Interventions for Suicide Survivors: A Review of the Literature

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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
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