Interventions for Suicide Survivors: A Review of the Literature

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342 Interventions for Suicide Survivors 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-

Jordan and McMenamy 343 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 reductions 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-

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