Interventions for Suicide Survivors: A Review of the Literature

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340 Interventions for Suicide Survivors 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
Jordan and McMenamy 341 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
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Interventions for Suicide Survivors: A Review of the Literature

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