More than 38,000 people in the U.S. die by suicide every year, leaving behind thousands of bereaved survivors.
In 2003, AFSP and the National Institute of Mental Health brought together a panel of scientists and clinicians from diverse disciplinary backgrounds to participate in a workshop addressing research on survivors of suicide.
Workshop participants summarized and critically assessed existing research on suicide survivors. They also were charged with identifying research that needs to be conducted so that the population of suicide survivors can be served effectively and appropriately. Results of the workshop are being used to develop an agenda for research on survivors of suicide.
The workshop was funded by the National Institute of Health Office of Rare Diseases, and by unrestricted educational grants from Forest Laboratories Inc. and the Stephen D. Lelewer Memorial Fund. It was stimulated by input from the suicide survivors' community regarding the critical importance of conducting research on the impact of suicide on survivors, and in response to their concerns about the limited scope of research-derived knowledge about suicide survivorship. The workshop program was developed by a core work group including Dr. Herbert Hendin, Dr. Ann P. Haas and Joanne Harpel, Esq., of AFSP, Dr. Jane Pearson of NIMH, Patricia Horgas, R.N., and Dr. Janice Genevro.
As highlighted by workshop participants, the research-based conclusions that can be drawn about suicide survivorship are constrained both by the relative paucity of research in this field, and by definitional and methodological limitations that characterize much of the research that has been conducted. Presenters sought to identify themes and formulate preliminary conclusions, based on existing studies on a number of topics related to survivors of suicide. These included:
- Defining and identifying "survivors of suicide"
- The emotional impact of suicide on: individual family members, families as a whole, therapists who were treating individuals who died by suicide and different cultural, racial and ethnic groups
- The social adjustment of suicide survivors
- The risk for suicide and other negative outcomes associated with survivorship
- The role of first responders (e.g., police officers, emergency medical technicians, emergency room personnel, clergy) in working with survivors
- Interventions for suicide survivors
- Methodological and ethical issues in suicide survivor research
In addition, workshop participants identified a number of topics which researchers have not yet systematically examined, such as the impact of suicide among gay and lesbian survivors, or persons who have lost multiple family members to suicide.
The workshop presentations, taken as a whole, pointed to six areas in which significant gaps in research knowledge exist. These areas, and the key research questions that need to be answered, can be summarized as follows:
Defining and Identifying "Survivors of Suicide"
A critical question that has long challenged researchers is how many people nationwide can be defined as a "survivor of suicide." Well-designed epidemiological studies are clearly needed to determine how many survivors there are, what their characteristics are, and what they need. Although such studies are beginning to be conducted, at the heart of such research is the issue of what defines a "survivor." Some recent studies have focused on identifying persons who have known someone who has died by suicide. But is this an adequate criterion for "survivorship?" Studies are needed to determine whether the status of survivor is better defined by kinship ties, by the nature and quality of the relationship one has shared with the deceased, or by other specific characteristics. Once meaningful definitions are established, methods to determine how many survivors of suicide there are remain to be explored.
Individual Vulnerability to Distress after Suicide
Research on suicide survivors to date does not identify them as suffering greater psychiatric disability than individuals bereaved by the unexpected and violent loss of a loved one. The evidence does indicate important qualitative differences—suicide survivors are more apt to feel guilt, more likely to experience social discomfort, and more prone to struggle with understanding why it happened. Rather than attempting to characterize the bereavement process for all survivors, even all survivors of a particular category such as spouses, parents, children, siblings, or peers, future research in this area needs to address the question of what makes some people particularly vulnerable to severe and persistent distress after a loss due to suicide. Is it a function of the nature and quality of the relationship with the deceased? Do survivors who have complicated and protracted bereavement show evidence of prior mental health vulnerability? What is the role of social support and "connectedness" within one's cultural or sub-cultural groups? What is the impact of such factors as being blamed by others for the death? Studies of the factors that contribute to resilience among survivors of suicide are also needed.
Impact of Suicide on Family Functioning and Suicide Risk
Although a considerable number of studies have looked at the emotional responses of individual family members, the impact of suicide on the family as a whole has received little attention. Key questions remain about how the suicide of a family member affects family stability and functioning, and how this is related to stability and functioning prior to the suicide. What distinguishes families who experience greater closeness and connection following the suicide, and those for whom the suicide results in fragmentation and emotional distance? What is the role of cultural values and religious and work institutions in this process? A related issue is the pattern of suicide in families. It has been established that individuals who have had a suicide in their families are at greater risk for suicide than those who have not. Studies of identical twins have indicated that genetic factors are more critical than environmental influences in determining the suicidal outcome. Researchers initially thought that this was linked to an inherited vulnerability to depression. Recent evidence suggests that there are specific genetic factors that make some depressed families more at risk for suicide than others. Can favorable psychosocial influences reduce this risk? Studies combining genetic and psychosocial perspectives in explaining suicide patterns within families are especially needed.
Interventions for Survivors of Suicide
The question of how best to help survivors of suicide remains pressing. Very little research evidence exists about the impact of those efforts that have been tried. One postvention model, in which responders work with a medical examiner's office and make contact with families at the scene of the suicide, appears to shorten the time between the death and the time that survivors seek services; the impact of the intervention on survivors' post-suicide adjustment has not been studied. Likewise, little is known about the impact of other "first responders," including emergency room providers, clergy and funeral directors, on survivors' emotional responses and adjustment. Although suicide-bereavement support groups are considered to be helpful by many survivors, data about their use and effectiveness have been based on small, non-representative samples. Findings related to other interventions have been mixed, depending on the intervention modality or method, the timing of the intervention and the characteristics of the people receiving the intervention. These studies, too, have tended to utilize small, self-selected samples, and to lack appropriate control or comparison groups. Key questions in this area include what is "treatment as usual" for survivors of suicide? Who seeks treatment, how is it accessed, how often? What kinds of interventions are effective for whom, when and under what circumstances? Which interventions are best for which subgroups? How can knowledge of the special problems faced by survivors be utilized in treatment? Are there iatrogenic effects of interventions, and if so, what are they? Finally, little is known about the effects of suicide bereavement on physical health, or whether survivors need special services or interventions in this area.
Insufficient research has been conducted on suicide survivors from different cultural, racial, or ethnic backgrounds to draw conclusions regarding possible differences in responses or experiences of survivorship. The impact of cultural patterns on African American, American Indian, Alaska Native, Hispanic and Asian American survivors are particularly in need of study. Of special importance in regard to these groups is achieving a better understanding of the ways in which culture, ethnicity, socio-economic status and religious/spiritual ties interact to shape the experience of suicide survivorship. In particular, what is the impact of religious beliefs and traditions that either support survivors, or estrange them? Virtually no research has been conducted on the impact of suicide among gay and lesbian survivors, and it is unclear whether there are special problems for these groups. Other populations in need of study include families who have lost more than one member to suicide.
Cross-cutting issues in carrying out future research include both a number of methodological considerations that must be addressed: the low base rate of suicide; design challenges such as finding less biased samples; conducting randomized experimental trials of interventions with carefully defined and selected comparison groups; the development and use of valid and reliable measures of specified outcomes (e.g., severity of survivor distress, psychological closeness between the survivor and the individual who died by suicide); and the challenges involved in studying subgroups with unique issues. The use of psychological autopsy-catchment area studies in which virtually all families that lost someone to suicide are interviewed would solve the selectivity of sampling that characterizes other approaches. Combining studies aimed at learning about the suicide victim as well as the impact of the suicide on the family presents challenges but the one such study that has utilized such an approach suggests its potential.
Request For Proposals
AFSP is encouraging research proposals addressing one or more of the knowledge needs identified by the Survivors of Suicide Workshop. Applications related to survivor issues may be submitted within each of the AFSP grant categories: Distinguished Investigator Grants, Standard Research Grants, Young Investigator Grants, Postdoctoral Research Fellowships and Pilot Grants. Interested investigators are should visit the research grants section of the AFSP website for information on grant policies and application forms.