Interventions for Suicide Survivors: A Review of the Literature

Suicide and Life-Threatening Behavior 34(4) Winter 2004 337 

© 2004 The American Association of Suicidology 

Interventions for Suicide Survivors: 

A Review of the Literature 

John R. Jordan, PhD, and Jannette McMenamy, PhD 

Mourning after suicide is frequently a difficult experience. Research suggests 

that suicide survivors may be at elevated risk for several psychiatric and 

somatic complications. Despite this, very little research has focused on developing 

and empirically evaluating clinical interventions for this population. This paper 

attempts to stimulate interest in intervention research by reviewing three relevant 

areas: (a) studies of the perceived needs of survivors; (b) implications of the research 

on general bereavement interventions for work with survivors; and (c) research 

documenting the efficacy of specific interventions for adult survivors. Recommendations 

for future studies are discussed. 

There is considerable evidence that suicide be at elevated risk for someday completing 

survivors may have an elevated risk for devel- suicide themselves (Moscicki, 1995; Roy, 

oping complicated mourning responses, as 1992; Runeson & Asberg, 2003). 

well as other psychiatric and medical compli- Given the potential risk for negative 

cations, after the death of a loved one (Bail- outcomes, postvention with survivors could 

ley, Kral, & Dunham, 1999; Brent, Moritz, be a powerful form of primary and secondary 

Bridge, Perper, & Canobbio, 1996; Clark, prevention, one that might avert future psy- 

2001; Rudestam, 1992; Seguin, Lesage, & chiatric and family dysfunction and even fu- 

Kiely, 1995; Shneidman, 1981). Jordan’s (2001) ture suicides. Unfortunately, as Campbell (1997) 

literature review points to many possible has observed, there is “a poverty of resources 

complications for survivors, including height- for survivors and a flawed entry system for 

ened levels of guilt, shame, anger, family dys- those services (in the United States)” (p. 

function, and social stigmatization. Indeed, 333). Furthermore, relatively little effort has 

survivors of any sudden, traumatic death of a been made within suicidology, thanatology, 

loved one may have an increased chance of or trauma studies to develop empirically 

developing disorders such as traumatic grief based interventions for survivors (Clark, 

(Prigerson & Jacobs, 2001) and PTSD (Bres- 2001; Constantino, Sekula, & Rubinstein, 

lau et al., 1998; Zisook, Chentsova-Dutton, 2001; Farberow, 2001). This article, there- 

& Shuchter, 1998). Perhaps most tragically, fore, has two primary goals: to assess the 

evidence suggests that suicide survivors may present level of scientific knowledge about 

interventions for survivors, and to develop 

recommendations for future research in this 

John R. Jordan, PhD, is with the Family area. More generally, we hope to stimulate a 

Loss Project in Sherborn, MA. Jannette Mc- more dedicated effort within these disciplines 

Menamy, PhD, is with the Department of Pediatrics 

at The Floating Hospital for Children, Tufts- 

New England Medical Center. 

Address correspondence to John R. Jordan, 

The Family Loss Project, 26 Curve Street, Sher- 

to study the efficacy of treatment procedures 

for survivors. 

To meet these goals, several topics are 

addressed. First, we review the existing studborn, 

MA 01770; jjordan50@aol.com. ies on the self-reported needs of suicide sur-

338 Interventions for Suicide Survivors 

vivors. Second, given the lack of research de- ceive. In a telephone survey of 144 next-of- 

voted to interventions with suicide survivors, kin survivors, Provini et al. (2002) found that 

we provide a short discussion of recent re- approximately one quarter of their sample in- 

views of the research into the efficacy of dicated specific concerns (18%) and needs 

psychosocial interventions after all types of (26%), while approximately one third indi- 

bereavement. Third, empirical studies of incated that they had no specific concerns 

terventions specifically for suicide survivors (35%) or needs (31%). Only about 25% indi- 

will be reviewed. Finally, conclusions are cated that they had received either formal or 

drawn and recommendations made for im- informal help since the suicide, although for- 

proving future research efforts. While there mal help was listed as a form of assistance 

is a small amount of literature on interven- desired by almost three quarters of those who 

tions with child and adolescent suicide survi- indicated a need for help. Family related 

vors (see for example, Pfeffer, Jiang, Kakuma, problems were the most frequently men- 

Hwang, & Metsch, 2002), a full review of intioned types of concerns, with families conterventions 

for child survivors is beyond the taining minor children expressing signifi- 

scope of this article. 

cantly more concerns than those without 

children. Bereaved widows and parents appeared 

to be underrepresented in the study, 

REPORTED NEEDS 

and the sample was also relatively young, 

OF SURVIVORS with 42% of respondents in the 25–44 age 

range. Approximately one third of the sample 

Estimates of the number of impacted felt able to cope without any assistance. 

survivors after a completed suicide vary wide- In another recent study of 179 Norwe- 

ly, from six to several hundred, depending on gian survivors, Dyregrov (2002) found that 

the operational definition of survivorhood bereaved survivor parents experienced high 

(Crosby & Sacks, 2002; Provini, Everett, & levels of psychosocial distress on measures of 

Pfeffer, 2000; Wrobleski, 1991). A recent and general health functioning, traumatization, 

methodologically sound national telephone and complicated bereavement, along with 

survey of 5,238 respondents indicated that as considerably greater levels of perceived and 

much as 7% of the U.S. population (approxi- unmet needs for services and support than 

mately 13.2 million people) has been exposed the Provini et al. sample. For example, 88% 

to a suicide within the last 12 months, with of the participants expressed the need for 

approximately 1.1% of the sample having lost professional help for their bereavement. Eighty- 

an immediate family member (Crosby & five percent reported that they had already 

Sacks, 2002). It is important to note, how- received some kind of contact with commuever, 

that the question of what constitutes nity professionals, and about half had experi- 

“survivorhood” is one that has not been set- enced direct outreach from professionals. 

tled for either clinical or research purposes, This support, however, was typically of short 

since it has not been established that expo- duration (67% less than 6 months), and was 

sure to suicide necessarily results in the nega- offered shortly after the loss. Thus, many retive 

effects implied in the term survivor. At spondents expressed the need for on-going 

this point in the development of our knowl- and longer term outreach from caregivers, 

edge, we simply do not have good data about since they had difficulty initiating the search 

the percentages of exposed people who are for help on their own, given their emotion- 

significantly impacted in a negative way by ally traumatized state. Similar to the Provini 

suicide (American Foundation for Suicide et al. sample, respondents expressed a strong 

Prevention, 2003; McIntosh, 1999). need for help with supporting minor children 

Likewise, very few empirical studies after the suicide, as well as targeted help in 

have addressed the question of what types of dealing with posttraumatic experiences of in- 

support services survivors need or actually re-trusive 

memories and images. Dyregrov also

Jordan and McMenamy 339 

surveyed community professionals and found and the efficacy of the support received. Such 

that while there was a general congruence evidence is critically important to guide the 

between the type of help offered and received development of appropriate and timely inter- 

by caregivers and survivors, professionals 

tended to overestimate the percentage of survivors 

who actually received help from mediventions 

for at-risk survivors. 

cal personnel (doctors, psychiatric nurses, or GENERAL INTERVENTIONS 

public health nurses) or from survivor support 

groups. 

FOR THE BEREAVED 

The conflicting findings between the Given the extensive literature on be- 

Provini et al. and Dyregrov studies may perreavement interventions, we have restricted 

haps be attributed to differences in the orga- our review to meta-analytic studies or large- 

nization of health care in the United States scale reviews of the literature. On the whole, 

and Norway, as well as to demographic dif- these studies reveal a surprising and rather 

ferences in the two samples. For example, distressing lack of effectiveness for general 

municipalities in Norway are able to provide bereavement interventions. At the same time, 

more organized postvention services than they also highlight the importance of identi- 

most communities within the United States, fying high-risk subgroups of bereaved indi- 

since Norway has a nationalized health care viduals such as suicide survivors. For a more 

system. Given that both samples indicated comprehensive discussion of the implications 

that many of their concerns centered around of the reviews that follow, please see Jordan 

the impact of suicide on children in the fam- and Neimeyer (2003). 

ily, the relatively younger age of the Provini Allumbaugh and Hoyt (1999) performed 

et al. sample and the smaller proportion of a meta-analysis of 35 bereavement interven- 

spousal and child loss may have resulted in tion studies that included either a control 

fewer people with children, and therefore less group or a pre-post treatment design, but not 

of a perceived need for professional guidance. necessarily random assignment. Overall, these 

Also, the mean length of time since the sui- authors found an effect size across studies for 

cide in the Dyregrov study (15 months) was bereavement interventions of .43, a finding 

much longer than in the Provini study (5 that contrasts with the typical effect size of 

months). Given that many participants in the approximately .80 found in most psychother- 

Dyregrov study indicated that brief, early apy outcome research (Lambert & Bergin, 

support was not adequate, the Provini et al. 1994; Robinson, Berman, & Neimeyer, 1990). 

study may have contacted families too soon, Additional analyses of 12 “moderator” vari- 

before they were able to identify specific conables that might account for the low effect 

cerns and long-term needs. size suggested that better results were associ- 

Studies have also indicated that many ated with the following factors: more highly 

more survivors feel a need for professional trained practitioners (vs. nonprofessional thermental 

health services than actually access apists), individual counseling (vs. group treat- 

them. Saarinen, Irmeli, Hintikka, Lehtonen, ment), a greater number of sessions, and ini- 

and Loennqvist (1999) found that while half tiation of treatment closer in time to the 

of their sample felt the need for psychiatric death. A marginally significant trend toward 

services, only 25% actually sought them out. a greater effect size was also found for clients 

Likewise, both Provini et al. and Dyregrov defined as high-risk mourners. 

found that only about one in four survivors Using more rigorous selection criteria 

actually participated in support groups. Given which included random assignment to treat- 

the general lack of research as well as the disment and control groups, similar recruitment 

crepant findings in existing needs research, procedures for both groups, and initiation of 

additional information is needed about adult the intervention only after the loss had oc- 

survivors who receive help, the forms it takes, curred, Kato and Mann (1999) provided a


qualitative and quantitative (meta-analytic) re- interventions with children than with adults. 

view of bereavement intervention studies. The authors also evaluated seven secondary 

Their review of 13 studies yielded an overall prevention studies that focused on bereaved 

effect size of .052, .272, and .095 for the re- persons defined as being at high risk for deduction 

of depressive, somatic, and all other veloping bereavement related problems. Re- 

psychological symptoms, respectively. The view of these studies revealed a modest amount 

authors also computed a global effect size of of support for intervention efficacy. Finally, 

.114 across all outcome measures, and con- Schut et al. (2001) examined seven tertiary 

cluded from these findings “psychological in- intervention studies for people who had al- 

terventions for bereavement are not effective ready developed a complicated mourning 

interventions” (p. 293). No statistical exami- response, including populations who were 

nation of moderator variables was reported suffering from clinical levels of depression, 

in this review. anxiety, and other bereavement induced dis- 

In another meta-analytic review, Fororders at the time of entry into the studies. 

tner and Neimeyer (in Neimeyer, 2000) re- Despite some methodological limitations, the 

viewed only investigations that met their cri- authors found that tertiary intervention was 

teria of random assignment to treatment and generally successful, and concluded that: 

control groups. They included studies in- “The general pattern emerging from this revolving 

interventions for both children and view is that the more complicated the grief 

adults across all types of losses. The authors process appears to be, the better the chances 

found an overall effect size of .13 across the of interventions leading to positive results” 

total sample of 23 studies. Using a novel mea- (p. 731). 

sure of “treatment induced deterioration” What conclusions can be drawn about 

(Neimeyer, 2000, p. 544), they also found the effectiveness of general bereavement inthat 

approximately 38% of participants would terventions from this brief summary of re- 

have had a better outcome had they been ascent reviews, and what implications do they 

signed to the control, rather than the treat- have for interventions with suicide survivors? 

ment condition. In an examination of moder- In general, the literature suggests that the efator 

variables, the researchers also found that fect size of formal interventions for the be- 

a greater length of time since the death, reaved is quite low, with the greatest reported 

younger age of the subject, and higher levels effects being less than half those of typical 

of risk (sudden violent death or evidence of psychotherapy outcome studies. While the 

chronic grief) were related to increased effect reasons for this rather surprising finding are 

size for the interventions (Neimeyer, 2000). not clear, one likely explanation is that most 

No effects were found for other variables uncomplicated grief is naturally self-limiting 

such as length of therapy, credentials of the for the majority of mourners (Raphael, Min- 

therapist (professional vs. nonprofessional), kov, & Dobson, 2001; Stroebe, Hansson, 

modality of treatment (individual vs. group), Stroebe, & Schut, 2001). This is evidenced 

or theoretical approach used by the therapist. by the fact that in many studies, participants 

In the most recent qualitative review in the control groups tended to improve 

of bereavement intervention research, Schut, without any intervention, thus washing out 

Stroebe, van den Bout, and Terheggen (2001) differences between control and treatment 

provided a qualitative summary of three cate- groups. This same phenomenon may also be 

gories of studies: primary, secondary, and ter- true for some suicide survivors, raising the 

tiary interventions after loss that included in- important possibility that some survivors may 

dividual, group, and family modalities. Their be neither at risk nor in need of formal sup- 

evaluation of 16 primary intervention studies port services (McIntosh, 1999). 

revealed little data to support the effective- A second factor that may contribute to 

ness of such programs, although there was the apparent ineffectiveness of grief counsel- 

marginally more support for the efficacy of 

ing is the possible differential response of


men and women to intervention. There is clude deaths that are sudden and unexpected, 

growing evidence that men and women may violent, and/or the result of human activity 

use different coping styles to deal with loss (Stroebe & Schut, 2001). All of this suggests 

(Martin & Doka, 2000; Murphy, Johnson, & that survivors may be more likely to benefit 

Weber, 2002). The typical structure of sup- from formal interventions than the general 

port interventions (e.g., self-disclosure and 

sharing of feelings) may be less effective, or 

perhaps even deleterious, for people with an 

population of bereaved persons. 

instrumental and more avoidant orientation SUICIDE SPECIFIC 

to coping, which is generally more characteristic 

of males. Again, this would tend to wash 

INTERVENTIONS 

out positive effects in studies of bereavement Turning to studies of suicide specific in- 

interventions if data are not analyzed sepatervention programs, a search was conducted 

rately by gender. of the PsychLit and the Suicide Information 

Lastly, it is quite possible that the typi- and Education databases for studies related 

cal bereavement intervention is significantly to suicide bereavement and intervention/ 

below the “therapeutic dosage” level needed treatment. While numerous positive descrip- 

to produce a desirable effect. Most research tions of groups or programs for survivors ex- 

intervention protocols involve a relatively ist (Apel & Wrobleski, 1987; Freeman, 1991; 

small number of treatment sessions (usually Juhnke & Shoffner, 1999), only a handful of 

8 to 12), typically offered shortly after the empirical studies have been conducted to asloss 

and in rapid (usually weekly) succession. sess the effectiveness of these programs. Given 

In contrast, there is evidence that for some the dearth of methodologically rigorous repeople 

bereavement, particularly after trau- search, we have included in this review any 

matic loss, is a long-term adaptational pro- study that involved some type of objective 

cess, one that may even become more diffi- evaluation of the effectiveness of the intercult 

in the second and third years (Murphy, vention, regardless of the utilization of con- 

2000; Murphy, Johnson, Wu, Fan, & Lohan, trol groups or random assignment. Due to 

2003; Wortman & Silver, 2001). Longer- space limitations, the review was limited to 

term support may therefore be needed after formal interventions with adults. Furtherthese 

types of losses. Indeed, some of the remore, while interventions targeting organizaviews 

have suggested that bereavement in- tions rather than individuals or families (e.g., 

terventions might be more effective when postventions in business or hospital settings) 

offered later, rather than earlier, after the would be eligible for inclusion, we were undeath. 

This would also coincide with the able to locate any studies that included objec- 

survey data from suicide survivors indicating tive attempts to measure the impact of such 

a perceived need for longer-term support interventions. 

(Dyregrov, 2002). Farberow (1992) conducted a controlled 

Of a more hopeful nature are the find- study of 60 participants in an 8-week, semiings 

that interventions for high-risk and/or structured group support program for survihigh 

distress mourners are generally more efvors. The control group consisted of 22 perficacious. 

It appears that interventions have sons who had signed up for the program and/ 

their greatest impact on those who are either or attended one session, and then dropped 

in high-risk categories (e.g., suicide survi- out. Participants were asked to estimate the 

vors), or who are specifically seeking help be- intensity of nine different feelings (anger, grief, 

cause they show high levels of distress at the guilt, etc.) at three points: time of the death 

start of the intervention. Many of the factors (retrospectively evaluated), pre-intervention, 

that are present in most, if not all, suicides and immediately post-intervention. Results 

are also relatively well established as risk fac- indicated that the treatment group had sigtors 

for complicated bereavement. These in- nificantly higher levels of grief, shame, and


guilt at the start of the intervention than did was also included. Selection criteria were not 

controls. By the post-intervention assessment, clear from the report, but apparently partici- 

however, program participants had declined pants were selectively recruited from callers 

on ratings of eight of the nine feelings, while to a suicide prevention center; people with 

controls had declined on only one variable. severe personality disorders or pathological 

Furthermore, the intervention group had de- bereavement reactions were excluded. Selfclined 

to the level of the controls on grief, report measures of depression and anxiety 

shame, and guilt, although they had also de- prior to entering the groups and 6 weeks 

veloped higher scores on depression and puz- after its conclusion revealed a significant 

zlement scales than controls. Although lack- drop in depressive and situational (though 

ing random assignment, this study suggests not trait) anxiety symptoms. The total num- 

that a treatment program provided for selfber of participants and descriptive statistics 

selected survivors with higher initial distress on pre- and post-intervention measures were 

levels may be successful in lowering symptom not reported. Moreover, the design did not 

levels to the level of less distressed controls. involve a comparison group or random as- 

Also, participants reported high levels of satsignment to conditions. 

isfaction with the program. Constantino and her colleagues re- 

Rogers, Sheldon, Barwick, Letofsky, ported data from two studies comparing two 

and Lancee (1982) reported on pre- and types of support groups for widowed persons 

post-test evaluation data from a structured bereaved by suicide: (1) a bereavement fo- 

program for recent survivors. A trained vol- cused group designed to explicitly facilitate 

unteer met with family members for eight the grieving process; and (2) a social activi- 

sessions, with discussion focusing on specific ties group designed to improve mood, selftopics 

related to suicide bereavement. Folconfidence, and a sense of belonging (Conlowing 

these sessions, participants were in- stantino & Bricker, 1996; Constantino et al., 

vited to attend four group meetings which 2001). Both groups consisted of eight 90 

allowed for the sharing of feelings and rein- minute weekly sessions, and assessments were 

forcement of ideas presented in the family made on self-report measures of depression, 

meetings. Fifty-three participants filled out a psychological distress, grief, and social ad- 

standardized psychiatric symptom checklist justment at the start and end of the groups, 

before and after participating in the program. and at 6 and 12 months after termination. 

Results showed declines on all symptom cate- Thirty-two participants in the first study and 

gories, although the authors failed to report 47 participants in the second were randomly 

any inferential statistics on the comparisons, assigned to one of the group formats. The 

and the design did not include any compari- first study (Constantino & Bricker, 1996) found 

son group. Participants’ responses to a feed- that, contrary to expectations, both groups 

back questionnaire indicated that the three produced significant reductions in depression 

most successfully met program goals were and measures of psychological distress. Re- 

helping participants to put the suicide in per- sults of the follow-up second study employed 

spective, to express feelings without feeling a larger sample size and paralleled the find- 

judged, and to discuss the suicide. As with the ings from the first study (Constantino et al., 

Farberow study, participants reported high 2001). The authors concluded that both the 

levels of satisfaction with the program. bereavement and the social support formats 

Renaud (1995) reported on a 10-session showed promise, and speculated that any 

support group for survivors which combined group format that allows survivors to interact 

mutual support, focused discussion of various with other survivors in a professionally led 

suicide-related themes, and an out-of-session group may be of benefit. The authors do ac- 

homework assignment. A follow-up session 5 knowledge, however, that the lack of any true 

weeks after completion of the initial sessions “no-treatment” control group makes it diffi-


cult to draw conclusions about the superior- each 2-hour session into a problem-focused 

ity of group interventions over non-interven- psychoeducational and skill building compotion. 

nent, followed by an emotion-focused sup- 

Building on the writing intervention portive discussion. The problem-focused comdeveloped 

by Pennebaker (see Pennebaker, ponent was designed to provide information 

Zech, & Rime, 2001 for a recent summary), and skills to reduce negative consequences of 

Kovac and Range (2000) reported on a prom- bereavement after violent death. The emotion- 

ising intervention that asked undergraduate focused component was structured to offer 

student suicide survivors to write about the emotional sharing and support among mem- 

suicide of a loved one. Forty subjects were bers, as well as cognitive reframing of aspects 

randomly assigned to write either about their of the loss experience. Outcome measures assuicide 

loss or about a neutral subject four sessed parents’ levels of mental distress, post- 

times over a 2-week period. Participants were traumatic reactions, loss accommodation (grief 

given self-report measures of suicide specific response), physical health, and marital role 

and general grief reactions, trauma symp- strain. Assessments were made prior to be- 

toms, and indicators of health care utilization ginning the intervention, at the conclusion, 

on three occasions: immediately before and and 6 months post intervention. 

after the intervention, and 6 weeks post in- Based on previous indications that men 

tervention. Results indicated significant de- and women may respond differentially to be- 

creases in suicide specific grief, although not reavement support interventions, data was 

in general grief, trauma symptoms, or health analyzed separately for fathers and mothers. 

care utilization among the treatment group. In general, the intervention did not prove to 

The authors concluded that writing interven- be superior to the control situation in reduc- 

tions might be particularly suited for being symptoms associated with the loss. Of 

reavement after suicide, noting that many importance, however, was a significant inter- 

participants in the intervention group made action between gender and initial distress 

spontaneous comments that participation had level in the treatment group. When partici- 

allowed them to better understand why the pants were grouped by initial level of distress, 

death had occurred and to begin talking to bereaved mothers with initially high levels of 

others about the death. The authors also sug- emotional distress and grief symptoms had 

gested that, based on a previous meta-analy- lower levels of these symptoms at the conclu- 

sis of similar interventions, this approach sion of the intervention in comparison to 

may be particularly helpful for males, who control group mothers. Furthermore, particiare 

less likely to disclose traumatic experipation in the intervention appeared to inences 

to others (Smyth, 1998). crease the PTSD symptoms of fathers in the 

In one of the most methodologically treatment group. As with most other prorigorous 

studies to date, Murphy and her col- gram descriptions, participants generally in- 

leagues reported on the efficacy of a 10-week dicated great satisfaction with the program. 

support group intervention for 261 bereaved In addition to the clinical trial of this 

parents (Murphy, 2000; Murphy et al., 1998). intervention, Murphy (2000) has reported 

Parents who had experienced the sudden data from a longitudinal follow-up at 2 and 5 

death of a child (aged 12 to 28) by suicide, years that combined the treatment and con- 

homicide, or accidental death within the 7 trol groups. The sample continued to show 

months prior to recruitment were identified greatly elevated levels of mental distress, 

through death records and invited into the trauma symptoms, and health problems at 2 

study. All parents were randomly assigned to and 5 years, although there was a steady de- 

either a treatment or a nontreatment control cline in symptoms over the course of the 

condition. The intervention consisted of a study. Murphy also noted that parents who 

theory-based group program which divided engaged in certain health protective behav-


iors (e.g., exercise) showed better outcomes. changes in parents’ depression after partici- 

Gender differences were also observed, with pation. The comparison group consisted of 

mothers generally showing improvement in families contacted but assigned to the no- 

health and functioning, and fathers showing treatment condition. The results showed 

deterioration in PTSD symptoms and health significant decreases for children in the treatover 

the 5-year period. Importantly, Murphy ment group in depression and anxiety symp- 

also noted that participants reported that toms, although not in trauma or social ad- 

their greatest period of accommodation to justment scores. Unfortunately, there were 

the loss occurred in the third and fourth no significant changes in parent’s depression 

years after the death and not in the first year, scores, a result that the authors attribute to 

as is commonly assumed. the fact that the intervention was designed to 

Mitchell and Kim (2003) have recently educate parents about bereavement in chilreported 

on a debriefing intervention modi- dren, rather than directly affect parents’ own 

fied for early intervention with suicide survivors. 

In this study, 60 recently bereaved (one 

month or less) suicide survivors were ran- 

grief responses. 

domly assigned to either a single session de- RECOMMENDATIONS 

briefing group or to a treatment as usual 

group. Participants filled out measures of 

AND CONCLUSIONS 

perceived stress, complicated grief, depres- At this point, we can return to the 

sion, PTSD, general psychiatric symptoms, original goals of the article. These included 

and general quality of life at 4 and 12 weeks reviewing the current status of knowledge 

after the intervention. The treatment group about interventions for suicide survivors, and 

was found to be less distressed prior to the developing recommendations for future reintervention 

than the controls, and this was search on this topic. The literature on gen- 

found to be related to the closeness of the eral bereavement interventions suggests that 

kinship relationship to the deceased (controls many services may be of dubious value, at 

had closer kinship connections than treat- least as delivered in the research studies. 

ment group), and controlled by using change However, there is evidence that interventions 

scores rather than direct comparisons be- for high-risk populations, such as suicide sur- 

tween groups. There was also significant atvivors, may be more effective. The literature 

trition in follow-up participation, so that the also indicates that the design of interventions 

final results were based on an n of 27. Results may need to take into account gender differ- 

showed trends toward greater improvement ences, with men responding differently and/ 

in grief and perceived stress for the treatment or less positively than women to typical in- 

group at 4 weeks. Likewise, at 3 months the terventions. Lastly, bereavement studies sugtreatment 

group showed greater improvegest that many of the interventions are simment 

on general mental health and a trend ply of insufficient strength and duration to 

toward less perceived stress. Despite the make a measurable impact. This may be par- 

methodological issues, the results suggest a ticularly true for traumatic losses such as suimodest 

potential for a positive effect for an cide, where clinical experience and the self- 

early, CISM type intervention for survivors. reported needs of survivors strongly suggest 

Finally, Pfeffer et al. (2002) reported that brief interventions delivered early in the 

on a well-designed support group interven- mourning trajectory may be insufficient to 

tion for children who had experienced the address the magnitude of disruption engen- 

suicide of a parent or sibling. Although it was dered by a suicide (Murphy et al., 2003). For 

primarily an intervention with bereaved chil- a more extensive discussion of these concludren, 

the research is noted here because the sions, please see the recent review by Jordan 

intervention included a psychoeducational in- and Neimeyer (2003). 

tervention for parents which was assessed by The studies that have empirically eval-


uated interventions specifically designed for surround the survivor. Other areas that may 

survivors are somewhat more promising, and show differences in the bereavement expe- 

also have similar implications for future re- rience include the impact of suicide on the 

search and clinical intervention. Most of the assumptive world of survivors and possible 

studies found at least some effect for the in- long-term “sleeper” effects, particularly for 

tervention and also report high levels of children who lose parents to suicide. 

participant satisfaction with the services. Un- There is also a lack of consensus about 

fortunately, the methodological rigor of the whether there is a universal pattern of re- 

studies has generally been weak, with many sponse among suicide survivors, or alternaresearchers 

failing to utilize random assigntively, a diversity of responses that are influment 

and appropriate comparison groups. enced by variables over and above the loss. 

Moreover, the studies that have employed This suggests the need for continuing rethe 

most careful research designs (Kovac & search into which factors tend to produce 

Range, 2000; Murphy et al., 1998; Pfeffer et which types of responses for which groups of 

al., 2002) also tended to find the least confir- survivors (Farberow, 2001). In addition, very 

mation that the interventions were success- little is known about the coping strategies 

ful. Hence, while there is anecdotal evidence that survivors develop on their own, and only 

and a general clinical impression that services slightly more about what types of formal and 

are helpful, we must conclude that the effi- informal assistance survivors receive from 

cacy of formal interventions for survivors has professional caregivers, family, friends, and 

yet to be scientifically established. The state others in their social network. Careful longiof 

our knowledge about how, when, and with tudinal research with a diverse, community- 

whom to intervene after a suicide is still quite based sample of survivors would greatly in- 

primitive, suggesting a pressing need for furcrease our understanding of the challenges 

ther research that addresses several key is- involved and the coping skills required after 

sues. We turn to this topic in the final section a suicide. It would also provide much needed 

of this article. information about the large number of survivors 

(quite likely the majority) who never 

Recommendations for Future Research attend organized support groups or receive 

professional assistance. Such research would 

The first need is for better information allow us to generate creative strategies for inabout 

the “natural” course of bereavement tervention that build on the natural coping 

after suicide. We have not yet definitively an- efforts that different types of survivors typiswered 

the question as to what, if any, differ- cally make and the support resources they 

ences exist between suicide bereavement and utilize. Differences in coping strategies based 

other types of losses (Clark, 2001). Mc- on gender, personality, and cultural differ- 

Intosh’s (1999) summary of the literature ences need to be studied and incorporated 

concluded that most suicide bereavement is into treatment planning. To summarize, it 

nonpathological, suggesting that whatever seems likely to us that the “one size fits all” 

differences exist between bereavement after approach to understanding and intervening 

suicide and other types of losses appear to with survivors which has been dominant 

disappear after the first 2 years. Jordan (2001) since the inception of modern suicidology 

has also reviewed this literature and reached needs considerable refinement (Ellenbogen 

a more complex conclusion, suggesting that & Gratton, 2001). 

while quantitative evidence for differences in Second, we need methodologically sound 

outcome has received only mixed support, studies of the efficacy and effectiveness of 

there appear to be important distinctions in formal interventions for survivors. Given the 

the thematic content of the grief experience present state of knowledge, we believe that it 

for many survivors, in addition to differences is generally premature to study comparative 

in social support and family processes that treatment interventions at this time. Since


most of the services reported in the literature types of interventions. The quality of re- 

seem to involve some variation of the basic search methodology in intervention outcome 

bereavement support group, we believe that studies to date has generally been very poor, 

the first “wave” of research on interventions posing a major threat to the internal validity 

should involve naturalistic studies of the ef- of the studies and hence their usefulness for 

fectiveness of existing groups. This could in- drawing sound conclusions about the interclude 

data gathering about the perceived ventions. Future controlled studies in this 

needs, coping tactics, and sources of support second wave of studies should employ ran- 

employed by the participants. This type of dom assignment to treatment conditions and 

field research could evaluate the elements appropriate comparison groups, which could 

that appear to be common in most bereave- include both waiting list controls of survivors 

ment support groups. These include mutual, who have sought formal assistance along with 

nonjudgmental emotional support in a set- “community standard” controls who do not 

ting where survivors can tell their stories and seek treatment. The latter is particularly im- 

receive advice about coping from others with portant in bereavement outcome studies, since 

similar experiences. Comparison groups might no-treatment comparison groups are neces- 

be constructed of a community sample of sary to control for the natural tendency of 

matched controls that do not participate in bereavement related symptoms to remit over 

such groups. Such research should include time, with or without formal intervention. 

both quantitative and qualitative methods for Moreover, explicit delineation of the 

participants to describe their own under- treatment protocols involved, the theoretical 

standing of what aspects of the group experi- basis for the intervention, and evidence of 

ence are most helpful. Qualitative measures adherence to the treatment are also required 

of outcome that extend assessment beyond for methodologically sound investigations 

psychiatric symptoms to broader constructs and for the effective dissemination of treat- 

such as changes in the individual’s assumptive ment approaches to practitioners. Most early 

world, quality of life, and social adaptation studies are quite vague as to the actual proce- 

might also reveal a different type of intervendures employed in the intervention, although 

tion success. Furthermore, with a sufficient more recent studies have been based on man- 

sample size, the research could provide inforualized protocols (Murphy et al., 1998). These 

mation that may account for differences in second wave studies should focus on investi- 

outcome for different types of survivors, such gating interventions for specific groups of 

as timing of entry and duration of participa- survivors. For example, the general bereavetion, 

group format (e.g., time limited vs. onment intervention literature indicates that ingoing; 

structured vs. unstructured; psychoed- dividuals who are in high risk categories (e.g., 

ucational vs. expressive), and the background bereaved parents) and/or who already show 

and training of the leader (e.g., survivor vs. high distress levels (e.g., symptoms of clinical 

nonsurvivor, professional vs. nonprofessional) depression or PTSD) are the most likely to 

(see also Farberow, 2001). This more natural- benefit from professional intervention ( Joristic, 

effectiveness-oriented research on exdan & Neimeyer, 2003). Thus, “generic” suiisting 

groups could then lay the foundation cide survivor support groups may work well 

for a second wave of more controlled studies for many survivors, while specialized groups 

of specific intervention techniques for spe- (or other treatment modalities) for high-risk 

cific types of survivors. 

survivors may be preferable and more effica- 

With sufficient knowledge of the range cious at preventing future dysfunction, in- 

of the coping responses made by survivors, cluding future suicide. 

and of the factors that appear to enhance the These targeted interventions could in- 

effectiveness of existing interventions, we beclude approaches that have shown at least 

lieve that the field will then be in a position some promise in previous studies, such as 

to rigorously study the efficacy of particular 

writing interventions (Kovac & Range, 2000),


psychoeducational and skills building pro- entifically based knowledge about how to as- 

grams (Murphy et al., 1998), and combisist survivors is far behind our ability to 

nations of informal “survivor-to-survivor” intervene with other at-risk populations (e.g., 

support and more structured group interven- trauma victims) or with many forms of psytions. 

Additional techniques that have been chiatric disorder (e.g., depression or anxiety 

shown to be of help in other types of trau- disorders). Although there are encouraging 

matic losses should be explored for possible signs that this is changing, it is our impres- 

adaptation for interventions with survivors sion that survivors have been a low priority 

(Doka, 1996; Figley, 1997, 1999). These in- for researchers and clinicians in suicidology, 

clude therapeutic modalities such as Eye whose main interest has focused on preventa- 

Movement Desensitization and Reprocessing tive work with suicidal individuals. It is our 

(EMDR; Solomon & Shapiro, 1997) and Trau- strong conviction, however, that “postvenmatic 

Incident Reduction (Descilo, 1999), tion is prevention” (Shneidman, 1981), and 

cognitive-behavioral therapies (Fleming & that work with survivors is an obvious and 

Robinson, 2001), family techniques (Horo- efficient way to contribute to the prevention 

witz, 1997), and narrative approaches (Ry- of future distress, psychiatric disorder, and 

nearson, 2001). even suicide itself. We hope that this review 

Conclusions 

will contribute to the growing interest within 

suicidology in studying and assisting suicide 

There is much work to be done (Far- survivors as they seek healing after this very 

berow, 2001; Clark, 201). Currently, our sci- difficult type of loss. 

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Revision Accepted: December 28, 2003

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