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Adolescent Survivors After Suicide: Australian Young

People’s Bereavement Narratives Warren Bartik1, Myfanwy Maple1, Helen Edwards2, and Michael Kiernan3

1School of Health, University of New England, Armidale, Australia 2School of Education, University of New England, Armidale, Australia

3School of Psychology, Charles Sturt University, Bathurst, Australia

Abstract. Background: While the research literature exploring suicide bereavement has expanded in recent years, this has been primarily quan- titative and has focused more on the bereavement experience of parents and siblings. The bereavement experience of young people affected through the suicide death of a friend remains under-conceptualized and not well understood. Aims: To develop an understanding of the experi- ences of young people bereaved by the suicide of a friend. Method: Ten young people participated in a pilot study with in-depth interviews to explore their suicide bereavement experiences. Narrative inquiry methodology was utilized to analyze the qualitative data. Results: The findings indicated multiple grief experiences caused by suicide. Four themes reported are meaning making, feeling guilt, risky coping behavior, and rela- ting to friends following suicide loss. Conclusions: Implications include the need for increased awareness that friends of young people who die by suicide may have significant health and well-being challenges associated with bereavement, and that friends in these circumstances may not readily present at services for assistance.

Keywords: suicide, young people, suicide survivors, bereavement

Introduction

A decade ago Australian commonwealth and state govern- ments in partnership with the nongovernment sector fund- ed a range of activities to specifically tackle the growing numbers of young people taking their own lives (Mitch- ell, 2000). During that period, suicide in the age group of 15–24 years had fallen from a peak of 19.3 per 100,000 in 1997, to 9.4 per 100,000 in 2008 (Australian Bureau of Statistics, 2010). Despite this welcome reduction in deaths, suicide continues to account for over 20% of all deaths in the 15- to 24-year-old age group, compared to 1% of deaths among people aged 25 years and over (Aus- tralian Bureau of Statistics, 2010). The suicide death of a young person is particularly disturbing (Ash, 2007) with a disproportionate representation in an age group that is expected to reflect the best and most productive years of health and quality of life.

Mental health problems are inextricably linked to su- icide (Mitchell, Kim, Prigerson, & Mortimer-Stephens, 2004). In the 15–24-year age group, mental disorders ac- count for 49% of the burden of disease (Australian Insti- tute of Health and Welfare, 2007). Recent statistics suggest that young people are experiencing increased psycholog- ical problems (Australian Bureau of Statistics, 2007), and it has been argued that the fall in youth suicide rates may

reflect “that more young people are seeking and getting help, not that fewer need help” (Eckersley, 2008, p. 13).

To date most of the focus of youth suicide prevention has been directed toward known suicide risk factors in an attempt to reduce the number of young people dying (Aus- tralian Government – Department of Health and Ageing, 2007). However, the needs of those most intimately affect- ed by the suicide death of a young person, namely, their parents, family, and friends, have been largely ignored (Maple, 2005; Grad, 2011). While remaining an under-con- ceptualized area of research, the emerging literature exam- ining the bereavement experiences following suicide adds new understanding about how suicide affects those close to the deceased. People bereaved by suicide can often ex- perience a range of psychological and social difficulties (Cvinar, 2005; McMenamy, Jordan & Mitchell, 2008) and are themselves at elevated risk of suicide (Feigelman, Jor- dan & Gorman, 2008–2009; Jordan & McIntosh, 2011). The human tragedy of suicide has far-reaching effects. It has been estimated that six people are affected by one suicide death (Shneidman, 1972), with most agreeing that this is a conservative estimate and many more are likely to be affected (Jordan & McIntosh, 2011; Wrobleski, 2002; Berman, 2011).

There is a paucity of well-designed research examining suicide bereavement (Hjelmeland & Knizek, 2010). How-

W. Bartik et al.: Adolescent Survivors After Suicide212

ever, where such studies do exist, most often the only meas- ure used to identify those affected is kinship (Andriessen, 2009), with research into the parental experience of suicide bereavement being most common (Dyregrov et al. 2011). Although exploring those most intimately involved with the deceased through their kinship ties is vital, this strat- egy ignores the complexity of broader relationships that individuals engage in, along with the ways in which per- ceived closeness to the deceased and affect of their death may be measured. Several authors have recently offered definitions of who may be identified as a survivor, ranging from identification by relationship and intimate affect (An- driessen, 2009) to intimate affect and self-identification as a survivor (Berman, 2011). The emotional states of others not related to the deceased are typically not immediately recognized as significantly affected by the death (for ex- ample, acquaintances, counselors, therapists, members of school communities, work associates). Importantly for the population under study here, peer groups are rarely identi- fied as affected by the suicide death of a friend. The value of peer group relationships is well understood (Gilchrist & Sullivan, 2006) and a death at this time can have pro- found effects on developmental factors (Forward & Garlie, 2003). Research in this area has been advocated as a prior- ity (Robinson et al., 2008).

Studies that do address suicide bereavement and young people have reported disturbing effects and out- comes for these individuals. For example, Brent and colleagues (1994) reported an increased risk of recur- rent depression and concluded that grief was a risk fac- tor for depression in nonrelated peers of suicide victims. A decade later, Melham and colleagues (2004) reported findings from a large quantitative study of friends and acquaintances of individuals who died by suicide, and they identified the occurrence of traumatic grief symp- toms was independent from depression and posttrau- matic stress disorder (PTSD). Further, traumatic grief at 6 months predicted the onset of depression and PTSD at subsequent assessment in participants. More recently, in a narrative exploration of the suicide death of a signifi- cant other (a relative or friend), Hoffman, Myburgh, and Poggenpoel (2010) cited experiences that worsened with time including guilt, self-blame, depression, suboptimal coping patterns, changed relationship dynamics, and sui- cidality.

Adolescence and young adulthood is recognized as a time of significant physical, cognitive, and psychoso- cial change (Forward & Garlie, 2003), but studies thus far lack an understanding of the young person’s lived experiences that can influence their coping and adapta- tion to life following a suicide death (Cerel, Jordan, & Duberstein, 2008). An increased understanding of the effect of suicide during these key transition periods has the potential to inform the direction and delivery of both suicide prevention activities and suicide support servic- es. The aim of this initial pilot study was to investigate the impact of bereavement for young people who lose a friend to suicide given the limited empirical research in this area, and to gain insight into, and understanding of, their grief experience.

Method

This pilot study aimed to investigate the experience of young people who had lost a friend to suicide. The overall study had both quantitative and qualitative components; however, only the qualitative findings are reported here, with quantitative findings to appear in forthcoming publi- cations. In-depth interviews were employed to gain new in- sights into the conceptualization of this event in the young people’s lives through an exploration of their experiences.

Human research ethics approval was obtained and the study was publicized in local and regional media to locate young people who were aged between 12 and 24 years when they had experienced the death of a friend by sui- cide. Participants who responded to media exposure of the study made contact with the first author and additional in- formation about the project was provided, including what participation in the study would entail. At this time, selec- tion criteria were checked (age at time of death and suicide bereaved). Upon agreement to participate, interview dates and locations were arranged at a mutually convenient time and place.

The study sample comprised ten participants (8 female and 2 male subjects) with an average age at interview of 24 years (SD = 3.43). The age of the participants when they first experienced the suicide death of a friend ranged from 16 to 24 years (M = 19.3 years, SD = 2.58); time since death ranged from 1 year to 8 years (M = 4.7 years; see Table 1).

Although participants were recruited to the study on the basis of their prior experience of a suicide death of a friend, the interview process revealed that the ten partic- ipants had collectively experienced a total of 24 suicide deaths comprising 22 friends and two family members. Only one participant had experienced a single suicide death. The participants also had experienced a total of sev- en other deaths, five of whom were friends plus a sibling in motor vehicle accidents, and one other friend who died of natural causes.

The interviews followed a structured format includ- ing: rapport building, informed consent and demograph- ics, quantitative questionnaires, and an in-depth interview, which began with the statement:

I would like to hear about your experience of losing a friend to suicide. You can tell your story in any way you feel comfort- able, perhaps begin with telling me a bit about [friend’s name inserted] death, and then your journey since the suicide.

A recursive technique was used to gain a deeper under- standing of the issues the participants identified (Min- ichiello, Aroni, Timewell, & Alexander, 1995). In this way, as important elements were presented in the research in- terview, the interviewer was able to explore these in more detail in subsequent interviews to obtain the common- alities and differences in experiences across and within the sample. All interviews were audio-recorded and later transcribed verbatim, with the participant’s name, along with any persons referred to, changed to pseudonyms to maintain anonymity. The narrative interview data were analyzed by the first author to identify themes considered

W. Bartik et al.: Adolescent Survivors After Suicide 213

to capture important aspects in relation to the research question. As the themes were identified, these were fur- ther analyzed by the research team. The narrative analysis process was a form of pattern recognition where emerg- ing themes became the categories for analysis (Fereday & Muir-Cochrane, 2006). The analysis began with close reading of the interview transcripts and repeated listening to the audio files. Subsequent readings were used to code key points, which were then grouped together as general themes. These were further refined as recurrent and co- herent themes identified from the entire data set, in line with Polkinghorne’s (1995) narrative orientation. Overall, there were three layers of analysis, as per previous nar- rative-oriented suicide bereavement research (Maple & Edwards, 2010). The first examined the causal features of the friend’s death identified by the participant. The second looked at the ways the participant made meaning of this event in their life. Finally, this information was analyzed within the social context of the participant.

Results

Four key themes are reported here that arose from the data: meaning making, feeling guilt, risky coping behaviors, and relating to friends. Each is described below, highlighted by quotes from the participants to illustrate the theme dimen- sions that developed.

Meaning Making

Meaning making was the first theme, which centered on the participant’s inability to understand the death of their friend/s. This was particularly an issue for close friends who struggled to make meaning in relation to understand- ing why their friend had not been able to confide in them prior to their death. Subsequently, this brought into ques-

tion the nature, strength, and meaning of the relationship. Chrissie, for example, admitted that while she felt she did not have to understand her friend’s decision to take his life, she continued to have trouble coming to terms with the de- cision he made. Chrissie had seen her friend earlier on the day of his death and asked herself why he did not say some- thing to her: “One of the unique things about suicide is that you never have an answer … like when they die, it’s gone.”

Chrissie highlighted the fact that most often the de- ceased person takes their reasons for acting lethally to the grave with them, leaving those connected with them to ru- minate around this choice. Jane described her frustrations that her friend chose to end his life, when she believed there were other options for him, other ways for him to act:

I think it was a bad decision … so that makes me feel really upset about his decision because he felt, well, I don’t know how he felt, but if he did feel like there was no-one he could turn to or that sort of thing, because there was.

Here Jane described a common theme in suicide bereave- ment: the inability to understand how her friend could feel there was no other option, and how this led then to her judging this decision making as poor. Such responses also contributed to the feelings of guilt that these young people expressed.

Feeling Guilt

Feeling guilt was another prominent theme in the data, which highlighted the complexity of emotions that exist- ed within these young people’s relationships. They were struggling to understand their emotions relating to the death/s, as Ella described:

I don’t know, I feel really guilty all the time in case I wasn’t the kind of friend I should have been, like I’m not quite sure what else I could have changed exactly, but I feel like I should have been there more.

Table 1. Participants

Subject code Age (interview) Gender Age (first suicide) Gender (friend) Total suicide deaths experienced

A1 19 F 18 F 1

A2 29 F 21 M 2

A3 18 F 16 M 2

A4 23 F 17 M 2

A5 24 F 18 M 2

A6 25 F 19 M 4

A7 23 F 18 M 3

A8 27 M 24 M 2

A9 26 F 23 M 2

A10 26 M 19 M 3

Average 24 years F = 80% M = 20%

19.3 years Male deaths (22) 96%

2.3 suicide deaths

Female deaths (1) 4%

W. Bartik et al.: Adolescent Survivors After Suicide214

The participants’ narratives expressed feeling guilt on a number of levels. The first was guilt about not having done more, or been more available for their friend when they were alive, as Jane explained above. Josh, too, expressed his regret:

I probably should have helped a bit more, I feel now that I regret not having rung him up or checked up on him, I heard he was going better, he was picking up again and then they found him hanging.

The second level of feeing guilt revolved around not hav- ing recognized that their friend was considering ending their life in the period immediately before the death. For Chrissie, this was extremely difficult as she had talked to her friend on the day he ended his life:

The frustration that I had seen him that afternoon and the thought that he was talking to me and less than an hour later he was just not there anymore … I wish he had talked to me cause he, he had obviously made up his mind, he had made a conscious decision that that was what he was going to do.

The third level of feeling guilt was concerned with entitle- ment to be a member of the group identified as bereaved. The participants questioned their own level of distress in comparison to others whom they deemed to be closer to the deceased, such as family. Chloe expressed the un- known boundaries of guilt feelings and relationships when a young person dies by suicide within the context of a broader friendship network:

It was really difficult for me because I was a neighbor, I knew a lot of the people he knew but I didn’t know him as well as they knew him and so it was like I felt, I can’t really describe it, I was really, really hurting but it was like I wasn’t as close to him as some people and I shouldn’t be hurting this much.

While Chloe was juggling these feelings, she was expe- riencing significant grief due to the loss. Competing with these grief feelings were those emotions around closeness to the deceased and entitlement to be part of the social grieving rituals, such as the funeral.

The final level of feeling guilt was expressed as being unsure of how openly to demonstrate what they were ex- periencing. This was described by Chrissie, as she looked to her friend’s family for guidance. She saw that they may not have been outwardly expressing their emotional state, which led her to a confused state of uncertainty about her entitlement to feel as she did:

When you are friends with someone who commits suicide, sometimes you think that you don’t deserve that kind of care or that kind of service offered to you … like I thought that if his family aren’t having counseling why should I?

These guilt feelings added to the uncertainty in knowing how to respond to their friend’s family in these circum- stances. Whereas in the past the participant may have felt at ease with their friend’s family, they were now left unsure of how to speak with them, to contact them, or the role they should play, as Mae clearly described:

I saw [friend’s mother] walk out of a shop and I pretty much ran the other way because I didn’t know how to deal with it, I

didn’t know what to say to her and looking back on that I think that’s so bad but at the time I was young, I didn’t know how to communicate … I mean do you bring it up or do you try and talk about other things, of course you can’t talk about other things because this is their whole lives at the moment.

The participants were dealing with an extremely complex onslaught of emotions and struggled to make sense of the events. They were unsure of how to act and react following the death/s.

Risky Coping Behavior

Risky coping behavior, in several forms, was identified as the third theme within this sample. Alcohol misuse, for ex- ample, was common in the immediate period of grieving between the death and the funeral. For most participants, this continued well beyond this initial grief stage, and at dangerous levels of consumption. The problematic use of alcohol was recognized by many, including Angel:

Alcohol was a bad thing … I sort of felt like I was in this vicious cycle where I would try to make myself feel better by drowning my sorrows but I wasn’t drowning them, I was bringing them all to the surface and I didn’t like that either.

Risk-taking behavior to cope with the death extended be- yond alcohol to other drugs and to risky sexual behaviors for some, as described by Mae:

Greg’s death had a really weird effect on everyone, people were doing things they shouldn’t have been doing. There was increase in drinking and we were all under age so underage drinking, and smoking, and people were having sex with peo- ple that they shouldn’t be and all that sort of stuff, just doing whatever they had to do to get through the days.

In some cases, risk-taking behavior in the form of alcohol and drugs became quite serious, leading to self-harm and suicide risk, as Jean described:

At that stage I was dabbling with drugs a bit. Once Keith died I did everything I could to not think about it, not feel anything. Just any reason I could think of to take drugs I would … I end- ed up being off my head and taking so many drugs that they weren’t even working. I would just take anything people were giving me … I was self-harming.

These behaviors, and the risk that was associated with them, were potentially life threatening. Within this sample, most had engaged in these behaviors.

Relating to Friends

Relating to friends was the last theme, which referred to the impact on current and future links with others. For some participants there was the struggle with friends and others who did not understand or know how to respond, which had an impact on them socially. There was also a longer-term impact on future friendships and their capaci- ty to maintain a sense of trust in these relationships. Angel,

W. Bartik et al.: Adolescent Survivors After Suicide 215

who had experienced the suicide death of four friends dur- ing her teenage years, voiced her frustration about other friend’s responses, but she also recognized their despair in not knowing what to do to help her: “They didn’t really know what to say … I think they sort of, not got annoyed, but it was sort of like: ‘Here we go again, I don’t know what to say again.’”

The period since the deaths occurred had provided these young people with time to reflect, as well as mature, which assisted them in making meaning of the events they had experienced. Josh described the importance of peer groups, who he perceived as being his de facto family. Over time he had become more circumspect about how friendships were developed and maintained:

At one point in time my closest friends were my family; now, however, that has changed … I mean I don’t surround myself with a lot of friends, I have a few very close friends that I spend time with.

Discussion

There are always two sides in a death – the person now deceased and those left behind to grieve (Toynbee, 1968). While suicide is usually considered a solitary act leading to a lonely death, those left behind need to rebuild their lives, trying to understand the reasons for the decision the deceased person made (Cerel et al., 2008). Previous research with people bereaved by suicide has confirmed they are at risk of a variety of psychological concerns including depression, prolonged grief, and in some cases self-harm and suicide (Mitchell et al., 2004). The narra- tives reported here explored the participants’ search for meaning in their suicide-bereavement experiences. The complexity this revealed highlighted the difficulties these young people had in incorporating the absence of their friend(s) into their lives. Some had engaged in risky be- haviors as they sought comfort within; others had been unable to maintain meaningful relationships, and contin- ued to experience complex guilt reactions. In some cases, these young people identified their own suicidal thoughts following the loss of their friend(s). The themes of feel- ing guilt and making meaning of the death replicated the findings of prior studies with other suicide-bereaved populations (Maple, Plummer, Edwards, & Minichiello, 2007; Ratnarajah & Schofield, 2008), as did risky coping behaviors for bereaved young people (Hoffmann et al., 2010).

The guilt feelings experienced by the young people in the current study were similar to the survivor guilt reported in other studies of those bereaved by suicide (Hoffmann et al., 2010; McMenamy et al., 2008) but the questioning of their entitlement to grieve compared to others they deem to be closer to the deceased, such as family members, was unique. If bereaved young people avoid or deny their grief for this reason, they may be less likely to seek support ser- vices to assist them. Not seeking support was identified in the narratives and perhaps could explain why familial

connection resulted in better resolution of grief for young siblings compared to friends (Brent et al., 1996). Given the absence of outlets for their grief, there may also be a greater likelihood that these young people will adopt other behaviors to deal with their emotional pain.

Increased alcohol consumption in the form of binge-drinking, use of other drugs, plus increased and possibly unsafe sexual activity were all raised in the par- ticipants’ narratives. While such behavior can often be considered within the realm of normal adolescent devel- opment and experimentation (Muir et al., 2009), for the young person who had experienced the suicide of a friend, these behaviors appeared to become more extreme and potentially harder to control even by their own standards. The results also suggest these risky coping behaviors could continue for a period of years, meaning that these young people were potentially at increased risk for poor health outcomes over a considerably longer period of time as a consequence.

Meaning making in the field of suicide bereavement has been reported consistently, especially in relation to the need to understand “why” (see, for example, Jordan & McIntosh, 2011). The difficulty in making meaning of the suicide death arose out of questioning why their friend had not spoken to or confided in them. While there have been some reports of suicide being somewhat expected in families (e.g., Maple et al., 2007), those who were close were not expecting it to occur. In the context of the sample of multiple bereaved young people, issues with predicta- bility and security of relationships are raised. Normal de- velopment in this transitional period is characterized by consistent and dependable relationships with significant others. Social networks are critical to engagement and growth. The data indicated that these friends became more isolated, reduced their circle of close friends, and general- ly became more circumspect in relationships. This could be interpreted as fear of the risk of investing too much into good friendships because their experience was that friends die. This experience of death and tragedy could result in the same fear of abandonment as expressed by child survivors of parental suicide (Ratnarajah & Scho- field, 2008).

Limitations

This study was a pilot and comprised a small number of participants whose experience may not be totally repre- sentative of this age group. Additionally, five of the par- ticipants had experienced the same initial suicide death. These five young people had then experienced another 14 unrelated suicide deaths and four other deaths, including one sibling. High exposure to traumatic bereavement may be unique to this group of young people and thus may have influenced the findings. The death rate from suicide in Australia for young people aged 15–24 years was 12.5 and 3.9 per 100,000 for males and females, respectively (Australian Bureau of Statistics, 2012).

The participants in this study expressed interest in discussing their experience, and having volunteered to

W. Bartik et al.: Adolescent Survivors After Suicide216

participate are perhaps more motivated to try and make meaning of their experience. Further research with young people bereaved through suicide will assist in extending these results and in reporting other results not expressed by this group. The findings reported may also be limited by self-selection bias of the participants, the consideration that these volunteer participants’ narratives exhibit charac- teristics that are not necessarily shared by all young people who lose a friend to suicide.

Future research should consider expanding participant numbers and including younger adolescents to determine any impact on developmental issues unique to this age group. Any future study would also be strengthened by a longitudinal design, consideration of the time since the death occurred and the interview, and consideration of pro- cesses that might have occurred since the suicide death. Consideration might also be given to the potential differ- ences between rural and urban populations and, particular- ly, the impact on rural communities more broadly above and beyond those who self-identify as friends. Friendships need to be more fully embraced to consider the potential extent of people who might be affected when the suicide death of a young person occurs. Participants in the study were all aged in their late teens to early twenties when they experienced the suicide death of their friend/s. This is a significant time in terms of life transitions for young peo- ple. Future research should consider how the suicide death of a friend impacts normal developmental experience and its potential later life consequences.

As suicide death of young people remains at unaccept- ably high levels in Australia, the impact of these deaths on other young people is an important public health issue. Ul- timately, research-informed practice and support for those bereaved by suicide may assist in prevention and interven- tion to address the needs of these groups.

Acknowledgments

This article is based on research undertaken by the first named author as partial fulfillment of a Master of Psychol- ogy (Clinical). This author acknowledges the supervision provided by Associate Professor Michael Kiernan from Charles Sturt University. An internal research grant award- ed to Maple, Edwards, and Bartik from the Faculty of The Professions, University of New England, contributed to the financial support for the research.

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Received December 19, 2011 Revision received July 31, 2012 Accepted August 03, 2012 Published online January 30, 2013

About the authors

Warren Bartik is a clinical psychologist and has worked in the area of children, adolescents, young people, families, and mental health for over 20 years. He is a PhD candidate in the Collabora- tive Research Network for mental health and well-being in rural and regional communities with the University of New England (Australia) continuing his area of research of young people and suicide.

Dr. Myfanwy Maple is an associate professor in the School of Health, Collaborative Research Network for mental health and well-being in rural and regional communities, at the University of New England (Australia). She has particular research interests in the areas of suicide, family, mental health, trauma, grief, and bereavement and has published widely in national and interna- tional journals in the area of suicide bereavement.

Dr. Helen Edwards is a lecturer in early childhood education in the School of Education at the University of New England (Aus- tralia). She has particular research and publication interests in Aboriginal education, learning in rural and remote environments, and youth suicide.

Associate Professor Michael Kiernan is the head of the School of Psychology at Charles Sturt University (Australia) and is also a member of the Psychology Council of New South Wales. He has broad research and teaching interests including cognitive neuropsychology, childhood disorders, and developmental disa- bilities.

Warren Bartik

School of Health University of New England Armidale, NSW Australia Tel. +61 2 6773 2462 E-mail [email protected]