Of all the statistics we hear about, suicide statistics are among the bleakest. In Norway, from 2017 to 2021, 3,222 people took their own lives. More than 70% of these were men. For every suicide, there are at least six close family members who live on as the bereaved.
Thus, almost 20,000 of us have experienced a trauma of this kind within the last five years. But what kind of help are the bereaved getting, and how are they coping?
We have reviewed current international research into the bereaved left behind following suicides, focusing on studies of how this group accesses and uses health and other support services.
A suicide is experienced by the majority of the bereaved as an intense trauma.
Many risks developing a grief reaction that continues with unrelenting intensity over long periods, and which can have a marked impact on their day-to-day functioning.
Two to three times higher risk
Research shows that those close to a suicide victim are at a two to three times higher risk than others of attempting to take their own lives. Helping the bereaved can thus be regarded as a preventive measure.
And it isn’t only the health services that can play a role here. We can all pluck up the courage to ask if there is any way we can help. The bereaved will move through a variety of stages of grief, with varying needs for support. Initially, the shock may be so great that they have great difficulty telling us what kind of help they need. Later, they may find that it becomes painful, or even deeply embarrassing, to ask for help.
Intense feelings of guilt
While the world goes on as before, the bereaved can remain locked in their grief. Intense feelings of guilt, combined with the question ‘what could I have done differently to prevent what happened?’ are typical for many of those left behind.
Shame, linked to a feeling of not having done enough, as well as thoughts of what others are thinking, are also common.
In some cultures, this sense of shame among the bereaved is also linked to the realisation that by taking their own life, the deceased has committed a crime. Even in Norway, suicide was unlawful up until 1902. It is vital that the support services are aware that suicide is regarded differently in different cultures.
Many experience social stigma and a feeling of being rejected by society. Anger and frustration towards the deceased are also common aspects of the grief reaction, and these may only serve to exacerbate their sense of guilt.
Women are overrepresented not only among the interviewees in these research studies but also among those left behind after men have taken their own lives.
We need more research-based knowledge about people of other genders who become bereaved, as well as those from minority groups, children and young people.
Need for treatment
Kari Dyregrov is one of Norway’s most experienced researchers into issues relating to the bereaved following suicides. She has demonstrated that between 70% and 80% of bereaved persons in Norway say that they needed medical or psychological treatment for their grief.
Children who experience the suicide of their parents are particularly vulnerable, being subject to an increased risk of depression, poor performance at school, and suicide themselves.
Grief support groups
Several studies indicate that grief support groups and peer support initiatives may help to counteract social isolation and stigma among the bereaved. They can also offer alternative ways of normalising the grief process to those provided by the health services.
At the same time, studies point out that it is important that those who lead grief and peer support groups are well trained.
Many articles highlight the negative impacts of participation in such groups. Sharing one’s own stories and listening to other people’s can be experienced as very difficult. Groups in which just a few participants dominate over others are also not experienced as positive.
‘Pathway’ through the health system
It is important that the bereaved receive recognition of their need for help and that the options made available to them are adapted to these needs. However, we also lack knowledge of the ‘pathway’ through the health system that those left behind after suicide have to navigate.
Most research has involved investigations into the psychological treatment of complex grief reactions.
We need more information about the treatment of other mental illnesses, somatic diagnoses and outcomes in the employment market. We also lack research into the follow-up of persons going through the different stages of grief. Needs in the immediate early phases may be very different from those later on.
In Norway, only very few bereaved persons have access to tailored support services close to home. Everyone else has to rely on general health service provision, and we are having to think innovatively about how help can be provided by digital means.
For this reason, we have to boost expertise in suicide follow-up not only in primary healthcare services but also in other agencies and among the general population.
In theory, general practitioners can play a key role in monitoring the bereaved, but they are not always in the best position to offer help. Nor do all GPs feel that they have the skills or the time to attend to patients experiencing complex grief processes.
Our review of current research has shown that we have some knowledge of the need for, and experience with, the health services and other support agencies, but that we lack information about patient pathways, how the bereaved seek help, and the coordination of available services.
Nor do we know enough about the long-term outcomes of those left behind after a suicide. For example, do they experience exclusion from school and the employment market? More importantly, we know too little about how we can effectively protect the bereaved from such negative outcomes.
Individually adapted treatment
Not only the health service providers that encounter the bereaved in the immediate aftermath of suicide but also other support agencies such as grief and peer support groups, as well as online resources, must all adapt their provision to the needs of the individual. We also require adequate training for all those responsible for the provision of such services.
We achieve much simply by showing empathy and genuine understanding for the situation faced by the bereaved, and by reminding ourselves that their support needs may change over time
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