Bereavement After Suicide

Children and adolescents are bereaved by the suicide of a relative in one third of the suicides in the US (Pfeffer, Jiang, Kakuma, Hwang, & Metsch, 2002). In a survey of a representative sample of US adolescents, Cerel and Roberts (2005) found that 1.2% had been exposed to the suicide of a close relative, and 3.2% of adolescents had been exposed to the suicide of a peer in the year before the survey (Cerel, Roberts, & Nilsen, 2005).

The suicide of a friend or a relative can have a profound, debilitating, and potentially long-lasting impact on the bereaved adults as well as adolescents (Cerel & Aldrich, 2011; Pitman, Osborn, King, & Erlangsen, 2014). However, aspects of the impact, such as the grief experience, mental health, at-risk behaviors, and suicidal behavior, may be expressed differently over time. Despite its potentially life-changing impact, grief is not a disease (Zisook & Shear, 2009). It is the psychological and behavioral reaction to the loss of a significant other. Grief experiences can be both traumatic and benign.

But what factors play a role in the impact of the loss and the process of adaptation after the loss? While most research has focused on adult populations, this editorial identifies major issues to enable better understanding of the impact and adaptation after the loss among adolescents and to better address the means of supporting bereaved young people.

Characteristics of the Death

Those bereaved by suicide might experience feelings of rejection, shame, stigma, blaming, guilt, suicidal ideation, anger, relief, and a continuous search for explanation. Though more prominent in grief after suicide, these reactions are not unique when compared with bereavement after other types of death (Sveen & Walby, 2008). Jordan and McIntosh (2011) developed a model that distinguished feelings and thoughts that are found after all types of death (sorrow, pain, missing the deceased and yearning to be reunited), unexpected deaths (shock and a sense of unreality), violent deaths (experience of trauma and shattered illusion of personal invulnerability), and suicide (anger, aggression, abandonment, and rejection). Although the model was not developed specifically for adolescent grief, it helps us to understand that feelings after a death do not occur dichotomously (yes or no), but are related to characteristics of the death. Every suicide is different and occurs with varying degrees of violence or exposure, for example, through witnessing the suicide of a peer (Brent et al., 1993) or the (un-)expectedness of the death (Dyregrov & Dyregrov, 2005).

Quality of Relationships

More than 50 years ago, Hilgard, Newman, and Fisk (1960) investigated the impact of the death of a parent during childhood among a sample of adults (N = 65). They determined that a compatible relationship between parents prior to the death, a strong surviving parent who can manage a dual role including keeping the remaining family together, and providing stability for the bereaved child were protective factors for a healthy development of the child after the loss, irrespective of the type of death of the parent, for example, suicide or illness. Over subsequent years the findings of this pioneering study have been confirmed by others, and, for example, Melhem, Walker, Moritz, and Brent (2008) found that higher level of functioning of the remaining parent (contrary to complicated grief in the remaining parent) and offspring self-esteem were protective factors for adolescents bereaved by the death of a parent through suicide, accident, or illness.

These findings are consistent with other studies that have noted that children who are most impacted by the loss might have experienced the most pre-loss problems (e.g., a dose–response effect; Christiansen, Goldney, Beautrais, & Agerbo, 2011), whereas children who have been separated from the suicidal parent might cope well with the loss (Cerel, Fristad, Weller, & Weller, 2000). They adapt to the loss without serious effects, and despite possible major changes in living circumstances, they appear to be helped by "the fact that ill parent died and the well one survived" (Shepherd & Barraclough, 1976, p. 272).

Closeness of Relationship

There is evidence from adolescent studies that emotional closeness of the relationship is positively associated with levels of grief (Abbott & Zakriski, 2014), new-onset depression, anxiety, suicidal ideation (Melhem, Moritz, Walker, Shear, & Brent, 2007), and suicidal communication and suicidal plans (Ho, Leung, Hung, Lee, & Tang, 2000). However, studies did not find an increase in suicide attempts or suicides among exposed adolescents versus non-exposed adolescents despite increased psychopathology shortly after bereavement (Brent, Moritz, Bridge, Perper, & Canobbio, 1996a). Contrary to theories and (modest) evidence of modeling and imitation of suicidal behavior (De Leo & Heller, 2008; Insel & Gould, 2008), Brent et al. (1996a) concluded that exposure to the suicide of a friend might in fact serve as a protective factor against suicidal behavior in adolescents. The finding is important because it showed that despite the potential detrimental impact of exposure to suicide, other factors might mitigate the impact of exposure, such as closeness of the relationship and attitudes toward suicide (Abbott & Zakriski, 2014) as well as quality of the family context (Ratnarajah & Schofield, 2008).

Social Support

Bereaved people might benefit from social support of family, friends, or community organizations (Dyregrov, De Leo, & Cimitan, 2013). In addition, bereaved people might become actively involved in the provision of peer support or other community activities (Oulanova, Moodley, & Séguin, 2014). Research has shown that social support among bereaved people after elderly suicide (and natural deaths) might meet emotional and practical needs of the bereaved (Farberow, Gallagher-Thompson, Gilewski, & Thompson, 1992). With regard to adolescents bereaved by suicide, social support among peers seems to have beneficial effects on more helpful attitudes toward suicide (e.g., the belief that suicide is preventable), but also to more negative or stigmatizing attitudes (e.g., the belief that suicide is normal or selfish; Abbot & Zakriski, 2014). Also, social support of friends might prolong grief through mechanisms of co-rumination defined as an extremely negative form of self-disclosure that involves discussion focused on problems and emotions to the exclusion of other activities or discourse (Rose, 2002). Levels of co-rumination are found to predict the onset of depression, as well as its severity and duration (Stone, Hankin, Gibb, & Abela, 2011).

Meaning of Relationships

Every death has its forgotten grievers (Gyulay, 1975). With regard to suicide bereavement, this label has been attributed to the bereaved siblings (Rostila, Saarela, & Kawachi, 2012). Dyregrov and Dyregrov (2005) reported that siblings thought that their parents were more affected by the loss, yet felt overlooked themselves.

There appears to be a difference in grief expression and long-term mental health outcomes between adolescents bereaved by peer suicide versus sibling suicide. Contrary to adolescent peer suicide bereavement, no sustained mental health problems were found in sibling bereavement (Brent et al., 1996b). The authors hypothesized that increased expression of grief among siblings, compared with friends, might serve as a protective factor for sibling mental health. This is a striking finding because friends and siblings tend to be in the same age group. Yet, the differences in grief and mental health might point to a different meaning associated with the kinship relationship.

A sibling relationship is crucial in identity formation and the process of acquiring life skills. Siblings have a constant, interactive, dyadic relationship, with a potential for conflict and rivalry. Death of a sibling affects identity formation as bereaved siblings must redefine their roles in the absence of their primary referent (Hogan & DeSantis, 1996). Friendships, on the other hand, are defined by characteristics such as enjoyment of common activities, values such as acceptance, loyalty and commitment, as well as ego reinforcement and helping. Reciprocity and intimacy (or closeness) are key elements in the relationship. Death of a close friend is the loss of an intimate, a confidant, and a support (Oltjenbruns, 1996). As siblings are part of a family dynamics, the quality of the relationship with a parent might mitigate the impact of the loss, whereas co-rumination among bereaved friends might amplify its impact.

Implications for Research

Suicide should not be considered as an isolated event, and its impact should be understood within a broader context. The impact of suicide and the bereavement outcome among adolescents might be mediated by three types of features: (1) pre-loss features related to personal and family history, type of (kinship) relationship, and especially emotional closeness of relationship; (2) the type of death; and (3) post-loss issues such as quality of remaining relationships. It appears that closeness of relationship prior to the death, rather than type of relationship, is related to impact of the loss. Closeness and quality of remaining relationships (after the loss) buffer the impact of the loss, whereas social support among friends might have negative effects as well.

Support for people bereaved through suicide has been identified as an important strategy in suicide prevention (Andriessen, 2009; World Health Organization, 2014). However, findings from bereavement studies with adult populations are not necessarily applicable to bereaved adolescents, and the developmental context has to be taken into account (Balk & Corr, 2001). Future studies should focus not only on risk factors for adverse outcomes or maladaptive coping, but also on protective factors to better understand adaptation processes after a significant loss through death. For example, little is known regarding attitudes toward life, death, and suicide or resilience and help-seeking among adolescents bereaved through suicide.

Implications for Support

Support for people bereaved by suicide, including adolescents, is available in a variety of formats, for example, support groups, grief counseling, or therapy, in face-to-face or online sessions (Krysinska & Andriessen, 2013). It is, however, advised that any therapy would be provided in a supportive and educational climate, for bereaved individuals (adults and children) and families alike (Andriessen & Krysinska, in press). An involved, humanistic, compassionate approach would be preferred to overly directive or passive approaches (Dunne, 1992). Effective bereavement support would share three characteristics (Andriessen & Krysinska, in press). First, the needs and the questions of the bereaved person have to be assessed. This includes an assessment of familial relationships, suicidal thoughts of the bereaved person, and the availability of a social network (Kaslow, Samples, Rhodes, & Gantt, 2011). Second, the grief reactions have to be addressed. Bereavement through suicide is a new and "alien" experience for adolescents for which they lack any "reference point" (Jordan & McIntosh, 2011, p. 203). As such, adolescents might benefit from a safe environment to acknowledge, validate, and normalize the experiences, such as the psychological distress, guilt, shame, blaming, etc. (Dyregrov, 2009). It can provide opportunities to address problem-solving skills, for example, in dealing with familial relationships, feelings, suicidal ideation, and social or perceived stigma (Kaslow et al., 2011). Third, the support should improve the bereaved adolescent's insight into the suicidal person and the suicide they have experienced. Discussing the suicidal process, the occurrence of so-called warning signs, and the cultural (societal) perspective on suicide, in a warm and supportive climate might increase insight into the suicidal mechanisms and might facilitate the creation of a personal "suicide story." The story would allow integration of the suicide in one's own life (Grad & Andriessen, 2015).

Conclusion

Specific research is needed to better understand the nature, the impact, and the long-term outcome of suicide bereavement among adolescents, vis-à-vis other types of death or other age groups. Research efforts should also focus on social and professional bereavement support to identify ingredients that render such support effective, a research field still much in need of development, especially with regard to young people (Dyregrov, 2009; Rosner, Kruse, & Hagl, 2010).