Article
Suicide of a close family member through the eyes of a child: A narrative case study report
Journal of Child Health Care 1–9 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493513519297 chc.sagepub.com
Debra Jackson University of Technology, Sydney, Australia
Kath Peters and Gillian Murphy University of Western Sydney, Australia
Abstract A narrative case study approach was used to collect a storied account from Joseph about his recollections and experience of the completed suicide of a family member with whom he lived with at 13 years of age. Data are presented longitudinally to capture Joseph’s perceptions and recollections of events leading up to, surrounding and following the suicide. Findings reveal that, as a child Joseph felt strong responsibility to keep his uncle safe and maintain his uncle’s life; and perceived a lack of support for himself and his family throughout the events. Today as a young man, Joseph remains profoundly affected by this suicide and the events surrounding it, and experiences flashbacks and intrusive thoughts, though his distress remains largely invisible to others. It is important that the acute and longer term needs of children affected by suicidality and suicide are recognised. We argue that increased awareness on the part of health professionals about the ongoing grief and distress surrounding suicide survivorship can create opportunities for opportunistic assessment and review of child survivor welfare. Keywords Case study, child health, family health, family support, narrative, suicide
Background The prevalence of completed suicide is of international concern, with suicide being responsible for an estimated one million deaths annually (Andriessen and Krysinska, 2012). Despite its
Corresponding author: Debra Jackson, Faculty of Health, University of Technology, Sydney, Australia. Email: [email protected]
Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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prevalence, there remains a paucity of literature addressing the specific needs and interventions for those impacted by suicide (Cutcliffe and Stevenson, 2008). In particular, the experiences and narratives of children bereaved by suicide have received insufficient attention in the literature (Ratnarajah and Schofield, 2008). A suicide survivor can be defined as ‘a person who has lost a significant other (or loved one) by suicide, and whose life is changed because of the loss’ (Andriessen, 2009: 43). Although it is difficult to determine the exact numbers of people affected by individual deaths, it is estimated that there are approximately 10 survivors for each completed suicide (Australian Bureau of Statistics (ABS), 2007a, 2007b). There is conflicting evidence within literature regarding the severity of grief experienced by survivors of suicide and those bereaved by other means. Using quantitative methods, Dyregrov et al. (2003) found no significant difference in the level of distress experienced by parents bereaved by suicide compared to those bereaved by accidents, although both the aforementioned groups experienced significantly greater distress than survivors of sudden infant death syndrome. In contrast, young survivors of parental suicide have been found to have an increased risk of depression and substance abuse than those bereaved by other means (Brent et al., 2009). Further, a review of qualitative studies found survivors of suicide have more individual and contextual risk factors that lead to complicated bereavement (Botha et al., 2009). One such factor identified as contributing to complicated grief is stigma (Aguirre and Slater, 2010; Feigelman et al., 2009; Sveen and Walby, 2008), which is also cited as one of the major barriers for suicide survivors seeking assistance (Aguirre and Slater, 2010). However, this barrier to help-seeking may now be somewhat diminished with the increasing culture of Internet usage. The Internet can offer survivors of suicide anonymity and a non-judgemental, non-confrontational space to access information and support needs (Chapple and Ziebland, 2011). While the extant literature highlights the impact of suicide, including social stigmatisation and the support needs of adult survivors, there is limited discourse about the experiences and needs of children of familial suicide. This means that there are limited insights into the experiences and needs of children bereaved as a result of suicide. This article is drawn from a larger study that sought to explore the experiences of immediate family survivors of completed suicide. Previous findings pertaining to events prior to the completed suicide are reported elsewhere (Peters et al., 2013). In this current article, we provide an in-depth account from a young man who as a child experienced the completed suicide of a close family member, after a long period of suicidality. This article provides an important first-person retrospective account of suicide survivorship through the eyes of a child.
Method This article used a narrative case study approach to illuminate the experiences of one child who faced immeasurable challenges in managing his uncle’s suicidality and in witnessing his eventual suicide. The use of case study allowed us to give voice to Joseph (pseudonym) by presenting his story. Case study is a valuable method that allows the deep exploration of an exceptional case within a broader qualitative study (Borbasi and Jackson, 2011; Luck et al., 2006), where the unique case may be either symbiotic or inextricably linked with the broader context of the research (Yin, 2003). Further, the presentation of a case study has been shown to be an effective educational tool, particularly in health disciplines, as it provides a platform to authentically convey life events, which augments understanding (Luck et al., 2006; Stake, 2000; Yin, 2003). 2 Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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Prior to constructing this article, all authors immersed themselves in the transcript of Joseph’s story. In listening to and reading his story, the authors were guided by the work of Frank (1995), which advocates listening with stories rather than about them, and to experience the story in terms of it ‘affecting one’s own life’ (p. 23). As acknowledged by Frank, listening to stories of suffering is difficult and subsequently these stories become all too easy to ignore. However, research participants often give of their time freely, and in good faith that their participation may somehow make a difference. Therefore, we are ethically bound to not only listen but also convey their stories to those who can effect change.
Recruitment Potential participants for the larger study were recruited through a print media release, in which interested people meeting the selection criteria were invited to make contact with the research team. On contact with the potential participants, an initial screening was undertaken to ensure fulfilment of the inclusion criteria. Inclusion criteria required that participants were aged over 18 years, were able to converse freely in English, have experienced the suicide of a family member at least 12 months prior to participation in the study and had dealings with official agencies associated with the person’s death. Once eligibility was established, the researchers sent out participant information sheets to interested individuals explaining in detail what participation in the study would involve. Ethical approval for this study was obtained from the relevant institutional Ethical approval for this study was obtained from the relevant institutional ethics committee, who required details of counselling facilities be made available to any participants who required it. Pseudonyms are used in all outputs arising from the study.
Setting the scene The case reported here involves a minority migrant family from non–English-speaking background, who were affected by various forms of social disadvantage including economic deprivation and intimate partner violence (IPV). At the time of events described, the family consisted of Joseph (13 years), Anna (Joseph’s sister 18 years), Susan (Joseph’s mother 36 years) and William (Joseph’s maternal uncle aged 33 years). Joseph describes William as a father figure who had been a loving presence to Joseph and had no role in the previous IPV experienced by Joseph’s mother Susan. William completed suicide after three months of active suicidality when Joseph was aged 13 years. During the period of the suicidality of his uncle, as the only remaining male in his family, Joseph felt he had responsibility for the well-being of his mother and family and felt he had to step into the role of ‘man of the family’. Thus, even at his early age, he dealt with agencies at the time of William’s suicide. At the time of data collection, Joseph was in his early 20s, with a period of 11 years having elapsed since William’s death.
Findings Joseph’s motivation for participating in this study was to help raise awareness of the needs of children affected by suicidality in the family. Eleven years after the events, Joseph remained profoundly affected by the suicide of his uncle and the events surrounding it. He continued to reflect on the events and was left with many lingering and unanswered questions. Throughout his story, Joseph’s narrative revealed his primary and ongoing concern for the effects of his uncle’s death on others. His concern for 3 Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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the potential distress of others remained evident, when he asked for permission before describing the suicide scene for the purposes of this research project. Data are presented longitudinally to capture Joseph’s perspectives of events leading up to, surrounding and following the suicide.
The pre-suicide period Joseph recalls the pre-suicide period as being characterised by tension and family stress associated with increasing concern about the mental health and well-being of his uncle, William. Family members had tried to access adequate mental health assessment and support for William, and this was most often sought through the act of phoning for an ambulance in the context of an acute event, most often an overt attempt at suicide. However, despite regular and frequent calls on acute services, as a strategy this was ultimately unsuccessful in obtaining access to effective and ongoing mental health assessment and support. They [ambulance personnel] took him away and he spent time in the hospital overnight. I think he was back the next day. This reoccurring theme of calling Triple 0 [emergency number in Australia], having him sort of return the next day, was quite common and quite frustrating as well. It was sort of like clearly this person is in need of support and help, is very sick and unwell, both physically and mentally. Yet every time we try to go to authorities about it, he comes back home the next day . . . and he’s still in his state, he’s not recovered.
The lack of professional help meant that the family were left to cope with the limited resources they could draw upon. This resulted in Joseph and his sister feeling they had to maintain a close watch on their uncle. Though matters were not openly discussed with their mother, Joseph recalls the two children actively engaging in silent and ongoing watchfulness of their uncle in an attempt to keep him safe. Joseph recounts being on suicide watch in the home. Suicide watch consisted of sitting in front of the telly which was outside his bedroom and just pretending to watch telly, being very, turning the volume down really low and just being in tune and in check with the different noises that were happening in his bedroom. We knew the classic sounds of what he was up to. If you could hear him walking and pacing around, if you could hear him rattling cords or chains, if you heard anything like glass bottles or the scariest thing was, every couple of minutes we would look under his doorway, we’d look under the doorway and if we’d see the four legs of a stool there we’d know we’ve just got to barge in there. We saw that on multiple occasions and when you see that your heart races, you don’t know if he’s already hung himself.
This vigilance took its toll on the children who were fearful of losing their uncle to suicide and exhausted through their efforts at maintaining his safety. Their fear and fatigue was complicated further by the perceived lack of support and the unwillingness of others to allow Joseph and his sister to give full voice to their fears. That was extremely scary. It was extremely fatiguing. We would sort of rotate our watches until we essentially passed out. I would fall asleep outside his door just peering under the door right to 2.00 am . . . it would have been great if there were support services available, someone that I could speak to or confide in at school. Your friends . . . don’t know how to react, they don’t know what to do. A lot of them just say, don’t talk about it, it’s upsetting or let’s not talk about it because it will upset you. 4 Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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The well-being of his uncle became consuming for Joseph, and he spent considerable time trying to think up things to say that would foster his uncle’s will to live. However, in trying to bargain with him, Joseph was also fearful that he might say the wrong thing that could make things worse rather than better. So back then it was just you on your own trying to think, well if I say this, he’s going to react this way. If I say this, it might sound good. Having read things that you perhaps should say now, years after the fact, I realise I’d probably said some things which didn’t help the situation as well. Some of those things being you know, Uncle I want you to be around when I get married, I want you still in my life . . . don’t you want to see me grow up?
Memories of the suicide Events of the day of the suicide are imprinted in Joseph’s memory. On the day of his uncle’s demise, Joseph was in the company of his mother and sister and away from the family home. He recalls a sense of knowing – a premonition that his uncle would suicide. I just knew that it was going to be the night. I couldn’t sleep at all. The moments where I did fall asleep momentarily, I just remember being jolted at a particular point in the night and my heart sank and I just, for some reason, I knew that he’d passed away at that point . . . it was not, is he going to be alive, it’s what am I going to come back to see? . . . It was where am I going to find him? What is this going to look like? Is it going to be a mess? Is there going to be blood everywhere?
Even as an adolescent, as the lone male in his immediate family, Joseph felt a responsibility to protect his female family members. On arriving back to the family home, Joseph was alert to the possibility of finding his uncle deceased and so quickly searched the house to ensure that if a body was to be found, it would be he, not other family members who would find it. Joseph vividly recalled his own distress arising from seeing the body of his uncle. Yet despite his young age and the shock associated with finding the body of his uncle, Joseph’s thoughts were to protect others from this shock. Being a guy I had to be the one that sort of went to go into the house first, to protect Mum and my sister from perhaps seeing what was there . . . . Stepping into the house, everything seemed intact, everything seemed okay. But the bedroom door was closed. Mum sort of, I can’t remember what she did, I think she went upstairs, just went to the kitchen. I stood in front of [uncle’s] door. I stood in front of the door and obviously you don’t call the house clear until you’ve checked every room, you’ve checked every possible place that he might be. Opening the door [to find uncle’s body] was an experience that sort of replayed on my mind over and over for a couple of years . . . .
The death scene is one that stayed with Joseph. He experienced intrusive images for some years after and is still able to recall the event in considerable detail.
Events after the suicide In the initial post-suicide period, Joseph became quite isolated, and he described avoiding engaging with people, even non-verbally.
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Journal of Child Health Care That image of him . . . stayed with me, that stayed on my mind for a period of six or 12 months after. Every time I looked at a person, that was what I saw. It was such a horrendous sight because every time I talked to someone it would bring it back to that experience. So I just ended up walking around, looking down, not engaging in eye contact, not looking at people. That was how I sort of dealt with it. It wasn’t obviously an ideal way to deal with it but that’s what I had to do to get by, through my daily functioning.
Joseph’s narrative reveals that even within the family, family members became isolated in their grief and were not able to openly acknowledge or discuss the events. This meant that as an adolescent and young man, Joseph was left with the sense that his uncle’s death was due to his own failing. This was a burden that remains with Joseph, though he is now developing an awareness that he could not have done any more for his uncle. After that period [funeral] was when no one talked at all about what had happened, for what reasons, I don’t know. I was sort of on my own, my sister was on her own, Mum was on her own. That’s been that way ever since. We didn’t know the struggle that we were having. I remember after that situation my line of thinking at the time was so much disappointment in myself that I’d failed my uncle. That was a burden that I carried with me just forever. Probably last year or this year was the first time in which I sort of now realised that maybe I shouldn’t be so hard on myself.
Joseph’s grief for his uncle was also complicated by the new fear that his mother would also die as a result of suicide. This fear was overwhelming for Joseph. It consumed him. As a child in a singleparent family and living in a newly adopted homeland, he had few supports and was totally dependent on his mother as a provider and source of parental nurturing. Furthermore, as the lone male in the family, even as a young child, Joseph felt deep responsibility for the welfare of his family. After that incident my focus shifted to my Mum. I was so incredibly concerned that this would lead to a chain suicide. I didn’t think that Mum was going to be able to cope with it. So after it happened it was almost like suicide watch again. I would stand outside Mum’s room every night and listen to her sleep, I would listen to her breathing until I knew that she was asleep before I went to bed. She wouldn’t know that I did that but that’s what I had to do to ensure that she was well.
Discussion Many children and young people are directly affected by suicide. In this article, we have presented a detailed analysis of one young man’s recalled experiences of familial suicide in childhood. The suicide of his uncle cast a shadow over Joseph’s childhood, and raises a number of issues for reflection and consideration. Initially, there was a lack of availability of mental health support and when this family asked for assistance, services did not provide effective longer term help; instead, they clarified his immediate safety and simply sent the uncle home again. This resonates with other literature suggesting services are not adequate to meet the needs of families struggling with a family member with mental ill health (Peters et al., 2013). Furthermore, there is a lack of continuity of services, and though some follow-up services exist, they are unable to meet community demand, and many families, such as Joseph’s, simply do not receive sufficient care and support (Lamb et al., 2011). Joseph’s family was particularly vulnerable for a number of reasons. In the period following the suicide, Joseph recalls he and his family becoming increasingly isolated, both in the home with one another and outside the home. They were new to the country and were from a cultural 6 Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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minority group. Literature suggests that people from minority groups may have particular needs that are not easily met by services (Endrawes et al., 2007a). Furthermore, migrant families often lack social and family support and so may struggle and become isolated when challenged by a family member with mental ill health (Endrawes et al., 2007b). Effective community-based support provides important opportunities for the prevention of suicide and supporting family members of suicidal people. This case study highlights a real need for community health workers to be visible and accessible to newly arrived families who may have little options for social support, particularly when challenged by stigmatised health concerns such as suicidality. Furthermore, there needs to be sensitivity and alertness to the isolation and lack of support experienced by many migrant families, particularly when meeting the challenges associated with mental illness in the family. Through Joseph’s story, the need for family-based support and intervention is made clear. Survivors of suicide are at risk of post-traumatic stress disorder (Murphy et al., 2003), an ensuing complicated grief (Feigelman et al., 2009; Parker and McNally, 2008), and increased rates of suicide themselves (Jordan, 2008). A critical review of the literature on children’s bereavement following parental death by suicide also highlights the fact that ‘those with a family history of suicidal behaviour are at greater risk for similar outcomes’ (Hung and Rabin, 2009: 786). These documented risks emphasise the need for improved surveillance of bereaved families and greater training for professionals so that effective interventions can be offered. Joseph’s experience also emphasises the particular needs of children and the need for both acute care and ongoing follow-up of children and young people affected by suicide. In Joseph’s case, the grief for the loss of his loved uncle was complicated by stigma, guilt and a sense of failure, that he (Joseph) was somehow responsible for the death. Joseph was unable to reach out and talk to anyone about how he was feeling. Clearly, children and young people need to be able to talk about the issues that the suicide has raised for them in a therapeutic environment with skilled mental health staff (Hung and Rabin, 2009). Ratnarajah and Schofield (2008) also stress the importance of effective family-based intervention and support. Failure to provide appropriate individual and family-based supports likely further complicates grief, and, as highlighted in Joseph’s situation his feelings of distress were compounded by the fact he found his uncle’s body and had subsequently experienced years of intrusive thoughts and unpleasant imagery. Hung and Rabin’s (2009) comprehensive review highlights many issues and difficulties establishing clear evidence base for effective interventions that can support children bereaved by suicide (similarly Ratnarajah and Schofield, 2008). Their findings reinforce the need for raised awareness in the health and social care community of the effects of acute and longitudinal effects of suicide on children and young people. We argue that increased awareness on the part of health professionals about the ongoing grief and distress surrounding suicide survivorship can create opportunities for appropriate surveillance, opportunistic assessment and review of child survivor welfare.
Conclusion Everything begins with a story. Through Joseph’s story, some of the effects on children of living with suicidality are made visible and it is clear that the effects of suicide survivorship on children can be extensive. In engaging with Joseph’s story of his own experiences of suicide survivorship, we are able to see the profound effects of his uncle’s suicide and how it generated greater emotional complexities during Joseph’s childhood and over the lives and relationships of Joseph’s family 7 Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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members. We argue that there is a need for people affected by completed familial suicide to have the time and space that will allow them to construct their narrative. Through participating in this study, Joseph was able to construct and give voice to his narrative in a space that was affirming and free of judgement and stigma. It is important that the experiences and needs of children affected by suicide and suicidality are recognised and acknowledged, in order to better provide children and their families with both acute and ongoing support. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References Aguirre RTP and Slater H (2010) Suicide postvention as suicide prevention: Improvement and expansion in the United States. Death Studies 34(6): 529–540. Andriessen K (2009) Can postvention be prevention? Crisis 30(1): 43–47. Andriessen K and Krysinska K (2012) Essential questions on suicide bereavement and postvention. International Journal of Environmental Research and Public Health 9(1): 24–32. Australian Bureau of Statistics (2007a) Suicides 1995-2005. (Cat no. 3309.0). Canberra, Australia: Australian Bureau of Statistics. Australian Bureau of Statistics (2007b) Australian Social Trend Population. (Cat no. 4102.0). Canberra, Australia: Australian Bureau of Statistics. Borbasi S and Jackson D (2011) Navigating the Maze of Nursing Research: Enhancing Nursing and Midwifery Practice. Chatswood NSW, Australia: Mosby Australia. Botha KJ, Guilfoyle A and Botha D (2009) Beyond normal grief: A critical reflection on immediate postdeath experiences of survivors of suicide. Australian e-Journal for the Advancement of Mental Health 8(1): 1–11. Brent D, Melhem N, Donohoe MB and Walker M (2009) The incidence and course of depression in bereaved youth 21 months after the loss of a parent to suicide, accident, or sudden natural death. The American Journal of Psychiatry 166(7): 786–794. Chapple A and Ziebland S (2011) How the internet is changing the experience of bereavement by suicide: A qualitative study in the UK. Health 15(2): 173–187. Cutcliffe JR and Stevenson C (2008) Never the twain? Reconciling national suicide prevention strategies with the practice, educational, and policy needs of mental health nurses (Part two). International Journal of Mental Health Nursing 17: 351–362. Dyregrov K, Nordanger D and Dyregrov A (2003) Predictors of psychosocial distress after suicide, SIDS and accidents. Death Studies 27: 143–165. Endrawes G, O’Brien L and Wilkes L (2007a) Mental illness and Egyptian families. International Journal of Mental Health Nursing 16: 178–187. Endrawes G, O’Brien L and Wilkes L (2007b) Egyptian families caring for a relative with mental illness: A hermeneutic study. International Journal of Mental Health Nursing 16: 431–440. Feigelman W, Gorman BS and Jordan JR (2009) Stigmatization and suicide bereavement. Death Studies 33: 591–608. Frank A (1995) The Wounded Storyteller: Body, Illness and Ethics. Chicago, IL: University of Chicago Press. Hung NC and Rabin LA (2009) Comprehending childhood bereavement by parental suicide: A critical review of research on outcomes, grief processes, and interventions. Death Studies 33(9): 781–814. Jordan JR (2008) Bereavement after suicide. Psychiatric Annals 38(10): 679–685. 8 Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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Lamb J, Bowler P, Rogers A, Dowrick C and Gask L (2011) Access to mental health in primary care: A qualitative meta-synthesis of evidence from the experience of people from ‘hard to reach’ groups. Health 16(1): 76–104. Luck L, Jackson D and Usher K (2006) Case study: A bridge across the paradigms. Nursing Inquiry 13(2): 103–109. Murphy SA, Johnson C, Chung I and Beaton RD (2003) The prevalence of PTSD following the violenet death of a child and predictors of change 5 years later. Journal of Traumatic Stress 16(1): 17–25. Parker HA and McNally RJ (2008) Repressive coping, emotional adjustment, and cognition in people who have lost loved ones to suicide. Suicide and Life-Threatening Behavior 38(6): 676–687. Peters K, Murphy G and Jackson D (2013) Events prior to completed suicide: Perspectives of family survivors. Issues in Mental Health Nursing 34(5): 309–316. Ratnarajah D and Schofield MJ (2008) Survivors’ narratives of the impact of parental suicide. Suicide and Life-Threatening behavior 38(5): 618–630. Stake R (2000) Case studies. In: Denzin N and Lincoln Y (eds) Handbook of Qualitative Research. Thousand Oaks, CA: Sage Publications Inc, pp. 435–454. Sveen CA and Walby FA (2008) Suicide survivors’ mental health and grief reactions: A systematic review of controlled studies. Suicide and Life-Threatening Behavior 38(1): 13–29. Yin R (2003) Case Study Research: Designs and Method. 3rd ed. Thousand Oaks CA: Sage Publications Inc.
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Suicide of a close family member through the eyes of a child: A narrative case study report
Journal of Child Health Care 1–9 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493513519297 chc.sagepub.com
Debra Jackson University of Technology, Sydney, Australia
Kath Peters and Gillian Murphy University of Western Sydney, Australia
Abstract A narrative case study approach was used to collect a storied account from Joseph about his recollections and experience of the completed suicide of a family member with whom he lived with at 13 years of age. Data are presented longitudinally to capture Joseph’s perceptions and recollections of events leading up to, surrounding and following the suicide. Findings reveal that, as a child Joseph felt strong responsibility to keep his uncle safe and maintain his uncle’s life; and perceived a lack of support for himself and his family throughout the events. Today as a young man, Joseph remains profoundly affected by this suicide and the events surrounding it, and experiences flashbacks and intrusive thoughts, though his distress remains largely invisible to others. It is important that the acute and longer term needs of children affected by suicidality and suicide are recognised. We argue that increased awareness on the part of health professionals about the ongoing grief and distress surrounding suicide survivorship can create opportunities for opportunistic assessment and review of child survivor welfare. Keywords Case study, child health, family health, family support, narrative, suicide
Background The prevalence of completed suicide is of international concern, with suicide being responsible for an estimated one million deaths annually (Andriessen and Krysinska, 2012). Despite its
Corresponding author: Debra Jackson, Faculty of Health, University of Technology, Sydney, Australia. Email: [email protected]
Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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prevalence, there remains a paucity of literature addressing the specific needs and interventions for those impacted by suicide (Cutcliffe and Stevenson, 2008). In particular, the experiences and narratives of children bereaved by suicide have received insufficient attention in the literature (Ratnarajah and Schofield, 2008). A suicide survivor can be defined as ‘a person who has lost a significant other (or loved one) by suicide, and whose life is changed because of the loss’ (Andriessen, 2009: 43). Although it is difficult to determine the exact numbers of people affected by individual deaths, it is estimated that there are approximately 10 survivors for each completed suicide (Australian Bureau of Statistics (ABS), 2007a, 2007b). There is conflicting evidence within literature regarding the severity of grief experienced by survivors of suicide and those bereaved by other means. Using quantitative methods, Dyregrov et al. (2003) found no significant difference in the level of distress experienced by parents bereaved by suicide compared to those bereaved by accidents, although both the aforementioned groups experienced significantly greater distress than survivors of sudden infant death syndrome. In contrast, young survivors of parental suicide have been found to have an increased risk of depression and substance abuse than those bereaved by other means (Brent et al., 2009). Further, a review of qualitative studies found survivors of suicide have more individual and contextual risk factors that lead to complicated bereavement (Botha et al., 2009). One such factor identified as contributing to complicated grief is stigma (Aguirre and Slater, 2010; Feigelman et al., 2009; Sveen and Walby, 2008), which is also cited as one of the major barriers for suicide survivors seeking assistance (Aguirre and Slater, 2010). However, this barrier to help-seeking may now be somewhat diminished with the increasing culture of Internet usage. The Internet can offer survivors of suicide anonymity and a non-judgemental, non-confrontational space to access information and support needs (Chapple and Ziebland, 2011). While the extant literature highlights the impact of suicide, including social stigmatisation and the support needs of adult survivors, there is limited discourse about the experiences and needs of children of familial suicide. This means that there are limited insights into the experiences and needs of children bereaved as a result of suicide. This article is drawn from a larger study that sought to explore the experiences of immediate family survivors of completed suicide. Previous findings pertaining to events prior to the completed suicide are reported elsewhere (Peters et al., 2013). In this current article, we provide an in-depth account from a young man who as a child experienced the completed suicide of a close family member, after a long period of suicidality. This article provides an important first-person retrospective account of suicide survivorship through the eyes of a child.
Method This article used a narrative case study approach to illuminate the experiences of one child who faced immeasurable challenges in managing his uncle’s suicidality and in witnessing his eventual suicide. The use of case study allowed us to give voice to Joseph (pseudonym) by presenting his story. Case study is a valuable method that allows the deep exploration of an exceptional case within a broader qualitative study (Borbasi and Jackson, 2011; Luck et al., 2006), where the unique case may be either symbiotic or inextricably linked with the broader context of the research (Yin, 2003). Further, the presentation of a case study has been shown to be an effective educational tool, particularly in health disciplines, as it provides a platform to authentically convey life events, which augments understanding (Luck et al., 2006; Stake, 2000; Yin, 2003). 2 Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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Prior to constructing this article, all authors immersed themselves in the transcript of Joseph’s story. In listening to and reading his story, the authors were guided by the work of Frank (1995), which advocates listening with stories rather than about them, and to experience the story in terms of it ‘affecting one’s own life’ (p. 23). As acknowledged by Frank, listening to stories of suffering is difficult and subsequently these stories become all too easy to ignore. However, research participants often give of their time freely, and in good faith that their participation may somehow make a difference. Therefore, we are ethically bound to not only listen but also convey their stories to those who can effect change.
Recruitment Potential participants for the larger study were recruited through a print media release, in which interested people meeting the selection criteria were invited to make contact with the research team. On contact with the potential participants, an initial screening was undertaken to ensure fulfilment of the inclusion criteria. Inclusion criteria required that participants were aged over 18 years, were able to converse freely in English, have experienced the suicide of a family member at least 12 months prior to participation in the study and had dealings with official agencies associated with the person’s death. Once eligibility was established, the researchers sent out participant information sheets to interested individuals explaining in detail what participation in the study would involve. Ethical approval for this study was obtained from the relevant institutional Ethical approval for this study was obtained from the relevant institutional ethics committee, who required details of counselling facilities be made available to any participants who required it. Pseudonyms are used in all outputs arising from the study.
Setting the scene The case reported here involves a minority migrant family from non–English-speaking background, who were affected by various forms of social disadvantage including economic deprivation and intimate partner violence (IPV). At the time of events described, the family consisted of Joseph (13 years), Anna (Joseph’s sister 18 years), Susan (Joseph’s mother 36 years) and William (Joseph’s maternal uncle aged 33 years). Joseph describes William as a father figure who had been a loving presence to Joseph and had no role in the previous IPV experienced by Joseph’s mother Susan. William completed suicide after three months of active suicidality when Joseph was aged 13 years. During the period of the suicidality of his uncle, as the only remaining male in his family, Joseph felt he had responsibility for the well-being of his mother and family and felt he had to step into the role of ‘man of the family’. Thus, even at his early age, he dealt with agencies at the time of William’s suicide. At the time of data collection, Joseph was in his early 20s, with a period of 11 years having elapsed since William’s death.
Findings Joseph’s motivation for participating in this study was to help raise awareness of the needs of children affected by suicidality in the family. Eleven years after the events, Joseph remained profoundly affected by the suicide of his uncle and the events surrounding it. He continued to reflect on the events and was left with many lingering and unanswered questions. Throughout his story, Joseph’s narrative revealed his primary and ongoing concern for the effects of his uncle’s death on others. His concern for 3 Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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the potential distress of others remained evident, when he asked for permission before describing the suicide scene for the purposes of this research project. Data are presented longitudinally to capture Joseph’s perspectives of events leading up to, surrounding and following the suicide.
The pre-suicide period Joseph recalls the pre-suicide period as being characterised by tension and family stress associated with increasing concern about the mental health and well-being of his uncle, William. Family members had tried to access adequate mental health assessment and support for William, and this was most often sought through the act of phoning for an ambulance in the context of an acute event, most often an overt attempt at suicide. However, despite regular and frequent calls on acute services, as a strategy this was ultimately unsuccessful in obtaining access to effective and ongoing mental health assessment and support. They [ambulance personnel] took him away and he spent time in the hospital overnight. I think he was back the next day. This reoccurring theme of calling Triple 0 [emergency number in Australia], having him sort of return the next day, was quite common and quite frustrating as well. It was sort of like clearly this person is in need of support and help, is very sick and unwell, both physically and mentally. Yet every time we try to go to authorities about it, he comes back home the next day . . . and he’s still in his state, he’s not recovered.
The lack of professional help meant that the family were left to cope with the limited resources they could draw upon. This resulted in Joseph and his sister feeling they had to maintain a close watch on their uncle. Though matters were not openly discussed with their mother, Joseph recalls the two children actively engaging in silent and ongoing watchfulness of their uncle in an attempt to keep him safe. Joseph recounts being on suicide watch in the home. Suicide watch consisted of sitting in front of the telly which was outside his bedroom and just pretending to watch telly, being very, turning the volume down really low and just being in tune and in check with the different noises that were happening in his bedroom. We knew the classic sounds of what he was up to. If you could hear him walking and pacing around, if you could hear him rattling cords or chains, if you heard anything like glass bottles or the scariest thing was, every couple of minutes we would look under his doorway, we’d look under the doorway and if we’d see the four legs of a stool there we’d know we’ve just got to barge in there. We saw that on multiple occasions and when you see that your heart races, you don’t know if he’s already hung himself.
This vigilance took its toll on the children who were fearful of losing their uncle to suicide and exhausted through their efforts at maintaining his safety. Their fear and fatigue was complicated further by the perceived lack of support and the unwillingness of others to allow Joseph and his sister to give full voice to their fears. That was extremely scary. It was extremely fatiguing. We would sort of rotate our watches until we essentially passed out. I would fall asleep outside his door just peering under the door right to 2.00 am . . . it would have been great if there were support services available, someone that I could speak to or confide in at school. Your friends . . . don’t know how to react, they don’t know what to do. A lot of them just say, don’t talk about it, it’s upsetting or let’s not talk about it because it will upset you. 4 Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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The well-being of his uncle became consuming for Joseph, and he spent considerable time trying to think up things to say that would foster his uncle’s will to live. However, in trying to bargain with him, Joseph was also fearful that he might say the wrong thing that could make things worse rather than better. So back then it was just you on your own trying to think, well if I say this, he’s going to react this way. If I say this, it might sound good. Having read things that you perhaps should say now, years after the fact, I realise I’d probably said some things which didn’t help the situation as well. Some of those things being you know, Uncle I want you to be around when I get married, I want you still in my life . . . don’t you want to see me grow up?
Memories of the suicide Events of the day of the suicide are imprinted in Joseph’s memory. On the day of his uncle’s demise, Joseph was in the company of his mother and sister and away from the family home. He recalls a sense of knowing – a premonition that his uncle would suicide. I just knew that it was going to be the night. I couldn’t sleep at all. The moments where I did fall asleep momentarily, I just remember being jolted at a particular point in the night and my heart sank and I just, for some reason, I knew that he’d passed away at that point . . . it was not, is he going to be alive, it’s what am I going to come back to see? . . . It was where am I going to find him? What is this going to look like? Is it going to be a mess? Is there going to be blood everywhere?
Even as an adolescent, as the lone male in his immediate family, Joseph felt a responsibility to protect his female family members. On arriving back to the family home, Joseph was alert to the possibility of finding his uncle deceased and so quickly searched the house to ensure that if a body was to be found, it would be he, not other family members who would find it. Joseph vividly recalled his own distress arising from seeing the body of his uncle. Yet despite his young age and the shock associated with finding the body of his uncle, Joseph’s thoughts were to protect others from this shock. Being a guy I had to be the one that sort of went to go into the house first, to protect Mum and my sister from perhaps seeing what was there . . . . Stepping into the house, everything seemed intact, everything seemed okay. But the bedroom door was closed. Mum sort of, I can’t remember what she did, I think she went upstairs, just went to the kitchen. I stood in front of [uncle’s] door. I stood in front of the door and obviously you don’t call the house clear until you’ve checked every room, you’ve checked every possible place that he might be. Opening the door [to find uncle’s body] was an experience that sort of replayed on my mind over and over for a couple of years . . . .
The death scene is one that stayed with Joseph. He experienced intrusive images for some years after and is still able to recall the event in considerable detail.
Events after the suicide In the initial post-suicide period, Joseph became quite isolated, and he described avoiding engaging with people, even non-verbally.
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Journal of Child Health Care That image of him . . . stayed with me, that stayed on my mind for a period of six or 12 months after. Every time I looked at a person, that was what I saw. It was such a horrendous sight because every time I talked to someone it would bring it back to that experience. So I just ended up walking around, looking down, not engaging in eye contact, not looking at people. That was how I sort of dealt with it. It wasn’t obviously an ideal way to deal with it but that’s what I had to do to get by, through my daily functioning.
Joseph’s narrative reveals that even within the family, family members became isolated in their grief and were not able to openly acknowledge or discuss the events. This meant that as an adolescent and young man, Joseph was left with the sense that his uncle’s death was due to his own failing. This was a burden that remains with Joseph, though he is now developing an awareness that he could not have done any more for his uncle. After that period [funeral] was when no one talked at all about what had happened, for what reasons, I don’t know. I was sort of on my own, my sister was on her own, Mum was on her own. That’s been that way ever since. We didn’t know the struggle that we were having. I remember after that situation my line of thinking at the time was so much disappointment in myself that I’d failed my uncle. That was a burden that I carried with me just forever. Probably last year or this year was the first time in which I sort of now realised that maybe I shouldn’t be so hard on myself.
Joseph’s grief for his uncle was also complicated by the new fear that his mother would also die as a result of suicide. This fear was overwhelming for Joseph. It consumed him. As a child in a singleparent family and living in a newly adopted homeland, he had few supports and was totally dependent on his mother as a provider and source of parental nurturing. Furthermore, as the lone male in the family, even as a young child, Joseph felt deep responsibility for the welfare of his family. After that incident my focus shifted to my Mum. I was so incredibly concerned that this would lead to a chain suicide. I didn’t think that Mum was going to be able to cope with it. So after it happened it was almost like suicide watch again. I would stand outside Mum’s room every night and listen to her sleep, I would listen to her breathing until I knew that she was asleep before I went to bed. She wouldn’t know that I did that but that’s what I had to do to ensure that she was well.
Discussion Many children and young people are directly affected by suicide. In this article, we have presented a detailed analysis of one young man’s recalled experiences of familial suicide in childhood. The suicide of his uncle cast a shadow over Joseph’s childhood, and raises a number of issues for reflection and consideration. Initially, there was a lack of availability of mental health support and when this family asked for assistance, services did not provide effective longer term help; instead, they clarified his immediate safety and simply sent the uncle home again. This resonates with other literature suggesting services are not adequate to meet the needs of families struggling with a family member with mental ill health (Peters et al., 2013). Furthermore, there is a lack of continuity of services, and though some follow-up services exist, they are unable to meet community demand, and many families, such as Joseph’s, simply do not receive sufficient care and support (Lamb et al., 2011). Joseph’s family was particularly vulnerable for a number of reasons. In the period following the suicide, Joseph recalls he and his family becoming increasingly isolated, both in the home with one another and outside the home. They were new to the country and were from a cultural 6 Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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minority group. Literature suggests that people from minority groups may have particular needs that are not easily met by services (Endrawes et al., 2007a). Furthermore, migrant families often lack social and family support and so may struggle and become isolated when challenged by a family member with mental ill health (Endrawes et al., 2007b). Effective community-based support provides important opportunities for the prevention of suicide and supporting family members of suicidal people. This case study highlights a real need for community health workers to be visible and accessible to newly arrived families who may have little options for social support, particularly when challenged by stigmatised health concerns such as suicidality. Furthermore, there needs to be sensitivity and alertness to the isolation and lack of support experienced by many migrant families, particularly when meeting the challenges associated with mental illness in the family. Through Joseph’s story, the need for family-based support and intervention is made clear. Survivors of suicide are at risk of post-traumatic stress disorder (Murphy et al., 2003), an ensuing complicated grief (Feigelman et al., 2009; Parker and McNally, 2008), and increased rates of suicide themselves (Jordan, 2008). A critical review of the literature on children’s bereavement following parental death by suicide also highlights the fact that ‘those with a family history of suicidal behaviour are at greater risk for similar outcomes’ (Hung and Rabin, 2009: 786). These documented risks emphasise the need for improved surveillance of bereaved families and greater training for professionals so that effective interventions can be offered. Joseph’s experience also emphasises the particular needs of children and the need for both acute care and ongoing follow-up of children and young people affected by suicide. In Joseph’s case, the grief for the loss of his loved uncle was complicated by stigma, guilt and a sense of failure, that he (Joseph) was somehow responsible for the death. Joseph was unable to reach out and talk to anyone about how he was feeling. Clearly, children and young people need to be able to talk about the issues that the suicide has raised for them in a therapeutic environment with skilled mental health staff (Hung and Rabin, 2009). Ratnarajah and Schofield (2008) also stress the importance of effective family-based intervention and support. Failure to provide appropriate individual and family-based supports likely further complicates grief, and, as highlighted in Joseph’s situation his feelings of distress were compounded by the fact he found his uncle’s body and had subsequently experienced years of intrusive thoughts and unpleasant imagery. Hung and Rabin’s (2009) comprehensive review highlights many issues and difficulties establishing clear evidence base for effective interventions that can support children bereaved by suicide (similarly Ratnarajah and Schofield, 2008). Their findings reinforce the need for raised awareness in the health and social care community of the effects of acute and longitudinal effects of suicide on children and young people. We argue that increased awareness on the part of health professionals about the ongoing grief and distress surrounding suicide survivorship can create opportunities for appropriate surveillance, opportunistic assessment and review of child survivor welfare.
Conclusion Everything begins with a story. Through Joseph’s story, some of the effects on children of living with suicidality are made visible and it is clear that the effects of suicide survivorship on children can be extensive. In engaging with Joseph’s story of his own experiences of suicide survivorship, we are able to see the profound effects of his uncle’s suicide and how it generated greater emotional complexities during Joseph’s childhood and over the lives and relationships of Joseph’s family 7 Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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members. We argue that there is a need for people affected by completed familial suicide to have the time and space that will allow them to construct their narrative. Through participating in this study, Joseph was able to construct and give voice to his narrative in a space that was affirming and free of judgement and stigma. It is important that the experiences and needs of children affected by suicide and suicidality are recognised and acknowledged, in order to better provide children and their families with both acute and ongoing support. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References Aguirre RTP and Slater H (2010) Suicide postvention as suicide prevention: Improvement and expansion in the United States. Death Studies 34(6): 529–540. Andriessen K (2009) Can postvention be prevention? Crisis 30(1): 43–47. Andriessen K and Krysinska K (2012) Essential questions on suicide bereavement and postvention. International Journal of Environmental Research and Public Health 9(1): 24–32. Australian Bureau of Statistics (2007a) Suicides 1995-2005. (Cat no. 3309.0). Canberra, Australia: Australian Bureau of Statistics. Australian Bureau of Statistics (2007b) Australian Social Trend Population. (Cat no. 4102.0). Canberra, Australia: Australian Bureau of Statistics. Borbasi S and Jackson D (2011) Navigating the Maze of Nursing Research: Enhancing Nursing and Midwifery Practice. Chatswood NSW, Australia: Mosby Australia. Botha KJ, Guilfoyle A and Botha D (2009) Beyond normal grief: A critical reflection on immediate postdeath experiences of survivors of suicide. Australian e-Journal for the Advancement of Mental Health 8(1): 1–11. Brent D, Melhem N, Donohoe MB and Walker M (2009) The incidence and course of depression in bereaved youth 21 months after the loss of a parent to suicide, accident, or sudden natural death. The American Journal of Psychiatry 166(7): 786–794. Chapple A and Ziebland S (2011) How the internet is changing the experience of bereavement by suicide: A qualitative study in the UK. Health 15(2): 173–187. Cutcliffe JR and Stevenson C (2008) Never the twain? Reconciling national suicide prevention strategies with the practice, educational, and policy needs of mental health nurses (Part two). International Journal of Mental Health Nursing 17: 351–362. Dyregrov K, Nordanger D and Dyregrov A (2003) Predictors of psychosocial distress after suicide, SIDS and accidents. Death Studies 27: 143–165. Endrawes G, O’Brien L and Wilkes L (2007a) Mental illness and Egyptian families. International Journal of Mental Health Nursing 16: 178–187. Endrawes G, O’Brien L and Wilkes L (2007b) Egyptian families caring for a relative with mental illness: A hermeneutic study. International Journal of Mental Health Nursing 16: 431–440. Feigelman W, Gorman BS and Jordan JR (2009) Stigmatization and suicide bereavement. Death Studies 33: 591–608. Frank A (1995) The Wounded Storyteller: Body, Illness and Ethics. Chicago, IL: University of Chicago Press. Hung NC and Rabin LA (2009) Comprehending childhood bereavement by parental suicide: A critical review of research on outcomes, grief processes, and interventions. Death Studies 33(9): 781–814. Jordan JR (2008) Bereavement after suicide. Psychiatric Annals 38(10): 679–685. 8 Downloaded from chc.sagepub.com at UNIV PRINCE EDWARD ISLAND on August 24, 2015
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Lamb J, Bowler P, Rogers A, Dowrick C and Gask L (2011) Access to mental health in primary care: A qualitative meta-synthesis of evidence from the experience of people from ‘hard to reach’ groups. Health 16(1): 76–104. Luck L, Jackson D and Usher K (2006) Case study: A bridge across the paradigms. Nursing Inquiry 13(2): 103–109. Murphy SA, Johnson C, Chung I and Beaton RD (2003) The prevalence of PTSD following the violenet death of a child and predictors of change 5 years later. Journal of Traumatic Stress 16(1): 17–25. Parker HA and McNally RJ (2008) Repressive coping, emotional adjustment, and cognition in people who have lost loved ones to suicide. Suicide and Life-Threatening Behavior 38(6): 676–687. Peters K, Murphy G and Jackson D (2013) Events prior to completed suicide: Perspectives of family survivors. Issues in Mental Health Nursing 34(5): 309–316. Ratnarajah D and Schofield MJ (2008) Survivors’ narratives of the impact of parental suicide. Suicide and Life-Threatening behavior 38(5): 618–630. Stake R (2000) Case studies. In: Denzin N and Lincoln Y (eds) Handbook of Qualitative Research. Thousand Oaks, CA: Sage Publications Inc, pp. 435–454. Sveen CA and Walby FA (2008) Suicide survivors’ mental health and grief reactions: A systematic review of controlled studies. Suicide and Life-Threatening Behavior 38(1): 13–29. Yin R (2003) Case Study Research: Designs and Method. 3rd ed. Thousand Oaks CA: Sage Publications Inc.
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