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Teen Suicide: Helping Survivors Make Sense of Sudden Loss
Teen Suicide continuing education addiction counselor CEUs

Section 10
Adults Mourning Suicide:
Self-Reported Concerns About Bereavement

CEU Question 10 | CEU Answer Booklet | Table of Contents | Grief
Psychologist CEs, Social Worker CEUs, Counselor CEUs, MFT CEUs

Although some next-of-kin had not sought help because they felt able to cope without assistance, others encountered barriers to receiving desired help. These findings warrant increased and sustained community outreach to this population. Recommendations include public education regarding de-stigmatization of suicide and the needs of the suicidally bereaved, enhancement of internal and external coping supports, facilitation of access to both professional and community help, and better coordinated and more culturally appropriate serviceThis study empirically characterized the experiences of 227 adult next-of-kin as they mourned suicides that had occurred in New York City during 1997. Next-of-kin reported psychosocial problems including family difficulties, comorbid stressors, psychiatric symptomatology, and unresolved bereavement. Professional intervention was the most frequently reported need and the most frequently reported type of desired help. In terms of actual receipt of assistance, participants reported having received help from families, friends, and communities as well as from professionals.s.

Adult relatives of suicide victims may experience particularly stressful bereavement, as suggested by both clinical observation (Moore & Freeman, 1995; Ness & Pfeffer, 1990; Praeger & Bernhardt, 1985; Shapiro, 1994) and empirical study (Demi & Howell, 1991; Pfeifer, Martins, Mann, & Sunkenberg, 1997; Wagner & Calhoun 1991). A crucial first step in designing outreach programs for this population is gathering reliable information regarding their perceived psychological and psychosocial functioning, as well as perceived needs for particular types of support and intervention during the grieving process. The literature on the suicidally bereaved, however, offers few empirical studies providing such information (Praeger & Bernhardt, 1985). The present investigation therefore aimed to describe adult next-of-kin's perceptions of their psychosocial functioning, perceived needs for bereavement-related assistance, reported help-seeking (i.e., whether professional services and/or assistance from friends and family had been obtained and/or were desired), reported reasons they would not desire help, and reported barriers to their not receiving desired help.

Suicide is ranked ninth among the leading causes of death in the United States, and the most recent figure available indicates that 32,649 suicides occurred during 1995 (Anderson, Kochanek, & Murphy, 1997). At least 65,000 relatives may have been bereaved by suicide that year, and the cumulative nature of bereavement dictates that during any given year, several times this number mourn a suicidal death. Relatives of White males make up the largest proportion of individuals grieving suicidal losses each year (Anderson et al., 1997).

Reports of clinical observation and empirical examination with small samples suggest that adults who have experienced suicidal loss of a relative may face particularly complicated bereavement (Dunne, 1987; Moore & Freeman, 1995; Stroebe, Stroebe, & Hansson, 1993). Complications may include questioning the reasons for the suicide and self-blaming for the death (Dunne, 1987) and stigmatization by family and friends, which often leads to a lack of emotional support (Moore & Freeman, 1995). Suicidally bereaved adults may also feel isolated, in that members of their social networks seem unable to truly empathize with them (Moore & Freeman, 1995). In addition, adult family members may blame each other for the suicide and avoid discussing the death for fear of being overwhelmed by grief (Stroebe et al. 1993).

Adults who must care for children while themselves grieving a suicidal death have additional responsibilities that involve helping children process the loss (Shapiro, 1994; Wallbank, 1992). Difficulty addressing children's needs may leave caretakers feeling powerless or guilty and further complicate their bereavement (Murphy, 1996). Child needs that caretakers frequently find difficult to meet include encouraging and modeling open mourning (Demi & Howell, 1991), providing accurate information about the suicidal nature of the death (Worden, 1996), and recognizing expressions of child grief (Goldman, 1996; Morgan, 1990; Murphy, 1996).

Relatively little is known about perceptions of needs and the types of help desired by adults who have experienced suicides of relatives. Relatives of suicide victims have, however, expressed a preference for help provided through peer support groups (Wagner & Calhoun, 1991), and peer support groups may simultaneously provide healthy role models for grieving while increasing social support (Moore & Freeman, 1995). Because suicidal bereavement places children at increased risk for psychiatric disorders and maladjustment (Brent, Perper, Moritz, & Liotus, et al., 1994; Pfeifer et al., 1997), adult caretakers may also need help in maintaining adequate parenting and supporting children's mourning. By gathering information directly from a sample of suicidally bereaved adults, the present investigation sought to expand the limited knowledge base concerning this population's perceptions of their functioning and needs for help, as well as their reports of help-seeking behavior, reasons for not desiring help, and barriers to receiving desired help.

The Sample
The majority of the 227 suicidal deaths comprising the present study's sample were committed by males (n = 167, 74%). Younger adults between the ages of 25 and 44 constituted the largest age group among suicide victims (n = 92, 42%), followed by older adults age 45 to 64 (n = 67, 30%), youth age 11 to 24 (n = 32, 15%), and those over age 65 (n = 29, 13%). Using New York City population rates for 1997 (Smallman, Clark, Ellis, & Wakin, 1997), the suicide rate calculated based on the present sample was 3.24/100,000 New York City residents during 1997. Of the five boroughs, Manhattan (n = 78) was found to have the highest suicide rate (5.24/100,000 persons). This was followed by the Bronx (n = 50) with a suicide rate of 4.17/100,000 persons, Queens (n =48, suicide rate of 2.94/100,000), Staten Island (n = 11, suicide rate of 2.90/100,000), and Brooklyn (n = 40, suicide rate of 1.74/100,000).

Extensive outreach efforts resulted in 144 (63%) of the original sample of 227 adult next-of-kin being contacted by telephone. Table 1 reports the relationships of contacted next-of-kin to the deceased. The 144 contacted individuals identified 225 additional relatives impacted by the suicidal death, resulting in a total of 369 reportedly impacted individuals, an average of 2.6 impacted individuals per death.

For the largest proportion (n = 82, 57%) of the next-of-kin, staff made telephone contact between 3 and 6 months after the suicidal death. The average length of time from death to initial contact was about 5 months (M = 154 days, SD = 58.5 days). There was no significant relationship between time to contact and interest in receiving help from CARES staff, Chi2(1) = 10.476, p = .4. Eighty-three (37%) of the families could not be contacted by telephone within 1 year of the death, despite repeated attempts to reach next-of-kin at different times of the day. The majority of these next-of-kin were not at home when calls were made (n = 72, 87%); however, available telephone information was incorrect for a small portion of cases (n = 11, 13%). A significantly greater number of male next-of-kin (n = 42, 67% of total males in sample) than female next-of-kin (n = 41, 28% of total females in sample) were unable to be contacted by telephone, Chi2(1) = 11.1, p = .001. No significant differences were found between the contacted and not-contacted groups in terms of next-of-kin's borough of residence Chi2(6) = 6.9, p = .32; the deceased's age, Chi2(3) = 4.3, p = .22; deceased's gender, Chi2(1) = .92, p = .33; or deceased's borough of residence, Chi2(4) = 4.7, p = .31).

Needs, Concerns, and Help-Seeking Behavior of Families Bereaved by Suicide
Seventy-six (53%) of the 144 contacted next-of-kin engaged in telephone conversations with staff, during which they volunteered information about their concerns. Of these individuals, 26 (18% of those contacted) identified concerns relevant to the suicidal death, whereas 50 (35% of those contacted) reported that they had no specific concerns regarding their recent losses. Because some participants preferred not to discuss their concerns with staff, and/or because contacts were too brief for staff to elicit sufficient information, concerns could not be identified for another 68 (47%) of contacted next-of-kin. As noted previously, concerns were defined as difficulties or problems experienced by a bereaved individual that might prompt him/her to seek assistance from family, friends, or professionals. Examples include inability to maintain family routines, feelings of depression and anxiety, difficulty disclosing the nature of the death to others, and economic difficulties. Those next-of-kin who identified concerns reported an average of two concerns (M = 2.19, SD = .52) per individual, comprising four categories: family relationships, stressor-related, psychiatric symptomatology, and bereavement-related. Table 2 presents frequencies for the above categories.

In addition to concerns, next-of-kin identified specific needs for assistance related to the suicidal death. Eighty-one (57%) of the 144 contacted next-of-kin engaged in sufficiently informative conversation about their needs. Of these individuals, 37 (26% of those contacted) identified one or more specific needs for assistance, whereas 44 (31% of those contacted) stated that they had no need for assistance. Because some participants preferred not to share their needs with staff, needs could not be identified for another 63 (43%) of contacted next-of-kin. Needs were defined as specific instances in which next-of-kin expressed a desire for assistance from family, friends, or professionals. Examples include needs for professional therapy, help in disclosing the nature of the death to family members, and emotional support. Those next-of-kin who identified needs reported an average of two needs (M = 1.6, SD = 1.1) per individual, comprising three categories: formal services, bereavement help, and coping assistance. Table 2 presents frequencies for the above categories.

Almost one-fourth of the 144 contacted next-of-kin (n = 34, 24%) reported having received various types of formal services from professionals and peers, and informal assistance from family and friends, since the suicidal death. Table 3 shows that of those reporting having received help, close to half had received formal help only, close to half had received informal help only, and only a small proportion had received both formal and informal help. Next-of-kin also identified the type(s) of formal and informal help, if any, they would like to receive, with formal assistance being the most commonly reported type of desired help (see Table 3). Ten (7%) next-of-kin who reported currently receiving services indicated a desire for additional services.

A portion of the next-of-kin reported reasons for not desiring assistance from either formal or informal sources. Forty-eight (33%) next-of-kin stated that they had not received help and were not interested in future help because they felt able to cope without assistance. Forty-seven (33%) next-of-kin stated that they were not interested in help because they were satisfied with assistance that they had previously received or were currently receiving. Only 4 (3%) next-of-kin stated that they did not desire additional help because they were dissatisfied with assistance they had previously received.

Barriers to receiving desired assistance were also identified by a portion of the next-of-kin and were grouped into three categories. Fifteen (10%) next-of-kin identified barriers involving family relationships (e.g., disagreements about whether help was needed), 12 (8%) of next-of-kin identified barriers due to language difficulties, and 9 (6%) reported systemic barriers (e.g., lack of time, money, or transportation).

Bereaved Families with Children
Fifty (35%) of the 144 contacted families included children and adolescents age 19 and younger. A significant difference was found between the number of concerns identified by families containing children and the number of concerns reported by families not containing children, Chi2(l) = 9.28, p = .005. Families including children reported an average of two more concerns than those without children, although no clear pattern emerged regarding specific types of concerns being more common among families with children. No statistically significant differences were found between families with and without children in terms of the number of reported needs, Chi2(1)= 3.44, p = .10; whether help had been received, (Chi2(1) = 3.5, p =.10); or whether help was desired, Chi2(1) = 1.14, p = .10.

In this study, participants consisted of adult next-of-kin who experienced the deaths of relatives from suicides occurring in New York City during 1997. The sample of next-of-kin are considered representative of the population of adults bereaved by suicide in New York City each year, suggested by the fact that the average age and gender of suicide victims and rates of suicide for the five city boroughs were similar to those identified in previous studies of New York City suicidal deaths (Marzuk, Tardiff, Leon, Stajic, et al., 1992; Marzuk, Leon et al., 1992; Marzuk, Tardiff, Leon, Hirsch, et al., 1997). Specifically, in the current study, males comprised the majority (74%) of suicidal deaths; the largest percentage of suicides occurred in the younger adult (25-44) age group, followed by the older adult (45-64) age group, and the youth (11-24) and 65-and-older age groups. The estimated 1997 rates of suicide for each of the five New York City boroughs, calculated using recent city population figures, indicated that Manhattan had the highest suicide rate.

Locating and contacting next-of-kin was a challenge, entailing a large number of attempts at telephone contact (a total of 1,145 phone attempts were made to the 227 next-of-kin) and in several cases, extensive follow-up procedures for locating next-of-kin that included contacting neighbors and relatives and sending certified mail. Efforts were moderately successful, however, because telephone contact was obtained within 6 months of the death for the majority (63%) of the sample. Also noteworthy is the finding that males were more difficult to contact than females. Special efforts may therefore need to be made to locate and establish contact with male next-of-kin. The current study showed no relationship between the length of time that had passed since the suicidal death and families' interest in receiving help in the form of the CARES program. This finding suggests that bereavement from suicide is an ongoing process and that offers of assistance may need to be repeated at many different times during the period of bereavement to adequately address the needs of this population.

Needs, Concerns, and Help-Seeking Behavior of Families Bereaved by Suicide
Many next-of-kin were reluctant to provide information about their needs (43% of those contacted) and concerns (47% of those contacted). This finding is consistent with those of Ness and Pfeifer (1990), who found that suicidally bereaved individuals often have difficulty discussing their experiences. The finding that the majority of next-of-kin who did discuss their concerns, needs, and help-seeking behaviors came from families including children and adolescents suggests the fact that families with children may experience more complicated bereavement. Additionally, families who were not eligible for CARES (i.e., families who had no children between age 5 and 18) may not have been willing to discuss bereavement issues with staff when only indirect assistance (i.e., referrals to local peer-support groups) was offered.

Among the next-of-kin who did identify concerns, family relationship concerns were most common (reported by 65%), followed by stressor-related concerns such as paying bills and physical illness (reported by 62%), psychiatric concerns (reported by 54%), and bereavement-related concerns such as difficulty expressing grief (reported by 38%). The fact that reported concerns spanned multiple domains of psychosocial functioning suggests that suicidally bereaved families do indeed experience particularly complicated bereavement. Although the literature has discussed these individuals' concerns regarding issues such as emotional support, guilt over the death, and feelings of isolation and depression (Dunne, 1987; Moore & Freeman, 1995), it has not adequately addressed their practical survival concerns, such as difficulty in paying bills. Thus, community outreach efforts to help these families should supplement formal therapeutic interventions with case management services, which can assist families with immediate, practical concerns such as finalizing burial arrangements.

The primary need for assistance identified by the next-of-kin involved that for formal services such as professional therapy. Two additional types of needs identified by next-of-kin can further inform community outreach efforts: next-of-kin discussed needing information about ways to discuss the death with children and relatives and about providing support for, and receiving support from, other family members. These needs may be particularly pressing, considering that next-of-kin identified 225 additional relatives impacted by the suicidal deaths. Addressing the assistance needs of this population therefore seems appropriate not only for mental health professionals, but also for clergy, primary care physicians, and other professionals who have contact with the suicidally bereaved (Resnick & Rozensky, 1996).

The present study's findings further suggest that suicidally bereaved individuals may not take full advantage of the services of mental health professionals or peer support groups. The proportion of next-of-kin desiring formal services (13%) was slightly larger than the proportion of next-of-kin that had actually received a type of formal service (11%). This pattern was observed for formal but not informal help, suggesting that stigma surrounding suicide or discomfort and unfamiliarity with formal services (e.g., feeling vulnerable in a therapist's office or hospital setting) may make suicidally bereaved individuals less willing to seek this type of help (Moore & Freeman, 1995). This finding may also reflect the inaccessibility of formal services. Public education campaigns should therefore focus on decreasing the stigma surrounding suicide and demystifying the formal therapy process. In addition, it would be beneficial to increase the feasibility of formal services through services such as transportation, and to address financial concerns (e.g., lack of insurance coverage for therapy). Since only a small proportion of next-of-kin reported having received informal help from family, friends, and others in the community, community education should also target members of suicidally bereaved individuals' support systems, to stress the potential benefits of receiving informal social support (Wagner & Calhoun, 1991).

The present research also helped identify reasons suicidally bereaved individuals did not desire help. The most common reason for not desiring help, among those who were not currently receiving either formal (professional) or informal (family and community) help, was that they felt it was not needed in their families. This finding has several implications. First, these individuals, although they did not explicitly state it during conversations, may effectively be dealing with their losses using either personal coping strategies or support within their immediate families. Public education should therefore focus not only on the benefits of survivors seeking outside help, but also on strengthening these individuals' personal coping strategies. Second, bereaved individuals may not have felt ready to seek help at the time they were contacted by staff. This interpretation is suggested by the comments of several participants, who stated that they did not desire help "right now" or "at this time," and by the fact that seeking help may require considerable investment of physical and psychological energy that is unavailable during the early stages of mourning. Thus, as mentioned previously, offers of assistance may need to be repeated over the course of bereavement. Future research in this area should also prospectively address the longitudinal course of suicidal bereavement to determine how individuals are impacted by a suicidal death over time. Third, study participants may have understated their needs for help, or may have felt uncomfortable sharing their needs with staff during telephone conversations. This interpretation may reflect, in addition to the stigma discussed previously, an American cultural norm of avoidance of death-related issues (Ellis, 1989), and suggests that public educators and clinicians should attempt to counteract potentially harmful normative beliefs. Participants' reluctance to share their experiences with staff is also consistent with the finding that adults mourning suicidal deaths prefer to speak to others who have experienced similar losses (Wagner & Calhoun, 1991).

Perhaps also relevant to community outreach efforts are this study's findings concerning barriers too receiving desired help. Identified barriers involved family relationships, language difficulties, and systemic barriers. Barriers due to family relationships, such as pressure from other family members to avoid seeking outside help, may also be the result of perceived stigma related to suicide and a tendency to avoid death-related issues which, as mentioned earlier, could be addressed through public education and outreach.

This study's results also highlight the need for culturally appropriate services. Identified barriers due to language difficulties, such as speaking a language other than English, seem particularly troubling, especially because feelings of isolation and lack of social support may be exacerbated by a suicidal death in non-English speaking families who may have also recently immigrated (Lester, 1997). In addition, other research suggests that the presence of available social support among recent immigrants moderates the relationship between acculturation, stress, depression, and suicidal ideation (Hovey & King, 1997). Although the lack of foreign-language speaking and/or minority mental health professionals is well documented (Dana, 1993), community outreach efforts targeting these groups must be able to provide culturally sensitive services, if not services in clients' native languages. Finally, next-of-kin noted systemic barriers such as poorly located services and inability to pay for services. Sliding-scale options for help, as well as service locations in underserved and poor neighborhoods, should be expanded.
- Provini, Celine & Jessica Everett; Adults mourning suicide: self-reported concerns about bereavement; Death Studies; Jan/Feb 2000; Vol. 24; Issue 1.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #3
The preceding section contained information regarding self-reported concerns about bereavement in adults mourning suicide.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 10
What are three child needs that adults, who must care for children while grieving a suicidal death, find difficult to meet? Record the letter of the correct answer the CEU Answer Booklet

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The article above contains foundational information. Articles below contain optional updates.
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