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Suicide and Life-Threatening Behavior 35(6) December 2005 2005 The American Association of Suicidology
Siblings After Suicide— “The Forgotten Bereaved” Kari Dyregrov, PhD, and Atle Dyregrov, PhD
There is scarce research on “the forgotten bereaved”—the children and adolescents who lose a sibling by suicide. In this paper we explore their psychosocial situation and needs for assistance through a Norwegian nationwide study. The results show that particularly younger bereaved siblings are suffering from posttraumatic and grief reactions, depression, and anxiety. Most of the difficulties are not individual, but rather relational and social in nature, and largely contextually dependent. Necessary help is impeded due to the extraordinary experience leaving the siblings outside the circle of friends and parental grief community. A systematic outreach help program is presented.
In 1972 Shneidman stated “The person who commits suicide puts his psychological skeleton in the survivor’s emotional closet.” This refers to the fact that after every suicide many people are left behind in deep grief and with after-effects that may last for years; this includes the siblings of the deceased. McIntosh and Wrobleski (1988) described the suicide’s bereaved siblings as the “forgotten mourners” and they reported that there was limited research available on these children and adolescents. There is still little research in the field. An international literature review (last 30 years) only uncovered eight empirical research studies focusing on the situation of children and adolescents after the suicide of a sibling. The focus of this paper is on adolescents who have lost a brother or a sister by suicide, and is based on a nationwide research project in Norway from 1997–2000. The Kari Dyregrov and Atle Dyregrov are with the Center for Crisis Psychology in Bergen, Norway. Address correspondence to Kari Dyregrov, Sociologist, PhD/postdoctoral fellow, Center for Crisis Psychology, Fabrikkgaten 5, 5059 Bergen, Norway; E-mail:
[email protected]
purpose is first and foremost to present adolescents’ subjective experiences of the traumatic impact of the suicide of a brother or sister. Help and support for the siblings, and how the situation for bereaved siblings can be improved, are also discussed. Due to length limitations, adolescent coping strategies are not discussed. Before the method and results are presented, some relevant statistics and theory are provided. SIBLINGS BEREAVED BY SUICIDE
The number of siblings bereaved by suicide in Norway is unknown, but it is suspected to be a large number. As in most Western countries, the suicide statistics in Norway increased gradually during the 1970s and 1980s. There then was a gradual reduction from 1988 until 1995, when the suicide rate stabilized, until the latest statistics of 2002 when it dropped slightly. The most recent statistics show that the number of suicides per 100,000 inhabitants is 16.1 for men and 5.8 for women in 2002 (Statistics Norway, 2004). The statistics also indicate that the clear increase in suicides of 15 to 24 year olds from 1995–2001, has stabilized. Over
Dyregrov and Dyregrov the years the ratio has continued to be about three times higher for men compared to women. Theoretical Framing In one of the few studies in the field, Brent and colleagues (1993) documented that 25 adolescents experienced significantly higher levels of depression, anxiety, and posttraumatic stress symptoms 6 months after a suicide of a sibling than a matched control group. The symptoms were: lack of energy, sleep problems, appetite and weight problems, increased psychomotor activity, guilt, social withdrawal, concentration problems, and suicidal ideation. They also documented that severe depression was seven times as frequent among bereaved siblings compared with adolescents of the same age. However, the researchers found few differences between the groups after 5 years, and depression among the adolescents was strongly correlated with previous psychiatric history and psychiatric history or depression of other close family members (Brent et al., 1993). In the follow-up study of Pfeffer and colleagues (1997), 22 children in 16 families were assessed. The children had recently lost their parents (12) or their siblings (4) by suicide. The researchers concluded that children bereaved by suicide had significantly greater risks for specific forms of psychosocial dysfunction than children who had experienced other types of deaths, and posttraumatic symptoms were only observed in the children who had experienced death by suicide. Nearly half (40%) of the children’s scores were above the cut-off score for posttraumatic stress disorder (PTSD) as measured by the Child Posttraumatic Stress Reaction Index (CPTSRI). The reported symptoms were: invading memories and thoughts, concentration problems, and greater restlessness and psychomotor activity. In comparison, Sethi and Bhargava (2003) found that 21% of children and adolescents who had lost siblings or parents by suicide fulfilled the criteria for PTSD, as measured by CPTSRI, on average at 91⁄2 months after the loss. As an
715 important observation, the researchers highlighted that all three children who had found the dead person had developed PTSD and severe depression. Both Brent, Moritz, Bridge, Perper, and Canobbio (1996) and Pfeffer and coworkers (1997) found that suicidal ideation was evident in 31% of bereaved families compared with 0% in control groups, and that it was more frequent among siblings who were depressed than those who were not. Despite this, they did not find an increase in suicidal behavior among siblings who had lost a brother or a sister. In Rakic’s (1992) comprehensive qualitative dissertation study, five years following the deaths, he conducted in-depth interviews with adolescents who had lost their siblings due to suicide and illness and compared their difficulties. They reported that feelings of shock and numbness were followed by feelings of anger, vulnerability, sadness, loneliness, and depression. The conclusion was that siblings after suicide are affected more deeply and longer by the death, and experience more intense and confused feelings due to the self inflicted nature of the loss. They also experienced prolonged grief to a greater extent than adolescents who lost siblings because of illness. Importantly, Rakic suggested that many of the difficulties are not individual, but rather relational and social in nature, and largely contextually dependent. Factors of Importance for the Impact of Suicide Davies (1995) indicated the following factors as important circumstances for an adolescent’s grief process after suicide: (1) individual characteristics such as age and sex; and (2) situational circumstances such as type of death, whether sudden or not, the place it happened, and time since the death. (3) Moreover, Davies stressed that factors such as the phase of the adolescent’s development and the resources available to them will have a strong impact on how the suicide is experienced and handled. (4) Also, the adolescent’s daily context will be crucial for how the grieving process is experienced. This includes
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parent resources; life circumstances; communication between parents and children; previous traumatic events in the family; support within the family; and how adolescents are initially supported by their peers, school, and other social networks.
METHOD
Procedure The sibling study was part of “The Support and Care study” (Dyregrov, 2002, 2003, 2003–2004; Dyregrov, Nordanger, & Dyregrov, 2003) which studied parents and siblings after the sudden death of an offspring by suicide (deceased under 30 years old), SIDS (under 2 years old), or accident (under 18 years old). The subjects for the study comprised 232 parents and 90 siblings from 140 families. All the deaths occurred between July 1, 1997 and December 31, 1998. After a thorough process of application, The Ministry of Law and Justice in Norway gave access to the national police register (Strasak) of families bereaved by suicide, SIDS, and child accident. The Attorney General, The Council for Professional Secrecy and Research, the Medical Ethical Research Committee, and the Data Inspectorate of Norway also gave permission for the study. The 11⁄2 year cohort of bereaved families after suicide (162), and SIDS/child accidents (132)1 were contacted by letter in April 1999. Both parents and siblings were thoroughly informed about the purpose of the project, and were at the same time offered telephone contact with the researcher. Based on thorough information about anonymity and confidentiality, both groups gave informed and written consent. Fifty-three percent of the families chose to participate in the study (50% of the suicidally bereaved). Due to confidentiality, the Attorney General did not permit inquires
1. The police register did not differentiate clearly between SIDS/accidents.
about nonresponders beyond the information of the gender, age, mode of death, and place of residence of the deceased already provided in the register. There were no statistically significant group differences between participants and nonparticipants concerning these demographic variables. Participating family members (age > 15) were asked to fill in questionnaires and were requested to participate in an interview study later. The collection of questionnaires ended in August 1999, while the interviews were conducted during the autumn of 1999. The interviews, conducted in the homes of the bereaved, lasted 2.5 hours on the average per person (range = 1.5–4 hours). Samples Data in the present study were collected from 83 families, consisting of 128 parents and 70 siblings (>15 y.) who lost a child/sibling (35 for nonclinical populations was used to define a risk zone. The 15-item test comprises two subscales: intrusion (7 items) and avoidance behavior (8 items). Intrusion is characterized by unbidden thoughts, images, dreams into consciousness, and strong emotional reactions. Avoidance involves denial of the event and its consequences, and the blunting or numbness of emotions and sensations. Possible scores can range from 0 to 35 on the Intrusion subscale, and 0 to 40 on the Avoidance subscale (Horowitz et al., 1979). The Cronbach’s alpha for the total scale was .85; it was .82 for the Intrusion subscale, and .77 for the Avoidance subscale. Assistance Questionnaire. The Assistance Questionnaire was a questionnaire developed for the study by the author and coworkers (229 variables). The siblings were asked about what types of help they received from professional groups, the frequency and timing of assistance, the process of contact-establishment, the duration of the contact, the possi-
717 bility of support group participation, and their level of satisfaction with and suggestions for improvement of professional assistance. Moreover, the questionnaire contained questions about their experience with their own social support network (family, friends, school mates/ working colleagues, neighbors, etc.); including questions about the type of support offered, the level of satisfaction, any lack of support, and their experience with various means of self-help. The questions were ranked according to degree (to a large degree, to some degree, not at all), or “yes” or “no,” and four questions were open-ended. The questionnaire also registered background information about the bereaved: age, gender, marital status, relation to the deceased, education, employment status/situation, place of residence, length of residence there, and siblings left at home, as well as their subjective opinion regarding the mode of death. Four of the adolescents and five of the older siblings were interviewed in-depth. For the interviews a theme guide based on four areas was used as a starting point for encouraging the survivors’ narrative activity. The interviews were aimed at illuminating the siblings’ experiences of the death, as well as qualitative dimensions of the support, ideal support, and self-help strategies. Results are presented from both sources of the sibling data.
RESULTS
Parents’ Situation—An Important Context for Siblings As contexts for the siblings, the situation of the parents is briefly summarized. A year and a half after the death, most of the 128 parents bereaved by suicide reported serious physical, social, and psychological problems. Sixty-two percent had scores of high levels of psychosocial distress as mapped by the General Health Questionnaire (GHQ), reflected by somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression that might lead to long-term im-
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pairment of quality of life. Fifty-two percent suffered from high levels of posttraumatic distress as measured by the Impact of Event Scale (IES) (Table 1), experiencing unwanted thoughts and images (intrusion reactions), as well as denial of the suicide and its consequences (avoidance reactions). Finally, 78% of the parents scored highly for complicated grief reactions as mapped by the Inventory of Complicated Grief (ICG), indicating preoccupation with thoughts of their child, searching and yearning for the child, experiencing disbelief about the death, and difficulties in accepting the death. Additionally, there was a profound tendency among the parents to withdraw and isolate themselves from others, which seemed to be linked to loss of energy and feelings of guilt and self-blame (Dyregrov et al., 2003). Posttraumatic Psychological Distress of Siblings The siblings described the unexpectedness of the suicide as being “hit by lightning from a clear sky.” Even though for some there had been warning signs or even previous suicide attempts, all siblings had been totally unprepared for the fact that their sisters or brothers actually could end their own lives. The siblings described shock, disbelief, and confusion as immediate reactions after the suicide. Thereafter they told about feel-
ings of grief, anxiety, depression, and various “strange and scaring” reactions unknown from previous experiences. Many of these reactions may be classified as posttraumatic stress reactions (Yule, 1999). A teenager, who found her brother hanged, described such reactions in an interview seventeen months after the death: In the beginning, the first six months, maybe the whole year, I had difficulty with the sight of where I found him. But in the end it became a picture I was familiar with. It didn’t hurt anymore, it became an unimportant picture. But, through nightmares, I sort of found him in different ways. I found him wherever I went. I dreamt that he returned and killed himself right in front of me. I am terrified of entering his apartment, and I still don’t do it. But I am dreaming that I am going in. It is terrible to think how cold he was, and how hard he was. I can feel it in my bones.—Just now, my brother has been put to the side. Maybe I have suppressed it . . . . I don’t really feel anything. I didn’t feel anything in the beginning. Then I had a period where I could cry, but I can’t do that now, not even when I have been drinking. It’s sort of closed off. It comes to a point when it’s enough. I have a need to close off. And then it may come in different ways, for example, physically. I have
TABLE 1
Posttraumatic Stress Reactions of Parents and Siblings Living Outside/Inside the Parental Home After Suicide Siblings living outside home (n = 59)
Parents (n = 128)
Measure of posttraumatic reactions
M
SD
Risk %
M
IES-15 IES-Avoidance IES-Intrusion
36 14 22
14
52
31 14 17
SD
Siblings living at home (n = 11)
Risk %
M
39
39 20 19
Risk (%) = percentage above the risk-zone. Risk-zone IES-15 = >35. M = Mean scores SD = Standard deviations
SD
Risk % 73
Dyregrov and Dyregrov been sick a lot, especially the last six months. So that’s the way it has manifested itself, but . . . As is clearly pictured, the girl was troubled by a lot of invading and intruding memories, sensations, and impressions. Also, she reports symptoms of heightened arousal, necessitating avoidant strategies to escape from the painful reality. As she points out, the cost of the latter was increased physical illness. The siblings evidenced severe reactions on the standardized measures of posttraumatic psychological distress (Table 1). A striking feature was that siblings living at home with their parents had higher total scores (M = 39) than their parents (M = 36), while older siblings living on their own experienced significantly less posttraumatic distress than the former groups (M = 31). As many as 73% of the younger siblings, and 39% of older siblings, were above the cut-off point denoting severe/“a high level” posttraumatic reaction, as measured by the Impact of Events Scale (see also Dyregrov & Dyregrov, 2005). The subscales of the IES showed that whereas parents were most troubled by invading memories and pictures related to the suicide, younger siblings scored the highest on event-related avoidance (Table 1). The interviews also proved that the traumatic loss challenged the siblings’ assumptions about their existence in the world, and made great demands on their capacity to confront and handle what had happened, cognitively as well as emotionally. Moreover, most of the siblings reported that lack of energy, and sleeping and concentration problems, periodically led to social withdrawal. Hidden Feelings and Experiences Many siblings maintained that when their brother or sister had died, suicidal thoughts had been actualized by the death, and they reported feelings of stigmatization, blame and guilt, and a strong experience of rejection. During the interviews the siblings who lived at home expressed to a larger degree than the older siblings that they were
719 angry at their loved one for choosing suicide as a method for ending or solving their problems. They also experienced guilt for having such feelings toward their sister or brother. Feelings of guilt also arose when the siblings thought that they had knowledge or information which could have prevented the death. Approximately one third of the younger siblings said that they had been aware of the suicide attempts and suicidal ideation of their sibling. They had even kept secret serious triggers for suicide from their parents which burdened them with guilt feelings. This, they felt, was a heavy burden to bear on top of their sadness and longing. In three different homes this became very obvious to the main author, who, after first having interviewed parents who continuously asked the question of why? the suicide happened, listened to the adolescent’s detailed version of a world completely unknown to the parents. We Are Only Siblings . . . We are only siblings. I think that is how we feel, because our parents are really suffering. I understand their dreadful situation, because they have lost their child. But I have lost my brother . . . This painful expression from one of the siblings shows that even if they can understand that the parents are suffering and therefore do not have the capacity to provide them with the support they require, it still does not take away the sibling’s need for support and help. In general, because parents had more than enough to manage just taking care of themselves, siblings experienced that they were alone in their grief. The interviews indicated that siblings, who lived with their parents at the time of death, often had feelings of being lost in the chaos. Parents also confirmed that the bereaved siblings were “forgotten” in the hours and days following the suicide. It could be months before siblings felt that they could lean on their parents again for emotional support. In the initial period it was often the older siblings who supported the parents, rather than vice versa (Dyregrov & Dyregrov, 2005). Even though
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many of the siblings were of the opinion that the death affected their parents more than themselves, it was painful to experience being second in line. The eldest siblings who lived at home at the time of death stated that it would be especially important that someone outside the core family take care of bereaved siblings. Adolescents should be able to speak about their difficulties and struggles to someone who could handle their pain, and who could be there just for them “without expecting anything back.” Support from parents was complicated by the fact that many parents began to panic that something critical would happen with surviving children, which could result in exaggerated attention or protection of adolescents. On the other hand, the youngsters also worried about their grief-stricken caregivers and sought to protect them long after the suicide. A 17-year-old sibling said: “I understand that mum and dad are concerned about me. However, I am actually just as worried about them . . . often.” In order not to stir painful memories and emotions in their parent/parents, the siblings living at home often restrained themselves from mentioning the death or the dead even though this conflicted with their desire to talk. If they expressed their need for parental support, they felt guilty about making such demands. One young sibling expressed this when she said: “If I see that my mum or dad is in a good mood, I don’t want to bother them if I feel sad. I don’t want to complain and say; “Oh, I think this is terrible.” If I do, you can see that they start to think of my dead sister immediately. The opposite also happens, if I am in a good mood, and they are sad. Therefore, I usually try to avoid them.” Thus, many siblings could not rely on parental emotional care and seemed to depend on the support from other family members, friends, or public community assistance. Outside the Circle of Friends The siblings experienced empathy and support from their social network, especially before the funeral and some weeks thereafter;
however, they experienced that the quality of the friendship gradually changed over time. Siblings explained that they experienced their old friends as “childish, immature and focused on irrelevant and meaningless things.” They had themselves experienced a sudden spurt of maturity. Thus, the siblings talked about a new epoch in their lives, another scale of values, a new philosophy of life, and even a changed identity as a result of the suicide. The event had led to changes in their social roles, identity, life expectations, and daily activities. Even though the death led to increased insight and personal maturity, the changes required great energy expenditure from the adolescents because it required substantial social and relational adjustment. Another fact that caused social upheaval was that the siblings experienced that the social network did not understand that grief takes time. Whereas some friends implicitly expressed that they found listening to the conversation around the suicide taxing, and as a result withdrew from the bereaved; siblings, on the other hand, withdrew from those with least empathy for their situation. Insufficient Professional Assistance The parents in the study reported that only 40% of the children had received community assistance after the death (Table 2). Also, the extent of the reported help was very limited, and they complained about having to ask for the help during a time when they had no energy or initiative. Two out of three parents would have liked more/or different kinds TABLE 2
Community Assistance to Younger Siblings as Reported by Parents (N = 128) Assistance Offered or Missed
%
Parents receiving help for siblings Parents missing more help for siblings Siblings taken into parental help Siblings helped longer than 3 months Siblings helped by a psychologist Parents missing help from psychologists
40 65 56 6 13 45
Dyregrov and Dyregrov of help for the younger siblings. Short-term assistance was mostly provided and only 6% of the children were given individual help for more than 3 months. In addition, almost half the children received help as a part of the help extended to the parents, often because the parents were given advice regarding their children. Although almost half of the parents reported lacking psychological assistance for their children, only 13% were in contact with a psychologist (Table 2). This was the type of help that was most reported as lacking (Dyregrov & Dyregrov, 2005). Although the younger siblings were more reluctant than the parents to ask for specific professional help, a representative sibling stated: “Of course everybody that experiences a suicide does need help. Because people are run down, help should automatically be provided. It is strange—there are rituals for those who are dead, but not routines for us who survive.”
DISCUSSION
An important finding in this study was that the younger siblings living at home experienced by far the most difficulties in the wake of the suicide; more than their older siblings as well as their parents. These results are similar to Brent and colleagues’ (1996) findings, and several reasons may account for this. The most plausible explanation is that the family “burden” of the younger siblings is greater than for the older ones, who spend less time with their parents. Age, marital status, and life circumstances may protect the older siblings as they avoid intimate exposure to their parents’ despair and to all the reminders of their dead sibling. At the same time many older siblings have their own core family and peer group available for support. Their significant others are no longer their mother and father, but their new family. In line with this, Worden, Davies, and McCown (1999) maintain that to lose a child as a result of suicide is such a great stress factor for parents that it will always lead to more difficult
721 and disturbed circumstances for the child who is still living at home (Worden et al., 1999). Calhoun, Abernathy, and Selby (1986) documented that child and adolescent development can be hampered by emotional neglect from parents due to grief and trauma reactions. Many researchers have indicated that suicide can lead to longer and more complicated grief reactions because family members do not have the capacity to share their experiences or thoughts, particularly the feelings of guilt that they are struggling with (Nelson & Frantz, 1996). Therefore, researchers highlight the importance of a shared understanding of the reality of a death, open communication about the loss, and a shared experience of the loss within a family (Calhoun et al., 1986; Dyregrov, 2001; Nelson & Frantz, 1996). The findings that siblings experience great difficulties in expressing their grief openly within the family is confirmed in Rakic’s study (1992). An important communication barrier between parents and siblings can reflect different ways of understanding the suicide. Although many of the parents, based on the background knowledge of their child, found it difficult to understand why the suicide had happened, siblings had different access to information, which enabled them to have their own theories as to why it happened. In addition, this information could not easily be shared with others following the suicide, adding to the burden. Because the question as to why the death occurred was a frequent issue for the parents, siblings had to withdraw and avoid the issue, in order not to reveal information given to them in confidence. This was information that could add to their parents’ suffering, or that could arouse guilt feelings and thoughts that they could have prevented the suicide. Another reason for the poor support and communication in the family was that many of the parents wanted to protect their children from seeing the pain and anguish that they experienced, as well as the fact that many siblings did not communicate their own pain and sorrow in order to protect their parents. In line
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with this, McFarlane (1987) documents that overprotection and dysfunctional family functioning have a great impact on the development of emotional and behavioral dysfunction among children following traumatic incidents. Nelson and Frantz (1996) point out that the extent of intimacy between parents and bereaved children is correlated with the family’s engagement, expressiveness, and togetherness following a death by suicide. The less engagement and the greater the level of conflict that adolescents experience within the family, the more distant they feel from their parents. Conclusively, open communication and closeness within a family is a process that takes time, because the parents are strongly affected by the loss of their child over an extended period of time. This implies that early assistance should be provided to bereaved parents to enable them to resume or fulfill their parental roles (Dyregrov & Dyregrov, 2005). It should, however, be expected that many parents naturally will be severely affected by the loss, and that followup resources need to be allocated to secure that bereaved siblings are seen, heard and supported by network members and professionals. More Help for Siblings The present study confirmed that siblings were only partly looked after by the family’s network and professionals because most of the attention was directed toward their parents. Despite the fact that parents often will be more seriously affected when they lose a child rather than a partner, outsiders often provide more support to siblings when they lose a parent than following the loss of a brother or a sister (Worden et al., 1999). Clinicians and researchers, who discuss the plight of bereaved children and adolescents after suicide, highlight a clear need for family-based advice and help (Brent et al., 1993, 1996; Dyregrov & Dyregrov, 2005; Nelson & Frantz, 1996; Pfeffer, Jiang, Kakuma, Hwang, & Metsch, 2002; Sethi & Bhar-
gava, 2003; Valente & Saunders, 1993). Nelson and Frantz (1996) and Dyregrov (2001) stress the need for improved family communication as an important prerequisite for helping the bereaved siblings and the family system. Also, Brent and colleagues (1993) suggest family-based interventions focusing on mainly affective problems and the grief of siblings and their parents. Davies (1998) stresses that it is crucial that bereaved siblings are provided with open and direct information about the suicide, get a chance to ask questions, and talk about and work through what has happened. Parents must be clearly directed not to hide the truth, express things unclearly or withhold information from siblings following suicide. If the information is given in a clear, slow, and careful manner, children and adolescents experience this as relief, rather than increase their distress as many parents often tend to believe. Walsh and McGoldrick (1991) document that bereaved people who get the opportunity to express their feelings in an acceptable and supported atmosphere will experience the grief process in a healthier manner than those who keep their feelings to themselves. Generally, well functioning families practice direct communication, which helps the family’s grieving and strengthens the family’s support/social network. In addition to the family, the school (including kindergarten) can play an important part in helping siblings, and cooperation between the home and school following a tragic loss can ease siblings’ distress (Dyregrov & Dyregrov, 2005). The school’s most important task is to ease the return to school, create a caring environment, provide expressive outlets if the siblings want this, and help bereaved children with the educational challenges that the loss may pose (Dyregrov, 2004). The Support and Care Study reported that many schools today have taken on the challenge and prepared plans and routines for emergency/crisis management in the school. Because, as also documented in this study, we know that the social and emotional withdrawal after a suicide may act as a barrier to accepting offers of assistance (Dyregrov 2002;
Dyregrov and Dyregrov Murray, Terry, Vance, Battistutta, & Connolly, 2000; Wertheimer, 1999), it is of paramount importance that such help is provided systematically; that is, in a pro-active and outreach manner. A Psycho-Educative Intervention Program Pfeffer and colleagues (2002) developed and evaluated a manual-based grief group intervention for children who had lost a parent or a sibling by suicide. The aim was to help the children manage their grief and reduce the risk of mental illness after suicide. The program is based on attachment theory, grief and loss theory, and cognitive management theory. The group intervention consists of 10 weekly sessions, lasting for 30 minutes. The program consists of psycho-educational and support components. The psycho-educational component focuses on children and adolescents understanding the meaning of death and its irrevocable nature, and on their acceptance and understanding of grief reactions. The adolescents develop knowledge about suicide, and reasons why people take their own lives. Children’s suicidal thoughts are acknowledged and there are opportunities for developing problemsolving and selfmanagement skills. The aim of the support component is to facilitate children’s ability to express grief, focus on positive aspects of the dead person, feel more optimistic, and manage the traumatic memories and stigmatization related to the suicide. Last but not least, the program encourages the adolescents to develop supportive interpersonal relationships. Groups for parents run parallel to the children groups. The aim of the psycho-edu-
723 cative and supportive component for parents is to help them understand children’s grief reactions, identify children’s grief, help children express their grief, discuss the suicide, and stimulate children’s emotional and social ability to function. The parents also get an opportunity to express their own grief reactions, and are provided with individual help, all of which aim to enable them to resume their parental role. Recently, more traumafocused grief treatments have been developed to help children following traumatic loss (Cohen, Mannarino, & Knudsen, 2004). CONCLUSION
In the wake of a suicide there are many individual and relational difficulties within and between family members and their outer social networks often resulting in siblings’ needs after suicide being overlooked or forgotten. Because parents who have lost their child to suicide often are devastated for a long time after the loss, and therefore have a reduced capacity for fulfilling their parental roles, surviving siblings need attention and support from resources outside the family system. Assistance to siblings needs to be provided both as direct help to siblings and parents, as well as to the family as a whole. Follow-up procedures should include both supportive and psycho-educational components to enable parents and siblings to continue their lives as individuals and as a family while at the same time being able to maintain the positive memories of the person that they have lost. In order to ensure help for all families that need it, such support should be provided by local authorities through systematic outreach assistance.
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