Interventions for Suicide Survivors: A Review of the Literature
Interventions for Suicide Survivors: A Review of the Literature
Interventions for Suicide Survivors: A Review of the Literature
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<strong>Suicide</strong> and Life-Threatening Behavior 34(4) Winter 2004 337<br />
© 2004 The American Association <strong>of</strong> Suicidology<br />
<strong>Interventions</strong> <strong>for</strong> <strong>Suicide</strong> <strong>Survivors</strong>:<br />
A <strong>Review</strong> <strong>of</strong> <strong>the</strong> <strong>Literature</strong><br />
John R. Jordan, PhD, and Jannette McMenamy, PhD<br />
Mourning after suicide is frequently a difficult experience. Research suggests<br />
that suicide survivors may be at elevated risk <strong>for</strong> several psychiatric and<br />
somatic complications. Despite this, very little research has focused on developing<br />
and empirically evaluating clinical interventions <strong>for</strong> this population. This paper<br />
attempts to stimulate interest in intervention research by reviewing three relevant<br />
areas: (a) studies <strong>of</strong> <strong>the</strong> perceived needs <strong>of</strong> survivors; (b) implications <strong>of</strong> <strong>the</strong> research<br />
on general bereavement interventions <strong>for</strong> work with survivors; and (c) research<br />
documenting <strong>the</strong> efficacy <strong>of</strong> specific interventions <strong>for</strong> adult survivors. Recommendations<br />
<strong>for</strong> future studies are discussed.<br />
There is considerable evidence that suicide be at elevated risk <strong>for</strong> someday completing<br />
survivors may have an elevated risk <strong>for</strong> devel- suicide <strong>the</strong>mselves (Moscicki, 1995; Roy,<br />
oping complicated mourning responses, as 1992; Runeson & Asberg, 2003).<br />
well as o<strong>the</strong>r psychiatric and medical compli- Given <strong>the</strong> potential risk <strong>for</strong> negative<br />
cations, after <strong>the</strong> death <strong>of</strong> a loved one (Bail- outcomes, postvention with survivors could<br />
ley, Kral, & Dunham, 1999; Brent, Moritz, be a powerful <strong>for</strong>m <strong>of</strong> primary and secondary<br />
Bridge, Perper, & Canobbio, 1996; Clark, prevention, one that might avert future psy-<br />
2001; Rudestam, 1992; Seguin, Lesage, & chiatric and family dysfunction and even fu-<br />
Kiely, 1995; Shneidman, 1981). Jordan’s (2001) ture suicides. Un<strong>for</strong>tunately, as Campbell (1997)<br />
literature review points to many possible has observed, <strong>the</strong>re is “a poverty <strong>of</strong> resources<br />
complications <strong>for</strong> survivors, including height- <strong>for</strong> survivors and a flawed entry system <strong>for</strong><br />
ened levels <strong>of</strong> guilt, shame, anger, family dys- those services (in <strong>the</strong> United States)” (p.<br />
function, and social stigmatization. Indeed, 333). Fur<strong>the</strong>rmore, relatively little ef<strong>for</strong>t has<br />
survivors <strong>of</strong> any sudden, traumatic death <strong>of</strong> a been made within suicidology, thanatology,<br />
loved one may have an increased chance <strong>of</strong> or trauma studies to develop empirically<br />
developing disorders such as traumatic grief based interventions <strong>for</strong> survivors (Clark,<br />
(Prigerson & Jacobs, 2001) and PTSD (Bres- 2001; Constantino, Sekula, & Rubinstein,<br />
lau et al., 1998; Zisook, Chentsova-Dutton, 2001; Farberow, 2001). This article, <strong>the</strong>re-<br />
& Shuchter, 1998). Perhaps most tragically, <strong>for</strong>e, has two primary goals: to assess <strong>the</strong><br />
evidence suggests that suicide survivors may present level <strong>of</strong> scientific knowledge about<br />
interventions <strong>for</strong> survivors, and to develop<br />
recommendations <strong>for</strong> future research in this<br />
John R. Jordan, PhD, is with <strong>the</strong> Family area. More generally, we hope to stimulate a<br />
Loss Project in Sherborn, MA. Jannette Mc- more dedicated ef<strong>for</strong>t within <strong>the</strong>se disciplines<br />
Menamy, PhD, is with <strong>the</strong> Department <strong>of</strong> Pediatrics<br />
at The Floating Hospital <strong>for</strong> Children, Tufts-<br />
New England Medical Center.<br />
Address correspondence to John R. Jordan,<br />
The Family Loss Project, 26 Curve Street, Sher-<br />
to study <strong>the</strong> efficacy <strong>of</strong> treatment procedures<br />
<strong>for</strong> survivors.<br />
To meet <strong>the</strong>se goals, several topics are<br />
addressed. First, we review <strong>the</strong> existing studborn,<br />
MA 01770; jjordan50@aol.com. ies on <strong>the</strong> self-reported needs <strong>of</strong> suicide sur-
338 <strong>Interventions</strong> <strong>for</strong> <strong>Suicide</strong> <strong>Survivors</strong><br />
vivors. Second, given <strong>the</strong> lack <strong>of</strong> research de- ceive. In a telephone survey <strong>of</strong> 144 next-<strong>of</strong>-<br />
voted to interventions with suicide survivors, kin survivors, Provini et al. (2002) found that<br />
we provide a short discussion <strong>of</strong> recent re- approximately one quarter <strong>of</strong> <strong>the</strong>ir sample in-<br />
views <strong>of</strong> <strong>the</strong> research into <strong>the</strong> efficacy <strong>of</strong> dicated specific concerns (18%) and needs<br />
psychosocial interventions after all types <strong>of</strong> (26%), while approximately one third indi-<br />
bereavement. Third, empirical studies <strong>of</strong> incated that <strong>the</strong>y had no specific concerns<br />
terventions specifically <strong>for</strong> suicide survivors (35%) or needs (31%). Only about 25% indi-<br />
will be reviewed. Finally, conclusions are cated that <strong>the</strong>y had received ei<strong>the</strong>r <strong>for</strong>mal or<br />
drawn and recommendations made <strong>for</strong> im- in<strong>for</strong>mal help since <strong>the</strong> suicide, although <strong>for</strong>-<br />
proving future research ef<strong>for</strong>ts. While <strong>the</strong>re mal help was listed as a <strong>for</strong>m <strong>of</strong> assistance<br />
is a small amount <strong>of</strong> literature on interven- desired by almost three quarters <strong>of</strong> those who<br />
tions with child and adolescent suicide survi- indicated a need <strong>for</strong> help. Family related<br />
vors (see <strong>for</strong> example, Pfeffer, Jiang, Kakuma, problems were <strong>the</strong> most frequently men-<br />
Hwang, & Metsch, 2002), a full review <strong>of</strong> intioned types <strong>of</strong> concerns, with families conterventions<br />
<strong>for</strong> child survivors is beyond <strong>the</strong> taining minor children expressing signifi-<br />
scope <strong>of</strong> this article.<br />
cantly more concerns than those without<br />
children. Bereaved widows and parents appeared<br />
to be underrepresented in <strong>the</strong> study,<br />
REPORTED NEEDS<br />
and <strong>the</strong> sample was also relatively young,<br />
OF SURVIVORS with 42% <strong>of</strong> respondents in <strong>the</strong> 25–44 age<br />
range. Approximately one third <strong>of</strong> <strong>the</strong> sample<br />
Estimates <strong>of</strong> <strong>the</strong> number <strong>of</strong> impacted felt able to cope without any assistance.<br />
survivors after a completed suicide vary wide- In ano<strong>the</strong>r recent study <strong>of</strong> 179 Norwe-<br />
ly, from six to several hundred, depending on gian survivors, Dyregrov (2002) found that<br />
<strong>the</strong> operational definition <strong>of</strong> survivorhood bereaved survivor parents experienced high<br />
(Crosby & Sacks, 2002; Provini, Everett, & levels <strong>of</strong> psychosocial distress on measures <strong>of</strong><br />
Pfeffer, 2000; Wrobleski, 1991). A recent and general health functioning, traumatization,<br />
methodologically sound national telephone and complicated bereavement, along with<br />
survey <strong>of</strong> 5,238 respondents indicated that as considerably greater levels <strong>of</strong> perceived and<br />
much as 7% <strong>of</strong> <strong>the</strong> U.S. population (approxi- unmet needs <strong>for</strong> services and support than<br />
mately 13.2 million people) has been exposed <strong>the</strong> Provini et al. sample. For example, 88%<br />
to a suicide within <strong>the</strong> last 12 months, with <strong>of</strong> <strong>the</strong> participants expressed <strong>the</strong> need <strong>for</strong><br />
approximately 1.1% <strong>of</strong> <strong>the</strong> sample having lost pr<strong>of</strong>essional help <strong>for</strong> <strong>the</strong>ir bereavement. Eighty-<br />
an immediate family member (Crosby & five percent reported that <strong>the</strong>y had already<br />
Sacks, 2002). It is important to note, how- received some kind <strong>of</strong> contact with commuever,<br />
that <strong>the</strong> question <strong>of</strong> what constitutes nity pr<strong>of</strong>essionals, and about half had experi-<br />
“survivorhood” is one that has not been set- enced direct outreach from pr<strong>of</strong>essionals.<br />
tled <strong>for</strong> ei<strong>the</strong>r clinical or research purposes, This support, however, was typically <strong>of</strong> short<br />
since it has not been established that expo- duration (67% less than 6 months), and was<br />
sure to suicide necessarily results in <strong>the</strong> nega- <strong>of</strong>fered shortly after <strong>the</strong> loss. Thus, many retive<br />
effects implied in <strong>the</strong> term survivor. At spondents expressed <strong>the</strong> need <strong>for</strong> on-going<br />
this point in <strong>the</strong> development <strong>of</strong> our knowl- and longer term outreach from caregivers,<br />
edge, we simply do not have good data about since <strong>the</strong>y had difficulty initiating <strong>the</strong> search<br />
<strong>the</strong> percentages <strong>of</strong> exposed people who are <strong>for</strong> help on <strong>the</strong>ir own, given <strong>the</strong>ir emotion-<br />
significantly impacted in a negative way by ally traumatized state. Similar to <strong>the</strong> Provini<br />
suicide (American Foundation <strong>for</strong> <strong>Suicide</strong> et al. sample, respondents expressed a strong<br />
Prevention, 2003; McIntosh, 1999). need <strong>for</strong> help with supporting minor children<br />
Likewise, very few empirical studies after <strong>the</strong> suicide, as well as targeted help in<br />
have addressed <strong>the</strong> question <strong>of</strong> what types <strong>of</strong> dealing with posttraumatic experiences <strong>of</strong> in-<br />
support services survivors need or actually re-trusive<br />
memories and images. Dyregrov also
Jordan and McMenamy 339<br />
surveyed community pr<strong>of</strong>essionals and found and <strong>the</strong> efficacy <strong>of</strong> <strong>the</strong> support received. Such<br />
that while <strong>the</strong>re was a general congruence evidence is critically important to guide <strong>the</strong><br />
between <strong>the</strong> type <strong>of</strong> help <strong>of</strong>fered and received development <strong>of</strong> appropriate and timely inter-<br />
by caregivers and survivors, pr<strong>of</strong>essionals<br />
tended to overestimate <strong>the</strong> percentage <strong>of</strong> survivors<br />
who actually received help from mediventions<br />
<strong>for</strong> at-risk survivors.<br />
cal personnel (doctors, psychiatric nurses, or GENERAL INTERVENTIONS<br />
public health nurses) or from survivor support<br />
groups.<br />
FOR THE BEREAVED<br />
The conflicting findings between <strong>the</strong> Given <strong>the</strong> extensive literature on be-<br />
Provini et al. and Dyregrov studies may perreavement interventions, we have restricted<br />
haps be attributed to differences in <strong>the</strong> orga- our review to meta-analytic studies or large-<br />
nization <strong>of</strong> health care in <strong>the</strong> United States scale reviews <strong>of</strong> <strong>the</strong> literature. On <strong>the</strong> whole,<br />
and Norway, as well as to demographic dif- <strong>the</strong>se studies reveal a surprising and ra<strong>the</strong>r<br />
ferences in <strong>the</strong> two samples. For example, distressing lack <strong>of</strong> effectiveness <strong>for</strong> general<br />
municipalities in Norway are able to provide bereavement interventions. At <strong>the</strong> same time,<br />
more organized postvention services than <strong>the</strong>y also highlight <strong>the</strong> importance <strong>of</strong> identi-<br />
most communities within <strong>the</strong> United States, fying high-risk subgroups <strong>of</strong> bereaved indi-<br />
since Norway has a nationalized health care viduals such as suicide survivors. For a more<br />
system. Given that both samples indicated comprehensive discussion <strong>of</strong> <strong>the</strong> implications<br />
that many <strong>of</strong> <strong>the</strong>ir concerns centered around <strong>of</strong> <strong>the</strong> reviews that follow, please see Jordan<br />
<strong>the</strong> impact <strong>of</strong> suicide on children in <strong>the</strong> fam- and Neimeyer (2003).<br />
ily, <strong>the</strong> relatively younger age <strong>of</strong> <strong>the</strong> Provini Allumbaugh and Hoyt (1999) per<strong>for</strong>med<br />
et al. sample and <strong>the</strong> smaller proportion <strong>of</strong> a meta-analysis <strong>of</strong> 35 bereavement interven-<br />
spousal and child loss may have resulted in tion studies that included ei<strong>the</strong>r a control<br />
fewer people with children, and <strong>the</strong>re<strong>for</strong>e less group or a pre-post treatment design, but not<br />
<strong>of</strong> a perceived need <strong>for</strong> pr<strong>of</strong>essional guidance. necessarily random assignment. Overall, <strong>the</strong>se<br />
Also, <strong>the</strong> mean length <strong>of</strong> time since <strong>the</strong> sui- authors found an effect size across studies <strong>for</strong><br />
cide in <strong>the</strong> Dyregrov study (15 months) was bereavement interventions <strong>of</strong> .43, a finding<br />
much longer than in <strong>the</strong> Provini study (5 that contrasts with <strong>the</strong> typical effect size <strong>of</strong><br />
months). Given that many participants in <strong>the</strong> approximately .80 found in most psycho<strong>the</strong>r-<br />
Dyregrov study indicated that brief, early apy outcome research (Lambert & Bergin,<br />
support was not adequate, <strong>the</strong> Provini et al. 1994; Robinson, Berman, & Neimeyer, 1990).<br />
study may have contacted families too soon, Additional analyses <strong>of</strong> 12 “moderator” vari-<br />
be<strong>for</strong>e <strong>the</strong>y were able to identify specific conables that might account <strong>for</strong> <strong>the</strong> low effect<br />
cerns and long-term needs. size suggested that better results were associ-<br />
Studies have also indicated that many ated with <strong>the</strong> following factors: more highly<br />
more survivors feel a need <strong>for</strong> pr<strong>of</strong>essional trained practitioners (vs. nonpr<strong>of</strong>essional <strong>the</strong>rmental<br />
health services than actually access apists), individual counseling (vs. group treat-<br />
<strong>the</strong>m. Saarinen, Irmeli, Hintikka, Lehtonen, ment), a greater number <strong>of</strong> sessions, and ini-<br />
and Loennqvist (1999) found that while half tiation <strong>of</strong> treatment closer in time to <strong>the</strong><br />
<strong>of</strong> <strong>the</strong>ir sample felt <strong>the</strong> need <strong>for</strong> psychiatric death. A marginally significant trend toward<br />
services, only 25% actually sought <strong>the</strong>m out. a greater effect size was also found <strong>for</strong> clients<br />
Likewise, both Provini et al. and Dyregrov defined as high-risk mourners.<br />
found that only about one in four survivors Using more rigorous selection criteria<br />
actually participated in support groups. Given which included random assignment to treat-<br />
<strong>the</strong> general lack <strong>of</strong> research as well as <strong>the</strong> disment and control groups, similar recruitment<br />
crepant findings in existing needs research, procedures <strong>for</strong> both groups, and initiation <strong>of</strong><br />
additional in<strong>for</strong>mation is needed about adult <strong>the</strong> intervention only after <strong>the</strong> loss had oc-<br />
survivors who receive help, <strong>the</strong> <strong>for</strong>ms it takes, curred, Kato and Mann (1999) provided a
340 <strong>Interventions</strong> <strong>for</strong> <strong>Suicide</strong> <strong>Survivors</strong><br />
qualitative and quantitative (meta-analytic) re- interventions with children than with adults.<br />
view <strong>of</strong> bereavement intervention studies. The authors also evaluated seven secondary<br />
Their review <strong>of</strong> 13 studies yielded an overall prevention studies that focused on bereaved<br />
effect size <strong>of</strong> .052, .272, and .095 <strong>for</strong> <strong>the</strong> re- persons defined as being at high risk <strong>for</strong> deduction<br />
<strong>of</strong> depressive, somatic, and all o<strong>the</strong>r veloping bereavement related problems. Re-<br />
psychological symptoms, respectively. The view <strong>of</strong> <strong>the</strong>se studies revealed a modest amount<br />
authors also computed a global effect size <strong>of</strong> <strong>of</strong> support <strong>for</strong> intervention efficacy. Finally,<br />
.114 across all outcome measures, and con- Schut et al. (2001) examined seven tertiary<br />
cluded from <strong>the</strong>se findings “psychological in- intervention studies <strong>for</strong> people who had al-<br />
terventions <strong>for</strong> bereavement are not effective ready developed a complicated mourning<br />
interventions” (p. 293). No statistical exami- response, including populations who were<br />
nation <strong>of</strong> moderator variables was reported suffering from clinical levels <strong>of</strong> depression,<br />
in this review. anxiety, and o<strong>the</strong>r bereavement induced dis-<br />
In ano<strong>the</strong>r meta-analytic review, Fororders at <strong>the</strong> time <strong>of</strong> entry into <strong>the</strong> studies.<br />
tner and Neimeyer (in Neimeyer, 2000) re- Despite some methodological limitations, <strong>the</strong><br />
viewed only investigations that met <strong>the</strong>ir cri- authors found that tertiary intervention was<br />
teria <strong>of</strong> random assignment to treatment and generally successful, and concluded that:<br />
control groups. They included studies in- “The general pattern emerging from this revolving<br />
interventions <strong>for</strong> both children and view is that <strong>the</strong> more complicated <strong>the</strong> grief<br />
adults across all types <strong>of</strong> losses. The authors process appears to be, <strong>the</strong> better <strong>the</strong> chances<br />
found an overall effect size <strong>of</strong> .13 across <strong>the</strong> <strong>of</strong> interventions leading to positive results”<br />
total sample <strong>of</strong> 23 studies. Using a novel mea- (p. 731).<br />
sure <strong>of</strong> “treatment induced deterioration” What conclusions can be drawn about<br />
(Neimeyer, 2000, p. 544), <strong>the</strong>y also found <strong>the</strong> effectiveness <strong>of</strong> general bereavement inthat<br />
approximately 38% <strong>of</strong> participants would terventions from this brief summary <strong>of</strong> re-<br />
have had a better outcome had <strong>the</strong>y been ascent reviews, and what implications do <strong>the</strong>y<br />
signed to <strong>the</strong> control, ra<strong>the</strong>r than <strong>the</strong> treat- have <strong>for</strong> interventions with suicide survivors?<br />
ment condition. In an examination <strong>of</strong> moder- In general, <strong>the</strong> literature suggests that <strong>the</strong> efator<br />
variables, <strong>the</strong> researchers also found that fect size <strong>of</strong> <strong>for</strong>mal interventions <strong>for</strong> <strong>the</strong> be-<br />
a greater length <strong>of</strong> time since <strong>the</strong> death, reaved is quite low, with <strong>the</strong> greatest reported<br />
younger age <strong>of</strong> <strong>the</strong> subject, and higher levels effects being less than half those <strong>of</strong> typical<br />
<strong>of</strong> risk (sudden violent death or evidence <strong>of</strong> psycho<strong>the</strong>rapy outcome studies. While <strong>the</strong><br />
chronic grief) were related to increased effect reasons <strong>for</strong> this ra<strong>the</strong>r surprising finding are<br />
size <strong>for</strong> <strong>the</strong> interventions (Neimeyer, 2000). not clear, one likely explanation is that most<br />
No effects were found <strong>for</strong> o<strong>the</strong>r variables uncomplicated grief is naturally self-limiting<br />
such as length <strong>of</strong> <strong>the</strong>rapy, credentials <strong>of</strong> <strong>the</strong> <strong>for</strong> <strong>the</strong> majority <strong>of</strong> mourners (Raphael, Min-<br />
<strong>the</strong>rapist (pr<strong>of</strong>essional vs. nonpr<strong>of</strong>essional), kov, & Dobson, 2001; Stroebe, Hansson,<br />
modality <strong>of</strong> treatment (individual vs. group), Stroebe, & Schut, 2001). This is evidenced<br />
or <strong>the</strong>oretical approach used by <strong>the</strong> <strong>the</strong>rapist. by <strong>the</strong> fact that in many studies, participants<br />
In <strong>the</strong> most recent qualitative review in <strong>the</strong> control groups tended to improve<br />
<strong>of</strong> bereavement intervention research, Schut, without any intervention, thus washing out<br />
Stroebe, van den Bout, and Terheggen (2001) differences between control and treatment<br />
provided a qualitative summary <strong>of</strong> three cate- groups. This same phenomenon may also be<br />
gories <strong>of</strong> studies: primary, secondary, and ter- true <strong>for</strong> some suicide survivors, raising <strong>the</strong><br />
tiary interventions after loss that included in- important possibility that some survivors may<br />
dividual, group, and family modalities. Their be nei<strong>the</strong>r at risk nor in need <strong>of</strong> <strong>for</strong>mal sup-<br />
evaluation <strong>of</strong> 16 primary intervention studies port services (McIntosh, 1999).<br />
revealed little data to support <strong>the</strong> effective- A second factor that may contribute to<br />
ness <strong>of</strong> such programs, although <strong>the</strong>re was <strong>the</strong> apparent ineffectiveness <strong>of</strong> grief counsel-<br />
marginally more support <strong>for</strong> <strong>the</strong> efficacy <strong>of</strong><br />
ing is <strong>the</strong> possible differential response <strong>of</strong>
Jordan and McMenamy 341<br />
men and women to intervention. There is clude deaths that are sudden and unexpected,<br />
growing evidence that men and women may violent, and/or <strong>the</strong> result <strong>of</strong> human activity<br />
use different coping styles to deal with loss (Stroebe & Schut, 2001). All <strong>of</strong> this suggests<br />
(Martin & Doka, 2000; Murphy, Johnson, & that survivors may be more likely to benefit<br />
Weber, 2002). The typical structure <strong>of</strong> sup- from <strong>for</strong>mal interventions than <strong>the</strong> general<br />
port interventions (e.g., self-disclosure and<br />
sharing <strong>of</strong> feelings) may be less effective, or<br />
perhaps even deleterious, <strong>for</strong> people with an<br />
population <strong>of</strong> bereaved persons.<br />
instrumental and more avoidant orientation SUICIDE SPECIFIC<br />
to coping, which is generally more characteristic<br />
<strong>of</strong> males. Again, this would tend to wash<br />
INTERVENTIONS<br />
out positive effects in studies <strong>of</strong> bereavement Turning to studies <strong>of</strong> suicide specific in-<br />
interventions if data are not analyzed sepatervention programs, a search was conducted<br />
rately by gender. <strong>of</strong> <strong>the</strong> PsychLit and <strong>the</strong> <strong>Suicide</strong> In<strong>for</strong>mation<br />
Lastly, it is quite possible that <strong>the</strong> typi- and Education databases <strong>for</strong> studies related<br />
cal bereavement intervention is significantly to suicide bereavement and intervention/<br />
below <strong>the</strong> “<strong>the</strong>rapeutic dosage” level needed treatment. While numerous positive descrip-<br />
to produce a desirable effect. Most research tions <strong>of</strong> groups or programs <strong>for</strong> survivors ex-<br />
intervention protocols involve a relatively ist (Apel & Wrobleski, 1987; Freeman, 1991;<br />
small number <strong>of</strong> treatment sessions (usually Juhnke & Sh<strong>of</strong>fner, 1999), only a handful <strong>of</strong><br />
8 to 12), typically <strong>of</strong>fered shortly after <strong>the</strong> empirical studies have been conducted to asloss<br />
and in rapid (usually weekly) succession. sess <strong>the</strong> effectiveness <strong>of</strong> <strong>the</strong>se programs. Given<br />
In contrast, <strong>the</strong>re is evidence that <strong>for</strong> some <strong>the</strong> dearth <strong>of</strong> methodologically rigorous repeople<br />
bereavement, particularly after trau- search, we have included in this review any<br />
matic loss, is a long-term adaptational pro- study that involved some type <strong>of</strong> objective<br />
cess, one that may even become more diffi- evaluation <strong>of</strong> <strong>the</strong> effectiveness <strong>of</strong> <strong>the</strong> intercult<br />
in <strong>the</strong> second and third years (Murphy, vention, regardless <strong>of</strong> <strong>the</strong> utilization <strong>of</strong> con-<br />
2000; Murphy, Johnson, Wu, Fan, & Lohan, trol groups or random assignment. Due to<br />
2003; Wortman & Silver, 2001). Longer- space limitations, <strong>the</strong> review was limited to<br />
term support may <strong>the</strong>re<strong>for</strong>e be needed after <strong>for</strong>mal interventions with adults. Fur<strong>the</strong>r<strong>the</strong>se<br />
types <strong>of</strong> losses. Indeed, some <strong>of</strong> <strong>the</strong> remore, while interventions targeting organizaviews<br />
have suggested that bereavement in- tions ra<strong>the</strong>r than individuals or families (e.g.,<br />
terventions might be more effective when postventions in business or hospital settings)<br />
<strong>of</strong>fered later, ra<strong>the</strong>r than earlier, after <strong>the</strong> would be eligible <strong>for</strong> inclusion, we were undeath.<br />
This would also coincide with <strong>the</strong> able to locate any studies that included objec-<br />
survey data from suicide survivors indicating tive attempts to measure <strong>the</strong> impact <strong>of</strong> such<br />
a perceived need <strong>for</strong> longer-term support interventions.<br />
(Dyregrov, 2002). Farberow (1992) conducted a controlled<br />
Of a more hopeful nature are <strong>the</strong> find- study <strong>of</strong> 60 participants in an 8-week, semiings<br />
that interventions <strong>for</strong> high-risk and/or structured group support program <strong>for</strong> survihigh<br />
distress mourners are generally more efvors. The control group consisted <strong>of</strong> 22 perficacious.<br />
It appears that interventions have sons who had signed up <strong>for</strong> <strong>the</strong> program and/<br />
<strong>the</strong>ir greatest impact on those who are ei<strong>the</strong>r or attended one session, and <strong>the</strong>n dropped<br />
in high-risk categories (e.g., suicide survi- out. Participants were asked to estimate <strong>the</strong><br />
vors), or who are specifically seeking help be- intensity <strong>of</strong> nine different feelings (anger, grief,<br />
cause <strong>the</strong>y show high levels <strong>of</strong> distress at <strong>the</strong> guilt, etc.) at three points: time <strong>of</strong> <strong>the</strong> death<br />
start <strong>of</strong> <strong>the</strong> intervention. Many <strong>of</strong> <strong>the</strong> factors (retrospectively evaluated), pre-intervention,<br />
that are present in most, if not all, suicides and immediately post-intervention. Results<br />
are also relatively well established as risk fac- indicated that <strong>the</strong> treatment group had sigtors<br />
<strong>for</strong> complicated bereavement. These in- nificantly higher levels <strong>of</strong> grief, shame, and
342 <strong>Interventions</strong> <strong>for</strong> <strong>Suicide</strong> <strong>Survivors</strong><br />
guilt at <strong>the</strong> start <strong>of</strong> <strong>the</strong> intervention than did was also included. Selection criteria were not<br />
controls. By <strong>the</strong> post-intervention assessment, clear from <strong>the</strong> report, but apparently partici-<br />
however, program participants had declined pants were selectively recruited from callers<br />
on ratings <strong>of</strong> eight <strong>of</strong> <strong>the</strong> nine feelings, while to a suicide prevention center; people with<br />
controls had declined on only one variable. severe personality disorders or pathological<br />
Fur<strong>the</strong>rmore, <strong>the</strong> intervention group had de- bereavement reactions were excluded. Selfclined<br />
to <strong>the</strong> level <strong>of</strong> <strong>the</strong> controls on grief, report measures <strong>of</strong> depression and anxiety<br />
shame, and guilt, although <strong>the</strong>y had also de- prior to entering <strong>the</strong> groups and 6 weeks<br />
veloped higher scores on depression and puz- after its conclusion revealed a significant<br />
zlement scales than controls. Although lack- drop in depressive and situational (though<br />
ing random assignment, this study suggests not trait) anxiety symptoms. The total num-<br />
that a treatment program provided <strong>for</strong> selfber <strong>of</strong> participants and descriptive statistics<br />
selected survivors with higher initial distress on pre- and post-intervention measures were<br />
levels may be successful in lowering symptom not reported. Moreover, <strong>the</strong> design did not<br />
levels to <strong>the</strong> level <strong>of</strong> less distressed controls. involve a comparison group or random as-<br />
Also, participants reported high levels <strong>of</strong> satsignment to conditions.<br />
isfaction with <strong>the</strong> program. Constantino and her colleagues re-<br />
Rogers, Sheldon, Barwick, Let<strong>of</strong>sky, ported data from two studies comparing two<br />
and Lancee (1982) reported on pre- and types <strong>of</strong> support groups <strong>for</strong> widowed persons<br />
post-test evaluation data from a structured bereaved by suicide: (1) a bereavement fo-<br />
program <strong>for</strong> recent survivors. A trained vol- cused group designed to explicitly facilitate<br />
unteer met with family members <strong>for</strong> eight <strong>the</strong> grieving process; and (2) a social activi-<br />
sessions, with discussion focusing on specific ties group designed to improve mood, selftopics<br />
related to suicide bereavement. Folconfidence, and a sense <strong>of</strong> belonging (Conlowing<br />
<strong>the</strong>se sessions, participants were in- stantino & Bricker, 1996; Constantino et al.,<br />
vited to attend four group meetings which 2001). Both groups consisted <strong>of</strong> eight 90<br />
allowed <strong>for</strong> <strong>the</strong> sharing <strong>of</strong> feelings and rein- minute weekly sessions, and assessments were<br />
<strong>for</strong>cement <strong>of</strong> ideas presented in <strong>the</strong> family made on self-report measures <strong>of</strong> depression,<br />
meetings. Fifty-three participants filled out a psychological distress, grief, and social ad-<br />
standardized psychiatric symptom checklist justment at <strong>the</strong> start and end <strong>of</strong> <strong>the</strong> groups,<br />
be<strong>for</strong>e and after participating in <strong>the</strong> program. and at 6 and 12 months after termination.<br />
Results showed declines on all symptom cate- Thirty-two participants in <strong>the</strong> first study and<br />
gories, although <strong>the</strong> authors failed to report 47 participants in <strong>the</strong> second were randomly<br />
any inferential statistics on <strong>the</strong> comparisons, assigned to one <strong>of</strong> <strong>the</strong> group <strong>for</strong>mats. The<br />
and <strong>the</strong> design did not include any compari- first study (Constantino & Bricker, 1996) found<br />
son group. Participants’ responses to a feed- that, contrary to expectations, both groups<br />
back questionnaire indicated that <strong>the</strong> three produced significant reductions in depression<br />
most successfully met program goals were and measures <strong>of</strong> psychological distress. Re-<br />
helping participants to put <strong>the</strong> suicide in per- sults <strong>of</strong> <strong>the</strong> follow-up second study employed<br />
spective, to express feelings without feeling a larger sample size and paralleled <strong>the</strong> find-<br />
judged, and to discuss <strong>the</strong> suicide. As with <strong>the</strong> ings from <strong>the</strong> first study (Constantino et al.,<br />
Farberow study, participants reported high 2001). The authors concluded that both <strong>the</strong><br />
levels <strong>of</strong> satisfaction with <strong>the</strong> program. bereavement and <strong>the</strong> social support <strong>for</strong>mats<br />
Renaud (1995) reported on a 10-session showed promise, and speculated that any<br />
support group <strong>for</strong> survivors which combined group <strong>for</strong>mat that allows survivors to interact<br />
mutual support, focused discussion <strong>of</strong> various with o<strong>the</strong>r survivors in a pr<strong>of</strong>essionally led<br />
suicide-related <strong>the</strong>mes, and an out-<strong>of</strong>-session group may be <strong>of</strong> benefit. The authors do ac-<br />
homework assignment. A follow-up session 5 knowledge, however, that <strong>the</strong> lack <strong>of</strong> any true<br />
weeks after completion <strong>of</strong> <strong>the</strong> initial sessions “no-treatment” control group makes it diffi-
Jordan and McMenamy 343<br />
cult to draw conclusions about <strong>the</strong> superior- each 2-hour session into a problem-focused<br />
ity <strong>of</strong> group interventions over non-interven- psychoeducational and skill building compotion.<br />
nent, followed by an emotion-focused sup-<br />
Building on <strong>the</strong> writing intervention portive discussion. The problem-focused comdeveloped<br />
by Pennebaker (see Pennebaker, ponent was designed to provide in<strong>for</strong>mation<br />
Zech, & Rime, 2001 <strong>for</strong> a recent summary), and skills to reduce negative consequences <strong>of</strong><br />
Kovac and Range (2000) reported on a prom- bereavement after violent death. The emotion-<br />
ising intervention that asked undergraduate focused component was structured to <strong>of</strong>fer<br />
student suicide survivors to write about <strong>the</strong> emotional sharing and support among mem-<br />
suicide <strong>of</strong> a loved one. Forty subjects were bers, as well as cognitive reframing <strong>of</strong> aspects<br />
randomly assigned to write ei<strong>the</strong>r about <strong>the</strong>ir <strong>of</strong> <strong>the</strong> loss experience. Outcome measures assuicide<br />
loss or about a neutral subject four sessed parents’ levels <strong>of</strong> mental distress, post-<br />
times over a 2-week period. Participants were traumatic reactions, loss accommodation (grief<br />
given self-report measures <strong>of</strong> suicide specific response), physical health, and marital role<br />
and general grief reactions, trauma symp- strain. Assessments were made prior to be-<br />
toms, and indicators <strong>of</strong> health care utilization ginning <strong>the</strong> intervention, at <strong>the</strong> conclusion,<br />
on three occasions: immediately be<strong>for</strong>e and and 6 months post intervention.<br />
after <strong>the</strong> intervention, and 6 weeks post in- Based on previous indications that men<br />
tervention. Results indicated significant de- and women may respond differentially to be-<br />
creases in suicide specific grief, although not reavement support interventions, data was<br />
in general grief, trauma symptoms, or health analyzed separately <strong>for</strong> fa<strong>the</strong>rs and mo<strong>the</strong>rs.<br />
care utilization among <strong>the</strong> treatment group. In general, <strong>the</strong> intervention did not prove to<br />
The authors concluded that writing interven- be superior to <strong>the</strong> control situation in reduc-<br />
tions might be particularly suited <strong>for</strong> being symptoms associated with <strong>the</strong> loss. Of<br />
reavement after suicide, noting that many importance, however, was a significant inter-<br />
participants in <strong>the</strong> intervention group made action between gender and initial distress<br />
spontaneous comments that participation had level in <strong>the</strong> treatment group. When partici-<br />
allowed <strong>the</strong>m to better understand why <strong>the</strong> pants were grouped by initial level <strong>of</strong> distress,<br />
death had occurred and to begin talking to bereaved mo<strong>the</strong>rs with initially high levels <strong>of</strong><br />
o<strong>the</strong>rs about <strong>the</strong> death. The authors also sug- emotional distress and grief symptoms had<br />
gested that, based on a previous meta-analy- lower levels <strong>of</strong> <strong>the</strong>se symptoms at <strong>the</strong> conclu-<br />
sis <strong>of</strong> similar interventions, this approach sion <strong>of</strong> <strong>the</strong> intervention in comparison to<br />
may be particularly helpful <strong>for</strong> males, who control group mo<strong>the</strong>rs. Fur<strong>the</strong>rmore, particiare<br />
less likely to disclose traumatic experipation in <strong>the</strong> intervention appeared to inences<br />
to o<strong>the</strong>rs (Smyth, 1998). crease <strong>the</strong> PTSD symptoms <strong>of</strong> fa<strong>the</strong>rs in <strong>the</strong><br />
In one <strong>of</strong> <strong>the</strong> most methodologically treatment group. As with most o<strong>the</strong>r prorigorous<br />
studies to date, Murphy and her col- gram descriptions, participants generally in-<br />
leagues reported on <strong>the</strong> efficacy <strong>of</strong> a 10-week dicated great satisfaction with <strong>the</strong> program.<br />
support group intervention <strong>for</strong> 261 bereaved In addition to <strong>the</strong> clinical trial <strong>of</strong> this<br />
parents (Murphy, 2000; Murphy et al., 1998). intervention, Murphy (2000) has reported<br />
Parents who had experienced <strong>the</strong> sudden data from a longitudinal follow-up at 2 and 5<br />
death <strong>of</strong> a child (aged 12 to 28) by suicide, years that combined <strong>the</strong> treatment and con-<br />
homicide, or accidental death within <strong>the</strong> 7 trol groups. The sample continued to show<br />
months prior to recruitment were identified greatly elevated levels <strong>of</strong> mental distress,<br />
through death records and invited into <strong>the</strong> trauma symptoms, and health problems at 2<br />
study. All parents were randomly assigned to and 5 years, although <strong>the</strong>re was a steady de-<br />
ei<strong>the</strong>r a treatment or a nontreatment control cline in symptoms over <strong>the</strong> course <strong>of</strong> <strong>the</strong><br />
condition. The intervention consisted <strong>of</strong> a study. Murphy also noted that parents who<br />
<strong>the</strong>ory-based group program which divided engaged in certain health protective behav-
344 <strong>Interventions</strong> <strong>for</strong> <strong>Suicide</strong> <strong>Survivors</strong><br />
iors (e.g., exercise) showed better outcomes. changes in parents’ depression after partici-<br />
Gender differences were also observed, with pation. The comparison group consisted <strong>of</strong><br />
mo<strong>the</strong>rs generally showing improvement in families contacted but assigned to <strong>the</strong> no-<br />
health and functioning, and fa<strong>the</strong>rs showing treatment condition. The results showed<br />
deterioration in PTSD symptoms and health significant decreases <strong>for</strong> children in <strong>the</strong> treatover<br />
<strong>the</strong> 5-year period. Importantly, Murphy ment group in depression and anxiety symp-<br />
also noted that participants reported that toms, although not in trauma or social ad-<br />
<strong>the</strong>ir greatest period <strong>of</strong> accommodation to justment scores. Un<strong>for</strong>tunately, <strong>the</strong>re were<br />
<strong>the</strong> loss occurred in <strong>the</strong> third and fourth no significant changes in parent’s depression<br />
years after <strong>the</strong> death and not in <strong>the</strong> first year, scores, a result that <strong>the</strong> authors attribute to<br />
as is commonly assumed. <strong>the</strong> fact that <strong>the</strong> intervention was designed to<br />
Mitchell and Kim (2003) have recently educate parents about bereavement in chilreported<br />
on a debriefing intervention modi- dren, ra<strong>the</strong>r than directly affect parents’ own<br />
fied <strong>for</strong> early intervention with suicide survivors.<br />
In this study, 60 recently bereaved (one<br />
month or less) suicide survivors were ran-<br />
grief responses.<br />
domly assigned to ei<strong>the</strong>r a single session de- RECOMMENDATIONS<br />
briefing group or to a treatment as usual<br />
group. Participants filled out measures <strong>of</strong><br />
AND CONCLUSIONS<br />
perceived stress, complicated grief, depres- At this point, we can return to <strong>the</strong><br />
sion, PTSD, general psychiatric symptoms, original goals <strong>of</strong> <strong>the</strong> article. These included<br />
and general quality <strong>of</strong> life at 4 and 12 weeks reviewing <strong>the</strong> current status <strong>of</strong> knowledge<br />
after <strong>the</strong> intervention. The treatment group about interventions <strong>for</strong> suicide survivors, and<br />
was found to be less distressed prior to <strong>the</strong> developing recommendations <strong>for</strong> future reintervention<br />
than <strong>the</strong> controls, and this was search on this topic. The literature on gen-<br />
found to be related to <strong>the</strong> closeness <strong>of</strong> <strong>the</strong> eral bereavement interventions suggests that<br />
kinship relationship to <strong>the</strong> deceased (controls many services may be <strong>of</strong> dubious value, at<br />
had closer kinship connections than treat- least as delivered in <strong>the</strong> research studies.<br />
ment group), and controlled by using change However, <strong>the</strong>re is evidence that interventions<br />
scores ra<strong>the</strong>r than direct comparisons be- <strong>for</strong> high-risk populations, such as suicide sur-<br />
tween groups. There was also significant atvivors, may be more effective. The literature<br />
trition in follow-up participation, so that <strong>the</strong> also indicates that <strong>the</strong> design <strong>of</strong> interventions<br />
final results were based on an n <strong>of</strong> 27. Results may need to take into account gender differ-<br />
showed trends toward greater improvement ences, with men responding differently and/<br />
in grief and perceived stress <strong>for</strong> <strong>the</strong> treatment or less positively than women to typical in-<br />
group at 4 weeks. Likewise, at 3 months <strong>the</strong> terventions. Lastly, bereavement studies sugtreatment<br />
group showed greater improvegest that many <strong>of</strong> <strong>the</strong> interventions are simment<br />
on general mental health and a trend ply <strong>of</strong> insufficient strength and duration to<br />
toward less perceived stress. Despite <strong>the</strong> make a measurable impact. This may be par-<br />
methodological issues, <strong>the</strong> results suggest a ticularly true <strong>for</strong> traumatic losses such as suimodest<br />
potential <strong>for</strong> a positive effect <strong>for</strong> an cide, where clinical experience and <strong>the</strong> self-<br />
early, CISM type intervention <strong>for</strong> survivors. reported needs <strong>of</strong> survivors strongly suggest<br />
Finally, Pfeffer et al. (2002) reported that brief interventions delivered early in <strong>the</strong><br />
on a well-designed support group interven- mourning trajectory may be insufficient to<br />
tion <strong>for</strong> children who had experienced <strong>the</strong> address <strong>the</strong> magnitude <strong>of</strong> disruption engen-<br />
suicide <strong>of</strong> a parent or sibling. Although it was dered by a suicide (Murphy et al., 2003). For<br />
primarily an intervention with bereaved chil- a more extensive discussion <strong>of</strong> <strong>the</strong>se concludren,<br />
<strong>the</strong> research is noted here because <strong>the</strong> sions, please see <strong>the</strong> recent review by Jordan<br />
intervention included a psychoeducational in- and Neimeyer (2003).<br />
tervention <strong>for</strong> parents which was assessed by The studies that have empirically eval-
Jordan and McMenamy 345<br />
uated interventions specifically designed <strong>for</strong> surround <strong>the</strong> survivor. O<strong>the</strong>r areas that may<br />
survivors are somewhat more promising, and show differences in <strong>the</strong> bereavement expe-<br />
also have similar implications <strong>for</strong> future re- rience include <strong>the</strong> impact <strong>of</strong> suicide on <strong>the</strong><br />
search and clinical intervention. Most <strong>of</strong> <strong>the</strong> assumptive world <strong>of</strong> survivors and possible<br />
studies found at least some effect <strong>for</strong> <strong>the</strong> in- long-term “sleeper” effects, particularly <strong>for</strong><br />
tervention and also report high levels <strong>of</strong> children who lose parents to suicide.<br />
participant satisfaction with <strong>the</strong> services. Un- There is also a lack <strong>of</strong> consensus about<br />
<strong>for</strong>tunately, <strong>the</strong> methodological rigor <strong>of</strong> <strong>the</strong> whe<strong>the</strong>r <strong>the</strong>re is a universal pattern <strong>of</strong> re-<br />
studies has generally been weak, with many sponse among suicide survivors, or alternaresearchers<br />
failing to utilize random assigntively, a diversity <strong>of</strong> responses that are influment<br />
and appropriate comparison groups. enced by variables over and above <strong>the</strong> loss.<br />
Moreover, <strong>the</strong> studies that have employed This suggests <strong>the</strong> need <strong>for</strong> continuing re<strong>the</strong><br />
most careful research designs (Kovac & search into which factors tend to produce<br />
Range, 2000; Murphy et al., 1998; Pfeffer et which types <strong>of</strong> responses <strong>for</strong> which groups <strong>of</strong><br />
al., 2002) also tended to find <strong>the</strong> least confir- survivors (Farberow, 2001). In addition, very<br />
mation that <strong>the</strong> interventions were success- little is known about <strong>the</strong> coping strategies<br />
ful. Hence, while <strong>the</strong>re is anecdotal evidence that survivors develop on <strong>the</strong>ir own, and only<br />
and a general clinical impression that services slightly more about what types <strong>of</strong> <strong>for</strong>mal and<br />
are helpful, we must conclude that <strong>the</strong> effi- in<strong>for</strong>mal assistance survivors receive from<br />
cacy <strong>of</strong> <strong>for</strong>mal interventions <strong>for</strong> survivors has pr<strong>of</strong>essional caregivers, family, friends, and<br />
yet to be scientifically established. The state o<strong>the</strong>rs in <strong>the</strong>ir social network. Careful longi<strong>of</strong><br />
our knowledge about how, when, and with tudinal research with a diverse, community-<br />
whom to intervene after a suicide is still quite based sample <strong>of</strong> survivors would greatly in-<br />
primitive, suggesting a pressing need <strong>for</strong> furcrease our understanding <strong>of</strong> <strong>the</strong> challenges<br />
<strong>the</strong>r research that addresses several key is- involved and <strong>the</strong> coping skills required after<br />
sues. We turn to this topic in <strong>the</strong> final section a suicide. It would also provide much needed<br />
<strong>of</strong> this article. in<strong>for</strong>mation about <strong>the</strong> large number <strong>of</strong> survivors<br />
(quite likely <strong>the</strong> majority) who never<br />
Recommendations <strong>for</strong> Future Research attend organized support groups or receive<br />
pr<strong>of</strong>essional assistance. Such research would<br />
The first need is <strong>for</strong> better in<strong>for</strong>mation allow us to generate creative strategies <strong>for</strong> inabout<br />
<strong>the</strong> “natural” course <strong>of</strong> bereavement tervention that build on <strong>the</strong> natural coping<br />
after suicide. We have not yet definitively an- ef<strong>for</strong>ts that different types <strong>of</strong> survivors typiswered<br />
<strong>the</strong> question as to what, if any, differ- cally make and <strong>the</strong> support resources <strong>the</strong>y<br />
ences exist between suicide bereavement and utilize. Differences in coping strategies based<br />
o<strong>the</strong>r types <strong>of</strong> losses (Clark, 2001). Mc- on gender, personality, and cultural differ-<br />
Intosh’s (1999) summary <strong>of</strong> <strong>the</strong> literature ences need to be studied and incorporated<br />
concluded that most suicide bereavement is into treatment planning. To summarize, it<br />
nonpathological, suggesting that whatever seems likely to us that <strong>the</strong> “one size fits all”<br />
differences exist between bereavement after approach to understanding and intervening<br />
suicide and o<strong>the</strong>r types <strong>of</strong> losses appear to with survivors which has been dominant<br />
disappear after <strong>the</strong> first 2 years. Jordan (2001) since <strong>the</strong> inception <strong>of</strong> modern suicidology<br />
has also reviewed this literature and reached needs considerable refinement (Ellenbogen<br />
a more complex conclusion, suggesting that & Gratton, 2001).<br />
while quantitative evidence <strong>for</strong> differences in Second, we need methodologically sound<br />
outcome has received only mixed support, studies <strong>of</strong> <strong>the</strong> efficacy and effectiveness <strong>of</strong><br />
<strong>the</strong>re appear to be important distinctions in <strong>for</strong>mal interventions <strong>for</strong> survivors. Given <strong>the</strong><br />
<strong>the</strong> <strong>the</strong>matic content <strong>of</strong> <strong>the</strong> grief experience present state <strong>of</strong> knowledge, we believe that it<br />
<strong>for</strong> many survivors, in addition to differences is generally premature to study comparative<br />
in social support and family processes that treatment interventions at this time. Since
346 <strong>Interventions</strong> <strong>for</strong> <strong>Suicide</strong> <strong>Survivors</strong><br />
most <strong>of</strong> <strong>the</strong> services reported in <strong>the</strong> literature types <strong>of</strong> interventions. The quality <strong>of</strong> re-<br />
seem to involve some variation <strong>of</strong> <strong>the</strong> basic search methodology in intervention outcome<br />
bereavement support group, we believe that studies to date has generally been very poor,<br />
<strong>the</strong> first “wave” <strong>of</strong> research on interventions posing a major threat to <strong>the</strong> internal validity<br />
should involve naturalistic studies <strong>of</strong> <strong>the</strong> ef- <strong>of</strong> <strong>the</strong> studies and hence <strong>the</strong>ir usefulness <strong>for</strong><br />
fectiveness <strong>of</strong> existing groups. This could in- drawing sound conclusions about <strong>the</strong> interclude<br />
data ga<strong>the</strong>ring about <strong>the</strong> perceived ventions. Future controlled studies in this<br />
needs, coping tactics, and sources <strong>of</strong> support second wave <strong>of</strong> studies should employ ran-<br />
employed by <strong>the</strong> participants. This type <strong>of</strong> dom assignment to treatment conditions and<br />
field research could evaluate <strong>the</strong> elements appropriate comparison groups, which could<br />
that appear to be common in most bereave- include both waiting list controls <strong>of</strong> survivors<br />
ment support groups. These include mutual, who have sought <strong>for</strong>mal assistance along with<br />
nonjudgmental emotional support in a set- “community standard” controls who do not<br />
ting where survivors can tell <strong>the</strong>ir stories and seek treatment. The latter is particularly im-<br />
receive advice about coping from o<strong>the</strong>rs with portant in bereavement outcome studies, since<br />
similar experiences. Comparison groups might no-treatment comparison groups are neces-<br />
be constructed <strong>of</strong> a community sample <strong>of</strong> sary to control <strong>for</strong> <strong>the</strong> natural tendency <strong>of</strong><br />
matched controls that do not participate in bereavement related symptoms to remit over<br />
such groups. Such research should include time, with or without <strong>for</strong>mal intervention.<br />
both quantitative and qualitative methods <strong>for</strong> Moreover, explicit delineation <strong>of</strong> <strong>the</strong><br />
participants to describe <strong>the</strong>ir own under- treatment protocols involved, <strong>the</strong> <strong>the</strong>oretical<br />
standing <strong>of</strong> what aspects <strong>of</strong> <strong>the</strong> group experi- basis <strong>for</strong> <strong>the</strong> intervention, and evidence <strong>of</strong><br />
ence are most helpful. Qualitative measures adherence to <strong>the</strong> treatment are also required<br />
<strong>of</strong> outcome that extend assessment beyond <strong>for</strong> methodologically sound investigations<br />
psychiatric symptoms to broader constructs and <strong>for</strong> <strong>the</strong> effective dissemination <strong>of</strong> treat-<br />
such as changes in <strong>the</strong> individual’s assumptive ment approaches to practitioners. Most early<br />
world, quality <strong>of</strong> life, and social adaptation studies are quite vague as to <strong>the</strong> actual proce-<br />
might also reveal a different type <strong>of</strong> intervendures employed in <strong>the</strong> intervention, although<br />
tion success. Fur<strong>the</strong>rmore, with a sufficient more recent studies have been based on man-<br />
sample size, <strong>the</strong> research could provide in<strong>for</strong>ualized protocols (Murphy et al., 1998). These<br />
mation that may account <strong>for</strong> differences in second wave studies should focus on investi-<br />
outcome <strong>for</strong> different types <strong>of</strong> survivors, such gating interventions <strong>for</strong> specific groups <strong>of</strong><br />
as timing <strong>of</strong> entry and duration <strong>of</strong> participa- survivors. For example, <strong>the</strong> general bereavetion,<br />
group <strong>for</strong>mat (e.g., time limited vs. onment intervention literature indicates that ingoing;<br />
structured vs. unstructured; psychoed- dividuals who are in high risk categories (e.g.,<br />
ucational vs. expressive), and <strong>the</strong> background bereaved parents) and/or who already show<br />
and training <strong>of</strong> <strong>the</strong> leader (e.g., survivor vs. high distress levels (e.g., symptoms <strong>of</strong> clinical<br />
nonsurvivor, pr<strong>of</strong>essional vs. nonpr<strong>of</strong>essional) depression or PTSD) are <strong>the</strong> most likely to<br />
(see also Farberow, 2001). This more natural- benefit from pr<strong>of</strong>essional intervention ( Joristic,<br />
effectiveness-oriented research on exdan & Neimeyer, 2003). Thus, “generic” suiisting<br />
groups could <strong>the</strong>n lay <strong>the</strong> foundation cide survivor support groups may work well<br />
<strong>for</strong> a second wave <strong>of</strong> more controlled studies <strong>for</strong> many survivors, while specialized groups<br />
<strong>of</strong> specific intervention techniques <strong>for</strong> spe- (or o<strong>the</strong>r treatment modalities) <strong>for</strong> high-risk<br />
cific types <strong>of</strong> survivors.<br />
survivors may be preferable and more effica-<br />
With sufficient knowledge <strong>of</strong> <strong>the</strong> range cious at preventing future dysfunction, in-<br />
<strong>of</strong> <strong>the</strong> coping responses made by survivors, cluding future suicide.<br />
and <strong>of</strong> <strong>the</strong> factors that appear to enhance <strong>the</strong> These targeted interventions could in-<br />
effectiveness <strong>of</strong> existing interventions, we beclude approaches that have shown at least<br />
lieve that <strong>the</strong> field will <strong>the</strong>n be in a position some promise in previous studies, such as<br />
to rigorously study <strong>the</strong> efficacy <strong>of</strong> particular<br />
writing interventions (Kovac & Range, 2000),
Jordan and McMenamy 347<br />
psychoeducational and skills building pro- entifically based knowledge about how to as-<br />
grams (Murphy et al., 1998), and combisist survivors is far behind our ability to<br />
nations <strong>of</strong> in<strong>for</strong>mal “survivor-to-survivor” intervene with o<strong>the</strong>r at-risk populations (e.g.,<br />
support and more structured group interven- trauma victims) or with many <strong>for</strong>ms <strong>of</strong> psytions.<br />
Additional techniques that have been chiatric disorder (e.g., depression or anxiety<br />
shown to be <strong>of</strong> help in o<strong>the</strong>r types <strong>of</strong> trau- disorders). Although <strong>the</strong>re are encouraging<br />
matic losses should be explored <strong>for</strong> possible signs that this is changing, it is our impres-<br />
adaptation <strong>for</strong> interventions with survivors sion that survivors have been a low priority<br />
(Doka, 1996; Figley, 1997, 1999). These in- <strong>for</strong> researchers and clinicians in suicidology,<br />
clude <strong>the</strong>rapeutic modalities such as Eye whose main interest has focused on preventa-<br />
Movement Desensitization and Reprocessing tive work with suicidal individuals. It is our<br />
(EMDR; Solomon & Shapiro, 1997) and Trau- strong conviction, however, that “postvenmatic<br />
Incident Reduction (Descilo, 1999), tion is prevention” (Shneidman, 1981), and<br />
cognitive-behavioral <strong>the</strong>rapies (Fleming & that work with survivors is an obvious and<br />
Robinson, 2001), family techniques (Horo- efficient way to contribute to <strong>the</strong> prevention<br />
witz, 1997), and narrative approaches (Ry- <strong>of</strong> future distress, psychiatric disorder, and<br />
nearson, 2001). even suicide itself. We hope that this review<br />
Conclusions<br />
will contribute to <strong>the</strong> growing interest within<br />
suicidology in studying and assisting suicide<br />
There is much work to be done (Far- survivors as <strong>the</strong>y seek healing after this very<br />
berow, 2001; Clark, 201). Currently, our sci- difficult type <strong>of</strong> loss.<br />
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