Three Sibling Survivors' Perspectives of their Father's Suicide: Implications for Postvention Support.

This qualitative case study describes three adult siblings' experiences and their perceptions of support connected with the time before and after their father's suicide. At the time of the suicide, participants were ages 1, 5, and 8 years old. We considered commonalities and disparities among the three survivors' perceptions. We also considered how their reported experiences compared to extant literature on child survivors of parent suicide. Our findings suggest that, although the siblings experienced the same traumatic event, each had unique perceptions of the parent's suicide. Immediately prior to closing each interview, to deescalate from the intense topic of suicide, participants offered their impressions of potentially therapeutic children's books and how bibliotherapy may or may not support surviving children. Participants' perceptions of selected children's picture books offer insights about opening communication and addressing challenges specific to a parent's suicide. Implications for teachers, parents, and school-based mental health professionals are provided. We conclude that postvention must consider and monitor each child's perceptions and provide individualized interventions that encourage open communication and support adaptive coping to navigate the intense grief associated with a parent's suicide.

Introduction

Worldwide, approximately 700,000 individuals die from suicide each year (World Health Organization, 2021). In the United States, suicide is the tenth leading cause of death, accounting for approximately 48,000 deaths each year (Centers for Disease Control [CDC], National Center for Health Statistics, 2020). Associated with these suicide statistics are a multitude of survivors who grieve the loss of their deceased loved one. Unfortunately, for survivors, the stigma associated with suicide exacerbates the grieving process, making it particularly difficult to talk about suicide—leading to further isolation and alienation (Hanschmidt et al., 2016).

Child Survivors of Parent Suicide (CSoPS)

The most vulnerable of suicide survivors are children (Hung & Rabin, 2009; Ratnarajah & Schofield, 2008; Schreiber et al., 2017). Each year in the United States, approximately 7,000 to 12,000 children experience their parent’s suicide (Cerel et al., 2008). For children, the death of a parent is one of the most stressful events they will experience in their lifetime (Cullen, 2018; Hagström, 2019; Hua et al., 2019; Worden, 1996; Yamamoto et al., 1996). In addition, when the parent’s death is caused by suicide, children are particularly vulnerable to both short- and long-term negative outcomes (Cerel et al., 1999; Hua et al., 2020; Sveen & Walby, 2008; Worden, 1996). For example, in a two-year study of 26 children whose parent died by suicide, Cerel et al. (1999) found that although bereavement from suicide initially resembled bereavement from other causes of death, during the second year, children whose parent died by suicide experienced much longer-lasting intense symptoms of grief, including higher levels of anger, shame, and anxiety. Additionally, Wilcox et al. (2010) found that death of a parent by suicide, when compared to other causes of parent death, increases the risk for developing mental health disorders, including psychosis, depression, and personality disorders. Furthermore, Wilcox et al. (2010) noted age differences: across time, younger children (ages 0–12 years) appeared to be more impacted by a parent’s suicide than were young adults (ages 18–25 years).

Other research indicates that CSoPS are more likely to suffer complicated grief that negatively impacts long-term peer relationships and job and career satisfaction (Brent et al., 2012). Perhaps most concerning, CSoPS are at a significantly increased risk for contemplating, attempting, and completing suicide (Hua et al., 2019; Serafini et al., 2015). Indeed, the grieving process for CSoPS seems to call for a unique approach to support children’s adaptive coping strategies and healthy adjustment (Hagström, 2019; Jordan, 2001; Sveen & Walby, 2008). In particular, Ratnarajah and Schofield (2008) identified the urgent need for resources to support CSoPS. Similarly, Andriessen (2014) describes the sparse number of both printed and online interventions and resources catered towards supporting this significant need, specifically school-based support (Loy & Boelk, 2014). Additionally, the bulk of research and financial support are focused on suicide prevention, not suicide postvention efforts (Loy & Boelk, 2014). Although prevention is imperative, postvention for children bereaved by suicide is a critical aspect of suicide prevention (Cerel et al., 2008; Hua et al., 2019). Prevention efforts must prioritize the development of evidence-based postvention interventions for CSoPS (Andriessen, 2014, Andriessen et al., 2019a, 2019b; Andriessen et al., 2020; Hua et al., 2020; Hung & Rabin, 2009).

Following traumatic events—due to a lack of available mental health professionals worldwide—the WHO (2011) notes a need for strengthening home and community social-emotional support. Likewise in the United States, the Centers for Disease Control and Prevention (n.d.) estimates that only 20% of children with mental, emotional, or behavioral disorders receive specialized care from a mental health professional. Research indicates that individuals such as survivors of suicide benefit from open communication and opportunities to talk about the suicide because this helps them process their thoughts and feelings (Cohen et al., 2017; Levi-Belz, 2019; Regehr et al., 2021).

Of the few studies investigating CSoPS, researchers note limited support for children and minimal communication regarding the suicide (Cerel et al., 2008; Hagström, 2019; Hung & Rabin, 2009; Leichtentritt et al., 2018; Schreiber et al., 2017). Lacking opportunities to talk about their parent’s suicide, children often suffer in silence and navigate their grief in isolation (Hagström, 2019; Hung & Rabin, 2009; Leichtentritt et al., 2018). This lack of access to professional mental health support suggests a need to consider interventions, such as bibliotherapy, that can be offered by caring adults in the child’s natural environment (Heath et al., 2005; Regehr et al., 2021).

Opening Communication about Suicide with Bibliotherapy

Following a parent’s suicide, children often struggle with feelings of abandonment, confusion, anger, fear, guilt, and self-blame (Hagström, 2019; Hanschmidt et al., 2016; Regehr et al., 2021). Reading stories with children is one way to facilitate conversations about tough topics and to normalize children’s experiences, helping them know that they are not alone in their suffering (Heath et al., 2005; Kanewischer, 2013; Regehr et al., 2021).

Bibliotherapy is a therapeutic intervention that utilizes stories to help individuals gain personal insight and learn coping strategies that empower them to face challenging situations (De Vries et al., 2017; Malchiodi & Ginns-Gruenberg, 2008). A positive aspect to consider is that this type of intervention feels safe and familiar to children, who enjoy having stories read to them (Cohen, 1987). In fact, Pardeck and Markward (1995) note that reading a story with a child helps build trust and rapport. However, when supporting CSoPS, minimal information is available to guide adults in selecting children’s books that might offer support to grieving children and open communication about death, specifically suicide (Regehr et al., 2021; Watson et al., 2021).

The Current Study

Learning from CSoPS

Existing suicide survivor research is commonly based on quantitative research (e.g., Sveen & Walby, 2008; Wilcox et al., 2010). However, qualitative studies, including interviews, offer valuable insights into the thoughts, feelings, and experiences of this population (Begley & Quayle, 2007; Ratnarajah & Schofield, 2008; Sveen & Walby, 2008). These insights hold potential in laying groundwork for evidence-based intervention to support CSoPS (Mitchell et al., 2006). Even though researching suicide is an extremely sensitive endeavor, adult suicide survivors who participate in interviews generally report that talking about their experience is cathartic and therapeutic (Moore et al., 2013; Omerov et al., 2013). However, due to the heightened vulnerability of CSoPS, very few research studies have included child interviews, particularly interviews with preschool and elementary school-age children (Schreiber et al., 2017). Additionally, research conducted with adults who as young children lost a parent to suicide is limited, with only a few studies investigating retrospective reports (Irwin, 2010; Kharay, 2011; Watson et al., 2021; Wilson et al., 2019). This dearth of research is associated with limited research-informed postvention support for CSoPS, including family-based support efforts (Andriessen, 2014, Andriessen et al., 2019a, b; Mitchell et al., 2006; Watson et al., 2021).

The current study focuses on the under-researched population of CSoPS, investigating their perceptions of children’s books that may provide postvention support (bibliotherapy). This study includes three sibling participants from a previous larger data set of 17 CSoPS (Wilson et al., 2019). The prior study investigated survivors’ perceptions of what they considered helpful and what they considered not helpful following their parent’s suicide. The current study is unique because we only focus on three siblings’ perceptions of their father’s suicide (one incident) and the three siblings’ perceptions of children’s picture books.

Research Questions

The expressed hope of this study was to gather information that would better inform intervention to support CSoPS. This study explores the perceptions of sibling survivors who as children experienced their father’s suicide. Our study investigated the following research questions:

How did adult siblings, CSoPS, remember their father’s suicide?

How did survivors perceive children’s picture books as a potential strategy to open communication following a parent’s suicide?

Method

Although the type of inquiry represented by this study may be questioned by those who are more familiar with quantitative data collection and analysis, qualitative methodology is gaining more recognition for quality research work that helps us gain a better understanding of “complex reality and the meaning of actions in a given context” (Queirós et al., 2017, p. 369). Best practices in qualitative research include standards of rigor that promote credibility and trustworthiness of the data (Brantlinger et al., 2005). Lincoln and Guba (1985) proposed that the standards of credibility, transferability, dependability, and confirmability be utilized to ensure trustworthiness. These standards help translate components of quality for those who are more familiar with quantitative methodologies. For example, a standard of rigor for quantitative work is associated with statistical generalization and the ability to effectively apply study results to a similar population. Rather than seeking to generalize study results to similar populations, a parallel quality indicator for qualitative work is the resonance of the work (Tracy, 2020). Resonance speaks to the transferability or naturalistic generalization of the research. Natural generalization includes a process in which readers intuitively apply a study’s findings to similar situations (Tracy, 2020)

Case Study

A collective case study design (Merriam, 2009) was chosen as the basis for conducting this research. This case study was exploratory in nature and sought to discover and describe how three siblings experienced their father’s suicide, specifically investigating their perceptions of support that may or may not have been helpful. Additionally, we sought their perceptions of potentially therapeutic children’s books that may open communication and offer support to CSoPS.

Case studies have been appropriately used across the social sciences to examine the context of real-life phenomena (Smith, 2018) ranging from community-based health programs (Killingback et al., 2017) to Covid-19 mental health challenges (Bhuiyan et al., 2020). Creswell (2013) suggested that case study design is typically chosen when researchers want to understand phenomena that are unusual, uncommon, or unique (e.g., adults who were CSoPS). According to Yin (2012), case study designs are a good fit when research focuses on “how” questions, such as this study’s research questions. Further, researchers employing a case study design pay particular attention to temporal context, such as focusing on child survivor’s memories before, during, and after the parent’s suicide. Case studies also help researchers view unique phenomena in a holistic manner—such as acknowledging and considering the details of each sibling’s unique experience (Cohen et al., 2017; Feagin et al., 1991; Van Dongen, 1993; Yin, 2012). Additionally, the case study design allows researchers to capture participants’ change across time, describing the ongoing and long-term effects of surviving their parent’s suicide. As such, the case study methodology allowed the researchers to drill down and explore the in-depth nuances and impact of three sibling survivors’ experiences (Smith, 2018).

Participants

After we received the sponsoring university’s Institutional Review Board’s (IRB) approval to conduct the research, three sibling participants’ interviews were selected from a larger, pre-existing data set for further analysis (N = 17; for additional details, refer to Wilson et al., 2019). The larger group of participants, that included the three siblings, were recruited from within 50 miles of the sponsoring university located in an urban area of the Intermountain West (USA). Invitations to participate were offered to individuals in bereavement groups, social media platforms, and suicide prevention groups. Invitations were also posted on city and college library bulletin boards. The invitation to participate included information about the initial study and researchers’ contact information for participants to set up an interview appointment. Three siblings contacted the primary interviewer through email. All three indicated an interest in being interviewed about their father’s suicide. To protect confidentiality, participants’ names were replaced with pseudonyms. At the time of the interview all siblings met the criteria to participate: All were older than 18 years and the parent’s suicide occurred more than two years prior to the interview. At the time of their father’s death, Denise was 8; Justin, 5; and Delani, 1 year old.

One of the most important tasks in qualitative inquiry is to identify appropriate study participants who can inform salient facets and perspectives related to the phenomenon being researched (Sargeant, 2012). Thus, qualitative participants are considered experts as “it is their perception of their own life-world that the researcher is striving to understand” (Austin & Sutton, 2014, p. 6). In addition to choosing appropriate study participants, appropriate sample sizes must be determined in both quantitative and qualitative studies. However, while sample size in quantitative work concerns itself with statistical power, sample size in qualitative work is concerned with sufficient information power (Malterud et al., 2016). Sufficient information power depends upon sample specificity, quality of dialogue and analysis strategy. Typically, the closer the match between the study phenomena and the life of the participant, the greater the information power. These three sibling participants were purposefully chosen for this study because they lived the shared trauma of their father dying by suicide. This study’s one-on-one interview protocol allowed each sibling to individually describe their lived experience.

Data Collection

Carefully planned, in-depth interviewing accompanied by attentive member checking and rich, thick (Tracy, 2020), multidimensional (Smith, 2018) descriptions of data episodes used for analyses (Malterud et al., 2016) creates higher quality dialogue. Sample specificity, quality of dialogue and intentional use of analysis strategy correspond with lower sample sizes with sufficient information power (Malterud et al., 2016).

The data for this study were collected through semi-structured interviews lasting from 40 to 90 min that were conducted in a mutually acceptable and conveniently located library’s private meeting room. Before the interviews, the participants filled out a basic demographic questionnaire (name; ethnicity; email contact information; current age and age at the time of the parent’s suicide; and the type of suicide death). The interviews were audio-recorded and following the interviews, transcribed verbatim. To add depth to the interview transcripts, the interviewer took field notes that described participants’ emotional responses.

The semistructured interview questions included the following prompts:

Having a parent who died by suicide – what was that like for you? Tell me about your experience.

In the immediate aftermath of the suicide, (a) What did you perceive as most helpful? (b) What did you perceive as least helpful? (c) Who was helpful and who was not helpful?

In the year following the suicide, (a) What did you perceive as most helpful? (b) What did you perceive as least helpful? (c) Who was helpful and who was not helpful?

Following the semi-structured individual interview, to help each participant move from talking directly about their personal experience as a CSoPS, each participant was invited to review three pre-selected children’s picture books. Two of these books were specifically about suicide, The Little Flower Bulb (Gormally, 2011) and After a Suicide: An Activity Book for Grieving Kids (The Dougy Center, 2001). The third book, The Invisible String (Karst, 2000), is commonly used by counselors to address a wide variety of children’s issues, including death and grief. The interviewer asked the participant to indicate which books they would or would not recommend to young children bereaved by suicide. The interviewer asked participants to explain their recommendations. Reviewing and commenting on the books expanded the main interview an additional 10 to 15 min and was intended as an activity to deescalate intense emotions and to help participants exit from the interview experience.

Coding and Analyses

The de-identified transcripts were downloaded to a word document which served as an organizational tool while data were read, coded, and analyzed for meaning. Described in the following sections, this analysis was completed manually in two phases: within-case analyses and cross-case analyses.

Within-case analyses

Because we sought to understand the lived experiences of each sibling before, during, and after their father’s death by suicide, it was necessary to code specifically for these active data episodes. We used a priori process coding during much of the within-case analyses. Process coding is especially beneficial to understand how actions intertwine with the dynamics of time in the data (Saldaña, 2015). In the within-case phase, we utilized the following five a priori process codes related to time:

Leading up to the suicide.

Finding out about the suicide.

Coping immediately after the suicide.

Adjusting after the suicide.

Living long term with the suicide.

In contrast, we also used open coding during the within-case analyses to uncover other important features of the siblings’ individual experiences in the context of surviving the suicide. Most often, open coding is a process a researcher uses when examining evidence in the data to answer a question such as, How did the siblings feel supported—if at all? (Charmaz, 2014). Most often, open codes initially emerge as a broad idea, such as support, then more detailed categories within the broader overarching idea are also coded, such as support from family, support from faith community, etc. Open codes that were particularly relevant in the within-case analysis included the support individuals received and the challenges individuals experienced.

After the a priori process and open coding were completed, only those data episodes that provided evidence for the codes where retained. Next, axial coding took place. Axial coding is a process through which researchers strategically connect codes to create interpretive segments or categories (Saldaña, 2015). During axial coding the properties or dimensions of these categories are specified and considered, such as the context surrounding how one of the siblings learned of the father’s death by suicide (Saldaña, 2015). Axial codes were then used to create an in-depth portrait of each sibling’s experience.

Cross-case analyses

The second phase of data analyses included comparing and contrasting the in-depth portraits of each sibling. The cross-case analyses allowed the researchers to notice the differences in how each sibling experienced their father’s suicide. For example, during phase one process and open coding, the researchers discovered that the participants often spoke of a variety of supports that were offered to help them cope. During axial coding in phase one, the researchers began to consider the context of each individual’s supports. In phase two, as the researchers compared and contrasted support systems across participants, it was discovered that the children had different perceptions of the specific supports and responded differently to the supports that were offered. Therefore, phase two, cross-case analyses yielded a more thorough and contextual understanding of the similarities and differences across sibling experiences. This sort of in-depth fusion of coding within cases, then across cases resulted in a more robust understanding of each participant’s lived experiences.

Methodological Framework Considerations

The method for this study was based upon certain philosophical presuppositions. First, we assumed a relational ontology. That is, we assumed that knowledge is produced, expanded, and preserved through relationships rather than an independent commodity (Gergen, 2009; McKenzie et al., 2013). Hence, the decision to look at three siblings’ experiences of a shared trauma.

Second, we acknowledged at the outset the inherent complications, uncertainties, and advantages of working with the retrospective stories of members of a vulnerable population (e.g., CSoPS). This study’s data are retrospective in nature and participants reported on memories of their experiences following their parent’s suicide. We rejected the criticism that retrospective memory work is too subjective a source for social science research (McLeod & Thomson, 2009). We ascribed to the idea that retrospective interviews by adults have been found to include more depth and emotional poignancy than memory work conducted with children (McCammon et al., 2012), can reflect more accurate representations of past family life (Bell & Bell, 2018), and can forge a missing voice for vulnerable or silenced populations (McLeod & Thomson, 2009), such as CSoPS. Therefore, we aligned with recognized principles of rigor for retrospective work by developing research questions that focused on a specific situation (parent suicide) rather than a life in its entirety. We also compared participants’ perceptions of past events (parent suicide) with participants’ present thoughts about which children’s books may be beneficial to CSoPS. As a team (through rounds of reflexivity described in the following section), we realized that child survivors’ perceptions across time, whether consistent or inconsistent, provided targets for supportive intervention (Supiano et al., 2017).

Third, because the study was centered on and intended for CSoPS and those who support them, we agreed that the study would be grounded in Cohen et al., 2017 trauma-focused cognitive behavioral therapy that includes strategies such as the individual trauma narrative and highlights the importance of opening communication about the trauma. As such, we opted for a more postmodern philosophical foundation that would allow us to simultaneously understand the relational components of the siblings’ experiences while recognizing the individual narrative within the shared trauma.

Trustworthiness

In this study, procedures incorporated to help ensure trustworthiness included triangulation, peer debriefing, member checking, thick description, external auditing, and researchers’ positionality (Brantlinger et al., 2005). These procedures are more fully described in this section. Using multiple views of the same phenomena (three sibling interviews were focused on the same trauma) helped to triangulate and strengthen the findings. The researchers also incorporated peer debriefing with an outside expert member. The outside expert member is a doctoral level licensed psychologist with an expertise in suicide postvention, particularly with CSoPS. The intent of involving the expert member was not to merely legitimize the findings, but rather to help the research team consider the plausibility of the findings as compared to current research and professional literature related to CSoPS.

Further, member checking was employed during data collection. Given the sensitive nature of the topic, each participant in the study reviewed their own typed transcript and made corrections as needed to ensure accuracy. A thick description of the context provided a better understanding of the individual’s perspective and their personal meaning making (Tracy, 2020). For example, during member checking, Denise expressed that her original transcript reflected too harsh of a description of her father. Consequently, she made a few minor changes in her transcript in order to offer a more positive view of her deceased father. After the transcriptions were approved by participants, the updated transcripts were de-identified and uploaded to a password secure server.

Finally, self-reflexivity was employed during the study to consider ways the researchers’ perspectives may have influenced the data analyses (Tracy, 2020). Rather than reporting on inter-rater and intra-rater reliabilities, qualitative researchers are currently encouraged to practice reflexivity in order to strengthen rigor and to gain deeper interpretive access to the data, (Goldspink & Engward, 2019). Reflexivity in the research process has been defined as the ability to reflect on and consider intersubjective dynamics between the researcher and the data (Biggerstaff & Thompson, 2008). Instead of seeking to bracket or diminish researcher roles in the inquiry process, reflexivity allows researchers the opportunity to acknowledge and explore their role in analyzing and interpreting the data (Shaw, 2010). We deliberately incorporated reflexivity rounds in the current study and kept notes throughout.

For example, prior to the study, one of the researchers shared that two of her close family members were child survivors of a parent’s death (not caused by suicide). Two additional members of the research team disclosed they had close family members who were child survivors of a parent’s death by suicide. The research team met multiple times to openly discuss how this lived experience both informed and impacted the analysis and findings of the data. We specifically discussed how the experiences of CSoPS were similar to or different from parental death by other causes.

Results

In this section, we provide a summary of the participants’ comments made during the individual interviews. Although each participant, at the time of the interview, was an adult (older than 18 years), at the time of their father’s death, the children were 8 (Denise), 5 (Justin), and one-year old (Delani). Each sibling related and remembered different aspects of life before the suicide, how they found out about the suicide, and how they dealt with the aftermath of the suicide (see Table 1).

Table 1

Synoptic Results Table

	Participants
Themes	Denise8a	Justin5a	Delani1a
Memories of Experiences Leading up to the Suicide	Despite awareness of parents’ marital issues and father’s depression, recalls words of reassurance that he loved her.	Described his father as being emotionally unavailable to Justin and his siblings as well as being physically absent from home.	No personal memories, mother describes to Delani that her father went through what seemed like a goodbye ritual the morning of his death.
Memories of Finding out About the Suicide	The day Denise found out about the suicide, she was going to go visit her father at her grandparents’ home. Although she had the initial impulse to check the grandparent’s barn for her dad, Denise decided instead to go to her aunt’s house, to play with a cousin when she heard sirens from five or six cop cars Denise and her aunt were among the first to arrive at the house after the emergency vehicles. Denise asked the police officers what happened. One officer, not realizing the victim was Denise’s father said’Yeah, he’s dead. You need to go away.’ Denise had a difficult time believing he was dead.	Justin remembered being at his grandparent’s house not feeling concerned as he and an uncle searched for his dad. After searching the basement, the search continued outside in the barn. Justin was behind his uncle and felt something was terribly wrong when his uncle yelled, ‘Go home! Run home now!’ Terrified, Justin started running, thinking there was a monster in the barn. Hours later, Justin’s mother came home and told the children their father was dead and young Justin’s first reaction was to ask, “Who killed him? Was it the monster in the barn?”	Delani grew up knowing her father had died, but not knowing the cause of death was suicide until she was much older. The information Delani gleaned about the suicide was bits and pieces her mother shared with her across time.
Memories of Mother’s Support	Although her mother spoke to her about her father’s death, Denise did not receive professional counseling in the aftermath of her father’s suicide. While trying to make sense of her father’s death, Denise simultaneously witnessed her mother’s emotional reaction to the suicide. Following the suicide, as time passed, a pattern of Denise wanting to reach out, support, and comfort her mother continued.	Justin did not remember much support available to him. He describes a gradual process over time of learning that his father died by suicide. Even after being told that his father died by suicide, young Justin continued to have questions about his father’s death. Eventually, Justin’s mother was the one who answered his questions of Why? She explained that his father struggled with mental illness.	Delani worried that she had somehow contributed to her father’s death. Hearing stories of how difficult Delani was as a baby, exacerbated the feeling that she was somehow responsible for causing her father to complete suicide.
Memories of Support Following Mother’s Remarriage	Denise identified her mother’s remarriage a year after her father’s suicide, as healing and supportive for her and the family.	Justin described his mother’s remarriage soon after his father’s death as positive.	Delani attributed her mother’s hasty remarriage as a necessity due to her mother having small children and limited financial resources. Although Denise reports the mother remarrying after a year, Delani reported that her mother remarried “within six months.”
Memories of Religious and Spiritual Support	Denise described how her faith community offered support in the form of meals, money, and visits. Following her father’s death by suicide, Denise also found comfort in spiritual dreams in which her father was present. Denise expressed her beliefs that she would see her father again and that he continually watched over her.	In contrast to Denise, Justin did not seem to find the same solace in his religious beliefs. A Sunday School teacher’s quick matter-of-fact response that his father could not go to heaven, fueled Justin’s fear that he would never see or be close to his father again.	In coping with her father’s suicide, Delani did not specifically identify faith or religious beliefs as helpful or unhelpful.
Memories of Support from Extended Family	Denise pointed out extended family members specifically being an important source of love and support following her father’s death and felt surrounded by extended family members’ loving help.	Unlike Denise, Justin did not perceive his extended family as being helpful or very supportive. He recalled his father’s brother blatantly blaming Justin’s mother for the suicide. The anger and resentment were to the point where at the time of the interview Justin had not interacted with his father’s side of the family in many years.	Delani not only described extended family as not supportive, she disclosed suffering long term abuse perpetrated by an extended family member.
Memories of Support from School Community and Neighbors	Denise felt supported by classmates, teachers, neighbors, and people in her school community.	Justin suggested that returning to school quickly helped to normalize his life after the suicide.	Delani did not talk about school or community support to her or her family after her father’s suicide.
Ongoing Challenges After the Suicide	Although Denise felt loved and supported by her family, had a positive experience with her mother’s remarriage, and felt that her faith supported her after her father’s death, she still felt shame when people asked about her father’s death.	Justin had difficulty in knowing how to tell others of his father’s death. He continues to deal with ongoing resentment towards his father. He also continues to question his own bereavement process.	Delani focused on dysfunctional extended family relationships following the suicide, such as the long-term negative effects of the abuse perpetrated by her male cousin.
Survivors’ Response to Children’s Books	Denise immediately identified with the explanations about chemical imbalances in the brain as a factor in a person choosing to die as explained in After a Suicide: An Activity Book for Grieving Kids. Denise appreciated the metaphor in, The Little Flower Bulb. She indicated that the idea of endowing a growing, living object with the memory of the father who died by suicide, was positive and seen as potentially helpful for CSoPS.	Justin displayed a strong negative, visceral reaction to The Little Flower Bulb. As soon as Justin saw the cover of the book, he immediately reacted negatively to the illustration style. The book’s cover included an illustration of a small boy surrounded by flowerpots and a toy bear. The boy’s head was tilted to one side. This was particularly off-putting for Justin who connected a cause of death to the dead-looking boy on the cover, based on the boy’s body posture. Justin went on to say that the overall feeling of the illustrations was completely negative.	Delani was drawn immediately to the mom in The Invisible String telling the children that no matter how she feels whether angry or not, their connection could never be broken. Delani also responded positively to the idea of the invisible string applying to separations caused by death and other traumatic situations. In contrast to her older sister Denise, Delani had a strong negative reaction to After a Suicide: An Activity Book for Grieving Kids. She described this book as very “cold.”

aDenotes age of participant at the time of the father’s death

Although each of their stories is unique, there was common ground: Each individual referred to their immediate and extended families. Whenever they referred to my family, they generally were describing their immediate family (their siblings and their mother and father). Whenever they referred to their extended family, they were typically referring to their father’s side of the family. At the time of the suicide, the immediate family and the paternal extended family lived in close proximity to one another.

Memories of Experiences Leading up to the Suicide

Denise

Denise was eight years old when her father died by suicide through hanging. When asked about her memories leading up to her father’s death, Denise did not recall precise details, but seemed to be aware that her parents were having difficulties in their marriage and that they had recently separated. Her father was staying close by, living with his parents, Denise’s paternal grandparents. Despite her parents’ marital issues, Denise warmly recalled her father and his words of reassurance that he loved her. She also remembers him giving fatherly advice. She commented, “I do remember him [dad] always expressing how much he loved me and, um, to always say my prayers, and things like that, you know.”

After the suicide, as she grew older, Denise reports becoming increasingly aware that her father struggled with depression. However, she could not recall him acting in a depressed way, asserting that he generally appeared happy and that he was “sweet.” She shared,“Yeah. And as a young child he didn’t seem depressed to me, and I’m sure that he would never have acted that way in front of me [even] if he was.”

Justin

Justin was 5 years old when his father died by suicide. When asked about his memories leading up to his father’s death, Justin described his father as being emotionally unavailable to Justin and his siblings as well as being physically absent from home. He said, “My dad was not around too much. I don’t think he was super emotionally available or very much physically, when we were kids.” After the suicide, Justin remembered his mother telling him that his father suffered from mental illness. “I mean, my mom says he kind of was troubled like he was depressed and she says it was a chemical imbalance and stuff like that.”

Justin was not inclined to describe his father as a good guy. Rather, Justin asserted his father did not take responsibility for his family or financial pursuits, including having or keeping a job, which Justin believed contributed to his father’s mental state. Because of Justin’s age at the time of the suicide, Justin’s memories of his father appeared to be influenced by how others perceived his father, particularly how his mother perceived his father. In referring to his father, he frequently referred to his mother’s input, stating “My mom says…” or “my Mom said…” He commented,

She [Mom] said he would, like, make money and then sort of not work for a while and sort of live off that money and then [he would say], “Oh, I’ve got to get up and do another job, I’ve kind of avoided that responsibility.”

Delani

Delani was one year old when her father completed suicide. She reported that all of her memories of what led up to the suicide, the actual suicide, and the immediate aftermath are based on what her mother told her. She said, “Everything that I know about it, my mom has told me. And it’s mostly me asking her. She isn’t very open about it.” The morning of the suicide, her mother described to Delani that her father went through what seemed like a goodbye ritual. Delani shared: “My mom said the morning of [the suicide], my dad was acting very strange and very sentimental. She said he hugged each one of my siblings for a weirdly long time.” These long, goodbye hugs included Delani as well. She described this final encounter:

[Mom] said he sat down on the couch and held me for a long time and was nuzzling me with his face and things like that. It was like he was saying goodbye to me. And then he said goodbye to her and left just like it was a normal day.

Delani explained that this was the last time the family saw the father. “He went to go to work, and he never came home. So, he was missing for two or three days, we couldn’t find him.”

Memories of Finding out About the Suicide

The day Denise found out about the suicide she was going to go visit her father. Since her parents’ separation, her father had been staying at her grandparents’ home, within walking distance of where she lived with her mother and siblings. Denise commented, “So I went over there, but I couldn’t find him. I yelled his name and was looking for him.” Although she had the initial impulse to check the barn for her dad, Denise decided instead to go to her aunt’s house, near her grandparents’ house, to play with a cousin. Denise explained: “…all of a sudden I heard a bunch of sirens, a ton of cop sirens, there were at least five or six cop cars at my grandparents’ house, and I looked at my aunt and said, ‘My dad’s there.”’

Denise and her aunt were among the first to arrive at the house after the emergency vehicles. Once at her grandparents’ house, Denise asked the police officers what happened. She stated, “I kept tapping on them saying, ‘What happened? Is he dead?’ like, ‘Is he hurt?’ and one of them looked at me and said, ‘Yeah, he’s dead. You need to go away.’” Denise reported that she experienced an immediate emotional response.

My heart just started throbbing. I was crying and I didn’t really want to believe that that’s what happened. Then my mom, came pulling up. She got out of the car, and she fainted. I just watched, like, her faint [crying] and I didn’t really know what to do, I was just scared.

Denise had a difficult time believing he was dead because she was sure she had seen him earlier on the same day that they found his body. “I didn’t believe [it] because I was like, ‘Well I saw him earlier that day,’ and I tried to tell them and they’re like, like, ‘I’m sorry, but it must have been someone else.’” But Denise continued to believe her father was alive. “I remember thinking, just not believing that he was dead, and thinking that he was going to come home. And so, I would sit at the bottom of the stairs for days and wait for him.” Finally, Denise’s mother talked to her. “My mom was like, ‘Denise, he–he’s not gonna come home’ [crying]. I think I probably should have had some sort of counseling, but… I never did [emotional], you know?”

On the day Justin found out about his father’s death, he remembered being at his grandparent’s house. Justin shared that he did not feel concerned as he and his uncle searched for his dad. The search in the house included searching the basement. “I remember going to their basement. I found a cookie monster toy that I loved and I was like ‘sweet!’ At the time, that’s all I cared about was that cookie monster toy [laughs].”

After searching the basement, the search continued outside. Justin recounts the details:

And then we went out to the barn, walked in, and I remember I was behind my uncle who was in front leading…. And I remember, feeling a kind of tension there. I think my uncle kind of knew something was wrong. He got to the top of the stairs. I was just about to the top of the stairs myself and I remember him going ‘Oh shit!’ Then he turned around and looked at me and yelled, ‘Go home! Run home now!’

Terrified, Justin started running. “I remember running home and I kept thinking there must have been a monster in the barn.” Justin remembered going home and feeling very frightened. Justin’s mother came home later and told the children their father was dead and young Justin’s first reaction was to ask, “Who killed him? Was it the monster in the barn?”

Justin recalled the time right after the suicide as being hazy and his reaction being something other than grief. He said:

It’s pretty blurry after that. I don’t remember crying. I don’t remember being particularly sad or stricken with grief at the time. Maybe I was just too young. I don’t remember grieving at all. I do remember feeling happy and then feeling guilty that I felt happy because everyone around me was sad.

Because Delani was only one year old when her father died, the information Delani gleaned about the suicide was bits and pieces her mother shared with her across time. When Delani was older, her mother explained that after leaving for work on the last day the family saw him,

He went into my grandfather’s barn and he tied himself up and he stepped through his arms so his arms were tied behind him. He had hung the rope very low and he just put it around his neck and sat down in it, basically.

Unlike Denise and Justin, Delani was the only sibling who elaborated on the mode of her father’s death. This may be in part because she was told about his death when she was older and she did not have the immediate emotional reaction of experiencing the horrific details of the suicide.

Delani grew up knowing her father had died, but not knowing the cause of death was suicide until she was much older. She recalled: “I kind of just grew up knowing that it had happened. My mom sat me down and asked: ‘Do you know what happened to your father?’ and I said, ‘Yeah, he’s dead, he’s gone.’ and that was it.”

Memories of Mother’s Support

Although her mother spoke to her about her father’s death, Denise did not receive professional counseling in the aftermath of her father’s suicide. Denise explained:

I don’t know if my mom thought about counseling. Maybe she just thought, ‘She’s young, and I’d rather just be there for her’ and you know. She would always ask me ‘Are you okay?’ And I would talk to her, if I was feeling sad, I would tell her. And so, it was really good.

While trying to make sense of her father’s death, Denise simultaneously witnessed her mother’s emotional reaction to the suicide. “I just remember, afterwards, um, just watching the sadness of my mom and watching her cry and wanting to comfort her.” Following the suicide, as time passed, this pattern of Denise wanting to reach out, support, and comfort her mother continued. It is interesting that Denise’s memories included supporting her mother and her mother supporting her.

A lot of times I would sleep in her bed if I was scared or if I thought she was lonely. If she was lonely, I’d go and sit by her, and ask her if she needed anything and stuff. If she was sad and crying, I would just sit there and give her a hug.

Although Denise described giving and receiving support from the mother, Justin did not remember much support available to him. He describes a gradual process over time of learning that his father died by suicide. Over the next several years, he continued to ask his mother about his father’s death: “Later on, a few years later, all I remember at first was asking: ‘Mom, who killed Daddy?’ and I think she must’ve just said it [he died].” Much later, after being told that his father died by suicide, Justin continued to have questions about his father’s death. He said:

And then it was like, ‘Why? Why did he do that?’ My mom would just say that he was sick, mentally ill, he had imbalances, stuff like that. We dealt with it pretty well. My mom didn’t really talk about it.

Though Justin described support as “limited,” he described his mother as the primary person who provided the support he received. Eventually, Justin’s mother was the one who answered his questions of Why? She explained that his father struggled with mental illness.

Delani worried that she had somehow contributed to her father’s death: Mom says that I was her ‘Mother’s Day present from hell.’ She says it jokingly, but apparently, I was the worst baby ever and I was born [the week of] Mother’s Day. As a child, hearing this made Delani worry that her father had chosen death by suicide because of her. She wondered if—because of her incessant crying—she was so difficult to live with that her father sought an escape. She worried that her constant fussiness made it overwhelmingly difficult for him. She said,

It makes me feel like maybe he did that [completed suicide] because of me, because I was born. It took me so long to get over and my mom did not help with this part. Me hearing how difficult I was as a baby and then my dad committing suicide when I was so young, I was like, ‘Oh my gosh, I must have been a part of the reason, if not the whole reason,’ you know?

Hearing stories of how difficult Delani was as a baby, exacerbated the feeling that she was somehow responsible for causing her father to complete suicide.

Memories of Support Following Mother’s Remarriage

Denise identified her mother’s remarriage a year after her father’s suicide, as healing and supportive for her and the family. “I think as time went on, I just like, I healed, because my mom—you know remarried someone else and he became a dad in my life. And he is an amazing person. He’s been a wonderful dad.” Denise identified the brevity of the time between her father’s death and her mother’s remarriage as a good thing, even something to be grateful for, because she felt she was not without a father figure for very long. “Mom met him probably a year after my dad died, so it wasn’t like I went that long without having a father in my life.”

Justin described his mother’s remarriage soon after his father’s death as positive. He commented,

My mom got remarried pretty quick. For me, it was like pretty quickly there was a replacement father figure, and he was cool. He’s a great guy. They would fight a lot though, him and my mom. But I liked him.

Justin perceived having a stepfather as a positive change in his own life. According to Justin, he and his stepfather got along and that there was minimal conflict in the new stepfather-son relationship. He said that changes to family life were manageable.

Delani attributed her mother’s hasty remarriage as a necessity due to her mother having small children and limited financial resources. Although Denise reports the mother remarrying after a year, Delani reported that her mother “got remarried pretty quickly—within six months. I don’t blame her though, I mean, she had kids and nothing except for the house she was living in.”

Delani says she always knew her stepfather was not her biological father, which was another factor in leading her to conclude her biological father was dead. “I mean I kind of figured it out. It basically stemmed from me knowing that my stepfather wasn’t my real dad.” Delani linked the remarriage to financial stability. Delani also noted that the remarriage was helpful because the new stepfather assisted in raising the young children.

Memories of Religious and Spiritual Support

Denise describes how her faith community offered support in the form of meals, money, and visits. “The people in our church were super kind and really supportive. They definitely brought dinners for weeks and weeks. There was always someone bringing food, and gifts, and money—just everyone was willing to help.”

Following her father’s death by suicide, Denise also found comfort in spiritual dreams in which her father was present.

I do remember having several dreams, where he would come to me tell me that he loved me, or he would be alive and I would be like, “He isn’t dead!” I think these dreams were sweet little blessings. I could see his face and talk to him. Before he died, he taught me to pray, and that a Heavenly Father loves me. It was really cool to listen to what he said, and then actually feel that in real life.

Denise expressed her spiritual belief that she would see her father again and that he continually watched over her.

In contrast to Denise, Justin did not seem to find the same solace in his religious beliefs. He describes an experience of being in church and asking the Sunday School teacher, “If someone kills themselves can they go to heaven?” Without hesitation, the Sunday School looked at Justin and replied. “No. Well, it’s technically like a form of murder and so you can’t really go to [heaven], or whatever.” The Sunday School teacher’s quick matter-of-fact response fueled Justin’s fear that he would never see or be close to his father again.

Delani shared that sometimes, while growing up, her siblings would quietly talk about wanting to die so they could go to heaven to be with their father. However, in coping with her father’s suicide, she did not specifically identify faith or religious beliefs as helpful or unhelpful.

Memories of Support from Extended Family

Denise pointed out extended family members specifically being an important source of love and support following her father’s death. “Everyone in my extended family was super loving. My grandparents were really loving and supportive, too.” Denise felt surrounded by extended family members’ loving help.

Unlike Denise, Justin did not perceive his extended family as being helpful or supportive. “I don’t think [Mom’s] siblings were supportive.” He also remembered his father’s brother blatantly blaming Justin’s mother for the suicide. “My uncle called her a ‘husband killer’ one time.” From Justin’s perspective, this comment seemed to typify the underlying anger and resentment present in extended paternal family relationships. “I know there is a lot of anger and resentment in my family from both sides. Neither side of the family really gets along and I don’t see any of my father’s siblings anymore.” Justin talked openly about the limited and challenging relationships. He stated, “I saw my aunt, his sister, for the first time in like seven years a couple days ago for my grandpa’s birthday.” He continued,

But none of them particularly like my mom and I don’t think she particularly cares for them so, kind of… they’re get along, like formally, if they have to meet somewhere, but it’s [the suicide] kind of, you know, severed those ties, in a sense.

Delani not only described extended family as not supportive, she disclosed suffering long term abuse perpetrated by an older cousin. When Delani was younger, she and her siblings often spent weekends with their cousins. She reported the following experiences:

When I was growing up, I was very close friends with a younger cousin. I would go to his house every weekend and have sleepovers with him because we were best buddies. It was me, my brother, my younger cousin, and my older cousin. When I turned about nine years old, every time I would go over there, my older cousin would molest me and do other terrible things to me. He did that to me for about three years.

After experiencing three years of abuse and the ongoing psychological and emotional repercussions of repeated abuse, Delani told her brother about the abuse. Then, Delani’s mother and stepfather got involved, initiating a process that resulted in her older cousin being placed in juvenile detention. Delani described her revelation about her cousin’s sexual perpetration and his subsequent incarceration as having huge implications for her relationships with extended family.

Memories of Support from School Community and Neighbors

Denise also felt supported by classmates, teachers, neighbors, and people in her school community. She explained,

Once they heard what I had been through, I remember fellow students giving me gifts and writing me notes. I remember teachers putting their arms around me, you know telling me that they loved me [crying]. It helped to go back to school and know that everyone wasn’t just talking about me. They were on my side.

Although Justin did not talk extensively about school or community support, he suggested that returning to school quickly helped to normalize his life after the suicide. He shared the following memories. “I remember going back to school. Going back to school must’ve helped to just normalize things because I felt pretty normal then.”

Delani did not talk about school or community support to her or her family after her father’s suicide. This topic was not mentioned during her interview.

Ongoing Challenges after the Suicide

Denise, Justin, and Delani all experienced ongoing challenges after their father’s suicide. In particular, two specific challenges were identified: responding when people asked about the suicide and living with the ongoing challenges associated with their father’s suicide.

Although Denise felt loved and supported by her family, had a positive experience with her mother’s remarriage, and felt that her faith supported her after her father’s death, she still struggled with her father’s death. She said,

I felt really ashamed that my dad had killed himself. And when people would ask me what happened, I would often lie about it. It wasn’t until I got older that I was actually able to say what really happened to him.

To overcome her shame, Denise was able to seek help from her mother. She recalled:

I would tell my mom, “Mom…I feel embarrassed when people ask me what happened, I don’t dare to tell them that dad killed himself. I feel like they’re going to look at me different.” And she would always say, “Denise, there’s nothing to be ashamed of. When someone asks me that, I tell them what happened.”

Despite her fears to the contrary, Denise did find acceptance when she was honest about her father’s suicide. “When I learned to be open and honest about it, it was like, people won’t judge me. Everyone goes through hard things. I felt more love when I actually told someone the truth.”

When meeting new people, Justin carefully watched people’s reactions. He watched closely in order to gauge how he would explain his family situation.

I remember I would anticipate it because every time you would meet new people, a friend’s parents or anything like that, you know, they’re inevitably going to start asking about family and all that so you kind of start to anticipate that question coming up and try to measure your response.

Justin reported that he often decided to tell the truth in simple terms. He commented. “I would generally just say something, like, I would just tell them, like, ‘oh, he killed himself.’”

Unlike his sisters, Justin did not become emotional during the interview. He appeared calm and understated in his responses. He did not express strong feelings about his father’s suicide impacting him in any long-term, negative way. However, he seemed to question his own bereavement process. He commented, “Sometimes, I still, think back and, I wonder about stuff. Maybe I’m still going through the grieving process very incrementally. I definitely have more resentment towards him [my Dad] now that I’m older.”

During the interview, Delani, did not share her feelings about how she responded to people when asked about her father’s suicide. This question was not directly probed, nor did this topic arise during her interview.

Pertaining to the ongoing effects from her father’s suicide, Delani focused on dysfunctional extended family relationships following the suicide, such as the long-term negative effects of the abuse perpetrated by her male cousin. She noted,

I’m going to therapy now. I don’t know that it is about my father though. So, with all of my therapies, the reason why I’m going to therapy now is mainly stemming from what happened to me when I was younger because I have a lot of issues from that.

Survivors’ Response to Children’s Books

At the close of each individual interview, Denise, Justin, and Delani were each presented with children’s picture books that could potentially be used to help support children bereaved by suicide, possibly opening communication about the suicide. The three siblings reacted strongly to certain aspects of the books. They further explained what they did or did not like about a specific book. The following information summarizes responses to three specific children’s picture books: The Little Flower Bulb (Gormally, 2011); After a Suicide: An Activity Book for Grieving Kids (The Dougy Center, 2001); and the Invisible String (Karst, 2000).

The Little Flower Bulb: Helping Children Bereaved by Suicide (Gormally, 2011) is a story about Jamie, his mother, and his two younger sisters. The story tells how Jamie and his family grieve his father’s suicide. The book is suggested for young children, ages 3–10. The central metaphor is based on planting a dry flower bulb, then later celebrating the blooming flower.

After a Suicide: An Activity Book for Grieving Kids (The Dougy Center, 2001), a brightly colored 48-page workbook, is geared to children ages 8–10. Not a traditional story book, this text includes short snippets of children’s personal comments, advice about coping with grief following a suicide, and activities such as artwork and puzzles. This book invites children to describe and draw pictures about their personal experience.

The Invisible String (Karst, 2000), a 38-page children’s book, provides a therapeutic metaphor for children who have experienced a traumatic separation from a loved one, such as when a parent dies by suicide. In the story, an invisible string connects family members. No matter the distance or challenges they face, children and their parents always maintain their connection.

When presented with a group of children’s books that might be helpful to a child bereaved by suicide, Denise immediately identified with the explanations about chemical imbalances in the brain as a factor in a person choosing to die as explained in After a Suicide: An Activity Book for Grieving Kids. She relayed:

When I was young, they explained this to me and it was really helpful, like, that there can be a chemical imbalance in the brain. Explaining that, like, not everyone’s brain, you know, is perfect, and that things can go wrong, and it [suicide] is not a normal thing that that person would do.

Denise had been told that her father had a chemical imbalance in his brain and it helped her to make sense of why he chose to die by suicide. Because of her personal experience, Denise liked one explanation offered in After a Suicide: An Activity Book for Grieving Kids. For Denise, the information in the book would help place the responsibility of the decision on issues outside the child survivor’s control and outside their relationship with the parent. She believed it was a positive and helpful aspect of the book. She commented,

I really like this book. It covers the ins and outs, everything. I think it can help a child understand, like I’m not the only person feeling this way. A child might be able to relate to that. And whoever is helping the child will be able to learn a lot about what is needed to help that child get through it.

Even though Denise responded positively to After a Suicide: An Activity Book for Grieving Kids, she suggested this book may not be appropriate for young children. She said: “I mean you would have to be at least 10 or older for this book. It would not be good with a young child.” She indicated that some of the details in the book would overwhelm a younger child.

Denise offered few reactions to the other books. However, with The Little Flower Bulb she cautioned that in order to help a child understand the text and how this book would relate to their experience, an adult would need to didactically offer explanations. “I think if I were younger, and my mom was reading it to me, it would be good as long as she, explained things throughout the reading, and made it personal to our life or our situation.” Although, in Denise’s view, The Little Flower Bulb required adult explanations, she appreciated the metaphor. She indicated that the idea of having a growing, living flower symbolizing memories of the father who died by suicide was positive and seen as potentially helpful for CSoPS.

When offered the books, in comparison to his two sisters, Justin was less talkative and reactive. He demonstrated no strong positive reactions to any of the books. However, he displayed a strong negative, visceral reaction to The Little Flower Bulb. As soon as Justin saw the cover of the book, he immediately reacted negatively to the illustration style: “I don’t like the art style, right away.” The book’s cover included an illustration of a small boy surrounded by flowerpots and a toy bear. The boy’s head was tilted to one side. This was particularly off-putting for Justin. “He kind of looks dead right there, to be honest, like, that hollow look in his eye…he looks dead in his eyes.” He then went further and connected a cause of death to the dead-looking boy on the cover, based on the boy’s body posture. “And his head is kinked. It makes it look like he’s hanging. This is not a book for children.” Justin went on to say that the overall feeling of the illustrations was completely negative.

When presented with children’s books, Delani was immediately drawn to The Invisible String. In particular, she reacted most positively to the book’s metaphor of a string connecting loved ones. She felt that this story’s message of attachment was something that would help children cope with the aftermath of a parent’s suicide.

I like how the book talks about how kids would take the invisible string with them wherever they go to feel connected. The book says, “Can a string reach all the way to Uncle Brian in heaven?” That’s good. I would’ve enjoyed this book as a kid. When the book says, “Does the string go away when you’re mad at us?” The mother responds, “Never.” I like that. Because that was my greatest fear with what happened to me as a little girl.

As a child, Delani expressed two fears related to loved ones being angry with her: (a) That her father’s suicide was somehow her fault because she was labeled a difficult baby and (b) that she felt scared to disclose to family members about her older cousin sexually abusing her because she was worried the adults would be angry with her. Therefore, Delani was drawn immediately to the mom in The Invisible String telling the children that no matter how she feels whether angry or not, their connection could never be broken. Delani also responded positively to the idea of the invisible string applying to separations caused by death and other traumatic situations.

In contrast to her older sister Denise, Delani had a strong negative reaction to After a Suicide: An Activity Book for Grieving Kids. She described this book as very “cold.” “I don’t really like this book. It’s just, cold, not creative. It would be hard for a kid to relate to this. I don’t get this. This just isn’t really a book for children.” Delani felt that the lack of creativity and warmth made the book “inaccessible” to children and that the book would alienate young readers. However, Delani responded positively to one message in the book. She referred directly to one statement: “You may think you did something to cause this to happen, this is not true.” Delani appreciated that the book emphasizes to young readers that a loved one’s death is not their fault. However, in her opinion, this one positive point did not outweigh the book’s deficits.

Discussion

Postvention Support: Implications for Practice

Denise, Justin, and Delani each reported unique memories of their father’s suicide and aftermath. They each reported experiencing a wide variety of reactions to the assistance and support that was provided. They each reported unique insights about adjusting and coping with their father’s suicide. If siblings with common family circumstances and shared trauma have such individualized experiences and reactions, then we must be careful to avoid drawing presumptive conclusions about children’s needs, assuming commonalities merely because they suffer a similar type of trauma and because they are members of the same family. Participants’ variety and personal nature of experiences in this study emphasize the importance of mental health professionals treating each child as an individual and offering support that fits each individual’s needs. Whether working with individuals or small groups, mental health professionals must acknowledge each person’s experience, validating and reassuring children that their thoughts and feelings are their reality (Cohen et al., 2017).

Additionally, providing opportunities for youth to talk about their parent’s suicide should be a major goal in postvention efforts to support CSoPS. Within families, communication about the parent’s suicide is limited, even nonexistent (Hanschmidt et al., 2016; Hung & Rabin, 2009; Leichtentritt et al., 2018; Mitchell et al., 2006; Regehr et al., 2021). Likewise, participants in this study commented on the difficulty of talking about their father’s suicide and expressed gratitude when others treated them normally, showed them affection, gave them thoughtful gifts, and offered kind words of support. The silence regarding their father’s suicide was particularly challenging for Delani, the youngest sibling. She indicated that although the surviving mother answered questions across time, neither the mother nor anyone else openly and compassionately talked about her father’s death by suicide. For the youngest survivors, challenges arise in helping them navigate the tasks of grief as described by Worden (1996). Their memories of the deceased parent are memories that have been implanted by those around them, filling the void that arises because they have no memories or extremely limited memories of the deceased parent. These children will have difficulty memorializing and feeling a connection with their deceased parent.

To address these needs, in Table 2 we listed a variety of resources for parents and teachers. These resources will help adults understand developmental differences in how children understand and respond to suicide. These resources will assist adults in talking with CSoPS and in understanding the surviving child’s needs.

Table 2

Postvention Resources to Support Child Survivors of Parent Suicide (CSoPS)

Brief handouts for parents and caregivers
https://www.mirecc.va.gov/visn19/docs/Talking_to_your_4–8yo_spanish.pdf  1-page handout available in Spanish for children ages 4–8.  Cómo hablar con un hijo de 4 a 8 años acerca de un intento de suicidio en la familia.
Dougy Center. (n.d.). Supporting children & teens after a suicide death. https://www.dougy.org/assets/uploads/Supporting-Children-Teens-After-a-Suicide.pdf  This suicide-specific 4-page handout is geared to parents and caregivers. This handout provides age-appropriate recommendations for talking about suicide and answering children’s questions in an age-appropriate manner.
Centre for Addiction and Mental Health (CAMH). (2020). When a parent dies by suicide: What kids want to know. CAMH. https://www.camh.ca/en/health-info/guides-and-publications/when-a-parent-dies-by-suicide  This 7-page handout is provided by Canada’s Centre for Addiction and Mental Health (CAMH). Information is available in English and French.
American Foundation for Suicide Prevention. (2014). Talking to children about suicide. https://www.pfw.edu/departments/cepp/depts/hs/centers/bhi/documents/AFSP%20talking%20to%20children%20about%20suicide.pdf  5-page handout for all adults who support children impacted by suicide. The information includes answering questions about a parent’s suicide, such as specific phrases to communicate with children under 3 and children ages 3–6.
Video
https://www.youtube.com/watch?v=W6s5U5VXzgI  (length: 3 min 5 s)  Example of a father talking with preschooler about mother’s suicide attempt.
Short articles
Koplewicz, H. S. (n.d.). Coping with a parent’s suicide: How to help children who are left behind. Child Mind Institute. https://childmind.org/article/coping-with-a-parents-suicide/  Short article is posted on the Child Mind Institute website. This information is also available in Spanish.
Bering, J. (2019, February 14). The telling: When a parent dies by suicide how the children are told casts a permanent shadow on their understanding of life and loss. https://aeon.co/essays/when-a-parent-dies-by-suicide-how-are-the-children-told  3,400-word article about the importance of how children are told about a parent’s suicide. This essay is posted on Aeon’s website, a nonprofit organiztion that communicates helpful information to families and professionals.
Kaslow, N. J., & Aronson, S. G. (2004). Recommendations for family interventions following a suicide. Professional Psychology: Research and Practice, 24(3), 240–247. file:///C:/Users/18013/Downloads/Recommendations_for_Family_Interventions%20(1).pdf.  This article is for counselors who work with families who are grieving the death of a loved one who died by suicide. Information is pertinent to school-based mental health providers. Translation of article is available in 24 additional languages.

Montgomery, S. S., & Coale, S. M. (2015). Supporting children after a suicide loss: A guide for parents and caregivers. Chesapeake Life Center.

32-page booklet for parents, caregivers, and school personnel who are supporting children following a suicide. Practical suggestions include how to talk with children about suicide. Information is offered to assist schools in providing postvention support for youth.

Requarth, M. (2006). After a parent’s suicide: Helping children heal. Healing Hearts Press.

This 280-page book was written by a counselor whose mother died by suicide. The book provides specific ways adults can support CSoPS.

Dougy Center. (2014). After a suicide: A workbook for grieving kids. The Dougy Center, The National Center for Grieving Children & Families.

Available for purchase through the Dougy Center [www.dougy.org] and other vendors, this 50-page workbook is designed to support children and teens who are grieving the death of a parent, sibling, or friend. Carefully review this book prior to sharing with children. Some information may not align with the child’s needs.

Karst, P. (2000). The invisible string. Little, Brown Books for Young Readers.

This 40-page children’s book helps children understand the connection we have with those we love, even when the person is not with us. Although this book is listed for children ages 4-8, this book is enjoyable for all ages.

National Suicide Prevention Hotline

For immediate concerns about suicide, contact The National Suicide Prevention Hotline

1-800-273-TALK (8255). Services are available 24/7.

Services are available in Spanish: Nacional de Prevención del Suicidio 1-888-628-9454.

Options For Deaf + Hard of Hearing are available by dialing 711 then 1-800-273-8255.

Lifeline Chat Service

https://suicidepreventionlifeline.org/chat/

The National Suicide Prevention Lifeline is facilitated by a national network of local crisis centers. Support is free and confidential to people in suicidal crisis or emotional distress 24 h a day, 7 days a week. This service is provided by the Substance Abuse and Mental Health Services Administration (SAMHSA).

Even though suicide postvention is encouraged by major organizations such as the World Health Organization (Fineran, 2012), minimal research has investigated the effectiveness of suicide postvention particularly for CSoPS. Additionally, studies that have been conducted reveal mixed results (Andriessen, 2014; Andriessen et al., 2019b). Therefore, when providing postvention support, interventions must be carefully monitored, noting how children are responding to the interventions.

Although a variety of resources and strategies for supporting grieving children are available, few interventions exist for children who experience a suicide loss and even fewer interventions exist for CSoPS (Mitchell et al., 2006; Ratnarajah & Schofield, 2008). Even though strategies for generalized or suicide grief may be helpful (Andriessen, 2014), CSoPS need supports designed for their specific experience. Furthermore, resources are needed for school-based mental health providers who support CSoPS and who may not be aware of effective interventions (Campbell, 1997; Ener & Ray, 2018).

Contact with suicide survivors

Contact with other suicide survivors, whether in group therapy or support groups is important for adults and children bereaved by suicide (Begley & Quayle, 2007; Pfeffer et al., 2002). Pfeffer et al. (2002) found that suicide-bereaved young people who participated in group grieving intervention focusing on reactions to suicide and coping skills showed a decrease in anxious and depressive symptoms. Veale’s (2012) longitudinal study followed five child survivors of suicide and found that interactions with groups across four years helped the children normalize their experience and feel camaraderie with those participating in the group.

Selecting Children’s Books to Support CSoPS

Although Justin and Denise both had negative reactions to The Little Flower Bulb, their reactions centered on different aspects of the book. Justin’s reaction was strongest towards the book’s illustrations, particularly on the front cover. Possibly triggering an image of his father’s suicide, Justin reported that the boy’s tipped head “makes it look like he’s hanging,” and the boy looked “dead in his eyes.”

When sharing books with children, adults must take care to consider which books might trigger memories of the parent’s method of suicide. Although Denise did not mention the book’s illustrations, she cautioned that adults might need to explain the metaphor of the flower bulb and help them make the connection between the flower bulb and the deceased parent. To the book’s credit, Denise liked the book’s metaphor. Adults might consider this book, extending the story by helping the child plant a flower bulb in memory of the deceased parent. Over time, by taking care of the bulb, the family would talk about their positive memories and show their love for the deceased parent.

The book, After a Suicide prompted Denise’s strongest positive reaction and conversely Delani’s strongest negative reaction. Denise expressed appreciation for the straightforward explanations of suicide in this book. To the contrary, the very characteristics Denise loved about the workbook, Delani found off-putting. The perceived lack of warmth and relatability in After a Suicide, is what Delani identified as the main reason she thought this book would not be helpful for CSoPS.

The Invisible String was especially appealing to Delani, who was a toddler at the time of her father’s suicide. Suffering from guilt and questioning if her father loved her or if she was in fact the cause of the suicide, the metaphor of the invisible string made sense and was comforting. Although this book does not mention suicide, the metaphor shows potential to help children feel connected to deceased loved ones, providing much needed assurance and comfort to CSoPS.

Taking into account the feedback offered by Denise, Justin, and Delani, when selecting a children’s book, adults must consider the specific needs of the child and how a story or workbook may or may not address an individual’s needs. Adults must also carefully watch a child’s reactions to a selected book, picking up on the child’s distress, anxiety, frustration, and confusion. Adults may consider having a selection of books and permitting the child to select a book that feels comfortable. Also, assuring the child that, as needed, “We can stop mid-story and move to another book.”

Limitations and Recommendations for Future Research

One limitation of the study is that during the triangulation process, the perspective of the caregiver was not taken into account. While the focus of the current study was limited to the perspective of the siblings’ lived experiences, given the vulnerable nature of the inquiry, more fully investigating the siblings’ interrelationships and communication among immediate and extended family members may also be an especially important focus for future research (Adams et al., 2019; Cerel et al., 2008; Griese et al., 2017; Zortea et al., 2019).

Future research may consider the sibling survivors’ relationships with one another, as a source of support or a source of contention that may affect adaptive coping and resilience following a parent’s suicide (Reed & Greenwald, 1991). Future research may also consider the sibling survivors’ protective factors that build their resilience, as well as the many risk factors associated with a parent’s suicide (Falgares et al., 2018; Pierazzuoli et al., 2020).

Conclusion

The concept of each person uniquely interpreting their traumatic event is supported by Cohen et al. (2017) and Van Dongen (1993). In particular, based on research associated with children’s traumatic grief, Cohen et al. (2017) encourage professionals to individualize a child’s personal trauma narrative. This personal trauma narrative encourages the child to construct their own story. This story includes memories of the facts, descriptions of their feelings associated with the facts, and ultimately identifying the most challenging and traumatic moment in their personal story. The trauma narrative is constructed over time, as the child becomes more comfortable talking about the trauma. The trauma narrative reduces stigma and isolation and encourages discussion about the trauma, rather than avoiding memories associated with the trauma (Cohen et al., 2017; Cohen & Mannarino, 2011).

Although Denise, Justin, and Delani grew up in the same home, with the same mother, the same family members, and all experienced their father’s suicide, each individual had their own set of memories. As children, their responses were related to the manner in which they interpreted the event in the context of their development and how others responded to the situation. Even within the same family, the distinctions between the children’s experiences are significant. These differences manifest how siblings’ shared trauma does not equate to uniform reactions and perspectives. Therefore, each child’s experiences surrounding this trauma must be considered on an individual basis and interventions should be tailored to the individual’s unique point of view and to the individual’s unique needs.

An additional finding from our research is that many years after a parent’s suicide, survivors continue to struggle with strong emotions and the stigma associated with their parent’s suicide. Open and supportive communication is needed. Even after all these years, the youngest participant, a toddler when her father completed suicide, continued to question if she, “the Mother’s Day gift from Hell,” caused her father to complete suicide. Addressing why a parent chose to complete suicide and addressing children’s guilt are critical components of postvention support for CSoPS.