This brief, but growing, page looks at some of the basic research and methodological issues involved in empirical studies of those who have experienced a suicide loss. It also references 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.
Perhaps the primary empirical question regarding suicide loss is: How many individuals does it affect? The generally accepted benchmark (attributed to Shneidmann) is that there are 6-8 individuals emotionally impacted by each completed suicide. Many authors have "done the math" and observed that, based on the annual number of reported suicides in the US alone, this suggests approximately 250,000 individuals enter (or re-enter) the ranks of suicide survivors yearly. A 1994 random survey of 5000 adults in the US found that 7% had experienced a suicide loss in the past year and that 3% had lost a close family member to suicide in that period (Crosby and Sacks 2002).
Another perennial issue is the lack of a commonly accepted operational definition about who is a suicide survivor. Is it defined by the personal experience of a suicide loss in a relative or friend? Is it demonstrated by the manifestation of signs and symptoms of traumatic loss? Is it a matter of self-definition? The term "suicide survivor" is itself a source of confusion (which, in part, led to the coining of "suicide attempt survivor" to reduce misunderstanding on one front).
Suicide loss is 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. 2005 data from coroners, MEs, law enforcement, and other sources from 16 states participating in the CDC's National Violent Death Reporting System indicates that 1.7% of suicide victims had lost a family member or friend to suicide in the previous five years.
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. McMenamy et al. (2008) found higher levels of depression, anxiety, and trauma in a sample of survivors involved with conferences and support groups. Mitchell et al. (2009) found that survivors most closely related to the victim showed more depression and anxiety in the early phase of bereavement than those more distantly related.
Most of what is known about suicide loss 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):
- Drawing representative samples of suicide grievers is difficult
- Differentiating suicide grievers from other traumatic loss victims is problematic
- 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:
- Too few control group studies involving different types of suicide grievers.
- Too few kin groups studied (i.e., primarily widows and parents of youth victims).
- 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.
Beautrais (2004) noted the need for appropriate methodologies for studying suicide loss. She specifically referenced valid outcome measures, handling privacy issues, establishing comparison and control groups, and assembling samples of sufficient size.
Cerel et al.(2009) posed some questions that need to be pursued in regard to the outcomes of suicide loss:
- What is the natural course of bereavement for survivors?
- Does participation in support groups play a role in the course of bereavement?
- Which types of support groups are perceived to be more helpful to survivors?
- Are there group characteristics associated with poor outcomes?
- What is the relationship between survivor support groups and advocacy/working for suicide prevention?
Dyregov (2004) made one of the few inquires regarding the stress experienced by the bereaved in participating in grief research. The bereaved parents in the study sample were positive on the research experience and saw it as an opportunity to "tell their stories." We are not aware of a similar study focusing exclusively on suicide survivors.
A body of research about suicide loss is appearing. It is concentrated on (Stillion 1996):
- The reaction of grievers to the suicide
- Postvention services to suicide grievers
- 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. Beautrais (2004) cites a need for research "identifying the features which make individuals vulnerable to, or protected from, severe grief outcomes following bereavement by suicide." There are only a few postvention studies (see Lindqvist et al, 2008).
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."
Jordan (2001) also notes that using survivors of other traumatic losses (e.g., those who lost loved ones in accidents) as comparison groups in studies of those bereaved by suicide may not demonstrate the how significantly both differ from "natural" deaths.
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). Cerel et al. (2009) have proposed an agenda for further suicide loss support group study.
Certainly an important consideration regarding suicide loss support group availability, accessibility, continuity, and effectiveness are the characteristics of those who act as group facilitators. Some hints may be taken from support group research with other needs.
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 are 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.
Little is known about suicide loss in non-white communities. Barnes (2006) conducted an exploratory qualitative study of the impact of suicide on a 19 Afro-American families. The majority of respondent reported that they had to go through the grieving process alone. Those survivors who did receive support most often received it from family members and friends.
A number of areas of suicide survivors research need demand attention. One concerns the effects of suicide loss on adult males, a population that itself accounts for most suicides in most nations. Little is known about suicide loss in settings unconducive to grieving (e.g., prisons, the military, or "macho" occupational sub-cultures such as law enforcement). Cerel et al. (2009) poignantly noted that "nothing is known about ... survivors who do not disclose their survivorship" because of community stigma.
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. Lastly, another helpful and informative source of insight into the needs, demographics, support preferences, and service utilization patterns of those touched by suicide loss are community surveys (see Davis & Hinger 2005 and Wilson & Clark 2004).
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.
Barnes, D. (2006) " The Aftermath of Suicide among African Americans" Journal of Black Psychology 32(3) 335-348.
Barry, L.C., et al. (2002) "Psychiatric Disorders among Bereaved Persons" American Journal of Geriatric Psychiatry 10(4) 447-457.
Beautrais, A. (2004) Suicide Postvention Christchurch, NZ: Christchurch School of Medicine & Health Services.
Cerel, J. et al. (2009) "A Call for Research: The Need to Better Understand the Impact of Support Groups for Suicide Survivors" Suicide and Life-Threatening Behavior 39(3) 269-281.
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
Crosby, A. and Sacks J. (2002) "Exposure to Suicide: Incidence and Association with suicidal Ideation and Behavior, US 1994" Suicide and Life-Threatening Behavior 32 321-328.
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
Lindqvist, P. (2008) "In the Aftermath of Teenage Suicide: A Qualitative Study of the Psychosocial Consequences for the Surviving Family Members" BMC Psychiatry 8(26). 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).
McMenamy, J., Jordan, J., and Mitchell, A, (2008) "What do Suicide Survivors Tell Us They Need? Results of a Pilot Study" Suicide and Life-Threatening Behavior 38(4) 375-389.
Mitchell, A. et al. (2009) "Depression, Anxiety, and Quality of Life in Suicide Survivors: A Comparison of Close and Distant Relationships" Archives of Psychiatric Nursing 23 2-10.
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.
Sakinofsky, I. (2007) "The Aftermath of Suicide: Managing Survivors' Bereavement" Canadian Journal of Psychiatry 52(Supplement 1)129s-136s.
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
Wilson, A. & Clark, S. (2004) South Australian Suicide Postvention Project Report University of Adelaide.
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).
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)