SUICIDE - SOME ANSWERS

Developing a Research Agenda for Suicide Survivors

During the past decade, there has been increasing awareness of the unmet needs of suicide survivors, and recently, an ever greater sense that there are no research data to guide any types of intervention programs that might be developed. At this time, NIMH would like to begin identifying and addressing the challenges posed by this population (or perhaps, it may be more accurate to say, populations), and we would like to obtain a broad and diverse array of ideas about the most important topics to study. We need your input with regard to: better understanding the psychosocial and biological consequences experienced by survivors, defining the factors that influence their longer term adjustments, and assessing the quantity and quality of available services specifically tailored for suicide survivors. Ultimately we seek to improve the availability and effectiveness of services to suicide survivors, and in turn, help improve their functioning.

The limited research on suicide survivors suggested until recently that there was little evidence that survivors of suicide had more difficulties than family survivors of other traumatic deaths, particularly after several years. However, newer studies are beginning to find that suicide survivors have some unique experiences and possibly different outcomes. For example, a study by Bailley, Kral & Dunham (1999) found that suicide survivors, compared to mourners of accidental, expected, and unexpected natural modes of death, had heightened feelings of responsibility and rejection, greater difficulty making sense of the death, and greater overall grief reactions. A recent reassessment of the research literature by Jordan (2001) also suggests that there remains a great need for research. There are a variety of topics that might be studied.

• Understanding the impact of social response (or lack of it) to suicide survivors (e.g., stigma or at least uncertainty as to how to provide support).

• Survivors' emotions, including guilt for not preventing the death or feeling ashamed that a family member took his or her life.

• Possible unique family interaction patterns: Family functioning/ communication deteriorates (hiding the true circumstances of the death; avoiding talking about family members); in some cases, some sense of relief where there had been ongoing mental illness, domestic violence, substance use and prior suicide attempts.

• Understanding the increased risk for suicide themselves due to biology and/or modeling by family members. When is the risk for suicidal ideation, attempted suciide, or suicide greatest? Who is most vulnerable? What characteristics (social, emotional, behavioral, psychiatric, biological) distinguish survivors who become depressed or suicidal versus those who do not? Are there risk factors for poor mental health outcomes that are specific to survivors (vs. general population)?

• Understanding the factors that promote resilience and strength in survivors.

• Understanding how the experience of survivors and the burdens they face may be different depending on the age of the suicide victim and the survivor (the place in the life course of each), and their relationship to one another (e.g., parent survivor-child victim; parent victim-child survivor, spouse victim-spouse survivor, etc.).

• Are there certain subgroups of survivors who face more or less burden, based on status as reflected by socioeconomic level, race, culture/ethnicity, religious affiliation, etc.?

• Determining what type of support services are most beneficial: Given the likely unique aspects of suicide bereavement, do suicide survivors benefit more from support by other suicide survivors, compared to support by others bereaved by any type of death? If so, what moderates or mediates this effect?

• Should support services for suicide survivors provide special treatment, such as education about suicide risk, or pay special attention to their increased risk for psychiatric disorders and suicidality? Should other family members be encouraged to attend given their risk for poor functioning?

• Should support services for suicide survivors focus on enhancing social networks? Do survivors need assistance with addressing stigma, shame, and ignorance by the community?

Another question is whether all survivors should be encouraged to attend support groups or other interventions, or whether there is something real about survivors being "ready" to receive support and engage with others. Some research in the bereavement literature suggests it is not always necessary for all bereaved individuals to go through "stages" of grief, or have to talk with others about their loss. Is there some way to better understand who can manage on their own, versus those who would benefit from outreach efforts?

Many family survivors cope by becoming active advocates for suicide prevention and/or survivor support. Is there any evidence that this activity helps their adjustment over time?

A separate area of study is "first responders" and providers and how they deal with suicide deaths and then how they deal with suicide survivors. First responders/providers include police, coroner/medical examiner, rescue personnel (firemen, emergency medical technicians), psychologists/counselors, nurses, physicians, clergy and funeral home directors. Many survivors have been further traumatized by insensitive first responders and providers. While addressing the reality of "postmortem confidentiality" research could also better document both helpful and hurtful interactions between providers and first responders and family members. It could assess first responders and providers knowledge about suicide to develop training approaches so that they could respond more appropriately to this early stage of bereavement.

These research ideas compiled from NIMH staff should be considered a starting point. We need to hear from you-- what you think additional research questions are.