen

Karolina Krysinska

Onja T. Grad

March 2017

|XVIII|References

Andriessen, K. (2009). Can postvention be prevention?Crisis,30(1),43–47. Crossref

Shneidman, E. (1969). Prologue: Fifty-eight years. In E.Shneidman (Ed.), On the nature of suicide (pp. 1–30). San Francisco, CA: Jossey-Bass.

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

|1|Part ICurrent Knowledge and Implications for Support

|3|Chapter 1Current Understandings of Suicide Bereavement

Karl Andriessen1, Karolina Krysinska1, and Onja T. Grad2

1School of Psychiatry, University of New South Wales, Sydney, Australia

2University Psychiatric Hospital, Ljubljana, Slovenia

Abstract: Suicide may have a lasting impact on those bereaved by the death – that is, the survivors. They may embark on a long journey of acknowledging and expressing their grief, either alone or with the help of family, friends, support groups, and clinicians. Over the years, suicide survivor support and research – in other words, postvention – has been increasing, and the World Health Organization has identified postvention as an important suicide prevention strategy. However, major challenges remain to be solved. To further develop the field and to facilitate communication, there is a need for clarity regarding (1) concepts and definitions, (2) how many people are bereaved through suicide, and (3) whether bereavement after suicide is different and/or similar compared with bereavement after other causes of death. In addition, over the decades, several grief models have been formulated, and this chapter highlights the major models that may help to understand the grief process after loss by suicide.

Introduction

Suicide ends the pain of one but brings new pain to those left behind. For centuries, the impact of suicide on bereaved individuals and families has been ignored. The act of suicide was condemned, and often the bereaved were blamed for having a family member die by suicide (Farberow, 2003).Shneidman (1972, p. xi) referred to the tragedies that continue after the self-destructive act as “the illegacy of suicide.” Only lately, since the 1960s, have the bereaved through suicide – that is, the survivors – received clinical and research attention. Contrary to past beliefs, it is now clear that those affected by suicide may face a long and painful process of acknowledging and expressing their emotions, thoughts, and behaviors to be able to move on with their lives (Grad & Andriessen, 2016). Those bereaved by suicide are at increased risk of suicidal behavior, either as a result of a bio-psycho-social vulnerability or because of identification with the person who has died by suicide (see Chapter 2 in this volume). Kinship, gender (see Chapter 4), psychological closeness, time since loss, personal and family history of mental health problems, and preloss life events, such as interpersonal loss and separations, may affect the impact of the suicide death among adults (see Chapter 2), as well as bereaved adolescents (see Chapter 3).

Over the last 50 years, the postvention field has evolved enormously (see Chapter 9 in this volume). Firstly peer, and subsequently clinical support and research activity emerged, and national survivor organizations were created. The International Association for Suicide Prevention (IASP) stressed the importance of survivor support by the establishment in 2011 of the Special Interest Group (SIG) on Suicide Bereavement and Postvention, the SIG being the for|4|mal continuation of the IASP Taskforce on Postvention initiated by Norman Farberow in 1999 (https://www.iasp.info/postvention.php). Currently, support for people bereaved through suicide is recognized as an important strategy for suicide prevention (World Health Organization [WHO], 2014). According to the WHO (2014), “intervention efforts for individuals bereaved or affected by suicide are implemented in order to support the grieving process and reduce the possibility of imitative suicidal behaviour” (p. 37), and “to be effective, national suicide prevention objectives could be designed to: … support individuals bereaved by suicide” (p. 54). As such, any discussion of suicide, a serious public health problem claiming globally more than 800,000 deaths per year, will be incomplete without taking into consideration the perspective of the bereaved.

Although the availability of, and research into, survivor support have increased, this chapter will discuss ongoing challenges in relation to postvention research, clinical practice, and the development of bereavement programs and policies. There is an increasing awareness that to further develop postvention and to facilitate communication from the local to the global level, certain issues have to be clarified (Andriessen & Krysinska, 2012; Jordan & McIntosh, 2011). There are challenges related to terminology and definitions, the number of people bereaved through suicide, and the question of if and how bereavement after suicide is different and/or similar compared with bereavement after other causes of death. In addition, over the decades, several general grief models, which also help to understand the grief process after loss by suicide, have been formulated, and these will be presented in this chapter.

Concepts and Definitions

A discussion about terminology and definitions may seem very technical, academic, and distant from the daily practice of supporting the bereaved. However, the primary aim of clarity in the usage of words and definitions is to facilitate communication between people involved in the field. The development of consensus definitions would require an international project in itself, and is beyond the scope of this chapter. However, it seems useful to start with a brief presentation of concepts and definitions related to postvention.

In general, the lack of consensus about terminology related to suicide survivor support can be understood in the context of its origin and history. The first suicide survivor support groups were created in the 1970s in the United States, followed by support initiatives in other countries and continents (see Chapter 9). These initiatives were often driven by the bereaved themselves, and building on the experiences of these local initiatives, national organizations were established. However, due to the grassroots (i.e., local) origins and bottom-up evolution of suicide bereavement support, consensus definitions of routinely used key concepts have never been developed.

Although the need to formulate consensus terminologies and definitions in the field of suicide bereavement has been noted before (Jordan & McIntosh, 2011), the previous attempts to formulate consensus definitions and nomenclature in suicidology have overlooked postvention (Silverman, 2016). There is a rising awareness of the necessity of dialogue and consensus finding, and a shared nomenclature – that is, a comprehensive set of mutually exclusive terms could improve communication within the field of suicidology and in the general community (Silverman, 2016). By addressing the definitions of the major concepts related to suicide bereavement, this chapter aims to contribute to a shared nomenclature in postvention, and invites researchers, clinicians, and bereaved people worldwide to join this endeavor.

|5|Postvention

The termpostventionwas coined and originally broadly defined byShneidman (1969, pp. 19 & 22) as “the helpful activities which occur … after a stressful or dangerous situation … after a suicidal event.” Shneidman specified that “postvention aims primarily at mollifying the psychological sequelae of a suicidal death in the survivor-victim” (Shneidman, 1969). Currently,postventionrefers to dealing with the aftermath of suicide, with a dual focus on bereavement support and suicide prevention among the bereaved. Postvention consists of “the activities developed by, with, or for suicide survivors, in order to facilitate recovery after suicide, and to prevent adverse outcomes including suicidal behavior” (Andriessen, 2009, p. 43). Postvention involves peer and social support, clinical work, advocacy, community action, research, and policy development related to suicide bereavement.

Survivor

There are many different words for describing a person who has lost someone through suicide, such assurvivor, suicide survivor, survivor of suicide, survivor after suicide, suicide loss survivor, survivor of suicide loss, bereaved by suicide,andbereaved through suicide.Words such assurvivorhave different meanings in different countries and contexts. For example, a survey among 293 people who receive the newsletterSurviving Suicideof the American Association of Suicidology showed that among 19 options mentioned by the respondents, more than half (58 %) endorsedsuicide survivoras their preferred term (Honeycutt & Praetorius, 2016). However, in the equally Anglo-Saxon environment of Australia, the termsuicide survivoris hardly used because of the confusion with suicide attempts, and the termbereaved by suicideis better understood (see, e.g., theInformation and Support Pack for Those Bereaved by Suicide or Other Sudden Death,developed under the national Living Is for Everyone framework: http://livingisforeveryone.com.au/Information--Support-pack-for-those-bereaved-by-suicide-or-other-sudden-death.html).

While the termsurvivorcommonly refers to those bereaved by suicide, it can mean both “to continue to live after the death of another” and “to remain alive, live on” [after an event] (Simpson & Weiner, 1989, Vol. 17, p. 313). Rather than surviving a suicide attempt, in postvention,survivorrefers to the behavior of someone else, the subsequent death and absence of that person, and the impact on the remaining persons (Farberow, personal communication, 2007). The termsuicide attempt survivor,recently introduced by the American Association of Suicidology in 2014, acknowledges those who have engaged in nonfatal suicidal behavior, while at the same time, makes a distinction withsuicide loss survivorsorsurvivors of suicide loss(http://www.suicidology.org).

Taking into account Farberow’s principles,Andriessen (2009, p. 43) defined a survivor as “a person who has lost a significant other (or a loved one) by suicide, and whose life is changed because of the loss.” Jordan and McIntosh (2011, p. 7) defined a survivor as “someone who experiences a high level of self-perceived psychological, physical, and/or social distress for a considerable length of time after exposure to the suicide of another person.” While acknowledging efforts to formulate these definitions,Berman (2011) noted inherent difficulties with the inclusion of the life-changing aspect in the first definition, and the high level of distress over a length of time in the second definition.

As implied by these definitions, being exposed to a suicide is not a sufficient condition to become a survivor. However, bystanders, witnesses, or acquaintances can be deeply affected by a suicide, with survivorship being predominantly a self-identified status (Andriessen, 2009). Psychological closeness appears to be a key concept in the identification as a survivor (|6|Cerel, McIntosh, Neimeyer, Maple, & Marshall, 2014). The formulation of a continuum of survivorship according to the magnitude of the impact of the loss (Cerel et al., 2014) may be an important approach to include the variations in survivor status inherent in the definitions. The model ofCerel et al. (2014) distinguishes four subgroups based on the level of impact: (1) those exposed to suicide without being personally affected; (2) those affected by a suicide; and those closest to the deceased who may experience grief reactions either on (3) a short-term or (4) a long-term basis. Research is needed to further specify how the different levels can be delineated and what risk or protective factors are involved.

Bereavement, Grief, Mourning

The termsbereavement, grief,andmourningare sometimes used interchangeably, whereas they do have different meanings. The wordbereavedis defined as “deprived or robbed,” and especially as “deprived by death of a near relative, or of one connected by some endearing tie” (Simpson & Weiner, 1989, Vol. 2, p. 123). Thus,bereavementrefers to “the fact of the loss” (Zisook & Shear, 2009) and is understood, in both the dictionary and the clinical literature, as the objective status of having lost someone significant (Stroebe, Hansson, Schut, & Stroebe, 2008;Stroebe, Hansson, Stroebe, & Schut, 2001).

Griefis defined as “hardship, suffering,” “mental pain, distress, or sorrow” (Simpson & Weiner, 1989, Vol. 6, pp. 834–835). In the clinical and research literature, this is understood as the “primarily emotional (affective) reaction to the loss of a loved one through death. It is a normal, natural reaction to loss” (Stroebe et al., 2008, p. 5). It incorporates diverse psychological (emotional, cognitive), physical, and behavioral responses to the death (Stroebe et al., 2001;Zisook & Shear, 2009).

Mourningis defined as “the action of mourn” and “the feeling or the expression of sorrow for the death of a person.” It is ”the conventional or ceremonial manifestation of sorrow for the death of a person” (Simpson & Weiner, 1989, Vol. 10, pp. 19–20). Consequently, in the clinical and research literature, mourning is understood as the public display of grief, the social expressions of grief that are shaped by the (often) religious beliefs and practices of a given society or cultural group (Stroebe et al., 2008, 2001;Zisook & Shear, 2009).Stroebe et al. (2008, 2001) emphasized the sociocultural nature of mourning. Grief expressions – for example, crying in public – that are acceptable or expected in one society may be unacceptable in other societies. Understanding grief reactions necessitates understanding the context in which the loss occurred. Given the fact that suicide bereavement has been studied almost exclusively in Western and Anglo-Saxon countries (Andriessen, 2014), while the majority of suicides occur in other parts of the world (WHO, 2014), the global understanding of suicide grief and mourning might still be in its infancy.

Complicated Grief

Whereas grief is understood as a normal, purposeful reaction to a loss, many words are currently in use to refer to an “abnormal” grief, such as traumatic, pathological, chronic, prolonged,orpersistent complex grief.Most of these words are routinely used without definition, but they refer to a grief that is different from the clinical or sociocultural norm with regards to the time course, intensity, or symptoms of the grief (Stroebe, Schut, & van den Bout, 2013;Stroebe et al., 2008). They entail a state of chronic debilitating mourning, with persistent and disruptive yearning, pining, and longing for the deceased – with, for example, expressions of separation anxiety and trauma (Stroebe et al., 2013;Zisook & Shear, 2009). Suicide loss can be a risk factor for complicated or prolonged grief, and it is estimated that 7–10 % of grievers fall into this category (Kersting, Brähler, Glaesmer, & Wagner, 2011).

|7|Most of these concepts have been developed by researchers, and are based on diagnostic criteria (Prigerson et al., 2009;Stroebe et al., 2013). However, the diagnostic criteria for these concepts often overlap. In addition, there is an overlap with diagnostic criteria for mental disorders, such as anxiety disorders, depression, posttraumatic stress disorder, and substance abuse (Stroebe et al., 2013).

Two issues warrant attention when trying to define complicated grief. Firstly, as mentioned above, cultural variation in grief expressions might challenge the understanding of “deviant” mourning. Secondly, there is a discussion in the literature over whether medicalization of grief and providing a label to a subgroup of grievers would either facilitate treatment for those in need, or increase stigmatization and treatment thresholds (Stroebe et al., 2013). A cultural and/or economic perspective might help to shed light on this discussion: A diagnosis might facilitate treatment in one country – for example, through health insurance reimbursement – but might deter people from seeking help in other countries.

Lived Experience

The expressionlived experience1is used in a variety of fields related to social and health issues, mostly without a definition. In mental health, it refers to people living with mental illness (i.e., consumers or users) and their family and friends (i.e., carers) (South Australia Health, 2016). Definitions related to suicidology are almost nonexistent. Suicide Prevention Australia has described lived experience as “having experienced suicidal thoughts, survived a suicide attempt, cared for someone who has attempted suicide, been bereaved by suicide, or been touched by suicide in another way” (Suicide Prevention Australia, 2016).As such, it appears to be an umbrella term for all suicide-related experiences, including suicidal ideation, nonfatal and fatal suicidal behavior, either from one’s own experience, or as a relative or carer. While this description has the potential of appealing to as many people as possible, its inherent broad character limits its usability for research purposes, and for application in postvention. In fact, the double meaning ofsurvivor(referring to a suicide loss vs. a suicide attempt) may further obfuscate the understanding of lived experience, and highlights the need for conceptual clarity.

Whilelived experienceis popular, it may not differ from well-established concepts such as experiential knowledgeandexperiential expertise(Borkman, 1976). The former term means “truth learned from personal experience with a phenomenon rather than truth acquired by discursive reasoning, observation, or reflection on information provided by others” (Borkman, 1976, p. 446), whereas the latter is defined as “competence or skill in handling or resolving a problem through the use of one’s own experience” (Borkman, 1976, p. 447).

How Many People Are Bereaved Through Suicide?

The question of how many people are bereaved by suicide, and potentially in need of support, is particularly important for service planning and delivery.Shneidman (1969, p. 22) originally estimated that on average a “half-dozen” survivors are left behind after a suicide. While this educated guess of six survivors per suicide has been perpetuated in the literature, other authors have |8|estimated higher numbers: for example,Wrobleski (2002) mentions 10 survivors per suicide. A survey byBerman (2011) among members of the Survivor Division of the American Association of Suicidology found that the estimated numbers of survivors varied depending on kinship and age: Parents bereaved by child suicide estimated that there were 80 survivors (“deeply affected”;Berman, 2011, p. 111), partners and spouses estimated the number of survivors as 60, and siblings and friends indicated between 45 and 50 survivors. For all respondents,Berman (2011) estimated an average of five immediate family members bereaved by a single suicide. Also, studies based on population registers have calculated the number of survivors per suicide for selected types of relationship.Kuramoto et al. (2010) andWilcox et al. (2010) found that on average two children are bereaved after the suicide of a parent.Botha et al. (2009) andChen et al. (2009) estimated an average of four to five relatives bereaved by a suicide in the family.

Findings regarding the variety of relationships of people being exposed to a suicide have fueled the ambiguity regarding the numbers of survivors. Campbell (1997) described 28 different types of relationship among individuals seeking suicide bereavement support from the Crisis Intervention Center in Baton Rouge, Louisiana, USA. The majority consisted of nuclear family members (80 %); other relatives, friends, and acquaintances accounted for the remaining 20 %. A telephone survey in the United States found 27 different relationships among individuals who knew someone who had died by suicide (Cerel, Maple, Aldrich, & van de Venne, 2013). In this study, friends were the largest relationship category (35 %), and nuclear family members accounted for 7.5 % of the group. In addition, while the reported exposure to suicide is higher among certain populations, such as clinicians, prisoners, and military veterans, it has been noted that the social networks of those dying by suicide are smaller than those of people with natural deaths (Stack, 2007). Those dying by suicide are more likely to be divorced, living alone, less frequent churchgoers, and more socially isolated. On the other hand, younger suicides may have more living relatives (Stack, 2007).

To better comprehend the diversity of numbers cited in the literature,Andriessen, Rahman, Draper, Dudley, and Mitchell (2017), conducted a meta-analysis of 18 population-based studies, which reported rates of past-year and lifetime prevalence of people who had experienced a suicide among family or friends, or had personally known someone who had died through suicide. The meta-analysis found that pooled lifetime prevalence of exposure to suicide was higher than past-year prevalence (21.8 % and 4.3 %, respectively). Past-year prevalence of suicide in the family (1.1 %) was significantly lower than exposure to suicide among friends and peers (5.6 %), and in all relationships (6.3 %). There were no statistically significant differences regarding past-year prevalence of exposure to suicide by age group – that is, adolescents versus adults.

Similar to the past-year prevalence, lifetime prevalence of suicide in the family (3.9 %) was significantly lower than exposure to suicide in friends and peers (14.5 %), and in all relationships (29.4 %). Life-time exposure to suicide by age group and type of relationship revealed a mixed picture. Among adults exposure to suicide in the family (3.9 %) was lower than exposure to suicide in all relationships (36 %) while there were no differences among adolescents.

Further analysis found that both past-year and lifetime prevalence of exposure to suicide in the family was approximately 8 to 5 times lower respectively, than prevalence of exposure in all relationships after controlling for country and age group of exposure. Given that the impact of suicide might be stronger when experienced at a younger age (see Chapter 3 in this volume), studies are needed to further investigate suicide exposure, impact of the loss, and support needs among adolescents, with regard to types of relationship and psychological closeness to the deceased.

|9|Is Suicide Bereavement Different From Other Bereavement?

There appear to be contradictions in the answers to the question of whether suicide bereavement is different from bereavement experienced after other causes of death, usually depending on who is answering the question. Personal accounts of the bereaved, including published autobiographies (e.g.,Fine, 1999), and narratives of clinicians seem to stress the uniqueness of the experience of suicide survivors. The recurrent themes in the narratives of survivors include guilt, shame, social stigma, search for meaning, and suicidal ideation. Research findings, especially from controlled studies, indicate that there are more similarities than differences between different groups of the bereaved, regarding major grief themes, the grief process, its duration and outcomes (Bolton et al., 2013;Sveen & Walby, 2008).

Figure 1.1 Aspects of bereavement related to the mode of death. Republished with permission of Routledge, from Jordan & McIntosh, 2011, p. 34; permission conveyed through Copyright Clearance Center, Inc.

The model developed by Jordan and McIntosh (2011, p. 34) might be helpful to accommodate the contradictory perspectives of survivors, clinicians, and researchers (Figure 1.1). The model consists of four concentric circles. The outside circle represents features of bereavement that may be found independent of the cause of death: sorrow, pain, missing, and yearning to be reunited with the deceased. The second circle includes features typical for bereavement after unexpected deaths, such as shock and a sense of unreality. The third circle includes features of bereavement after violent deaths, such as the experience of trauma, and the shattered illusion |10|of personal invulnerability. Finally, the fourth and inner circle includes features typically associated with bereavement after suicide. These include anger at the deceased, aggression, and feelings of abandonment and rejection (Jordan & McIntosh, 2011).

Some grief features seem to be more pronounced, though not unique, in suicide bereavement. The feeling ofguiltis one of the most common feelings experienced by suicide survivors (see also Chapter 6). The reasons for this feeling may differ for each individual,but they include the feeling of not having been able to recognize the possible suicide warning signs or not having been able to prevent the death. Guilt may be fueled by the feeling that not enough attention was given to earlier suicide attempts, depressive behavior, or the effects of mental disorders on the deceased. Special circumstances, such as not living together (e.g., parents of adult children), may also trigger guilt. Guilt may stem from the feeling of relief – for example, when the suicide ended suffering associated with a chronic mental or physical illness, or when family members or caregivers became fatigued and hoped that the suffering would stop. Overestimating one’s own responsibility and ability to stop the suicidal process, and thoughts and fears of having directly contributed to the death – for example, because of marital separation, a threat to leave, or a quarrel prior to the suicide – may also result in feelings of guilt (Grad & Andriessen, 2016). Sometimes the bereaved start to worry that another family member may become suicidal. Additional care and attention may be directed toward a family member who retains the same lifestyle as before the suicide, which seems dangerous, such as engaging in life-threatening sports or substance/alcohol abuse (Grad, 2011).

Another common theme is searching for reasons