HOW TO START A SURVIVORS SUPPORT GROUP

This document is one of a series of resources addressed to specific social and professional groups particularly relevant to the prevention of suicide.

It has been prepared as part of SUPRE, the WHO worldwide initiative for the prevention of suicide.

FOREWORD
Suicide is a complex phenomenon that has attracted the attention of philosophers, theologians, physicians, sociologists and artists over the centuries; according to the French philosopher Albert Camus, in The Myth of Sisyphus, it is the only serious philosophical problem.

As a serious public health problem it demands our attention, but its prevention and control, unfortunately, are no easy task. State-of-the-art research indicates that the prevention of suicide, while feasible, involves a whole series of activities, ranging from the provision of the best possible conditions for bringing up our children and youth, through the effective treatment of mental disorders, to the environmental control of risk factors. Appropriate dissemination of information and awareness-raising are essential elements in the success of suicide prevention.

PREVENTING SUICIDE: HOW TO START A SURVIVORS' GROUP

THE IMPORTANCE OF SELF-HELP SUPPORT GROUPS

What are self-help support groups?
Self-help support groups are groups made up of people who are directly and personally affected by a particular issue, condition or concern. They are run by their members, which means that those directly affected by the issue are the ones who control the activities and the priorities of their group.

While many self-help groups obtain resources and assistance from outside the group, e.g. from professionals or other groups, the members are the decision-makers.

Background
Evidence strongly suggests that self-help support groups are a powerful and constructive means for people to help themselves and each other. It has been shown that the groups can make a significant contribution to positive outcomes for those who participate. There appears to be an increasing tendency for individuals to get together and form such groups.

The drive for the establishment of groups has come from two directions: from individuals in response to unmet needs; from formal services in an effort to provide additional support and care.

The establishment of self-help support groups became popular after the Second World War. Groups to support bereaved widows in both North America and the United Kingdom were established in the 1960s.

Groups specifically for suicide bereavement started in the 1970s in North America and have since been established in various centres throughout the world. In a number of countries established bereavement groups branched out and formed suicide bereavement groups.

These include The Compassionate Friends, which was originally established in Coventry, England, and now operates extensively in Canada, Malta, New Zealand, the United Kingdom and the USA. Other such groups are CRUSE in England, SPES in Sweden and 'Verwaiste Eltern' in Germany. The majority of groups are in English-speaking countries.

Survivor ('survivor'- refers to those who are left behind) support groups are gaining recognition as a means of providing for the need of survivors, supported partially in some countries by government funds, but also by religious groups, donations and the participants themselves. The International Association for Suicide Prevention (IASP) has noted a marked increase in interest in this area over the past decade. The driving force behind the formation of many of the groups comes from survivors themselves.

Importance of self-help support groups for those bereaved by suicide
Research has demonstrated that the mode of death differentially affects grief reactions and supports the proposition that survivors of suicide grieve differently. Usual grief reactions are intensified by a suicide. Suicide survivors have been shown to exhibit elements of grieving that are less likely to be present in other bereaved people.

Suicide survivors report more frequent feelings of responsibility for the death, rejection and abandonment than those who have lost someone from natural causes. Feelings of stigmatization, shame and embarrassment set them apart from those who grieve a non-suicidal death. The survivor is more likely to spend a greater proportion of time pondering on the motives of the person who committed suicide, the question 'why' being continually present.

The universal assumption that parents are responsible for their children's actions can also place parents who have lost a child by suicide in a situation of moral and social dilemma. There are more taboos attached to the discussion of suicide than to any other form of death.

Those bereaved by suicide often find it very difficult to admit that the death of their loved one was by suicide, and people often feel uncomfortable talking about the suicide with them. Those bereaved by suicide therefore have less opportunit y to talk about their grief than other bereaved people. A support group can assist greatly, as a lack of communication can delay the healing process.

The coming together of those bereaved by suicide can provide the opportunity to be with other people who can really understand, because they have been through the same experience; to gain strength and understanding from the individuals within the group, but also to provide the same to others.

The group can provide:
  • a sense of community and support
  • an empathetic environment and give a sense of belonging when the bereaved person
  • feels disassociated from the rest of the world
  • the hope that 'normality' can be reached eventually
  • experience in dealing with difficult anniversaries or special occasions
  • opportunities to learn new ways of approaching problems
  • a sounding board to discuss fears and concerns
  • a setting where free expression of grief is acceptable, confidentiality is observed
  • compassion and non-judgemental attitudes prevail
The group may also take on an educational role, providing information on the grief process, on facts relating to suicide, and on the roles of various health professionals. Another major function is that of empowerment - of providing a positive focus enabling the individuals to regain some control over their lives.

One of the most devastating aspects of a suicidal or accidental death is that there is invariably much unfinished business and many unanswered questions, and yet the individual can see no way of resolving the situation. The support of a group can often gradually dissolve the feelings of hopelessness and provide the means whereby control can be regained.

SURVIVING A SUICIDE
The journey of a suicide survivor after the loss of a significant loved one can be excruciatingly painful, devastating and traumatic. Cultural, religious and social taboos surrounding suicide can make this journey all the more difficult.

An understanding and knowledge of factors relating to suicide will assist the survivor along the road to recovery and make the experience less bewildering and frightening. Some of the deaths may have been anticipated, but most survivors are faced with a death that is unexpected and often violent.

Shock and disbelief are generally the initial reactions to the news. The reality of the loss will gradually penetrate, and a variety of feelings will emerge. These feelings may range from anger to guilt, denial, confusion and rejection.

Past experiences from childhood and adolescence to adulthood have a great impact on how individuals are able to handle loss in the present. Automatic responses will surface and take over to a certain degree.

Gaining an understanding of the impact that intense grief has on everyday functioning will also assist in working through the complex emotions that accompany the loss.

Physical, behavioural, emotional and social reactions may remain with the individual in varying degrees for periods ranging from months to years. The aim of survivors will be to 'survive', initially from day to day, and eventually to resume life having learned to live with the loss and adjusting their lives accordingly.

In the early stages of grief this does not seem possible; survivors are consumed with thoughts of their loved ones and with often strong feelings of 'wanting to join them'. With the loss of a significant loved one the survivors often experience changes in their values or belief systems and emerge from the experience as different people.

Self-help support groups for suicide survivors can assist individuals to grow with the changes that confront them.

IMPACT OF SUICIDE
When an individual takes his or her life the impact of the death has a ripple effect. All who had a relationship to the person will feel a loss. The quality and intensity of that relationship have been identified as key variables influencing bereavement outcomes.

Caring for the immediate loved one will often overshadow the needs of other significant loved ones. If families and friends can be brought together to share and support each other during the bereavement the adjustment to the loss of the loved one will be more readily achieved.

People will need to resolve their feelings in their own way, in their own time. What works for one person may not work for another. If survivors can gain an understanding of the differing responses to grief that individuals may experience, they can all be helped by providing supports for each other.

A few of the factors influencing the grieving process are the relationship to the deceased, the age and sex of the survivor, the trauma of finding the deceased, and the availability of other support systems. It has been estimated by various sources that for each person who dies by suicide, the number of people severely affected by the loss is between five and 10.

This can represent a significant number as the circle is extended to include the contacts individuals and families make throughout their lives and within their communities. The effect of a suicide on various family members should be considered, as it may differ for each. A number of examples may serve to heighten awareness.

The needs of children in the family where a suicide occurs may be overlooked. A death in the family can be a very frightening and confusing event for a child. The natural impulse for the parents or carers of the young is to shield and protect them from the trauma. Nevertheless, the sound mental health response is to endeavour to cope positively with the situation.

Parental reaction to death has a definite impact on the child's reactions. At the core of helping children to cope and adjust is the need to include children in the grieving process, to be open and honest to the extent that they are able to comprehend, and to explore their knowledge and feelings on death and dying.

Adolescence as a developmental stage in growth brings with it many complex changes.

The conflicts of activity and passivity, pleasure and pain, love and hate, despondency and autonomy are shared by the developing adolescent and people who are grieving. Both involve coping with loss and the acceptance of reality.

Young people's grief reactions can differ markedly from those of adults and can often be misinterpreted. Behavioural response may be at either end of the scale from adopting a parent-like role not typical of their age group to adopting the opposite stance and 'acting out' to gain attention and assurance.

Males as portrayed in Western society do not encourage emotional expression. As an outlet for the release of tension adolescent males may exhibit such behaviours as aggression, anger, the testing of authority, and abuse of drugs and alcohol. Adolescent females, in contrast, will often feel a longing for comfort and reassurance.

Adolescents will often show resistance to professional intervention, e.g. counselling or self-help support groups. The main source of support for adolescents comes from within the family unit.

While it is acknowledged that adolescents often speak to peers about personal matters, significantly more boys and girls use family members as confidants. Programmes aimed at lessening the risk of post-bereavement disorders need to be considered for implementation with adolescents.

The elderly, whether as grandparents or parents who have lost an adult child, will suffer profoundly. The spouse or partner of the adult child will be the recipient of the first line of condolences. The community may consider, because the child has grown and been conducting an independent and separate life away from the parents, that the effect is lessened. This is not the case.

A child, regardless of age, will always be a part of the parent. To grandparents, the death of a grandchild imposes grief that is two-fold - the acute pain they feel as parents for their son or daughter and also the intense grief for the loss of their grandchild.

Friends and colleagues will also be affected by the death in varying degrees, depending on their relationship to the survivor, to the deceased and to the family as a unit. Preexisting attitudes will also influence reactions, as they do with all people coming into contact with suicide. Indeed, all who have a close relationship to the deceased may in some manner experience the feelings that are unique to those bereaved by suicide.

It is important to remember that suicide does not occur in isolation but within communities. Groups and organizations (schools, the workplace, religious groups) within the community that are affected by the loss may benefit from the assistance of professionals such as health care workers or similarly trained persons to provide after-care and guidance.

Cultural, religious and social beliefs can also be explored and discussed. This interaction can provide a safety net to identify those who may also be at risk and provide an increased understanding of the circumstances that can relate to a death by suicide.

A healthy community response is one where all sectors are considered in the stage after the event.

SOURCES OF HELP FOR THE BEREAVED
Self-help support groups for survivors of suicide have an important role to play in identifying and encouraging members to make full use of assistance and supports available to them.

While grief is a 'normal' process for individuals to work their way through, the death of a loved one by suicide is generally not experienced as 'normal' although suicide is a commonly recognized cause of death. The needs of people bereaved by suicide are many and can be quite complex. Assistance and support can be forthcoming from a variety of sources.

Each source or contact can play an important role in helping the individual experience the normal process of grieving. Seeking help should be seen by the bereaved as a strength, not as a weakness, and as a vital step to the integration of the deceased person into their resumption of a full life.

A range or variety of supports and assistance will offer choices to the individual, taking into account individual preferences. If a range of supports are utilized by individuals, this will enable them to express different levels of feeling.

Families are the major source of support and assistance. Families that are able to share their grief have found this to be a major factor in coming to terms with the loss. The sharing of grief will also serve to strengthen the family unit. Factors that may assist families in achieving this are the family's openness to expressing grief, the absence of secrecy surrounding the death, and the understanding of family members' right to grieve in their own way.

Problems that may inhibit families from grieving together are:
  • destructive coping strategies
  • hiding the pain
  • denying the feelings the death has brought
  • avoiding, by pushing the death out of consciousness
  • secrecy and hiding the means of death
  • fleeing - escaping from contacts and the environment that are associated with the person who has taken his or her life
  • working, as a coping strategy, and keeping extremely busy
  • developing addictive behaviours, e.g. eating disorders, abuse of alcohol or drugs
  • blaming family members for the death.
Self-help support groups can assist group members by sharing situations and discussing problem-solving strategies as they arise in the family setting.

Friends and colleagues have a vital role to play in assisting the bereaved. The reactions of those in close contact with the bereaved are important, as their support, care and understanding can provide the opportunity for a safe haven and relief. On the other hand, negative or judgemental reactions may increase the distress and isolation of the survivors.

Avoidance behaviour is common amongst friends and colleagues and can also occur within the families of the bereaved. Such behaviour may indicate ignorance of the facts relating to suicide or an inability to cope with the feelings that the suicide has raised for that person. Common fears which can inhibit communication and lead to avoidance behaviour may include:
  • 'I don't know what to say.'
  • 'I don't want to make it worse for them.'
  • 'They have lots of family/friends around, they don't need me.'
  • 'They need the help of a professional, there is nothing I can do.'
  • 'This is a personal family matter they don't need outsiders.'
  • 'What if I say the wrong thing?'
The self-help support group can provide the bereaved with an understanding of the reasons for behaviour relating to avoidance or negativity, thus opening the door to discussion and understanding.

Friends have a vital role to play in assisting the bereaved. Some of their functions may relate to:
  • Listening and hearing, and responding with empathy
  • Knowing when the person needs to talk of his or her loss and serving as a sounding board for emotional relief
  • Providing the safety-valve for the relief and ventilation of true feelings. Family members will often hide their pain from other family members to protect them
  • Assisting in clarifying concerns relating to other family members
  • Assisting in practical ways with formalities that need to be completed after a death or assistance in maintaining the family home
  • Suggesting professional help when appropriate
Suicide, like homicide and 'accidental' death, is generally perceived as an unnatural death that can be horrific. As suicides occur frequently in the home setting, the survivor may also have found the loved one. The mental anguish and torment, flashbacks and visualizations, as a result of the method chosen to take the person's life, will often stay with the bereaved for extended periods. Professional help is often necessary. Consulting the doctor of the bereaved can be the first step, as referrals can then be made.

Professional assistance can provide the opportunity for objective support. One of the benefits of professional support is that the bereaved will not feel that they have 'burdened' the individual. This is a real fear in contacts with family and friends.

Health professionals of different types can provide assistance in a variety of ways. If physical health problems are experienced as a result of the bereavement, the local doctor can provide the care needed. Advice on general health care and symptoms that may be of concern to the bereaved, either in themselves or in family members, can be discussed and addressed.

If there are mental health or other stressful issues relating to the death, professional counsellors may provide relief by helping survivors in integrating the reality of the deceased and seeking meaningful solutions. A counsellor who specializes in or who has an understanding of grief issues can help the bereaved by providing them with an understanding of the grief process itself, thereby 'normalizing' the feelings they are experiencing and reducing the sense of isolation.

Psychologists can work with the bereaved in resolving specific problems that may have arisen since the death, e.g. anxiety or panic attacks.

Psychiatrists can also play a vital role, particularly if the bereaved are experiencing prolonged depression in which they feel trapped. If they express the thought that they are 'losing their mind', the support of a psychiatrist and medication may be needed for a period.

'Normalizing' the use of specialist services is of vital importance.
Social workers can help the bereaved in integrating the social relationship impact of cultural taboos, social supports, professional resources and their personal responses in going through the grieving process

HOW TO INITIATE A SELF-HELP SUPPORT GROUP FOR SURVIVORS OF SUICIDE
There are no predetermined rules for support groups and no guarantees of success.

Cultural diversities will, of course, heavily influence their operation. For some, the idea of sharing the very personal feelings evoked by a suicide will create a major barrier to forming a group.

However, if two or three people can find a common basis for sharing their experiences and feelings, the group process can begin. Experience gained by support groups that have functioned for a number of years suggests that some guidelines merit consideration by those contemplating starting a group or those interested in evaluating an existing group. No claim is made that the following points are all-inclusive.

Getting started
Starting a support group can take a lot of time and energy. A number of factors need to be considered by the individual proposing to start the group. It is important to recognize that there are costs involved (to pay for meeting space, refreshments, mailing of notices, honoraria for professionals, etc.), and to deal with the issue early in the operation of the group.

1. Who will serve as leader or facilitator of the group?
If you are one who has been bereaved will you be a lead facilitator or will you seek professional help to support and conduct the meetings? In the early stages of the group, a member of a helping profession may assist in setting up the group. It may be that a mental health professional who has a special interest and skill in working with survivors of suicide will want to start a support group where clients can benefit from the group process. Or, a survivor of suicide may want to join forces with a mental health professional to start a group where the experience of each can contribute to its success.

2. Are you at a stage in your grieving that enables you to put the necessary energy into setting up the group?
In the early stages of grief people's energies may be needed just to survive on a day-to-day basis. Those who are further along the grieving process, i.e. one to a few years, will have more strength, will likely have made some progress in regaining a purpose and meaning in life, and probably have 'integrated' the loss of their loved one or friend enough to be able to reach out to help others.

3. If you are a bereaved person and intend to be closely involved in facilitating the group, do you have the support of family members? They may not wish to be part of the group but if they are supportive of your need to form a group this will assist you.

4. Do you feel a commitment to help others in the same situation?


5. Do you feel the commitment to sustain a group over a period of time? There is a responsibility that goes with the formation of the group; once started, it will need to be sustained.

6. Do you have experience - possibly from a work situation, committees or group work '“ or organizational skills that can help you to get started? Skills in facilitating and working with groups are also useful. You should not hesitate to talk to professionals in your community about ways of obtaining additional skills or assistance. Once the group has been formed, it will have a pool of skills to draw on to so that its members can take on the roles identified for the group to function effectively.

7. What kind of bereavement support groups already exist in your local community?
You can check likely sources of information by reading local newspapers, talking to your doctor, asking at the community health centre, scanning community notice boards, or visiting your local library.

8. What has been the history or success of these groups?

9. What have the leaders of these groups learned about what works and what does not?

10. Is there an organization in the community that could serve as an umbrella organization for your group (for example, in Australia, a religious group, the Salvation Army, supports survivors' groups)?

The survivors' group should be seen as non-religious, as a religious emphasis may be a discouragement for some individuals. If you are able to operate under a larger structure it will assist in sustaining the group. If that larger organization also provides access to referral services, that is an additional bonus. An agreement will need to be reached with the umbrella organization that sets out mutually approved aims and objectives for the group.

Identifying the Need
The first step in starting a self-help support group for survivors of suicide is to find out if there are others in the community who are in the same situation and wish to get together to form a group. To make contact with like-minded people and plan an initial meeting, some background work will be necessary. You could begin by preparing a notice/circular that provides the basic details for the intended group.

This notice will need to include:
  • The purpose of the meeting, e.g. that a self-help support group is to be formed for friends and families who have been bereaved by suicide.
  • The date of the meeting. Sufficient lead-time should be allowed to get the information out to people.
  • The time of the meeting. An evening meeting in the first instance will make it easier for people occupied during normal working hours to attend.
  • The venue for the meeting. You will need to decide whether to conduct the meeting in a public place or in a private home. Keep in mind that if it is held in a home the needs of family members will have to be considered and also the safety issues relating to inviting strangers into the home. Often a public place can be seen to be more neutral.
  • The venue should be warm, inviting, comfortable and safe. Facilities for tea-making or other refreshments will also need to be available. The room should not be too large or too small, and should be closable to ensure privacy. Preferably it should be located close to public transport. Public buildings such as local council premises, community centres, schools, libraries or health centres often have suitable rooms that can be hired free of charge or at low cost by community organizations.
  • A contact person for further information. It will not be easy for individuals to come to the group, which can take a lot of courage. It may be helpful for them to talk to those who are organizing the meeting prior to the date. Friends of the bereaved may also wish to make contact.
Copies of the notice will then need to be distributed throughout the community to reach people who might be interested.

Helpful distribution channels might include established organizations that may already support the bereaved such as community health and medical centres, doctors' offices, local hospitals, community centres, religious groups or other support groups, e.g. The Compassionate Friends and The Samaritans.

Other methods of contact will be through the media, and might include: local radio stations that make community service announcements, local and regional newspapers, community notice boards, notices in the local post office, and newsletters relating to an associated area, e.g. mental health.

Preparation for the first meeting
Planning for this meeting is likely to include the following steps:
  • Draw up a list of all the things that need to be done
  • Book and confirm the meeting place
  • Prepare an agenda for the first meeting - it is essential that the format of the meeting is planned and that those attending know how it is to proceed (suggestions for a possible agenda are listed below)
  • Prepare to collect written information, e.g. contact details for people attending
  • Have name tags available
  • Consider whether the support of a professional or an experienced group leader/facilitator may assist in this first meeting
A possible agenda would be:
  1. Welcome from the meeting organizer
  2. Introductions - those attending may be asked to give their first name and say how they found out about the meeting
  3. Explanation of the broad purpose of the group
  4. Topics relating to formation of the group (see points below)
  5. Refreshments and socializing Topics to be discussed at the first meeting by the group could include the following:
  6. Is there sufficient interest to form a group? Having attended the initial meeting, do people wish to continue? Two or three people can usefully support each other and share information and ideas. While some survivors prefer a small group of five or fewer so that each person can talk more, others like a larger group where they can 'get lost in the crowd'.
  7. The frequency of the meetings: should they be held weekly, every two weeks or monthly?
  8. Factors to consider are that if meetings are too frequent - e.g. weekly - the individuals may develop a dependency on the group; on the other hand, if meetings are too infrequent - e.g. monthly - bonds may be difficult to form.
  9. Length of meetings: how long should the meeting last? Most groups find that meetings of one and a half to two hours work well. If meetings are longer they can be too emotionally draining for the participants. A two-hour time-frame allows half an hour for settling in and updating, an hour for the meeting itself, and half an hour for refreshments and socializing. The group size may determine the length of the meeting, as larger groups may need longer group meetings. Keep in mind that if the group is large, it may be suitable to split it into subgroups for part of the meeting.
  10. What are the expectations of those attending? Develop a clear picture of why people are attending. Are the expectations realistic?
  11. Contact details of those who wish to continue to meet. The group may also wish to exchange contact numbers for support between meetings.
  12. Date of the next meeting.
DEVELOPING THE OPERATIONAL FRAMEWORK FOR THE GROUP
The next step is to develop a set of operational guidelines and framework for the group's functioning. Areas that will need to be considered are discussed below.

Aims and Objectives
The group will need to establish its aims, in the form of a statement that describes the overall purpose or vision of the group. Similarly, it should fix its objectives - a set of clear statements that define the areas the group wishes to focus on.

Establishing the group's structure
Two broad types of structure may be considered as options:
  1. 'Open' and ongoing, without a set end-point, meaning that the group members attend and stop attending according to their needs. The group is permanent and meets at certain times throughout the month/year.