This brief page looks at some of the methodological issues involved in empirical studies of those who have experienced a suicide loss. It also refernces some of the key findings about the nature of suicide loss and the effectiveness of interventions to support the recovery of those who have experienced a suicide.

Most of what is known is drawn from the personal experiences shared by those bereaved by suicide or those that they have turned to for help. There are three reasons for the paucity of research(Stillion 1996):

1. Drawing representative samples of suicide grievers is difficult
2. Differentiating suicide grievers from other traumatic loss victims is problematic
3. Working with suicide grievers who are often emotionally distressed is a challenge

A recent review of suicide loss research critiques (Ellenbogen and Gratton 2001) noted that concepts are not always operationalized, participant sample sizes are often quite small, measures not intended for grief are frequently used, the theories underlying the studies are not always clearly stated, refusal rates are high, and white, upper/middle class, female grievers are overrepresented.

McIntosh (1996) cites these weaknesses in the current research:

1. Too few control group studies involving different types of suicide grievers.
2. Too few kin groups studied (i.e., primarily widows and parents of youth victims).
3. Too few longitudinal studies measuring response at several points over time.

This lack of comparativeness, diversity, and temporal scope blurs the distinction between survivors and other bereaved, the impact of loss on siblings and parents of adult victims, and the long-term effects of the loss on all suicide grievers.

A body of research about suicide loss is appearing. It is concentrated on (Stillion 1996):

1. The reaction of grievers to the suicide
2. Postvention services to suicide grievers
3. Public attitudes towards suicide grievers

Most studies address the last area and show that suicide grievers are viewed less positively than victims of other losses and draw less social support. Griever response to the suicide is the focus of next largest number of studies which report grief reactions, guilt, stress, anger, relationship problems, and depression. There are only a few postvention studies.

The research to date hasn't convinced everyone that the aftermath of suicide loss differs significantly from other traumatic loss (e.g., van der Wal 1989-90). On the other hand, Jordan (2001) concludes that the literature indicates "that there are qualitative aspects of the mourning process that are more intensified and frequently more problematic for survivors of suicide loss than for other types of mourners."

A review of the suicide loss research for grief counselors (Barlow and Morrison 2002) observes that those trying to help suicide grievers must often turn to studies of other grievers for insight, but also notes that overall the suicide loss literature outlines the major needs and issues. Self-help mutual support groups are acknowledged as an effective and widely used resource by those who have expereinced a suicide but the research literature is sparse (see e.g., Clark et al., 1993); Rubey & McIntosh, 1996).

Jordan & McMenamy (2004) looked at the literature to try to assess the present level of evidence-based knowledge about suicide loss interventions. They concluded:

Currently, our scientifically based knowledge about how to assist survivors is far behind our ability to intervene with other at-risk populations or with many forms of psychiatric disorder. Although there are encouraging signs that this is changing, it is our impression that survivors have been a low priority for researchers and clinicians in suicidology, whose main interest has focused on preventative work with suicidal individuals.

They go on to note the irony of this situation insofar as "work with survivors is an obvious and efficient way to contribute to the prevention of future distress, psychiatric disorder, and even suicide itself" (Jordan & McMenamy, 2004). On a more cynical level, we wonder how much more research on suicide loss would be available if it could be resolved through pharmacology.

A much neglected area of research within the overall suicide loss community are individuals with serious mental illness (i.e., major depression, bipolar disorder, schizophrenia) and/or alcohol misuse disorders who have lost a family member, friend, or other to suicide. These individuals at at far greater risk of experiencing suicide loss than the general population. When they do they are vulnerable to consequences such as relapse or recurrence, crisis, and suicidality. There is scant research on the impact of bereavement on mental illness (see, e.g., Piper et al., 2001) and alcoholism and virtually none on the effect of suicide loss on those with these conditions. There is more research on mental illness as an outcome of traumatic loss (see e.g., Ness and Pfeffer, 1990; Barry et al., 2002).

Another significant void in suicide loss research involves elders, those age 65 and over. Within this fast growing demographic segment, males are at increasing risk of suicide as they age. Bereavement is a recognized suicide risk factor for older males. We can only speculate about how suicide bereavement affects elders. McIntosh (2005) recently called attention to this deficit in elder suicide survivor research.

The area of research most in need of attention concerns the effects of suicide loss on adult males.

A family history of suicide has long been acknowledged as a risk factor for suicide, but there has not been much research into the incidence of suicidal behavior among those affected by a suicide loss. Latham and Prigerson (2004) found that complicated grief among adults bereaved by suicide heightened the risk of suicidal ideation independent of the presence of depression and PTSD.

In any case, only cutting the number of suicides will lessen the number of suicide grievers. Until then more research, and more study of postvention techniques, can diminish their exposure. This can begin with a needs assessment to establish what suicide grievers feel are the problems and the kinds of help they see of value.

Jordan (2007) looks at bereavement studies in terms of what the research on grief, in general, and suicide loss, in particular, offer to those who have experienced a suicide. This may be the only such effort as most research is intended for other researchers or clinicians. Jordan characterizes himself as a "distant survivor" (having lost a great uncle). However, in this brief article and elsewhere he demonstrates that he has learned much about the suicide survivor perspective from the people that he has counselled. When it comes to understanding survivor needs, Jordan clearly "gets it."

Some of the studies referenced above or in the brief bibliography below identify factors that may be helpful in improving postvention services. However, few suicide loss needs assessments have been done. A good example of such a study is Davis and Hinger (2005).

Suicide loss research was the topic at a dinner meeting at the American Association of Suicidology's 2005 Conference in Bloomfield, CO. Michelle Linn-Gust summarized the discussion in "Survivor Research: Has the Time Finally Come?" in the AAS newsletter Surviving Suicide (17: Summer 2005). The NIMH paper, "Issues to Consider in Intervention Research with Persons at High Risk of Suicidality," offers guidance that is applicable to studies involving survivors.

Many parental survivors who participate in suicide loss support groups in the US responded to a survey by William Feigleman, PhD, of Nassau Community College in Long Island, NY. Some results are posted at Child Loss Survey.

Selected Readings and References

Bailley, S., Kral, M., and Dunham, H. (1999) "Survivors of Suicide do Grieve Differently: Empirical Support for a Common Sense Proposition" Suicide and Life-Threatening Behavior 29(3) 256-271. Abstract

Barlow, C.A., and Morrison, H. (2002) "Survivors of Suicide: Emerging Counseling Strategies" Journal of Psychological Nursing/40(1) 28-39. American Journal of Geriatric Psychiatry 10(4) 447-457.

Clark, S. (2001) "Bereavement After Suicide - How far have we come and where do we go from here?" Crisis 22(3) 102-108.

Clark, S. et al. (1993) "A Support Group for People Bereaved Through Suicide" Crisis 14(4) Abstract

Cooper, J. (1999) "Ethical Issues and their Practical Application in Psychological Autopsies of Suicide" Journal of Clinical Nursing 8(4) 467-475 Abstract

Cvinar, J.G. (2005) "Do Suicide Survivors Suffer Social Stigma: A Review of the Literature" Perspectives in Psychiatric Care 41(1) 14-21. Abstract

Davis, C. and Hinger, B. (2005) Assessing the Needs of Survivors of Suicide Calgary, Alberta: Calgary Health Region.

Dyregrov, K. (2004) "Breaved Parents Experience of Reserach Participation" Social Science & Medicine 58(2) 391-400. Abstract

Ellenbogen, S. and Gratton, G. (2001) "Do They Suffer More? Reflections on Research Comparing Suicide Survivors and Other Survivors" Suicide and Life-Threatening Behavior 31(1) 83-90.

Jordan, J.R., (2001) "Is Suicide Bereavement Different? A Reassessment of the Literature" Suicide and Life-Threatening Behavior 31(1) 91-103.

Jordan, J.R., (2007)"After Suicide Loss: What Can We Learn from Grief Research?" Surviving Suicide (AAS)19(2) 7-9.

Jordan, J.R. and McMenamy, J. (2004)"Interventions for Suicide Survivors: A Review of the Literature" Suicide and Life-Threatening Behavior 34(4) 337-349. Abstract

Latham, A. and Prigerson, H. (2004) "Suicidality and Bereavement: Complicated Grief as a Psychiatric Disorder Presenting Greatest Risk for Suicidality" Suicide and Life-Threatening Behavior 34(4) 350-362. Article

McIntosh, J.L. (1996) "Survivors of Suicide: A Comprehensive Bibliography Update, 1986-1995" Omega 33(2) 147-175.

McIntosh, J.L. (2005) "Survivors of Elderly Suicide: Opportunities Lost" Surviving Suicide Winter 2005 (American Association for Suicidology).

Ness, DE and CR Pfeffer (1990) "Sequelae of Bereavement Resulting from Suicide" American Journal of Psychiatry 147 279-285.

Piper, W.E. et al. (2001) "Prevalence of Loss and Complicated Grief Among Psychiatric Outpatients" Psychiatric Services 52(8) 1069-1074.

Rubey, C. and McIntosh, J. (1996) "Suicide Survivor Groups: Results of a Survey" Suicide and Life-Threatening Behavior 26(4) 351-358 Abstract

Rudestam, K.E. (1992)"Research Contributions to Understanding the Suicide Survivor" Crisis 13(1) 41-46.

Stillion, J.M. (1996) "Survivors of Suicide" in K.J. Doka (Ed.), Living With Grief After Sudden Loss: Suicide, Homicide, Accident, Heart Attack, Stroke Washington, DC: Hospice Foundation of America, 41-51

van der Wal, J., (1989-90) "The Aftermath of Suicide: A review of the Empirical Evidence" Omega 20 149-171.

Van Dongen, C.J. (1991) Experiences of family members after a suicide Journal of Family Practice

For an excellent and extensive on-line overview of studies and other material on suicide grievers see "The Grief Response Experienced by Survivors of Suicide" by Barbara Rubel, MA.

For an overview of suicide loss support in Europe see "Suicide survivor activities, an international perspective" from the International Association for Suicide Prevention (IASP) (2004; PDF).

See also

Developing a Research Agenda for Suicide Survivors

NIMH Research on Survivors of Suicide Workshop (2003)

AFSP Report on Survivors of Suicide Research Workshop

Grief After Suicide: Notes from the Literature (CSP SIEC Alert #46, 11/01)

The professional literature on suicide loss is quite extensive. The following search resources will help locate on-line sources, including abstracts or full text copies of some of the material cited above:

PubMed Central (NIH) - Free digital archive of biomedical and life sciences journal literature.

HighWire Press Journal Search (Stanford University)