84 How to help survivors of suicide loss

Survivors, i.e. relatives and friends of persons who have died by suicide, experience a plethora of emotional and societal difficulties. Due to the complicated nature of grieving in the aftermath of a suicide, emotional and social support to survivors can only ameliorate the life functioning of this population. The present chapter outlines therapeutic resources that will be beneficial to this unique group. Therapeutic groups, and many other group-related activities, have been established to assist survivors of suicide. Descriptive information with regards to these groups and how to create them is provided. The chapter ends with recommendations on additional resources and services for survivors of suicide.

Complicated grieving is defined as the emotional state of an individual who suffers from a loss due to crisis-related circumstances (e.g. depression, anxiety, cancer, etc.). Suicide is among contextual factors that clearly undermine the grieving process. Survivors of suicide suffer from a series of emotional sequelae following the traumatic, and sometimes rapid, death of their loved ones. Survivors of suicide are at risk for depression, suicidal ideation, anxiety, and negative existential values (Mitchell et al. 2005; Zisook and Kendler 2007 ; Sveen and Walby 2008).

In addition to common bereavement symptoms such as confusion, sadness, guilt, and anger, survivors of suicide may have recurrent rumination of a plausible avoidance of the suicidal act. They may also blame themselves for the suicidal act, and believe the cause of, or lead the deceased to commit suicide. Some survivors of suicide may perceive the suicide as a tangible expression of rejection from the deceased (Sveen and Walby 2008). If the deceased is a family member (e.g. a child), the homeostasis of the family is likely to be disrupted. Anguish may be experienced, especially if the deceased was the primary caregiver or the principal source of familial income (Hopmeyer and Werk 1994). Feelings of shame over societal stigma of suicide may also be present (Ellenbogen and Gratton 2001). These feelings of shame may be accentuated by the survivor's age and/or cultural affiliation. Children and adolescent survivors of suicide are more likely to take responsibility for the suicide than adult survivors of suicide. Children and adolescent survivors of suicide are also more at risk for major depressive disorder, post-traumatic stress disorder, and impaired social adjustment (Sethi and Barghava 2003). Moreover, in certain religions, such as Catholicism, suicide may be perceived as a sin, which may bring shame and desolation to survivors. Ultimately, the cultural identity of the family determines the intensity and evolution of the grieving process, as well as the emanation and severity of the aforementioned bereavement symptoms (Stack 1998).

Due to the sudden and traumatic nature of suicide, emotional assistance becomes fundamental to survivors. This chapter provides an overview of best practice for psychological and emotional assistance for survivors of suicide, with a strong emphasis on group-related assistance. We will first delineate common psychological and emotional assistance that is currently available to this population, followed by practical resources considered to be of the utmost benefit to them.

Literature differentiates emotional support provided to survivors of suicide into two categories: individual and group support. Groups are facilitated by professionals, peers, or experienced individuals (Parkes 1972). The individual is conceptualized as belonging to a spherical social environment and emotional assistance follows a systematic theoretical orientation (Raphael 1983). The individual is placed at the centre of this social sphere, and is influenced by immediate and remote contextual factors. Due to the crisis-related circumstance of the loss, survivors are, therefore, in need of immediate and remote members of their social realms in order to cope and move beyond their grief (Bronfenbrenner 1977; De Clerq and Dubois 2001). Provision of support from one's social sphere is empowering.

Feminist and humanistic ideas of empowerment, and unconditional positive regard, have also been therapeutic orientations employed with survivors of suicide (World Health Organization 2000). The ultimate goal is to provide a community-based environment in which survivors will gain support, disclose their emotional burden, and finally, be able to live a well-functioning life. The cultural identity of the survivor determines the type of resources that will be employed to recover their loss (Andriessen 2004).

Professional support mostly consists of individual or group therapy, which is facilitated by an accredited mental health professional, e.g. psychologist, psychiatrist, social worker, or licensed therapist/counsellor. Individual therapy for adults usually serves as a transition to group therapy, especially for survivors not ready for group interactions. Individual therapy may provide survivors with some needed additional one-on-one support; support that they may seek due to the deleterious consequences that suicide may have on an entire family. Individual therapy becomes a place to re-evaluate and disclose issues outside of the familial realm, a place where the survivors may feel more comfortable disclosing particular issues. Individual therapy may be appropriate for survivors of suicide whose pre-existing mental health condition was worsened by the complicated grief. Individual therapy is also generally warranted for individuals who do not feel comfortable participating in group interactions.

Special consideration should be given to the young population, whose developmental stage determines the emerging bereavement symptoms, as well as the appropriateness of services provided. Some children may be too young to openly express their emotional reaction, or to comprehend the nature and circumstances of suicide. The therapeutic intervention does not lie in how to hide the suicidal act from the child, but rather how suicide is explained and appropriately processed (Cain 2002). Due to the societal stigma of suicide, parents or loved ones may be inclined to conceal the cause of death from the child (Sveen and Walby 2008). Although controversy exists with regard to this matter, it is usually recommended that the child be informed of the circumstance of the death; however, providing specific details regarding the suicidal act should be avoided. Some studies reveal the benefit of informing children of the suicidal act rather than hiding it (Cain and Fast 1966; Cain 2002). It is believed that significant harm is done when the child is not allowed to properly grieve the death of a loved one. Grieving is, indeed, a significant part of living; the sudden death of loved ones ascertains some psycho-education, which implies the education of survivors of suicide on practical ways to cope with their grief, life, suicide, and the grieving process. The use of simple culturally appropriate terms rather than psychological or adult jargon to explain the suicide of a parent or a loved one is essential (Cain 2002). Therapy also focuses on allowing the child to reconstruct themself, through drawing or telling small stories. Narrative or play therapy is, therefore, strongly recommended for these groups that are still unable to appropriately describe their emotional state. Child survivors of suicide would also be reassured that most of the practical needs fulfilled by the deceased will be met and provided by close loved ones (Cain 2002). Suicide prevention is also critical for this population, as it serves to halt the perpetuation of a suicidal act within a social circle. Research does indicate a higher prevalence of mental health disorders in survivors who are relatives or close loved ones of the deceased by suicide (Sveen and Walby 2008).

Although individual therapy can be beneficial, it has mostly been in conjunction with group therapy, as it is perceived to be critical for survivors to go back to a seemingly normal lifestyle. The term therapeutic group applies to a set of individuals, whose:

broad purpose [is to increase] people's knowledge of themselves and others, assisting people to clarify the changes they most want to make in their own life, and giving people some of the tools necessary to make these desired changes.

Corey and Corey (1987)

Due to potential derogatory perceptions of the word therapy, and its sometimes non-applicability worldwide, other terms such as group discussions, group narratives, group coping, or spiritual groups may be more culturally appropriate. Nonetheless, all these terms are synonymous with therapeutic group, as these groups all serve to support and assist the survivors of suicide.

In a study by Hopmeyer and Werk (1994), adult participants who attended self-help or peer support-type of bereavement groups reported an overall satisfaction with regards to the support they received. Although minimal studies exist on the benefit of child survivors support groups, the few studies that have examined these groups denote a decrease in anxiety and depressive symptoms among participants (Pfeiffer et al. 2002; Mitchell et al. 2007). Social isolation and loneliness are quite common among survivors of suicide (Moore 1995). Group therapy allows for a gradual transition, because of the pseudo-societal reality formed within group sessions.

Therapeutic groups rely on interpersonal relationships to address and overcome grief. Most groups follow Yalom's (1995) theory on group therapy. Yalom ascertained that groups provided a safe pseudo-reality environment where survivors of suicide were able to disclose complex emotions, receive, and reciprocate positive and empowering feedback. Yalom recommended an average of 6–10 members in the 2-hour time period of each group interaction. Groups are either structured (with a predetermined agenda for each session) or unstructured, which implies that members are in charge of the themes of each group session. They may be open, allowing inclusion of additional group members at any given time, or closed, with a set number of group members from beginning to end. All groups are facilitated by one or two experienced mediators. The facilitator does not lead or moderate group discussions; the facilitator's role is to intervene and participate in extreme situations. Maintenance of confidentiality, civility, and all the predetermined rules of the group is upheld by the facilitator. The facilitator also holds experiential and practical knowledge with regards to suicide and survivors' experiences. Yalom denoted the facilitator's role in providing some practical and educational information to group members; however, group interaction was believed to be the primary source of healing.

Certain groups, however, hold a strong psycho-educational focus, while others only incorporate group interaction and self-disclosures. The overall nature and atmosphere of the group is mostly determined by the group facilitator and the group members. Different types of groups may therefore emerge: most groups that are believed beneficial to survivors of suicide are self-help/peer-related groups (Moore 1995). These groups are facilitated by either an experienced survivor of suicide, or a professional with experience in complicated grief. Groups may be psycho-educational, which implies educating survivors of suicide on practical ways to cope with their grief, or peer-related, where survivors manage the agenda and the overall evolution of the group.

Mitchell et al. (2003) offers a comprehensive description of the application of narrative theory in a therapeutic group for survivors of suicide: narrative therapeutic groups mostly consist of the use of life stories as therapeutic tools for healing. Rituals and any other culturally appropriate ways of grieving may apply in peer support group. Peer support may be appropriate for survivors of a collective suicide. France is currently seeing the emergence of collective (group) suicide within its youth (France Television 2008). Survivors of a same collective suicide may reunite and help each other cope with their collective loss. Constantino et al. (2001) examined the effectiveness of post-vention groups for widowed survivors of suicide: group members reported a significant decrease in depression, psychological distress, and grief. A significant improvement in social adjustment was also observed. Hence, in peer-related groups, the nature, duration, and specific tasks of the group will be moderated by group members, whose expertise and knowledge in a particular culture will be critical to the positive therapeutic process and outcome of the group.

The World Health Organization (2000) reports that traditional self-help groups are predominant in English-speaking countries; and other non-traditional therapeutic resources may be available to survivors originating from non-English speaking areas. Andriessen (2004) reports a prevalence of services in north-western and mid-European regions, countries such as Belgium, France, Ireland, Norway, Sweden, and the UK have the largest number of services available to survivors of suicide. In countries where limited resources are available, it becomes critical to provide a model of how to set up self-help groups that would be beneficial to regional survivors of suicide. Literature denotes several critical factors to consider when any individual, organization, or network is interested in establishing a support group for survivors of suicide (Moore 1995; WHO 2000; Andriessen 2004):

Further resources and recommendations on how to establish a group for survivors of suicide is available in the 2000 Report on survivors of suicide from the WHO Department of Mental Health (WHO 2000).

The establishment of support groups throughout a particular geographical location increases the likelihood of the establishment of national and international network for survivors of suicide. International networks can only benefit survivors, as the sharing of valuable resources will further impact survivors' functioning. The International Network for Survivors of Suicide was founded in 2000, and many other national networks have also been established (Andriessen 2004). The World Health Organization (WHO) founded the WHO International Network for Suicide Prevention and Research, which seeks to increase awareness and prevention of suicide. Survivors of suicide, group facilitator, and local organization's enrolment and participation in these national and international networks will allow for a systematic provision of services to this community.

With the advance of technology, many forums and online networks have emerged to support survivors of suicide. These provide a cybernetic environment, where survivors receive practical advice, and are able to disclose and receive support anonymously. Some forums or networks are created specifically for a particular group of survivors of suicide (parents or widows, survivors of suicide). Although these boards can be beneficial, due to their online characteristics, caution must be taken to maintain confidentiality of users, as well as to ensure the active participation of users in real-life social activities. It is recommended that survivors of suicide visit official national networks, which have been established in Belgium, Germany, and many other European countries: a directory of available national services and additional reliable resources are available for survivors of suicide (Andriessen 2004). Go for Happiness is an example of social network available for Belgian survivors of suicide; it is a non-profit organization founded by survivors of suicide for the prevention of depression and suicide in young people. Go for Happiness provides survivors of suicide an opportunity to volunteer and to advocate socially for the prevention of suicide, and works on the creation of a European platform in this field. Further resources for survivors of suicide include the circulation of several national newsletters pub-lished in France, Germany, and the UK; these newsletters can provide survivors and mental health professionals additional references and resources on survivors of suicide (Andriessen 2004).

Due to the difficult contextual factors of suicide, survivors are in need of fundamental resources that will help them grieve, heal, and function. Group-related resources and support are believed essential to this population. The aforementioned resources are, therefore, basic services that have been shown to be beneficial to survivors of suicide. Caution must, however, be taken with regards to the applicability of some resources cross-nationally. It is therefore recommended to establish group support or network nationwide in order to ensure a better shaping of resources for survivors of suicide.